COVID-19 Medical Surge Experiences and Related HHS Efforts (GAO-22-105461)
Summary
A GAO report to congressional addressees, GAO-22-105461, dated August 2022, on public health preparedness. It states that the COVID-19 pandemic highlighted the importance of hospitals' ability to evaluate and care for a volume of patients exceeding normal operating capacity, known as medical surge. All eight hospitals in GAO's review reported multiple challenges related to staff, supplies, space or information. The report describes these medical surge experiences and related efforts by the Department of Health and Human Services, which leads the nation's medical and public health preparedness for emergencies and disasters.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Full text
United States Government Accountability Office
Report to Congressional Addressees
August 2022
PUBLIC HEALTH
PREPAREDNESS
COVID19 Medical
Surge Experiences
and Related HHS
Efforts
Accessible Version
GAO-22-105461
August 2022
GAO Highlight PUBLIC HEALTH PREPAREDNESS
Highlights of GAO-22-105461, a report to COVID-19 Medical Surge Experiences and Related
congressional addressees
HHS Efforts
Why GAO Did This Study What GAO Found
HHS leads the nation's medical and The COVID-19 pandemic has highlighted the importance of hospitals’ abilities to
public health preparedness for, evaluate and care for an increased volume of patients exceeding normal
response to, and recovery from operating capacity, known as medical surge. All eight hospitals in GAO’s review
emergencies and disasters. This reported multiple challenges related to staff, supplies, space, or information.
includes helping hospitals and others These are critical components for an effective medical surge response, according
build medical surge readiness. to the Department of Health and Human Services (HHS). All eight hospitals
Emergencies, such as the COVID-19
reported staffing challenges, such as a lack of staff to care for the increase in
pandemic, put enormous strain on
sick patients or staff becoming ill and unable to work, affecting hospital services.
hospitals in times of crisis.
Hospitals took steps to address these challenges, such as supplementing staffing
The Pandemic and All-Hazards levels where possible or training staff on proper personal protective equipment
Preparedness and Advancing use to prevent infection. Health care coalitions—groups of health care and
Innovation Act of 2019 includes a response organizations in a defined geographic location supported by HHS
provision for GAO to review funding—aided hospitals. For example, they helped coordinate patient transfers
implementation of HHS’s regional to balance hospital loads, obtain and distribute needed medical supplies, and
preparedness and response guidelines communicate hospital needs to their states.
for hospitals and other facilities to
increase medical surge capacity. Health Care Workers Responding to the COVID-19 Pandemic
Issuance of these guidelines has been
delayed due to the continuing COVID-
19 response, according to HHS. The
CARES Act also includes a provision
for GAO to report on the federal
response to the pandemic. This report
describes (1) medical surge challenges
selected hospitals faced in responding
to the COVID-19 pandemic and how
health care coalitions have supported
their efforts, and (2) selected HHS
programs and activities underway to HHS has programs and activities underway intended to support medical surge
support medical surge readiness. readiness for hospitals and other health care organizations, but it is too soon to
know the effectiveness of these efforts. For example, HHS implemented a new
To do this work, GAO reviewed HHS
medical surge exercise for coalitions in 2021 to test readiness, and plans to
and hospital documentation. GAO also
interviewed HHS officials and establish targets to measure performance. It is also considering how to use the
representatives from a non- findings and lessons learned from its 2021 assessment of coalitions during the
generalizable sample of eight hospitals pandemic to improve its support of coalitions and their communities. HHS is also
and eight associated coalitions across funding the development of a regional disaster health response system, which
three states. These states were aims to develop effective approaches to medical surge response across multiple
selected based on their involvement in states. This includes improving data sharing on resource and capacity issues,
HHS regional preparedness and and developing specialized teams that can respond to a range of hazards. HHS
response efforts. is considering its next steps regarding the expansion of this regional system.
Further, HHS is developing regional guidelines for hospitals and other facilities
We provided a draft of this report to
related to treating patients and increasing medical surge capacity during public
HHS for review and comment. HHS
provided technical comments, which
health emergencies as required by statute. Officials did not provide a date for
we incorporated as appropriate. when the guidelines would be made publicly available.
View GAO-22-105461. For more information,
contact Mary Denigan-Macauley at (202) 512-
8552 or DeniganMacauleyM@gao.gov.
United States Government Accountability Office
Contents
GAO Highlight ii
Why GAO Did This Study ii
What GAO Found ii
Letter 1
Background 7
Hospital Medical Surge Challenges and Coalition Support
Responding to the COVID-19 Pandemic 12
ASPR’s Ongoing Hospital Preparedness Program and Other
Efforts to Support Medical Surge Readiness 26
Agency Comments and Our Evaluation 38
Appendix I: GAO Contact and Staff Acknowledgments 41
Related GAO Products 42
Tables
Table 1: The Four Key Health Care Preparedness and Response
Capabilities, according to the Office of the Assistant
Secretary for Preparedness and Response (ASPR) 11
Table 2: Examples of Strategies Used by Health Care Coalitions
to Address Hospital Challenges during the COVID-19
Pandemic 23
Table 3: Potential Areas of Additional Support for Health Care
Coalitions, as Identified by the Office of the Assistant
Secretary for Preparedness and Response (ASPR)
Technical Resources, Assistance Center, and Information
Exchange 30
Table 4: Examples of Ongoing Efforts by Three Office of the
Assistant Secretary for Preparedness and Response
(ASPR) Regional Disaster Health Response Health
System Demonstration Project Sites and Funding History 34
Figures
Figure 1: Hospital Preparedness Program (HPP) Cooperative
Agreement Funding, by Source, Fiscal Years 2002
through 2023 8
Page i GAO-22-105461 Medical Surge Readiness
Figure 2: Map of the Office of the Assistant Secretary for
Preparedness and Response’s (ASPR) Regional Health
Disaster Response System Demonstration Project Sites
in Four Department of Health and Human Services (HHS)
Regions, and Number of Health Care Coalitions in Those
Regions 33
Abbreviations
PAHPAI Act Pandemic and All-Hazards Preparedness and
Advancing Innovation Act of 2019
ASPR Office of the Assistant Secretary for Preparedness and
Response
HHS Department of Health and Human Services
HPP Hospital Preparedness Program
PPE personal protective equipment
This is a work of the U.S. government and is not subject to copyright protection in the
United States. The published product may be reproduced and distributed in its entirety
without further permission from GAO. However, because this work may contain
copyrighted images or other material, permission from the copyright holder may be
necessary if you wish to reproduce this material separately.
Page ii GAO-22-105461 Medical Surge Readiness
441 G St. N.W.
Washington, DC 20548
Letter
August 17, 2022
Congressional Addressees
Emergencies and disasters have highlighted the critical role that health
care organizations, such as hospitals and emergency medical services,
play in treating medical needs in the wake of mass casualty events.
Events such as the ongoing COVID-19 pandemic, extreme weather, and
acts of terrorism have required hospitals to rapidly and significantly
expand capacity and resources to provide medical care. This ability to
evaluate and care for a markedly increased volume of patients that
exceeds normal operating capacity is known as medical surge, according
to the Office of the Assistant Secretary for Preparedness and Response
(ASPR), within the Department of Health and Human Services (HHS).1
ASPR leads the nation’s medical and public health preparedness for,
response to, and recovery from emergencies and disasters. According to
ASPR, an effective medical surge response requires health care delivery
systems to build key planning and resource capabilities.2 ASPR supports
the advancement of these capabilities through the Hospital Preparedness
Program (HPP) cooperative agreement, among other efforts.3 This
program is the primary source of federal funding for health care system
preparedness for emergencies and disasters, which includes increasing
medical surge capacity. HPP funds and promotes the development of
1Office of the Assistant Secretary for Preparedness and Response, 2017-2022 Health
Care Preparedness and Response Capabilities (Washington, D.C.: November 2016).
In July 2022, the Secretary of Health and Human Services removed ASPR from the HHS
Office of the Secretary and created a new operating division in the department, to be
known as the Administration for Strategic Preparedness and Response. In this report, we
refer to ASPR under the organizational name and structure in place at the time we
conducted our review.
2ASPR, 2017-2022 Health Care Preparedness and Response Capabilities.
3A cooperative agreement is a federal award to a non-federal entity to carry out a public
purpose. Unlike grants, cooperative agreements generally provide for substantial
involvement between the federal awarding agency and the non-federal entity in carrying
out the activity contemplated by the award. For the purposes of this report, we will refer to
the HPP cooperative agreement as HPP. HPP provides funds to the public health
departments of 62 states and other jurisdictions through cooperative agreements,
according to ASPR.
Page 1 GAO-22-105461 Medical Surge Readiness
Letter
health care coalitions (coalitions)—groups of health care and response
organizations in a defined geographic location that coordinate emergency
preparedness and response activities across their members. Key coalition
activities include sharing real-time information, coordinating the
distribution and sharing of medical supplies, and coordinating joint
planning exercises, according to a document on ASPR’s website.
Since 2020, through our CARES Act work, we have reported on a number
of challenges faced by the nation, including hospitals, in responding to the
COVID-19 pandemic. For example, in March 2021, we reported that
hospitals expressed concerns about the availability of COVID-19 vaccines
and testing supplies, as well as other medical supplies, such as personal
protective equipment (PPE).4 In January 2022, we added HHS’s
leadership and coordination of public health emergencies to our high-risk
list, in part due to persistent deficiencies in the department’s ability to
execute its role leading federal public health and medical preparedness
for, and response to, public health emergencies.5
The Pandemic and All-Hazards Preparedness and Advancing Innovation
Act of 2019 (PAHPAI Act) required ASPR to publish regional guidelines
on practices and protocols for hospitals and other health care facilities to
provide appropriate patient care during, in advance of, or immediately
following a public health emergency.6 The purpose of these guidelines is
to assist facilities in their ability to treat patients and increase medical
surge capacity in the event of a public health emergency. The PAHPAI
Act includes a provision for GAO to review the extent to which hospitals
and health care facilities have implemented these guidelines.7 However,
according to ASPR, issuance of the regional guidelines has been delayed
largely due to ASPR’s continuing response to the COVID-19 pandemic.
4GAO, COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second
Year, GAO-21-387 (Washington, D.C.: Mar. 31, 2022).
5GAO, COVID-19: Significant Improvements Are Needed for Overseeing Relief Funds and
Leading Responses to Public Health Emergencies, GAO-22-105291 (Washington, D.C.:
Jan. 27 2022).
6Pub. L. No. 116-22, § 203(a), 133 Stat. 905, 911-13 (codified at 42 U.S.C. § 247d-3c).
7Pub. L. No. 116-22, § 203(b), 133 Stat. at 913-14.
Page 2 GAO-22-105461 Medical Surge Readiness
Letter
The CARES Act also includes a provision for us to report on the federal
response to the COVID-19 pandemic.8 In this report we describe
1. the medical surge challenges selected hospitals faced in responding
to the COVID-19 pandemic and how coalitions supported their efforts,
and
2. selected ASPR programs and activities that support medical surge
readiness.
