Highlights: Are hospitals prepared to deal with a wave of injured people as a result of natural disasters or terrorist attacks? Worse yet, are hospitals prepared in the event that the hospital itself is the target of a terrorist attack? This article provides some resources and suggestions that, if followed, could help hospitals prepare to deal with these deadly events.

We no longer live in a world we fully understand. We now need to anticipate circumstances that in the recent past were inconceivable.

In 1995, the Aum Shinrikyo sect killed 12 people and injured nearly 6,000 by releasing sarin nerve gas in the Tokyo subway system. In Madrid, Spain, a series of coordinated bombings in a commuter train system during rush-hour killed 191 people and sent 300 to local hospitals. These events inundated their hospital facilities. Years after the September 11 attacks, the nation’s emergency rooms and hospitals still are not prepared to deal with the “surge” of patients that could be caused by a natural disaster let alone a terrorist attack.

Rep. Henry Waxman, D-California, chairs the House Committee on Oversight and Government Reform that conducted a survey of 34 hospitals and found that not one was prepared at that moment on that day for a terror attack.

“The situations in Washington, D.C., and Los Angeles were particularly dire. There was no available space in the emergency rooms at the main trauma centers serving Washington, D.C. One emergency room was operating at over 200 percent of capacity: more than half of the patients receiving emergency care in the hospital had been diverted to hallways and waiting rooms for treatment. And in Los Angeles, three of the five Level I Trauma Centers were so overcrowded that they went ‘on diversion,’ which means they closed their doors to new patients. If a terrorist attack had occurred in Washington, D.C. or Los Angeles on March 25 when we did our survey, the consequences could have been catastrophic. The emergency care systems were stretched to the breaking point and had no capacity to respond to a surge of victims.”

In preparing this article, I queried various hospital architects, owners’ representatives, and hospital staff with regard to the extent that they considered disaster planning and hospital preparedness for emergency management in the design, programming, and construction of new hospital facilities. The response was almost unanimous. They were shocked that the question was asked and at the same time puzzled that they, in their collective experiences, had never considered homeland security in the design and construction of a hospital. Other than the typical security provisions, there were no considerations for physical planning, implementation, or mitigation.

To the extent that the hospitals had developed emergency management programs, the programs were reactionary, trying to fit the facilities they had into the emergency management programs rather than including such considerations in capital improvements. This was surprising, considering that such disaster and security measures are required and common for the design and rehabilitation of federal buildings. These considerations include limiting the ability of cars to approach buildings, providing blast walls for diversion or absorption of blast forces, limiting pedestrian overlays on the lower levels, and detailed security plans. The purpose of this article is to provide basic considerations and guidelines for security, evaluation, and planning, as well as hospital preparedness and response.

Planning for Disaster

International terrorism poses a new kind of threat to America. This new threat, however, is one that the U.S. healthcare system can plan for and respond to. Our healthcare system perfected its Trauma Response Program and, by doing so, has saved thousands of lives. The same thing must happen instinctively during a terrorist attack if lives are to be saved. Planning for biological, chemical, and nuclear (dirty bomb) terrorist attacks is a public health priority. Hospitals should prepare for not only external disasters, but also for internal events. Hospitals should consider themselves a prime target for an internal event with a secondary effect. That is, not only would an internal attack achieve its prime effect and damage, injury or death, but it would also have a secondary impact of limiting the ability of the hospital to respond to the emergency. This makes hospitals a primary target while at the same time possibly limiting the hospitals’ ability to respond to the community.

