Developing Health System Surge Capacity: Community Efforts in Jeopardy

Originally published as HSC Research Brief No. 5 by the Center for Studying Health System Change (HSC), June 2008. Authors: Laurie E. Felland, Aaron Katz, Allison Liebhaber, Genna R. Cohen. HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Developing Health System Surge Capacity: Community Efforts in Jeopardy

In the years following September 11, 2001, communities across the United States worked to strengthen their health care surge capacity -- the physical space, supplies, staffing, and management infrastructure needed to care for large numbers of injured or sick people during a terrorist attack, natural disaster, or infectious disease pandemic. Communities brought varying levels of emergency experience to this work, but all were building broad capabilities that spanned transportation, communication, hospital care, and mass fatality management, according to research by the Center for Studying Health System Change (HSC). Federal dollars served as a critical engine for this progress, helping communities coordinate across agencies and providers, run training exercises, recruit volunteers, and stockpile equipment and supplies. The federal government's growing emphasis on pandemic influenza preparedness had strengthened readiness for all types of emergencies, though communities sometimes struggled with funding requirements they found fragmented and restrictive.

Yet a fundamental tension ran through these efforts. The demand for surge capacity was growing at precisely the time that everyday health care capacity was stretched thin by workforce shortages, reimbursement pressures, and rising numbers of uninsured patients. No payer reimbursed hospitals for keeping beds empty in anticipation of a disaster, and it was not feasible for trained staff to wait idle until a crisis struck. Communities were trying to square this circle by designing surge capacity that doubled as support for routine operations and could be rapidly scaled up in an emergency. Many of these approaches -- bringing outpatient providers into surge planning, expanding clinical staff roles during crises, and adjusting standards of care for mass-casualty events -- required stronger coordination, clearer guidance, and more policy backing than existed. As the years since 9/11 and Hurricane Katrina accumulated, federal surge capacity funding was shrinking, and communities feared losing the preparedness infrastructure they had built.

Preparing for Multiple Types of Emergencies

After the 2001 terrorist attacks, the ability to rapidly expand medical care and public health services to treat large numbers of casualties became a top priority for policymakers and health care organizations. Hurricane Katrina in 2005 further underscored the urgency. Federal, state, and local governments invested heavily in disaster preparedness, with particular emphasis on local-level planning since community agencies and organizations serve as first responders. Federal bioterrorism preparedness funding, channeled mostly through state and local agencies, spiked after 9/11.

Initially focused on deliberate biological attacks, federal funding gradually broadened to cover a wider range of threats under an 'all-hazards' framework that included both manmade and natural disasters. Concern about pandemic influenza intensified as avian flu raised fears of a repeat of the 1918-19 pandemic, which killed an estimated 675,000 Americans and 50 million people worldwide. The Department of Homeland Security identified 14 additional preparedness scenarios covering natural disasters plus chemical, radiological, nuclear, and biological incidents.

Federal guidance converged around four core components of surge capacity. First, management structures and communication systems to lead the response, assign responsibilities, and deploy resources -- communities receiving federal funds had to comply with FEMA's National Incident Management System (NIMS). Second, stockpiles of equipment, supplies, and medications at national, state, and local levels, including specialized items like antiviral drugs for influenza. Third, physical facilities capable of rapid expansion -- the Department of Health and Human Services estimated a severe pandemic would require hospitalizing nearly 10 million people against roughly 1 million available staffed beds. Fourth, clinical and public health personnel sufficient to staff the response despite chronic workforce shortages, especially among nurses.

Federal Funding as Driver and Constraint

Communities depended heavily on federal dollars because state and local surge capacity funding was minimal. Federal money had raised awareness, enabled dedicated planning time, supported drills, helped build volunteer corps, and financed equipment purchases. But the funding came from multiple sources with differing requirements, making it hard for communities to pursue a unified strategy. As a Florida state official noted, requirements and restrictions made it difficult to fit local priorities into the various funding boxes, leaving some locally important risks without a funding source.

Funding levels fell well short of the costs involved in building hospital surge capacity. The Center for Biosecurity estimated that hospitals' pandemic preparedness costs far exceeded available federal funding through the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR). Health care financing simply did not support keeping beds, equipment, or workers idle, creating an inherent conflict with surge preparedness goals. As one hospital official explained: 'There is the tension of wanting to be prepared against the competing priority of not having the budget to do so.' Federal funding had declined in recent years, and communities worried about maintaining the systems, training, and supplies they had already established.

Coordination and Planning Across Stakeholders

Communities were working to develop wide-ranging surge capacity covering communications, transportation, hospital care, and mass fatality management. Effective preparation required ongoing coordination among stakeholders to determine who controlled resources, who held authority, and where to turn for help. One early payoff from post-9/11 federal funding was improved collaboration among public health agencies, fire and police departments, emergency management agencies, and health care providers. Lessons from past emergencies prompted partnerships with additional entities: Hurricane Katrina highlighted the need for police to secure hospitals, while state and local emergency management agencies and EMS became more involved in transportation logistics. Morgues and mortuaries joined mass fatality planning. Community health centers and long-term care and mental health providers were increasingly brought into surge planning to address the needs of vulnerable populations.

Communities were also preparing to operate independently for several days after a disaster -- or much longer during a severe pandemic, when the breadth of the event would limit outside assistance. HSC's study examined surge capacity development in six communities: Boston; Greenville, S.C.; Miami; Phoenix; Orange County, Calif.; and Seattle. Additional interviews covered New York City, Washington D.C., and New Orleans, along with national leaders. Each community brought different experience to the task, shaped by geography, demographics, and past exposure to large-scale emergencies.

Strategies for Space, Staff, and Supplies

Communities developed creative approaches to each of the four surge capacity components. For physical space, strategies included converting conference rooms, lobbies, and parking structures within hospitals; pre-identifying non-medical buildings such as schools and convention centers for emergency use; and deploying mobile medical units including federal Disaster Medical Assistance Teams. For staffing, communities recruited Medical Reserve Corps volunteers, developed mutual-aid agreements with neighboring jurisdictions, cross-trained existing workers for expanded roles, and planned for altered standards of care during mass-casualty events. Supply stockpiling involved participation in the Strategic National Stockpile system along with local caches of pharmaceuticals, personal protective equipment, and ventilators. Communities also worked to control demand on hospitals during emergencies through public communication campaigns, telephone triage hotlines, and expanded use of community health centers and pharmacies as alternative care sites.

Implications for Policy

The study revealed that communities had made meaningful progress since 9/11 but faced growing threats to that progress. The fundamental tension between surge readiness and daily operational pressures was not going away. Federal funding reductions risked eroding the coordination networks, training programs, and supply stockpiles that communities had painstakingly built. Policymakers needed to address several priorities: stabilizing and streamlining federal funding, developing clearer guidance on altered standards of care, supporting workforce strategies that served both routine and emergency needs, better integrating outpatient and community-based providers into surge plans, and creating meaningful benchmarks to track preparedness progress across communities.

Sources and Further Reading

This Research Brief was based on site visits and interviews conducted in six communities (Boston, Greenville S.C., Miami, Phoenix, Orange County Calif., and Seattle) along with supplemental interviews in New York City, Washington D.C., New Orleans, and with national leaders. The research was supported by the Robert Wood Johnson Foundation. The Chronic Care Model referenced in the study was developed by the Group Health MacColl Institute for Healthcare Innovation. Federal funding data drew on Congressional Research Service reports and the Center for Biosecurity estimates of hospital preparedness costs.