To address both objectives, we reviewed documents from and
interviewed officials from a non-generalizable sample of eight hospitals
and their associated eight coalitions in three selected states (Colorado,
Massachusetts, Nebraska).9 We also interviewed officials from the state
public health departments in two of the three selected states.10 The
documents we reviewed included academic articles about hospitals’
COVID-19 experiences and presentations hospital officials developed to
describe their COVID-19 responses. We also reviewed an ASPR report
assessing the engagement of coalitions in the COVID-19 response.11
Although the experiences of selected hospitals, coalitions, and state
officials are not generalizable across all states, coalitions, or hospitals,
their selection was intended to illustrate a variety of experiences. We
8Specifically, the CARES Act directs us to monitor and oversee the federal government’s
efforts to prepare for, respond to, and recover from the pandemic. Pub. L. No. 116-136, §
19010, 134 Stat. 281, 579-81 (2020). In addition to our reports on individual programs, we
have regularly issued government-wide reports on the federal response to the COVID-19
pandemic. For the latest report, see GAO, COVID-19: Current and Future Federal
Preparedness Requires Fixes to Improve Health Data and Address Improper Payments,
GAO-22-105397 (Washington, D.C.: Apr. 27, 2022). All of these reports are available on
GAO’s website at https://www.gao.gov/coronavirus.
9We originally selected nine hospitals and nine coalitions, but ultimately only eight
hospitals and eight coalitions were available to participate in an interview.
In Massachusetts, the state public health department operates the state’s single coalition,
and it is composed of entities, known as health and medical coordinating coalitions, which
represent smaller regions within the state. For the purposes of our study, we considered
these health and medical coordinating coalitions to be coalitions.
10The public health department for the state of Nebraska did not ultimately respond to our
request for an interview.
11Department of Health and Human Services, Office of the Assistant Secretary for
Preparedness and Response Technical Resources, Assistance Center, and Information
Exchange, Healthcare Coalition Engagement in COVID-19 Assessment (Washington,
D.C.: December 2021).
Page 3 GAO-22-105461 Medical Surge Readiness
Letter
selected those three states because each contains one of ASPR’s
demonstration sites for the Regional Disaster Health Response System;
according to ASPR officials, the sites’ experiences helped inform the
development of the regional guidelines required under the PAHPAI Act.12
For our sample, we included three hospitals from the selected
demonstration sites, as well as five other hospitals.13 To identify the
remaining five hospitals:
· We first used 2019 U.S. Census population data to identify the
geographic coverage areas of coalitions in each state that
corresponded with the most populous and least populous parts of
each state (after excluding coalitions associated with lead
demonstration site hospitals).14
· Within each selected coalition, we used the 2020 Centers for
Medicare & Medicaid Services’ Provider of Services data file, a
12According to ASPR, the goal of the Regional Disaster Health Response System
demonstration project is to test new approaches, establish regional partnerships to
improve disaster readiness capabilities and capacity, increase medical surge capacity,
enhance situational awareness, and extend the provision of specialty care. As of June
2022, ASPR has funded four Regional Disaster Health Response System hospital
demonstration sites, each located in one of 10 HHS regional offices across the nation,
which are composed of multiple states or territories.
13Specifically, we included in our sample three hospital demonstration sites at
Massachusetts General Hospital (Boston, MA), Nebraska Medicine (Omaha, NE), and
Denver Health and Hospital Authority (Denver, CO).We excluded from our review the
fourth demonstration site (Emory University Hospital; Atlanta, GA) as it had only recently
started its activities at the time of our review.
14For Massachusetts, we selected the hospital located in the least populated place
associated with the coalition coverage area.
Page 4 GAO-22-105461 Medical Surge Readiness
Letter
publicly available data source that contains information on hospitals,
to randomly select one hospital.15
For the purposes of this report, we refer to the three hospitals from
coalitions that cover the least populous area of their state as rural
hospitals. For our hospital interviews, we interviewed officials such as
staff in leadership positions, including chief executive, operating or
medical officers, and staff responsible for hospital emergency
preparedness activities. For our coalition interviews, we interviewed staff
such as coalition coordinators and clinical advisors. For our state public
health department interviews, we interviewed officials such as staff
responsible for managing HPP in their state or officials from state
emergency management agencies.
To provide additional information on medical surge challenges faced by
hospitals during the COVID-19 pandemic and how coalitions supported
their efforts, we also interviewed three individuals with subject matter
expertise on medical surge readiness issues who presented at recent
ASPR or National Academies of Sciences, Engineering, and Medicine
webinars on health care preparedness and response. Additionally, we
interviewed representatives from two national organizations that
represent the majority of hospitals (the American Hospital Association
and America’s Essential Hospitals).16 The American Hospital Association
represents all types of hospitals, including those in rural areas, and
15To capture the experiences of more traditional, short-term acute care hospitals, we
excluded critical access hospitals because they are special types of hospitals with
different conditions of Medicare participation, such as increased flexibilities in hospital
staffing requirements, and increased Medicare payment rates when compared to other
hospitals. According to the Centers for Medicare & Medicaid Services, to be designated a
critical access hospital, the hospital must meet certain criteria, such as: being located in a
rural area; being located either more than 35 miles from the nearest hospital or critical
access hospital or more than 15 miles in areas with mountainous terrain or only secondary
roads; and, maintain no more than 25 inpatient beds that can be used for either inpatient
or swing-bed services. In addition, according to ASPR, critical access hospitals have a
more limited range of services available when compared to other hospitals. According to
2020 Centers for Medicare & Medicaid Services data, 71 percent of hospitals certified to
participate in Medicare and/or Medicaid are short-term acute care hospitals. Within each
coalition coverage area, we also excluded any hospitals that are a part of the same health
care system associated with a hospital that we already selected. One of the nine coalitions
we selected was unable to participate because, according to ASPR, this coalition became
inactive during the COVID-19 pandemic. Additionally, one of the nine hospitals we
selected was unable to participate. We then contacted two other hospitals within the same
coalition, but neither one responded to our interview requests.
16According to the American Hospital Association, the organization represents
approximately 5,000 hospitals out of 6,093 in the United States. According to America’s
Essential Hospitals, the organization represents more than 325 hospitals.
Page 5 GAO-22-105461 Medical Surge Readiness
Letter
America’s Essential Hospitals represents safety net hospitals in urban
areas.
To describe selected ASPR programs and activities underway that
support medical surge readiness, we focused our review on ASPR efforts
that address all types of hazard events and are relevant to the
development of the regional guidelines required under the PAHPAI Act.
Specifically, we reviewed HPP, the Regional Disaster Health Response
System, and ASPR’s efforts to develop regional guidelines. In selecting
these efforts, we first identified the programs and activities funded
through the portion of ASPR’s budget that funds HPP. Those include the
Regional Disaster Health Response System, the ASPR Technical
Resources, Assistance Center, and Information Exchange, and the
National Special Pathogen System, among others. We focused on HPP
because it comprises about 78 percent of this budget line item for fiscal
year 2022. We also included the Regional Disaster Health Response
System because, according to ASPR officials, it is helping inform the
office’s development of the regional guidelines required under the
PAHPAI Act. We obtained and analyzed ASPR documents, such as
guidance on preparedness and response capabilities to support medical
surge readiness and reports on activities of the Regional Disaster Health
Response System, and coalition activities during the COVID-19
pandemic.17 In addition, we collected and analyzed progress reports from
the Regional Disaster Health Response System demonstration sites in
our sample. We also reviewed written responses and interviewed officials
from ASPR, as well as representatives from the Regional Disaster Health
Response System demonstration sites and coalitions in our sample.
We conducted this performance audit from October 2021 to August 2022
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
17See ASPR, 2017-2022 Health Care Preparedness and Response Capabilities; and
ASPR Technical Resources, Assistance Center, and Information Exchange, Healthcare
Coalition Assessment.
Page 6 GAO-22-105461 Medical Surge Readiness
Letter
Background
HPP Mission and Funding
According to ASPR, HPP enables the nation’s health care delivery
system to save lives during emergencies and disasters when they exceed
the day-to-day capacity of existing health and emergency response
systems.18 HPP develops coalitions to support cooperation among
different health care organizations, such as hospitals.19 HPP provides
funds to the public health departments of 62 jurisdictions through
cooperative agreements, according to ASPR.20 These recipients, in turn,
support the coalitions within their defined geographic areas. HPP
supported 321 coalitions, according to ASPR, based on June 2021 data.
Funding for HPP has generally decreased over time, according to ASPR
data (see fig.1). For example, funding for HPP decreased from about
$500 million in fiscal year 2003 to about $230 million in fiscal year 2022.
In certain years, supplemental appropriations enacted to address public
health emergencies have been used to provide additional funding to HPP
recipients. For example, as of June 2020, ASPR had provided about $159
million in COVID-19 relief funds to HPP recipients to further support the
work of coalitions and other health care facilities in their geographic
areas, according to ASPR data. In addition, ASPR implemented
flexibilities for states and other jurisdictions to request use of Ebola relief
funding, on a limited case-by-case basis, for the development of action
plans, training, and the rapid procurement of supplies needed during the
COVID-19 emergency response.21
18ASPR, 2017-2022 Health Care Preparedness and Response Capabilities. According to
ASPR, the health care delivery system includes but is not limited to hospitals, emergency
medical services, outpatient health care facilities, skilled nursing and long-term care
facilities, support service providers (such as clinical laboratories, pharmacies, and blood
banks), emergency management organizations, and local public safety agencies.
19ASPR, 2017-2022 Health Care Preparedness and Response Capabilities.
20The 62 jurisdictions consists of the 50 states, 8 territories and freely associated states,
and 4 cities.
21In addition, according to ASPR officials, in 2020, ASPR allocated other funding to further
bolster the COVID-19 health care response, including $175 million to hospital
associations, $6.5 million for Regional Ebola and other Special Pathogen Treatment
Centers, and $10 million for the National Emerging Special Pathogens Training and
Education Center.
