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Thursday, July 25th 2002

The Honorable Tom Ridge
Assistant to the President for Homeland Security
Office of Homeland Security
The White House
1600 Pennsylvania Ave., NW
Washington, D.C. 20500

Dear Governor Ridge:

This letter is to follow-up on discussions that the American Hospital Association (AHA) has had with your staff regarding the application of the Homeland Security Advisory System (HSAS) to the nation’s hospitals.  The AHA, which represents nearly 5,000 member hospitals, health systems, health networks, and other providers of health care, has previously submitted comments to the Administration regarding the HSAS in April, with a promise to follow-up with additional comments after we consulted with our members.  This letter summarizes what we have learned from America’s hospitals.

The terrorist attacks of September 11th and the subsequent anthrax attacks have changed how Americans view safety and security.  The attacks have also redefined the meaning of disaster readiness for the nation, communities and hospitals.  Over the past 10 months, as the nation has focused on strengthening our national security and emergency readiness, America’s hospitals have been upgrading existing disaster plans.  They continue to tailor their disaster plans to suit the individual needs of their communities in the face of new and more ominous threats of terrorism, particularly terrorist acts involving the use of chemical, biological or radiological agents. 

It is in this context that the AHA is pleased to provide you with additional insights into the way in which the nation’s hospitals view the proposed HSAS.  While the AHA continues to support the general structure of the proposed system and believes that it provides a useful touchstone for the ongoing integration of local, state and federal plans with health care providers’ plans, we have learned that hospitals respond to disasters somewhat differently than is outlined in the proposed system.

Most importantly, hospitals believe that a five-stage alert and response system does not fit with the way in which hospitals respond to disasters, including terrorist acts.  In dealing with disasters, hospitals perceive three distinct levels of response, with each stage building upon the previous one, ensuring that a foundation of readiness is set.  As levels of threat increase, additional measures are added:


1.      Current level of alert:  Hospitals, as entities that deal with medical emergencies on a daily basis, are always at a constant state of readiness.  They must be prepared to handle all sorts of disasters, natural or man-made.  However, since September 11, 2001, hospitals have increased their preparedness to address the new threats of terrorism.  Therefore, this first level of alert is described by the level of everyday readiness in which hospitals currently function.  Hospital administrators and staff do not believe that they will ever return to lower alert levels.  What this level of preparedness looks like depends on a hospital’s overall assessment of the terrorist threat its community faces. 

      Hospital activities at this level include such components as: staff training and drills; establishing relationships and coordinating planning with community partners; and establishing, enhancing, and disseminating hospital disaster plans.  Hospital disaster plans typically include plans and provisions for an emergency operations center; redundant backup communications; enhanced security; enhanced staffing levels; expedited discharge of patients and canceling of non-emergency surgery; enhancing supplies and inventory; enhancing mental health resources; and addressing personal protective equipment and decontamination procedures.

2.      Heightened alert level:  This level is reached when there is credible information communicated regarding a specific threat against the community in which the hospital operates.  National and non-specific alerts are not useful for hospital sector purposes.  Hospital activities at this level would depend on the nature of the threat but would generally include enhanced or “just in time” education and training, increasing communications with community partners, and activating various components of the hospital’s plan (described above), as appropriate.

3.      Attack is imminent or actual attack has occurred:  At this level of alert, information is communicated that a terrorist attack is about to occur or has occurred.  At this stage, a hospital would fully activate all components of its disaster plan, including taking actions that impact patient management, such as discharging or transferring patients and canceling non-emergency surgeries. 

We also continue to urge you to consider recommendations we made in our April comment letter.  These include:

The AHA urges the Administration to communicate threats to communities and their hospitals as expeditiously, directly and with as much specificity as possible, so that hospitals can proceed with an appropriate, timely and effective response.  We believe that a system that provides specific information about the location or type of terrorist threat is more helpful for health care providers than one that can only give broad national alerts.
We request that the Advisory System and its supporting systems provide hospitals with appropriate contact information for communicating possible threat information.


The AHA appreciates the Administration’s efforts to improve the coordination and communication among all levels of government and the American public in the fight against terrorism through the development of the proposed Homeland Security Advisory System.  Hospital caregivers perform heroic, lifesaving acts every day.  And, in the face of the unexpected, they will rise to meet the needs of their communities. 

On behalf of the nation’s hospitals, the AHA is committed to working with the White House Office of Homeland Security and other agencies and departments of the federal government to ensure that the nation’s hospitals continue to fulfill their critical role in planning for and responding to acts of terrorism in the communities they serve.

If you have questions regarding our comments, please do not hesitate to contact Roslyne Schulman, senior associate director for policy development, at (202) 626-2273 or at


Rick Pollack
Executive Vice President



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