AIA B206-2007 – Security Evaluation and Planning

Initially, hospitals should consider retaining the services of an architect or security expert to perform security evaluation and planning services. The American Institute of Architects (AIA) has proposed a “Standard Form of Architect’s Services: Security Evaluation and Planning” AIA Document B206-2007 that can be used as a guide. Such services would include considerations for the following:

  • Security Assessment that would include an asset analysis, as well as identifying and prioritizing the assets to be protected. These assets may include people, operations, information, and tangible real property. This analysis should address the nature of the asset needing protection, the value of the asset including current replacement value, where the asset is located, and how, when, and by whom the asset is accessed and utilized;
  • Vulnerability Analysis that identifies and analyzes the vulnerability of the assets relative to design and construction, technological systems, and operations. This analysis may include surrounding terrain and adjacent structures, site layout and elements, location and access to utilities, degree of resistance to explosive blast, building circulation patterns and special arrangements, and high risk assets within the facility;
  • Threat Analysis identifying the sources and types of potential threats that could interrupt, damage, or otherwise compromise the stability, function, physical condition, or operation of the facility; and
  • Facility Survey and Asset Inventory including the project site, building exteriors, building interiors, mechanical and electrical systems, and data and communication systems.

Based on the Security Assessments and Facilities Survey hospital’s should prepare a Facility Analysis that evaluates the location of existing or proposed structures and assets to determine detrimental effects of the specific threats designated in the Threat Analysis. The hospital also should provide a Risk Assessment of the potential effects of identified threats and provide recommendations for the type of security protection required for mitigation, including the costs and potential benefits of security measures. Based on the Risk Assessment and Facilities Analysis, the hospital, together with its design or security professionals, should prepare concepts for both the existing facility and proposed construction. These design concepts may include security concepts for the site perimeter including vehicle barriers, vulnerable building entrances and openings, electronic access monitoring systems, design criteria for the building structure including exterior hardness or physical locations to mitigate threats of explosive blasts, forced entry or ballistic attack, and protection of building occupants from the effects of a release of hazardous airborne substances both inside and outside the building.

All of this security evaluation and planning should be summarized in a “Security Evaluation and Planning Report” that would become a living document maintained by the healthcare facility. The Report would be used in the design and construction of new facilities, renovations, and maintenance of the healthcare campus, and it would be updated at regular intervals.

Hospitals need to develop Emergency Management Programs that are fairly consistent or standardized in structure and format with other hospitals throughout the country, flexible for hospital specific requirements, and are developed in synchrony with community operation plans and the National Incident Management System.

ASTM Guide for Preparedness and Response

The American Society for Testing and Materials (ASTM) International is an international standards organization that has developed a “Standard Guide for Hospital Preparedness and Response” designated as ASTM E2413-04. This standard was prepared by ASTM International’s Committee on Homeland Security to answer questions regarding the minimal levels of preparedness needed for hospitals to deal with large-scale terrorist attacks and other serious emergencies for emergency preparedness, training, and procedures. This new guide deals with the following issues:

  • The process for development of disaster preparedness and loss mitigation;
  • Organization of a hospital response plan;
  • Supplies that hospitals need to make available;
  • Existing regulations and guidelines; and
  • Protecting patients, staff, and facilities for normal operations while still providing an effective level of response.

This standard suggests minimal levels of preparedness for acute care hospitals, placing emphasis on the coordination of operations with community assets, including local emergency planning committees, and it emphasizes the effective development and utilization of a hospital vulnerability analysis. It also encourages the use of a hospital incident command system for organizing human resources and mandates communications and infrastructure systems to integrate the response.

Hospitals defined as First Responders may use the ASTM standard to focus their preparedness activities, and regulatory agencies will use the guide to assist hospitals in obtaining and maximizing physical resources for patient care and facilities management. ASTM E2413-04 gives hospitals all across the country uniform guidelines for preparing their facilities and personnel to handle catastrophes resulting from a large-scale terrorist attack and coordinating their preparations with other organizations in their communities. That is a major step towards domestic preparedness.


Hospitals are critical to a community’s ability to respond to a natural disaster or a terrorist attack. Hospitals need to prepare hospital response plans that incorporate the use of physical facilities. These plans shall not just be reactionary to the potential risks. When planning for new facilities or renovation of existing facilities, hospitals should include programmatic considerations for alternate ways that facilities might be used in the event of such disaster. Minor changes in design and construction might have significant impact on a hospital’s ability to respond.