Page 7 GAO-22-105461 Medical Surge Readiness
Letter
Figure 1: Hospital Preparedness Program (HPP) Cooperative Agreement Funding, by Source, Fiscal Years 2002 through 2023
Accessible Data Table for Figure 1
Fiscal year HPP annual cooperative agreement funding HPP supplemental Notes
funding
2002 0.13 0.00
2003 0.50 0.00
2004 0.50 0.00
2005 0.47 0.00
2006 0.46 0.00
2007 0.42 0.00
2008 0.40 0.08 H5N1 avian influenza
2009 0.36 0.00
2010 0.39 0.09 H1N1 pandemic influenza
2011 0.35 0.00
Page 8 GAO-22-105461 Medical Surge Readiness
Letter
Fiscal year HPP annual cooperative agreement funding HPP supplemental Notes
funding
2012 0.35 0.00
2013 0.33 0.00
2014 0.23 0.00
2015 0.23 0.16 Ebola
2016 0.23 0.00
2017 0.23 0.02 Ebola
2018 0.23 0.00
2019 0.23 0.00
2020 0.23 0.16 COVID-19
2021 0.23 0.00
2022 0.23 0.00
2023 0.24 0.00
Notes: Amounts for fiscal years 2002 through 2021 reflect total obligated amounts for the HPP
cooperative agreement. The amount shown for fiscal year 2022 reflects the allocated amount for the
HPP cooperative agreement; as of June 15, 2022, this amount had not yet been approved for
obligation. H5N1 avian influenza supplemental funding was awarded in fiscal year 2008 using
supplemental appropriations enacted in fiscal year 2006. H1N1 pandemic influenza supplemental
funding was awarded in fiscal year 2010 using supplemental appropriations enacted in fiscal year
2009. Ebola supplemental funding shown reflects funding from the HPP Ebola Preparedness and
Response Activities Part A cooperative agreement. In calendar year 2020, ASPR implemented
flexibilities for HPP cooperative agreement recipients to request use of Ebola funds, on a limited
case-by-case basis, for the development of action plans, training, and the rapid procurement of
supplies needed during the COVID-19 emergency response.
a
The amount shown for fiscal year 2023 reflects appropriations requested in the President’s fiscal
year 2023 budget.
Coalition Staffing and Membership
According to the fiscal year 2019-2023 HPP funding opportunity
announcement, coalitions must employ at least two staff members, a
coordinator and a clinical advisor.22 Specifically, the role of the
coordinator is to lead or support the activities of the coalition (including by
facilitating coalition planning, training, exercising, operational readiness,
and ongoing development), while the clinical advisor provides clinical
leadership and guidance to support the goals of the coalition. Coalition
activities include developing response plans and communication
protocols and systems, conducting joint planning exercises, and
educating and training health care personnel.
22These positions must add up to at least one full-time equivalent.
Page 9 GAO-22-105461 Medical Surge Readiness
Letter
Coalitions are required to include four core members that provide key
Medical Surge
Medical surge—the ability to evaluate and
support to the health care delivery system and play a critical role during
care for a markedly increased volume of emergencies and disasters: hospitals, emergency medical services,
patients that exceeds normal operating emergency management organizations, and public health agencies,
capacity—requires building both capacity and
capability, according to the Office of the according to ASPR.
Assistant Secretary for Preparedness and
Response, which defines each as follows.
Surge capacity: The ability to manage a ASPR’s Health Care Preparedness and Response
sudden influx of patients, and is dependent on
the variables of space, supplies, and staff,
Capabilities
among other things.
Surge capability: The ability to manage Although coalitions do not provide direct clinical care, they play a critical
patients requiring specialized medical care. role in developing the health care delivery system preparedness and
This includes providing services that are not
normally available at the location where they response capabilities needed for an effective medical surge response,
are needed (e.g., pediatric care provided at according to ASPR.
non-pediatric facilities or burn care services at
a non-burn center) and in response to
uncommon and resource-intensive patient To describe what the health care delivery system has to do to effectively
diagnoses to protect medical providers, other prepare for and respond to public health emergencies and disasters,
patients, and the integrity of the medical care
facility. ASPR issued its 2017-2022 Health Care Preparedness and Response
Source: Office of the Assistant Secretary for Preparedness Capabilities guidance (capabilities guidance), which identifies four key
and Response (information), Halfpoint/stock.adobe.com
(photo). | GAO-22-105461 health care preparedness and response capabilities (see table 1).23
23ASPR, 2017-2022 Health Care Preparedness and Response Capabilities. The intended
audience for the capabilities guidance is any health care delivery system organization,
health care coalition, or state or local agency that supports the provision of care during
emergencies, according to ASPR. This guidance is separate from the regional guidelines
that ASPR is required to publish under the PAHPAI Act.
Page 10 GAO-22-105461 Medical Surge Readiness
Letter
Table 1: The Four Key Health Care Preparedness and Response Capabilities, according to the Office of the Assistant
Secretary for Preparedness and Response (ASPR)
Capability Goal(s)
Foundation for health care The community’s health care organizations and other stakeholders have strong relationships, identify
and medical readiness hazards and risks, and prioritize and address gaps through planning, training, exercising, and managing
resources.
Such outcomes are facilitated by a sustainable health care coalition (coalition).a
Health care and medical With support from the coalition, the community’s health care organizations, their jurisdiction(s), and the
response coordination lead Emergency Support Function-8 agency plan and collaborate to share and analyze information,
manage and share resources, and coordinate strategies to deliver medical care to all populations during
emergencies and planned events.b
Continuity of health care With support from the coalition and the lead Emergency Support Function-8 agency, the community’s
service delivery health care organizations provide uninterrupted and optimal medical care to all populations in the face
of damaged or disabled health care infrastructure.
The community’s health care workers are well-trained, well-educated, and well-equipped to care for
patients during emergencies.
The community’s simultaneous response and recovery operations result in a return to normal, or ideally,
improved operations.
Medical surge The community’s health care organizations—including hospitals, emergency medical services, and out-
of-hospital providers—deliver timely and efficient care to their patients even when the demand for health
care services exceeds available supply.
In collaboration with the lead Emergency Support Function-8 agency, the coalition coordinates
information and available resources for its members to maintain conventional surge response.
In cases when an emergency overwhelms the coalition’s collective resources, the coalition supports the
health care delivery system’s transition to contingency and crisis surge response and promotes a timely
return to conventional standards of care as soon as possible.
Source: ASPR. | GAO-22-105461
Note: See Office of the Assistant Secretary for Preparedness and Response, 2017-2022 Health Care
Preparedness and Response Capabilities (Washington, D.C.: November 2016).
a
Health care coalitions are groups of individual health care and response organizations in a defined
geographic location, such as a state or an area within a state.
b
The lead Emergency Support Function-8 agency refers to the state or local agency that coordinates
with the federal government during emergencies and disasters for needed public health and medical
services as a part of the National Response Framework. ASPR is the lead federal entity for
Emergency Support Function-8 (public health and medical services).
Although the capabilities inform coalition activities, they are designed for
the entire health care delivery system. The capabilities encompass a
range of preparedness and response activities that, if conducted,
represent the ideal state of readiness in the United States, according to
ASPR. Further, these capabilities are intended to build upon each other
successively to establish a strong foundation for medical surge readiness.
Page 11 GAO-22-105461 Medical Surge Readiness
Letter
Hospital Medical Surge Challenges and
Coalition Support Responding to the COVID19
Pandemic
Medical Surge Challenges Selected Hospitals Faced
Responding to the COVID19 Pandemic
Officials we interviewed from all eight hospitals in our review, including
from three rural hospitals, described facing a number of medical surge
challenges during their COVID-19 responses, such as those related to
staffing, supplies, space, and information.24 They also described a range
of strategies they implemented to address these challenges as the virus
passed through communities of all sizes across the nation at various
times in waves, each lasting weeks or months and placing extraordinary
pressure on the health care system.
Prior to the pandemic, officials from all eight hospitals reported that they
experienced medical surges in the wake of events—such as shootings or
severe weather—or participated in emergency planning activities to
prepare them to implement an effective medical surge response to an
emergency or disaster. Examples of planning activities included exercises
or trainings to simulate actions hospitals would take in response to an
event or developing plans that described how hospitals would respond to
such an event. However, officials from multiple hospitals (six hospitals)
noted that prior exercises and events were insufficient to prepare them for
the realities of the response needed for the COVID-19 pandemic. For
example, based on trainings and exercises, one hospital official said they
anticipated that their hospital would be largely self-sufficient in an
emergency or disaster, but realized this was not the case when COVID-
19 hit their area, and they needed help. Officials from the selected
hospitals described the following challenges.
Staffing challenges. Officials we interviewed from all eight hospitals
indicated staffing was a challenge during the pandemic. Examples of
24The extent to which the challenges described were ongoing at the time of our interviews,
which were generally conducted between January and March 2022, varied by challenge
and hospital. For example, some of the challenges hospital officials described occurred
early on in the pandemic, or during the wave coinciding with the introduction of the Delta
variant.
Page 12 GAO-22-105461 Medical Surge Readiness
Letter
staff-related challenges included staffing shortages—such as those due
to resignations and illness—as well as staff burnout and low morale.
· Staffing shortages. Officials from multiple hospitals (five hospitals)
described how staffing shortages made it difficult for their hospitals to
continue to provide patient care and to respond to the pandemic. An
official from one hospital said, at one point during the Delta variant
wave, due to a combination of COVID-19 infections in the community
and among staff, their hospital did not have enough workers to be
able to operate all available beds.25 To address staffing shortages,
this official said their hospital requested and received nurses from the
federal government to supplement staffing levels.26 Officials from
other hospitals reported taking steps to increase their staffing levels,
for example, by hiring travel nurses from private staffing agencies,
expanding their hiring pool to include nurses with lower level
credentials than they would normally hire, or using existing staff in
different ways. For example, officials from one hospital reported
assigning staff from the radiology department to screen patients and
staff for COVID-19 infections. Hospital officials also reported
implementing strategies to prevent staff shortages due to illness; for
example, one hospital used telemedicine to provide patient care,
thereby reducing staff risk of infection while they continued to provide
patient care.
25According to the Centers for Disease Control and Prevention, Delta became the
dominant variant on June 1, 2021, and resulted in a wave of infections in summer 2021.
26During emergencies and disasters, states and other jurisdictions may request
assistance from the federal government as a part of the National Response Framework.
This framework is a guide for how the nation responds to emergencies and disasters and
includes emergency support functions, each of which covers an area of specific federal
resources and capabilities most frequently needed in a national response. Led by ASPR,
Emergency Support Function-8 covers public health and medical services, such as
medical staffing. For more information on the frameworks that form the basis of federal
incident response and crisis action plans, see GAO, Biodefense: After-Action Findings and
COVID-19 Response Revealed Opportunities to Strengthen Preparedness, GAO-21-513
(Washington, D.C.: Aug. 4, 2021).
Page 13 GAO-22-105461 Medical Surge Readiness
Letter
· Staff burnout and low morale. Officials from multiple hospitals (five
Personal Protective Equipment (PPE)
Training Videos hospitals) also discussed staff burnout and low morale among hospital
The correct use of PPE, such as gloves, staff. One hospital official said that staff were concerned about
respirators, and gowns, helps ensure an working in a hospital setting due to the increased risk of becoming
adequate amount of protection for the wearer
against disease transmission. To reduce the infected with COVID-19, while officials from another hospital said that
risk of COVID-19 infection among hospital the prolonged response to the pandemic was difficult and
staff, one hospital we interviewed developed overwhelming for staff. According to a National Academies of
and disseminated training videos on the
appropriate use of PPE. Science, Engineering, and Medicine report, health care worker
According to a hospital official, the training burnout can adversely affect patient care and safety, and can be
videos (1) helped hospital staff understand costly.27 To protect staff and increase staff feelings of personal safety,
how to use the specific types of PPE available
to them; (2) minimized the need for staff to one hospital official said their hospital provided PPE training for staff
meet as a group in person for training; and (3) and created a staff position dedicated to ensuring proper PPE use.28
enabled staff at area health care entities, such
as nursing homes, to receive training that
According to this hospital official, their hospital was able to avoid job-
otherwise may not have been available. related disease transmission by taking these steps.
