States are working to ensure medical surge capacity in mass casualty events like terrorist attacks and natural disasters, but difficult work remains, according [1] to a Government Accountability Office (GAO) report released Monday.

The 9-11 attacks, combined with the threat of natural disasters and disease pandemics, led Congress to request a GAO study of states' ability to provide adequate healthcare in such crises, and what the federal government can do to help.

The report identifies four key tasks states must address to provide adequate medical surge capacity. They must increase hospital capacity, establish alternate care sites to supplement existing hospital beds, and register and credential volunteer medical professionals. Finally, states must prepare altered care plans, essentially mass triage criteria to determine who would receive care during a major emergency, and who would not.

States have done well addressing the first three components, but have experienced difficulty satisfying the fourth,  the GAO found.

According to 20 states' emergency preparedness planning documents, all were developing bed reporting systems coordinated with department of Defense and Veterans Affairs hospitals to boost hospital surge capacity.

Eighteen of the 20 states were also in the process of choosing alternate care sites. One, according to the GAO, bought three mobile medical facilities, equipped with 200 beds each, to be placed in different parts of the state.

Fifteen of the states surveyed register volunteers electronically, and all but one of them had begun to verify the volunteers' medical qualifications. The report notes, however, that the verification processes do not completely identify " volunteers' skills and capabilities for providing care in a hospital."

Yet only 7 of the 20 states reviewed were developing triage plans. "Some states," says the report, "reported that they had not begun work on or completed altered standards of care guidelines due to the difficulty of addressing the medical, ethical, and legal issues involved in making life-or-death decisions about which patients would get access to scarce resources." Despite using federal guidelines when drawing up altered care plans, many states told the GAO they needed more assistance. 

The federal government awarded states $2.2 billion from 2002 to 2007 to help them reach disaster preparedness goals, including the development of medical surge capacity. Furthermore, the government has provided states a checklist of entities to leverage for more resources in case of a mass casaulty event in such documents as Reopening Shuttered Hospitals to Expand Surge Capacity [2].

Nevertheless, officials from the 20 states reviewed still harbor concerns, from shortages of medical professionals to whether or not they will be reimbursed for providing medical services at alternate sites, GAO found. State officials also reported volunteers wondered whether or not they would have to respond outside their state if state volunteer directories became part of a national database.

GAO recommended that the Department of Health and Human Services (HHS) serve as the clearinghouse for sharing the altered standards of care guidelines developed by some states and medical experts. HHS did not respond to the recommendation, according to GAO.

HHS has however, together with leading emergency care physicians, the Centers for Disease Control and Prevention, and the Department of Homeland Security, developed triage guidelines for critical care in a pandemic. For more on those guidelines and accompanying challenges, see "Hard Questions in Emergency Critical Care" in the upcoming August Issue of Security Management.