See text box for prior GAO work addressing these staffing challenges
raised by hospitals.
Selected GAO Reports Related to Medical Surge Staffing Challenges
Since 2020, we have reported on challenges hospitals experienced during the COVID-
19 pandemic, including federal efforts to respond to them. These include the following
related to staffing:
· Behavioral health effects. In December 2021, we reported that health care workers
may be at higher risk of behavioral health effects related to the pandemic due to
factors such as fear of contracting COVID-19 or transmitting it to family members
Hospital staff demonstrating proper use of and burnout, among others. (GAO-22-104437)
PPE. · Federal medical personnel. We have reported on the support federal medical
Source: Centers for Disease Control and Prevention personnel provided to hospitals and other health care entities during the pandemic.
(information), one hospital in GAO’s sample (information and
photo). | GAO-22-105461 For example, in June 2020, we reported on the personnel that the Department of
Health and Human Services, the Department of Defense, the Federal Emergency
Management Agency, and the Department of Veterans Affairs deployed between
January and May 2020. (GAO-20-625)
For a list of our previous work, see the Related GAO Products page at the end of this
report.
Source: GAO. | GAO-22-105461
Supply challenges. Officials we interviewed from all eight hospitals
indicated their hospitals experienced supply challenges during the
27National Academies of Sciences, Engineering, and Medicine. Taking Action Against
Clinician Burnout: A Systems Approach to Professional Well-Being (Washington, DC: The
National Academies Press, 2019, accessed June 1, 2022, https://doi.org/10.17226/25521.
28PPE refers to safety products designed to help prevent the spread of infectious disease,
such as COVID-19. Examples of PPE include nitrile gloves, N95 respirators, and surgical
gowns, among others.
Page 14 GAO-22-105461 Medical Surge Readiness
Letter
pandemic. These supply-related challenges primarily included insufficient
Three-Dimensional (3D) Printing of Face
Shields amounts of supplies—such as PPE, therapeutics, ventilators, and testing
To ensure their hospital had an adequate materials—according to hospital officials. Hospital officials described
supply of personal protective equipment some of the effects these challenges had on their hospitals. For example,
(PPE) despite supply shortages, one hospital
official said that their hospital used its 3D print an official from one hospital said the shortage of testing supplies early in
technology to manufacture face shields for the pandemic hindered the ability to identify COVID-19 cases, and the
staff to use. Hospital officials said that
ultimately, they never needed to use the face
shortage of therapeutics later in the pandemic limited treatment options
shields because they never ran out of eye for patients. An official from another hospital said that shortages of PPE
protection. Face shields are a type of PPE undermined staff safety and confidence.
that cover the entire face, providing eye
protection against COVID-19 and preventing
N95 respirators from contamination, enabling Hospital officials also discussed the strategies their hospitals used in an
their reuse.
attempt to address supply challenges. For example, an official from one
hospital said their hospital made its own sanitizer with available materials
when it was in short supply, while an official from another hospital said
that their hospital decontaminated and reused PPE to increase its supply.
An official from another hospital said during the first COVID-19 wave,
their hospital did not have sufficient supplies to appropriately test the fit of
N95 respirators on staff. According to the Centers for Disease Control
and Prevention, N95 respirators must fit correctly on the wearer’s face to
ensure adequate protection against disease; verifying that the respirator
fits correctly is called fit testing.29 To address this challenge, the hospital
official told us they identified a local company able to design and
manufacture the product the hospital needed for fit testing. The company
was able to start producing the product for the hospital within 1 month.
See text box for prior GAO work addressing these supply challenges
raised by hospitals.
A 3D printed face shield. Selected GAO Reports Related to Medical Surge Supply Challenges
Source: One hospital in GAO’s sample (information and Since 2020, we have reported on challenges experienced during the COVID-19
photo), Armijo, P.R., N.W. Markin, S. Nguyen, D.H. Ho, T.S.
Horsemen, S.J. Lisco, and A.M. Schiller. “3D Printing of Face pandemic, including federal efforts to respond to them. These include the following
Shields to Meet the Immediate Need for PPE in an related to medical supplies:
Anesthesiology Department during the COVID-19 Pandemic.”
American Journal of Infection Control, vol. 49, no. 3
(2021):302-308, accessed June 9, 2022,
https://doi.org/110.1016/j.ajic.2020.07.037 (information). |
GAO-22-105461
29One method of fit testing involves wearing a hood that is enclosed around the head and
shoulders to test whether the wearer is able to detect solutions that are sprayed into the
hood while wearing the respirator. Department of Health and Human Services, Centers for
Disease Control and Prevention, National Institute for Occupational Safety and Health,
Hospital Respiratory Protection Program Toolkit: Resources for Respirator Program
Administrators, 2015-117 (Atlanta, GA: revised Apr. 2022), accessed June 9, 2022,
https://doi.org/10.26616/NIOSHPUB2015117revised042022.
Page 15 GAO-22-105461 Medical Surge Readiness
Letter
· Medical supply availability. In September 2020, we reported that the demands of
the COVID-19 pandemic overwhelmed the medical supply chain, causing
constraints in the availability of personal protective equipment (PPE) like N95
respirators and gloves, and supplies to test patients for COVID-19. We made three
recommendations to the Department of Health and Human Services to improve
their efforts to address supply chain challenges and will continue to monitor HHS
actions that could help to address them. (GAO-20-701). In March 2021, we
reported that hospital staff we surveyed were concerned about the availability of
vaccines, PPE, and testing supplies. (GAO-21-387) In April 2022, we reported that
HHS and its interagency partners were developing plans to implement the National
Strategy for a Resilient Public Health Supply Chain, and that the department
planned to publicly release an annual implementation progress report.
(GAO-22-105397)
For a list of our previous work, see the Related GAO Products page at the end of this
report.
Source: GAO. | GAO-22-105461
Space challenges. Officials we interviewed from multiple hospitals (six
hospitals) indicated that their hospitals experienced space-related
challenges during the pandemic. Examples of space-related challenges
included lack of available and appropriate spaces to care for patients—
such as beds for patients—as well difficulty transferring or discharging
patients to other facilities, according to hospital officials.
· Lack of available and appropriate spaces to care for patients.
According to officials from multiple hospitals (four hospitals), their
hospitals did not always have enough beds—including specific types
of beds, such as intensive care unit beds—to accommodate all
patients. Officials from multiple hospitals (four hospitals) said when
possible, they transferred patients they did not have the capacity or
capability to care for to other hospitals that had available beds within
or outside of their states. In some cases, hospital officials described
how their hospitals repurposed spaces inside and outside of their
buildings to accommodate additional patients.
Page 16 GAO-22-105461 Medical Surge Readiness
Letter
Creating COVID-19 Screening Space
For example, an official from one hospital said they created makeshift
Outdoors intensive care units so that they could have enough space to care for
During the COVID-19 pandemic, officials we additional patients. An official from another hospital said they created
interviewed from multiple hospitals (seven an outdoor respiratory clinic where they could test and treat milder
hospitals) described how their hospitals took
steps to increase the physical distance COVID-19 cases to reduce the number of patients entering the
between staff, patients, and visitors to reduce emergency department, so the emergency department could be
the chance of spreading COVID-19. In some
cases, this included moving hospital reserved for more serious cases. In other instances, officials from
operations outdoors so that fewer people three hospitals said their hospitals did not have sufficient negative
were indoors. To minimize the number of
people coming into the hospital’s building, one
pressure rooms, which control the air flow in a room to reduce the risk
hospital official said that their hospital added of patients transmitting infectious diseases to other areas of the
electricity and heaters to outdoor structures hospital. To address this challenge, one hospital official said they
typically used for hunting, known as deer
blinds or deer huts, and stationed them in created temporary walls and hospital units with negative pressure
front of the hospital. In the deer blinds, rooms, helping to prevent virus spread and accommodate additional
hospital staff screened patients for COVID-19
and prescribed medication.
COVID-19 patients.
· Difficulty discharging and transferring patients to other facilities.
Officials from multiple hospitals (five hospitals) reported that during
the pandemic, they had difficulty finding other facilities—such as
skilled nursing facilities or other hospitals—for patients they needed to
transfer or discharge to receive additional care. For example, as of
January 2022, an official from one hospital said all of the hospitals in
their area were full, so transferring was not an option for them at that
time. An official from another hospital said if skilled nursing facilities
Outdoor structures used by one hospital for
had a patient with COVID-19, they were unable to accept any new
COVID-19 screenings. patients for fear of the virus spreading to the new patient. According to
Source: One hospital in GAO’s sample (information and the official, this adversely affected the hospital’s ability to discharge
photo). | GAO-22-105461
patients who needed further care and therefore affected hospital
capacity and their ability to accept new patients.
To facilitate patient transfers, an official from one hospital said
throughout the pandemic, leaders from different hospitals met
regularly to coordinate patient transfers across facilities to help ensure
area hospitals would not become overwhelmed and could continue to
provide patient care. An official from another hospital said they
provided information to state and federal data systems to share
information about bed availability across facilities.
Information challenges. Officials we interviewed from multiple hospitals
(seven hospitals) reported experiencing information challenges during the
pandemic. Examples of information challenges included communications
with state and federal officials about PPE use and decontamination,
testing, and staff isolation periods; as well as challenges with data and
data systems on hospital bed availability and COVID-19 cases.
Page 17 GAO-22-105461 Medical Surge Readiness
Letter
· Communication. Officials from multiple hospitals (six hospitals) said
that, at times, communication from state and federal agencies to their
hospitals—including communication related to facility space, supplies,
or staff—was not consistent, useful, or timely enough to support their
COVID-19 responses. For example, one hospital official shared that
federal masking guidance was sometimes contradictory across
federal agencies, as well as potentially with state or local agencies,
forcing the hospital to choose which guidance to follow. In addition,
another official from the same hospital stated that, initially during the
pandemic, PPE guidance from the Centers for Disease Control and
Prevention changed frequently and generated confusion and concern
among hospital staff, specifically around the use of N95 respirators
and alternatives, such as surgical masks, given supply challenges.30
Similarly, an official from another hospital said the rapid pace of
changes in the federal government’s PPE guidance during the
pandemic made it difficult for health care workers to keep their
knowledge current and adversely affected staff confidence. Finally, an
official from another hospital said they lacked sufficient guidance
about where to send COVID-19 tests or how to decontaminate N95
respirators when they were in short supply. See text box for examples
of other GAO work raising communication challenges during the
COVID-19 pandemic response.
30In commenting on a draft of this report, the Centers for Disease Control and Prevention
stated that its guidance for the care of patients with COVID-19 infection always included
an N95 respirator and, early in the pandemic, included the use of masks and other
alternatives only when supplies of N95 respirators were insufficient. The agency also
stated that it adjusted health care-specific guidance during the pandemic generally
infrequently (e.g., every 3 months) based on the evolving knowledge of the virus and its
transmission, and other factors.
Page 18 GAO-22-105461 Medical Surge Readiness
Letter
Selected GAO Reports Related to Communication Challenges
Since 2020, we have reported on challenges experienced during the COVID-19
pandemic, including federal efforts to respond to them. These include those related to
communication and COVID-19 testing:
· COVID-19 Testing. In November 2020, we reported that COVID-19 testing
guidelines changed several times over the pandemic with little scientific
explanation of the rationale behind the changes, confusing providers implementing
the guidelines and risking the erosion of trust in the federal government. We made
one recommendation to the Department of Health and Human Services to disclose
the scientific reasoning behind changes in guidance. As of June 2022, the
department’s efforts to address this recommendation were ongoing. (GAO-21-191)
In January 2021, we reported that the Department of Health and Human Services
had not issued a comprehensive and publicly available national testing strategy,
creating the risk of partners and the public lacking crucial information to support an
informed and coordinated testing response. We made one recommendation that
remained open as of June 2022. (GAO-21-265)
For a list of our previous work, see the Related GAO Products page at the end of this
report.
Source: GAO. | GAO-22-105461
Officials from multiple hospitals (six hospitals) also discussed
strategies they implemented to facilitate communication to ensure
hospital staff had the information they needed. For example, one
hospital official said they held meetings with groups of stakeholders to
help make decisions about infection control procedures, which the
group then relayed to hospital infection control staff to convey to front
line hospital staff. An official from another hospital said their hospital
placed quick response (QR) codes—barcodes that when scanned
with a smartphone display information—on hospital walls that showed
real-time information on PPE guidance, treatment protocols, and
COVID-19 testing to keep health care workers up to date on the latest
information and guidance.
· Data. State and federal data systems and data collection efforts were
designed, in part, to help address hospital medical surge challenges—
for example, by providing information on hospital space, staff, and
supplies—but officials from multiple hospitals (five hospitals) said that
issues with state or federal data systems created challenges for their
hospitals. For example:
· According to officials from multiple hospitals (three hospitals), it
was burdensome to enter data into multiple systems. Specifically,
these officials told us that states had their own data systems into
which hospitals reported information about their status during the
pandemic. These hospitals, however, also had to input data into
HHS Protect, a new federal data system created in April 2020 to
Page 19 GAO-22-105461 Medical Surge Readiness
Letter
capture information on hospital capacity and resource shortages.31
Officials from one hospital emphasized that it took a significant
amount of resources to enter data into both state and federal data
systems, particularly because these systems have different
reporting requirements. According to officials from multiple
hospitals (two hospitals), their states eventually streamlined their
data collection processes so that hospitals only had to enter data
into a single state data system, which officials said reduced the
burden for hospitals.
· According to officials from multiple hospitals (two hospitals), the
data that hospitals were required to report were not always useful
for clinical and logistical considerations. For example, one hospital
official said their hospital was required to report to HHS Protect
the locations within their facility where the hospital could
accommodate additional beds, even though the hospital was likely
unable to support those beds due to insufficient staff and other
resources. Similarly, an official from another hospital said HHS
Protect did not include the information necessary to make
decisions regarding patient transfers, as the data on hospital bed
availability was not available on HHS Protect in real time.
Although HHS Protect collected information on available inpatient
and intensive care unit beds, hospital officials said it was still
necessary to communicate with clinical and operational staff at the
hospitals with capacity in order to ensure that the hospital could
accept the patient. See text box for prior GAO work addressing
these data challenges raised by hospitals.
31According to ASPR, HHS Protect is a data system that serves as a hub for data analysis
and visualization across multiple datasets. Hospitals are able to report their COVID-19
information to HHS Protect through several methods, including states or state hospital
associations reporting information to HHS on their behalf. In September 2020, the Centers
for Medicare & Medicaid Services began requiring hospitals that participate in the
Medicare and Medicaid programs to report COVID-19 information in accordance with the
frequency and format specified by the agency. 42 C.F.R. § 482.42(e) (2021). This
requirement is in effect for the duration of the COVID-19 public health emergency.
Page 20 GAO-22-105461 Medical Surge Readiness
Letter
Selected GAO reports related to data challenges during the COVID-19 pandemic
Since 2020, we have reported on challenges hospitals experienced during the COVID-
19 pandemic, including federal efforts to respond to them. These include the following
related to data challenges:
· Hospital capacity data. In August 2021, we reported that the reporting
requirements for HHS Protect—developed to capture data from hospitals on
COVID-19 cases, bed availability, supplies, and COVID-19 treatments—created
challenges for hospitals and that public health stakeholders, and some states
relied on state and local data to inform their COVID-19 responses, rather than data
from HHS Protect. According to the Department of Health and Human Services,
because the system was developed in real-time to respond to the pandemic, it
required iterative development over time. The department planned to re-evaluate
the data being collected and streamline reporting requirements. (GAO-21-600)
Source: GAO. | GAO-22-105461
According to ASPR’s capabilities guidance, having and using a
coordinated approach for sharing information and data among response
partners during a medical surge response is necessary.32 We added
HHS’s leadership and coordination of public health emergencies to our
high-risk list in January 2022 in part due to deficiencies related to
communication, data, and data systems during the COVID-19 pandemic
and other public health emergencies.33
Challenges for rural hospitals. In addition to facing similar challenges
experienced by other hospitals during the pandemic, the three rural
hospitals in our review encountered additional challenges due to their
location and more limited availability of services, according to hospital
officials.34
For example, according to hospital officials, fewer beds and specialty
services limited their ability to provide care to COVID-19 patients. As a
result, officials from rural hospitals said they had to identify other hospitals
with the available space and services that could provide the level of care
that patients needed. According to an official from one rural hospital, the
nearest hospitals that could provide a more complex level of care, such
32ASPR, 2017-2022 Health Care Preparedness and Response Capabilities.
33Specifically, as we reported in January 2022, our prior work identified persistent
deficiencies in several areas, including providing clear and consistent communication to
key partners and the public and collecting and analyzing complete and consistent data to
inform decision-making. See GAO, COVID-19: Significant Improvements Are Needed for
Overseeing Relief Funds and Leading Responses to Public Health Emergencies,
GAO-22-105291 (Washington, D.C.: Jan. 27, 2022).
34According to ASPR and officials from one coalition, critical access hospitals experienced
challenges similar to those reported here, including difficulty transferring patients to other
facilities to obtain a more complex level of care.
Page 21 GAO-22-105461 Medical Surge Readiness
Letter
as more intensive respiratory services, were 150 miles away. This meant
they typically needed to transfer patients by air. An official from another
rural hospital said that in some cases, they sent patients to other states.
Transferring patients over great distances was logistically challenging and
did not always align with the preferences of patients or their families. For
example, officials from one rural hospital said they needed to assess
whether there was sufficient oxygen to make the longer trips and in some
cases, longer transfer times resulted in emergency transport systems
being unavailable in the community for longer periods of time. Further,
officials from one coalition said some emergency medical services units
did not have proper PPE to transfer COVID-19 patients over such long
distances. An official from another rural hospital said it was costly to
transfer patients over long distances, and when it was time to transfer
patients back to their communities, many patients did not have the
resources or stamina for the return trips.
Rural hospitals also faced greater challenges obtaining supplies
compared to other hospitals, according to officials we interviewed from a
national hospital association. For example, these officials said rural
hospitals that did not already have relationships with group purchasing
organizations could not obtain any supplies from them, and obtaining
supplies was a particular problem for smaller and rural hospitals. Group
purchasing organizations support the purchasing of medical supplies and
equipment on behalf of groups of providers.35
It is important to note that some of the challenges rural hospitals faced
during the pandemic were pre-existing.36 Officials from hospitals and
coalitions operating in rural areas described the scarcity of care and staff
in their areas. For example, officials from one rural hospital said that it is
the only hospital that delivers babies for many miles, and due to limited
staff, it was difficult to medically surge in response to increased demand
for hospital services even before the pandemic. Similarly, officials from
one coalition that operates in rural areas said that in the coalition’s 22
35For more information on group purchasing organizations, see GAO, Group Purchasing
Organizations: Funding Structure Has Potential Implications for Medicare Costs,
GAO-15-13 (Washington, D.C.: Oct. 24, 2014).
36In December 2020, we reported on some of the challenges facing rural health care
unrelated to the COVID-19 pandemic, noting that residents in areas affected by rural
hospital closures had to travel substantially farther to access certain health services. We
also found that the availability of health care providers in counties with rural hospital
closures generally was lower and declined more over time, compared to those without
closures. GAO, Rural Hospital Closures: Affected Residents Had Reduced Access to
Health Care Services, GAO-21-93 (Washington, D.C.: Dec. 22, 2020).
Page 22 GAO-22-105461 Medical Surge Readiness
Letter
county coverage area, there are only two acute care hospitals, which may
not always have the capacity to receive patient transfers. Officials from
another coalition that operates in a rural area shared that the pandemic
exacerbated health care staffing issues that existed prior to the pandemic,
in particular, for nurses.
Coalition Support for Hospital Medical Surge Challenges
Responding to the COVID19 Pandemic
Officials we interviewed from all eight coalitions in our review described
performing one or more response activities during the COVID-19
pandemic to support hospitals, including to address the medical surge
challenges noted above. These coalition activities varied from coalitions
offering a variety of support to one coalition being inactive during the
COVID-19 response at the time of this report.37 See table 2 for examples
of how coalitions sought to address hospital challenges and the variation
in coalition activities in each of these areas.
Table 2: Examples of Strategies Used by Health Care Coalitions to Address Hospital Challenges during the COVID-19
Pandemic
Type of hospital
challenge Strategies used by health care coalitions to support hospitals
Staffing · Shared information with area hospitals on staffing-related best practices and lessons learned from other
hospitals, such as information on splitting shifts between staff so that hospitals could use their existing
staff efficiently
· Reported to the state information about hospital staffing challenges; according to health care coalition
officials, this led to state activation of a staffing center, which provided additional staffing to hospitals
Supply · Compiled hospital resource requests and passed them to the state to be filled
· Created a health care coalition-level personal protective equipment (PPE) cache that contained different
types of PPE for use by hospitals and other partners
· Purchased specific supplies that hospitals needed, including powered air purifying respirators
Space · Organized the logistics for regular conference calls among area hospitals to address a lack of appropriate
spaces to care for patients so hospital staff could discuss patient transfers
· Contacted other hospitals in the region to try to find beds for patients, upon receiving word from hospitals
that they were unable to place patients in their facilities or health systems
· Used hospital bed availability data from the state data system to help to identify appropriate places to
transfer COVID-19 and non-COVID-19 patients
37ASPR officials told us they learned of the one coalition’s inactive status through ASPR
staff responsible for liaising with the coalition’s state public health department. ASPR
officials said that this coalition did not receive HPP funding while it was inactive. According
to ASPR officials, in response to several issues with this HPP funding recipient, ASPR
instituted funding restrictions.
Page 23 GAO-22-105461 Medical Surge Readiness
Letter
Type of hospital
challenge Strategies used by health care coalitions to support hospitals
Information · Participated in state medical emergency operations center meetings and statewide COVID-19 briefings,
enabling the health care coalition to share reliable information with hospitals
· Developed and disseminated reports on hospital capacity to all local hospitals and emergency medical
services to facilitate communication
· Trained hospitals on the state’s data system to support hospital reporting efforts
· Relayed partners’ questions about using the state’s data system to the state and sent answers back to
partners
Source: GAO interviews with a nongeneralizable sample of health care coalitions. | GAO-22-105461
Notes: This table is not exhaustive of all challenges and strategies reported by hospital and health
care coalition officials.
Page 24 GAO-22-105461 Medical Surge Readiness
Letter
Some of our findings on coalition activities during the COVID-19
Health Care Coalition Engagement in
COVID-19 Assessment (Coalition pandemic are consistent with information ASPR shared with us, as well
Engagement Report) as findings from a coalition engagement report produced by the ASPR
The Office of the Assistant Secretary for Technical Resources, Assistance Center, and Information Exchange’s
Preparedness and Response (ASPR)
Technical Resources, Assistance Center, and
coalition engagement report.38 For instance, in that report, ASPR reported
Information Exchange conducted a study to that coalitions identified information sharing as their most important
assess health care coalition engagement in
response activities during the COVID-19
activity during the pandemic, and that many coalitions helped members to
pandemic. access supplies during the pandemic, such as by maintaining caches of
Issued in December 2021, the goal of the supplies or serving as the main point of contact for resource requests.
study was to examine health care coalition ASPR’s report also found that coalitions had varying levels of involvement
success stories and provide information about
opportunities to help health care coalitions in transferring patients across facilities.
build their preparedness for future emergency
events.
The study analyzed information from a survey
of ASPR field project officers and 186 health
care coalitions, a literature review, and focus
groups with 29 health care coalitions.
Source: ASPR Technical Resources, Assistance Center, and
Information Exchange, Health Care Coalition Engagement in
COVID-19 Assessment (Washington, D.C.: December 2021).
| GAO-22-105461
38ASPR Technical Resources, Assistance Center, and Information Exchange, Healthcare
Coalition Assessment.
Page 25 GAO-22-105461 Medical Surge Readiness
Letter
ASPR’s Ongoing Hospital Preparedness
Program and Other Efforts to Support Medical
Surge Readiness
Efforts and Considerations to Enhance Coalition
Capabilities to Support Medical Surge Readiness
To support medical surge readiness, ASPR has multiple ongoing efforts
to assist coalitions funded through HPP, including considering potential
changes and updates to the capabilities guidance, according to our
review of ASPR documents and interviews with ASPR officials. Efforts to
support medical surge readiness have included the following.
Providing guidance and technical assistance to coalitions. In addition
to providing funding for health care preparedness and response, ASPR
offers guidance and technical assistance to help coalitions, hospitals and
others to understand the capabilities necessary to effectively prepare for
and respond to emergencies. According to ASPR, this assistance is
offered through regionally based field project officers and its Technical
Resources, Assistance Center, and Information Exchange. According to
ASPR’s website, the ASPR Technical Resources, Assistance Center, and
Information Exchange was created to meet the information and technical
assistance needs of regional ASPR staff, health care coalitions, and
others working in disaster medicine, health care system preparedness,
and public health emergency preparedness. According to ASPR officials,
as of December 2021, ASPR had responded to nearly 3,000 requests for
technical assistance through this resource, 700 of which were specifically
related to the COVID-19 pandemic. This COVID-19 technical assistance
included developing resources related to medical surge strategies, such
as the following:
· Medical surge management, including information and
recommendations to hospitals on increasing their capacity. ASPR
collected resources focused on increasing hospital capacity,
conducted and examined several case studies of hospitals that were
treating severe cases of COVID-19 to identify best practices, and
shared the findings on the ASPR Technical Resources, Assistance
Center, and Information Exchange website, for reference by
coalitions, hospitals, and other stakeholders. For example, it found
that one hospital examined in these case studies developed ways to
Page 26 GAO-22-105461 Medical Surge Readiness
Letter
increase the number of isolation rooms by reconfiguring treatment
spaces and updating ventilation systems.
· Clinical resources for physicians. The ASPR Technical Resources,
Assistance Center, and Information Exchange identified clinical
resources to assist physicians with medical surge response, such as
example policies for documenting patient care during a crisis—called
crisis charting—and information on the conditions of individuals
experiencing the long-term effects from COVID-19 infection. For
example, the use of crisis charting can reduce the amount of
information clinicians are required to enter into a patient’s record
during medical surge periods, according to ASPR Technical
Resources, Assistance Center, and Information Exchange
documentation. This, in turn, decreases the amount of time spent
recording patient information and increases the amount of time
available for patient care. According to ASPR documentation, a
provider of health care services viewed these options as a way to
mitigate the effects of a medical surge and avoid invoking crisis
standards of care.39 According to ASPR Technical Resource,
Assistance Center, and Information Exchange officials, the use of
crisis standards of care place patients at substantial risk of a poor
outcome. Thus, ideally, medical surge is managed in a way that
prevents the need to invoke them.
· Templates for COVID-19 treatment protocols. The ASPR Technical
Resources, Assistance Center, and Information Exchange provided
templates for physicians’ standing orders (i.e., written protocols that
allow a health care team to complete certain clinical tasks without
having to obtain a physician’s direct instruction) for administering
monoclonal antibodies to COVID-19 patients. Use of such orders may
allow clinicians to have more time to focus on providing more complex
care, according to one national physician organization.
Implementing a new medical surge exercise. In 2021, ASPR replaced
its previously required HPP annual exercise for coalitions with a new
exercise, known as the Medical Response & Surge Exercise, in an effort
to further support medical surge readiness. The objective of the new
exercise remains the same as the previous one—that is, to test each
coalition’s ability to assist in a medical surge event and identify gaps in
surge planning. ASPR officials told us they developed the Medical
39The National Academy of Medicine defines crisis standards of care as a substantial
change in the usual health care operations and the level of care delivered due to a
pervasive or catastrophic disaster. In such situations, the number of patients needing care
is more than the amount of resources available.
Page 27 GAO-22-105461 Medical Surge Readiness
Letter
Response & Surge Exercise in response to feedback that the previous
exercise was not flexible enough to respond to different types of possible
events, such as the COVID-19 pandemic. For example, according to
ASPR,
Importance of Preparedness and Response · The prior exercise simulated an evacuation involving at least 20
Exercising percent of a coalition’s bed capacity through hospitals or other patient
care facilities. In contrast, the new exercise allows coalitions to define
and exercise disaster and emergency scenarios that are typical of
their geographic area in order to test their ability to respond to events
beyond evacuation simulations, assess their specific needs in relation
to these events, and identify gaps in resources and personnel.
· The prior exercise was designed to test coalitions’ ability to respond to
an incident (e.g., transportation accidents or bombings) without prior
notice. In contrast, the new exercise removes the no-notice nature of
the prior exercise. According to ASPR officials, this change was made
Photo of Georgia’s emergency personnel to allow coalitions to tailor the exercise to their specific situation and to
conducting a statewide exercise.
increase participation in the exercise among coalition members;
According to the Department of Homeland
Security, exercises are the best way to however, ASPR does recommend that coalitions provide little or no
prepare teams to respond effectively to an notice of the exercise to their members to more closely mimic real-
emergency. Exercises enhance knowledge of
plans, allow members to improve their own
world situations.
performance, and identify opportunities to
improve capabilities to respond to real events.
ASPR officials stated that they will establish targets to measure whether
Therefore, exercises are important for coalitions are meeting expectations for the Medical Response & Surge
evaluating a preparedness program, testing or Exercise once 3 years of performance data from the exercise are
validating recently changed procedures or
plans, assessing the capabilities of existing available.
resources and identifying needed resources,
and increasing awareness and understanding
of hazards and their potential effect, among Updating existing capabilities guidance. To further assist with medical
other things. In August 2021, GAO reported on surge readiness, ASPR officials stated the office is working to update
exercise development and conduct among ASPR’s existing capabilities guidance.40 As previously noted, the
federal agencies. For more information and to
see GAO’s recommendations in this area, capabilities guidance informs coalition activities, but it is designed for the
please see GAO-21-513. entire health care delivery system. As a result, in updating the guidance,
Source: Department of Homeland Security,
http://www.ready.gov/exercises (information); GAO, ASPR officials said they will request feedback from different types of
Biodefence: After-Action Findings and COVID-19 Response
Revealed Opportunities to Strengthen Preparedness, stakeholders. These stakeholders include frontline health care providers,
GAO-21-513 (Washington, D.C.: Aug. 4, 2021) (information);
Centers for Disease Control and Prevention (photo). |
state and local government agencies, coalitions, and other ASPR
GAO-22-105461 programs and leadership, among others. ASPR officials said that their
preliminary areas of focus for the updates include the following.
40The current capabilities guidance reflects the project period of 2017 through 2022. See
ASPR, 2017-2022 Health Care Preparedness and Response Capabilities.
Page 28 GAO-22-105461 Medical Surge Readiness
Letter
· Increased focus on deliberate engagement of and planning for at-risk
groups to ensure preparedness and response functions do not
exacerbate health care inequities.41 According to ASPR, disasters and
emergencies such as the COVID-19 pandemic have affected
communities of color and underserved populations especially hard.
Therefore, understanding the complex relationships that affect fair
access to health care during emergencies may be beneficial to health
care professionals.
· Expanded guidance around critical aspects of medical response
efforts. This includes guidance related to hospital load balancing and
the use of medical operations coordination centers. According to
ASPR documentation, medical operations coordination centers are
groups of stakeholders—including health care facilities and
emergency medical services, and governmental partners—utilized
during the COVID-19 pandemic to facilitate patient movement, health
care staffing, and resource allocation within a jurisdiction.
· Expanded guidance around preparing for and carrying out different
types of medical surges. This can include guidance for medical surges
involving pediatric populations, as well as for events with long-term
consequences, known as prolonged surge response, according to
ASPR documentation. Expanding guidance around pediatric surges is
necessary because children have unique physical and behavioral
characteristics that make them particularly vulnerable to disasters and
emergencies, according to ASPR documentation. ASPR officials
stated that planning for prolonged surge responses should account for
factors such as staff burnout and illness, including mental health
concerns.
ASPR officials said the next update of the capabilities guidance will
address insights from the COVID-19 pandemic, but it will maintain its all-
hazard focus, encompassing other types of emergencies and disasters
that can result in medical surge.42 ASPR officials said they anticipate the
new capabilities guidance will be updated prior to the release of the notice
41Preparedness and response functions refer to the emergency support functions used to
manage any type of disaster or emergency response under the National Response
Framework.
42We previously recommended that HHS, in coordination with its federal and nonfederal
partners, define the set of capabilities—separate from those outlined in ASPR’s
capabilities guidance—needed to prepare for and respond to nationally significant, whole-
of-nation biological incidents like the COVID-19 pandemic. HHS agreed with the
recommendation and the department’s efforts to address this recommendation are
ongoing. For more details, see GAO-21-513.
Page 29 GAO-22-105461 Medical Surge Readiness
Letter
of funding opportunity for the next 5-year HPP project period, which
begins in fiscal year 2024.
Developing additional support for coalitions. ASPR is considering
developing additional support for coalitions based upon information the
office gathered from its 2021 coalition engagement report.43 As previously
noted, in this report, the ASPR Technical Resources, Assistance Center,
and Information Exchange collected information from coalitions on their
experiences during the first 2 years of the COVID-19 pandemic. Table 3
provides examples of issue areas in which ASPR is considering
developing further guidance or other resources for coalitions, as identified
by ASPR in the report.
Table 3: Potential Areas of Additional Support for Health Care Coalitions, as Identified by the Office of the Assistant Secretary
for Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange
Potential area Description
Crisis standards of care ASPR reported that the office could provide additional guidance on how health care coalitions
(coalitions) could support provider decision-making during times when crisis standards of care
are in use. Crisis standards of care are designed to achieve the best outcome for a group of
patients rather than focusing on an individual patient when there is a medical surge.a This can
mean, for example, allocating scarce resources to those patients who are most likely to benefit
from their use.
Coalition members took a variety of steps to mitigate the need for large-scale use of crisis
standards of care during the COVID-19 pandemic, ASPR reported. For example, coalitions
reported that their members used strategies to preserve personal protective equipment (PPE),
physically alter facility space, and modify staff ratios and roles, thus allowing them to maintain
standard care practices by preventing shortages in health care resources. As a result, many
coalitions told ASPR they were revisiting their crisis standards of care planning activities, and
were looking for guidance and frameworks from ASPR with which they can align their plans.
Medical operations coordination ASPR reported that the office could provide additional guidance to coalitions to better unify how
centers medical operations coordination centers may be used in future emergencies.
Use of medical operations coordination centers—emergency operation centers that help
coordinate medical responses—were a key success in many coalition jurisdictions, ASPR
reported. These coordination centers helped regions avoid invoking crisis standards of care.
However, the models used by regions were diverse.b
43ASPR Technical Resources, Assistance Center, and Information Exchange, Healthcare
Coalition Assessment.
Page 30 GAO-22-105461 Medical Surge Readiness
Letter
Potential area Description
Response roles for rural and urban ASPR reported that the office could better define urban versus rural expectations for response
health care coalitions roles.
Coalitions serving rural areas had fewer personnel and resources but played a crucial role in
helping to maintain staffing, share information, and provide and distribute PPE and other
supplies to their health care facilities and community partners, ASPR reported. According to
ASPR officials, coalition goals in rural areas are often very different than those in urban and
suburban areas. For example, rural communities do not have the ability to expand critical care
space and exercise in the same way as urban communities. ASPR officials also stated that rural
facilities and emergency medical services are particularly challenged by staffing issues in ways
that urban facilities are not.
Source: ASPR Technical Resources, Assistance Center, and Information Exchange, Health Care Coalition Engagement During COVID-19 Assessment (December 2021) and ASPR officials. |
GAO-22-105461
a
The National Academy of Medicine defines crisis standards of care as a substantial change in the
usual health care operations and the level of care delivered due to a pervasive or catastrophic
disaster. In such situations, the number of patients needing care is more than the amount of
resources available.
b
A group of hospitals working together to transfer patients across the health care system may be
considered an example of a medical operation coordination center, which refers to a type of
emergency operation center focused on the medical response. According to ASPR guidance on
establishing and implementing medical operation coordination centers, these coordination centers
helped facilitate patient transfers, among other medical response activities, during the COVID-19
response.
ASPR officials said the office continues to gather necessary information
to determine how it will incorporate this information and any other lessons
learned from the COVID-19 pandemic into future guidance and other
resources for coalitions. Officials said they have not yet determined
whether any program changes made based upon these areas of
opportunity would be reflected in the update of the existing capabilities
guidance or influence program expectations in the HPP project period
starting in 2024.
Regional Efforts for Promoting Medical Surge Readiness
As part of its ongoing efforts to promote medical surge readiness, ASPR
is currently involved in funding projects or developing guidelines that will
promote regional preparedness and response capabilities across
coalitions and states. These efforts include ASPR’s ongoing funding of
demonstration project sites in four regions, as well as its effort to develop
a set of regional guidelines in response to the PAHPAI Act. The
demonstration sites ASPR is funding are pilots to test and evaluate new
approaches to multi-state medical surge readiness.
Regional Demonstration Project Sites
To help develop effective approaches to medical surge readiness across
multiple states, ASPR has four regional demonstration project sites in
Page 31 GAO-22-105461 Medical Surge Readiness
Letter
place. (See fig. 2.) According to ASPR, the goals of the Regional Disaster
Health Response System demonstration project are to test new
approaches, establish regional partnerships to improve disaster readiness
capabilities and capacity, increase medical surge capacity, enhance
situational awareness, and extend the provision of specialty care. ASPR
officials added that the demonstration sites are helping to provide
technical assistance in a variety of areas, including related to the
promotion and sharing of strategic medical intelligence, clinical expertise,
and complex medical management, which have not as of yet been well
addressed.
Page 32 GAO-22-105461 Medical Surge Readiness
Letter
Figure 2: Map of the Office of the Assistant Secretary for Preparedness and Response’s (ASPR) Regional Health Disaster
Response System Demonstration Project Sites in Four Department of Health and Human Services (HHS) Regions, and
Number of Health Care Coalitions in Those Regions
Notes: The Regional Disaster Health Response System demonstration project is funded through
ASPR. According to ASPR, the goal of the Regional Disaster Health Response System
demonstration project is to test new approaches, establish regional partnerships to improve disaster
readiness capabilities and capacity, increase medical surge capacity, enhance situational awareness,
and extend the provision of specialty care. For example, according to ASPR documentation,
demonstration sites should work to coordinate coalitions within their state and across states in their
HHS region, among other things. Health care coalitions are groups of health care and response
organizations in a defined geographic location that coordinate emergency preparedness and
response activities across their members. The numbers of health care coalitions shown within each
Page 33 GAO-22-105461 Medical Surge Readiness
Letter
HHS region include coalitions located in United States territories and major metropolitan areas, which
are not depicted in this graphic due to spatial limitations. Health care coalition data were obtained
from ASPR’s website in May 2022 and are based on June 2020 data.
Additionally, according to ASPR documentation, demonstration sites
should work to coordinate coalitions within their state and across states in
their HHS region, among other things. For example, the Region 1
Regional Disaster Health Response System demonstration site, led by
Massachusetts General Hospital in Boston, is developing a disaster
telemedicine system to connect clinicians across the region to relevant
specialty care, such as trauma, burn, or pediatric care. According to
ASPR documentation, some coalition jurisdictions do not have such
specialty care in non-emergency times; and during disasters and
emergencies, access to such specialty care may become more
challenging given the large number of patients that may require services.
See table 4 for examples of other efforts as well as the funding history of
these demonstration sites.
Table 4: Examples of Ongoing Efforts by Three Office of the Assistant Secretary for Preparedness and Response (ASPR)
Regional Disaster Health Response Health System Demonstration Project Sites and Funding History
Demonstration site
(Regional Disaster Health
Response System funding Funding history
recipient) (fiscal years) Examples of efforts
Region 1 Regional Disaster 2018: $3 million · Developing a disaster telemedicine system capable of providing peer-to-
Health Response System 2019: $1.5 million peer clinical consultation in real time, from disaster subject matter
(Massachusetts General experts to front-line clinicians anywhere in the region for burn, trauma,
2020: $1.6 million pediatric, and other disaster medical care.
Hospital)
2021: $1.5 million · Developing and supporting state-level deployable disaster medical
teams that can be utilized at the request of a state to augment local
response.
· Developing a system to mobilize health care subject matter experts and
a novel electronic platform to support public health authorities during
large-scale patient movement events, such as no-notice mass casualty
incidents, hospital evacuations, and capacity crises to identify and utilize
all available health care capacity in the region.
· Identifying and addressing legal barriers to effective cross-jurisdictional
disaster response, such as sharing patient care and providing
telemedicine across state lines.
Region VII Regional Disaster 2018: $3 million · Developing specialized teams to respond to radiation and chemical
Health Response Ecosystem 2019: $1.5 million incidents.
(University of Nebraska Medical 2020: $1.5 million · Improving data use, data sharing, and interoperability across the state
Center) and region.
2021: $1.5 million
· Developing regional resources, such as (a) calculators to project needed
pharmaceutical and burn supplies, and (b) a cybersecurity manual that
describes health care facility responsibilities in the event of an attack on
the electronic health record system or other technology, which has the
potential to affect patient care.
Page 34 GAO-22-105461 Medical Surge Readiness
Letter
Demonstration site
(Regional Disaster Health
Response System funding Funding history
recipient) (fiscal years) Examples of efforts
Mountain Plains Regional 2020: $3 million · Building upon the successes of a Colorado state medical operations
Disaster Health Response 2021: $1.5 million coordination center and expanding that model to the region.
System · Working to enhance capabilities of health care coalitions and to better
(Denver Health & Hospital integrate them at the state and regional levels, including providing
Authority) resources such as guides and trainings.a
· Developing subject matter expert advisory group guides to demonstrate
to other states how to convene a subject matter expert advisory group
with core members and incident specific members.
Source: GAO interviews with Regional Disaster Health Response System demonstration site officials, Regional Disaster Health Response System demonstration sites progress reports, and ASPR
documentation. | GAO-22-105461
Notes: The Regional Disaster Health Response System demonstration project is funded through
ASPR. According to ASPR, the goal of the Regional Disaster Health Response System
demonstration project is to test new approaches, establish regional partnerships to improve disaster
readiness capabilities and capacity, increase medical surge capacity, enhance situational awareness,
and extend the provision of specialty care. For example, according to ASPR documentation,
demonstration sites should work to coordinate coalitions within their state and across states in their
Department of Health and Human Services region, among other things.
a
Health care coalitions are groups of health care and response organizations in a defined geographic
location that coordinate emergency preparedness and response activities across their members.
In addition to these individual efforts, the demonstration sites included in
our sample are also working jointly to develop performance metrics,
according to interviews we conducted with officials at these three sites.
The purpose of these metrics is to measure demonstration sites’ core
functions and contributions to regional preparedness and response
capabilities and actions to address a medical surge, according to officials
from one of the demonstration sites we interviewed. Additionally, these
metrics could help to evaluate a region’s performance and allow for
assessments, monitoring, and readiness designations, among other
things, according to ASPR documentation. ASPR officials said that once
these metrics have been developed, ASPR will review them and consider
any appropriate next steps for their potential use, such as incorporating
the metrics into HPP.
According to ASPR officials, the Regional Disaster Health Response
System demonstration sites have been successful in bringing coalitions
and state partners together to facilitate regional planning and coordination
efforts. Bringing these partners together can help develop or strengthen
medical surge readiness, including strengthening the connections
between the health care delivery system that treats patients and state and
local governments that provide administrative services, according to
ASPR documentation. For example, according to officials from one
demonstration site we interviewed, the site was able to connect with other
hospitals and stakeholders across the region, including helping to
Page 35 GAO-22-105461 Medical Surge Readiness
Letter
address medical supply issues, establish protocols, and provide subject
matter expertise, among other things. According to these same officials,
the demonstration site provided assistance, such as supporting patient
transfer and load balancing across hospitals. Further, one demonstration
site’s officials explained that early in the pandemic they began convening
meetings every 2 weeks with federal partners and the states across their
region. These meetings were an opportunity for federal partners to report
on what was happening at the federal level while also hearing about the
challenges and best practices from states’ responses to the COVID-19
pandemic in the region.
Representatives from three coalitions we interviewed expressed generally
positive attitudes toward the demonstration sites in their states. For
example, coalition representatives in one state said they were initially
concerned the demonstration site was duplicating the efforts of coalitions.
However, once they began collaborating with the demonstration site in
their area and better understood the demonstration project’s goals and
functions, these coalition representatives said they recognized the
potential enhanced coordination these regional projects could provide.
For example, officials from this coalition stated that the regional
coordination promoted by these demonstration sites has allowed them to
work with other poison control centers in the region and form partnerships
to develop a chemical response team.
ASPR officials said they are not awarding any new demonstration sites in
fiscal year 2022. These officials said they are still assessing the project as
a whole and the potential next steps they will take regarding the
expansion of the Regional Disaster Health Response System
demonstration project.44
44ASPR officials said they do not plan to conduct a formal assessment of the
demonstration project, rather they plan to conduct an internal review of it to inform a
longer-term strategy.
Page 36 GAO-22-105461 Medical Surge Readiness
Letter
Regional Guidelines Required under Developing Regional Preparedness and Response Guidelines
Statute
The Pandemic and All-Hazards Preparedness ASPR officials said the office is in the process of drafting regional
and Advancing Innovation Act of 2019
required the Office of the Assistant Secretary guidelines for hospitals and other health care facilities to assist them in
for Preparedness and Response (ASPR) to their ability to treat patients and increase their medical surge capacity in
publish regional guidelines for hospitals and
other health care facilities to provide
the event of a public health emergency, as required under the PAHPAI
appropriate patient care during, in advance of, Act. ASPR officials said they are working toward an internal completion
and immediately following a public health date of summer 2022, after which, following approval by the Assistant
emergency.
The purpose of these guidelines is to assist
Secretary for Preparedness and Response and clearance by HHS, the
facilities in their ability to treat patients and guidelines would be made publically available. ASPR officials did not
increase medical surge capacity in the event provide a date for when the guidelines would be made publicly available.
of a public health emergency. The guidelines
should reflect differences in facilities’
capabilities and capacity to treat patients, According to ASPR, consistent with the PAHPAI Act, adherence to these
among other considerations.
regional guidelines will be voluntary. In addition, in developing these
Source: Pub. L. No. 116-22, § 203(a), 133 Stat. 905, 911-13
(codified at 42 U.S.C. § 247d-3c). | GAO-22-105461 regional guidelines, the PAHPAI Act directed ASPR to seek input from
various stakeholders, such as health care facilities and providers, and to
consider the following:
· feedback related to the financial implications for hospitals, health care
facilities, and other entities engaged in regional preparedness
planning to implement and follow the guidelines; and
· financial requirements and potential incentives for entities to prepare
for and respond to public health emergencies as part of a regional
health care emergency preparedness and response system.45
ASPR officials stated they are considering options for incentivizing
guideline adoption but did not provide any further detail on how any
potential incentives would operate in practice. These officials noted that
since the guidelines are still in draft form, pre-decisional, and subject to
change, it would be premature to discuss operational aspects of the
guidelines. They stated their primary focus at this time is on finalizing the
guidelines.
Until the regional guidelines are complete, we cannot report on the extent
to which they may better prepare entities in planning for and responding
to future events, any challenges health care entities may have in
implementing them, or how future incentives ASPR develops may help to
encourage adoption. We have future work planned to examine ASPR’s
4542 U.S.C. § 247d-3c(c)(3) and (4).
Page 37 GAO-22-105461 Medical Surge Readiness
Letter
efforts to further promote health care system preparedness and response
capabilities.
Agency Comments and Our Evaluation
We provided a draft of this report to HHS for review and comment. HHS
provided technical comments, which we incorporated as appropriate.
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Health and Human Services, and other
interested parties. In addition, the report is available at no charge on the
GAO website at https://www.gao.gov.
If you or your staffs have any questions about this report, please contact
me at (202) 512-7114 or DeniganMacauleyM@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this report.
Mary Denigan-Macauley
Director, Health Care
Page 38 GAO-22-105461 Medical Surge Readiness
Letter
List of Addressees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chair
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
Page 39 GAO-22-105461 Medical Surge Readiness
Letter
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Richard Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
The Honorable Michael Bennet
United States Senate
Page 40 GAO-22-105461 Medical Surge Readiness
Appendix I: GAO Contact and Staff
Acknowledgments
Appendix I: GAO Contact and
Staff Acknowledgments
GAO Contact
Mary Denigan-Macauley, (202) 512-7114 or
DeniganMacauleyM@gao.gov
Staff Acknowledgments
In addition to the individual named above, Shannon Legeer (Assistant
Director), Stella Chiang (Analyst-in-Charge), Justin Cubilo, and Mallory
Kennedy made key contributions to this report. Also contributing were
Kaitlin Farquharson, Laurie Pachter, Cynthia Khan, Sean Miskell,
Brandon Nakawaki, and Ethiene Salgado-Rodriguez.
Page 41 GAO-22-105461 Medical Surge Readiness
Related GAO Products
Related GAO Products
COVID-19: Current and Future Federal Preparedness Requires Fixes to
Improve Health Data and Address Improper Payments. GAO-22-105397.
Washington, D.C.: April 27, 2022.
COVID-19: Significant Improvements Are Needed for Overseeing Relief
Funds and Leading Responses to Public Health Emergencies.
GAO-22-105291. Washington, D.C.: January 27, 2022.
Behavioral Health and COVID-19: Higher-Risk Populations and Related
Federal Relief Funding. GAO-22-104437. Washington, D.C.: December
10, 2021.
COVID-19: HHS’s Collection of Hospital Capacity Data. GAO-21-600.
Washington, D.C.: August 5, 2021.
Biodefense: After-Action Findings and COVID-19 Response Revealed
Opportunities to Strengthen Preparedness. GAO-21-513. Washington,
D.C.: August 4, 2021.
COVID-19: Continued Attention Needed to Enhance Federal
Preparedness, Response, Service Delivery, and Program Integrity.
GAO-21-551. Washington, D.C.: July 19, 2021
COVID-19 Pandemic: VA Provides Health Care Assistance to Civilians as
Part of the Federal Response. GAO-21-395. Washington, D.C.: May 20,
2021.
COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its
Second Year. GAO-21-387. Washington, D.C.: March 31, 2021.
COVID-19: Critical Vaccine Distribution, Supply Chain, Program Integrity,
and Other Challenges Require Focused Federal Attention. GAO-21-265.
Washington, D.C.: January 28, 2021.
Rural Hospital Closures: Affected Residents Had Reduced Access to
Health Care Services. GAO-21-93. Washington, D.C.: December 22,
2020.
Page 42 GAO-22-105461 Medical Surge Readiness
Related GAO Products
COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal
Response. GAO-21-191. Washington, D.C.: November 30, 2020.
COVID-19: Federal Efforts Could Be Strengthened by Timely and
Concerted Actions. GAO-20-701. Washington, D.C.: September 21, 2020.
COVID-19: Opportunities to Improve Federal Response and Recovery
Efforts. GAO-20-625. Washington, D.C.: June 25, 2020.
Public Health Preparedness: HHS Should Take Actions to Ensure It Has
an Adequate Number of Effectively Trained Emergency Responders.
GAO-20-525. Washington, D.C.: June 18, 2020.
(105461)
Page 43 GAO-22-105461 Medical Surge Readiness
GAO’s Mission
The Government Accountability Office, the audit, evaluation, and investigative
arm of Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability of the
federal government for the American people. GAO examines the use of public
funds; evaluates federal programs and policies; and provides analyses,
recommendations, and other assistance to help Congress make informed
oversight, policy, and funding decisions. GAO’s commitment to good government
is reflected in its core values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony
The fastest and easiest way to obtain copies of GAO documents at no cost is
through our website. Each weekday afternoon, GAO posts on its website newly
released reports, testimony, and correspondence. You can also subscribe to
GAO’s email updates to receive notification of newly posted products.
Order by Phone
The price of each GAO publication reflects GAO’s actual cost of production and
distribution and depends on the number of pages in the publication and whether
the publication is printed in color or black and white. Pricing and ordering
information is posted on GAO’s website, https://www.gao.gov/ordering.htm.
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card, MasterCard,
Visa, check, or money order. Call for additional information.
Connect with GAO
Connect with GAO on Facebook, Flickr, Twitter, and YouTube.
Subscribe to our RSS Feeds or Email Updates. Listen to our Podcasts.
Visit GAO on the web at https://www.gao.gov.
To Report Fraud, Waste, and Abuse in Federal
Programs
Contact FraudNet:
Website: https://www.gao.gov/about/what-gao-does/fraudnet
Automated answering system: (800) 424-5454 or (202) 512-7700
Congressional Relations
A. Nicole Clowers, Managing Director, ClowersA@gao.gov, (202) 512-4400, U.S.
Government Accountability Office, 441 G Street NW, Room 7125, Washington,
DC 20548
Public Affairs
Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, DC 20548
Strategic Planning and External Liaison
Stephen J. Sanford, Managing Director, spel@gao.gov, (202) 512-4707
U.S. Government Accountability Office, 441 G Street NW, Room 7814,
Washington, DC 20548
File and source
- File
- gao-22-105461.pdf
- Size
- 1,371,563 bytes
- SHA-256
- b347605aed3a1b5bc684378dff2a170e34ff6c6814b7b145d824fdc094449dd9
- Our copy
- gao-22-105461.pdf
- Original
- www.gao.gov