How to Use This Toolkit

Public Health Emergency Preparedness

Reopening a closed ("shuttered") hospital to expand surge capacity in an emergency requires significant planning. This Toolkit is a step-by-step guide to assist staff responsible for management, legal, facility, staffing, security, materials management, and transportation planning. The kit includes sections for each staff type/responsibility. The sections address:

  1. Planning.
  2. Reopening a closed hospital within 3 to 7 days.
  3. Operating the facility.
  4. Closing the facility down again.

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1. Team Development and Partnering

Description: As part of overall homeland security and disaster response planning at the local, county, or State level, the need for additional hospital surge capacity may be an identified issue. If response planners choose to pursue use of area shuttered hospitals for surge capacity, key local authorities will need to come together to make these plans a reality. Local authorities should seek guidance from the Federal Government as part of this process.

Timeframe: As soon as decision is made to pursue use of shuttered hospitals for surge capacity.

  • Identify all authorities/agencies/organizations having interest in and/or jurisdiction over hospital surge capacity planning in the region. Examples include: major hospitals, public health departments, homeland security officials, emergency management authorities, emergency medical system authorities, fire departments, and police officials.
    • Contact these entities and enlist participation.
    • Collect, review, and assess existing homeland security and disaster response plans for the area. Identify any overlap or restriction on the efforts to create surge capacity readiness at a local shuttered hospital.
  • Identify Federal authorities having jurisdiction over hospital operations and emergency planning.
    • Contact these entities to seek guidance on interpreting Federal requirements.
    • Seek waivers when Federal rules prevent creation or operation of a surge facility.
  • Identify what can be provided by each entity.
    • Expertise.
    • Participation on surge facility planning and management team.
    • Direct management of surge facility operations.
    • Staff and equipment for use at the surge facility.
    • Funding.
  • Formalize a surge facility planning and management team. Expertise in the following areas is needed, with preference for those with knowledge about operating under emergency conditions.
  • Disaster response/emergency management coordination (management, coordination of work with involvement of multiple entities).
    • Hospital staffing.
    • Facilities.
    • Security.
    • Patient transport.
    • Patient information management.
  • Designate a team leader with responsibility for maintaining contact with the team, arranging meetings, and representing the team as needed (with press, at larger scope emergency planning meetings, etc.).

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2. Designation of Authority

Description: A critical component of the surge facility planning will be to determine who will be in charge of operating the surge facility when it is needed. Ideally, a major hospital in the area will have this responsibility so that the surge facility acts as a temporary satellite of the major hospital with the benefits of use of hospital contracts, staff, equipment, and expertise. This may not be feasible in all cases, so an alternate plan must be developed. Also, a reporting structure and chain of command must be formalized so that coordination between the organizations involved occurs smoothly.

Timeframe: This should be the first order of business for the newly assembled surge facility management and planning team.

Action Checklist

  • Review the identified level of involvement of the various management team members and partner organizations.
  • Outline and achieve consensus on the details and specific scenarios for the intended surge facility use based on the surge capacity needed in the region (i.e., number of beds needed, noncritical medical/surgical patients only, isolation/quarantine facility, etc.).
  • Designate who will have authority over surge facility management and operations when the facility is open (e.g., local major hospital manages and operates the facility, or public health department oversees the facility with use of various external providers for staff, equipment, and services).
  • Establish a chain-of-command and reporting hierarchy for the surge management team.
  • Review available information on surge facility organization systems and staffing.
  • Develop an organizational structure and reporting hierarchy for line area management of surge facility operations and staff while the facility is open.
  • Work with local regulators or legislative bodies if any of the surge facility plans are not in compliance with current regulations.
  • Formalize arrangements with surge facility partners not serving on the management team.
  • Notify all affected authorities, agencies, and organizations not serving as partners about the general plans for the surge facility.

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3. Facility Assessment and Selection

Description: Shuttered hospitals in the region will need to be identified and then assessed for potential surge use. Ideally, one or a few of the shuttered hospitals will then be selected for surge capacity use readiness preparations.

Timeframe: As soon as the surge facility management team has been assembled and organized.

Action Checklist

  • Obtain a list of all shuttered hospitals in the area (likely available from State departments of public health).
  • Select best candidates for surge use from list of shuttered hospitals. Preferred characteristics include:
    • Shortest time since closure as in-patient facility.
    • Not fully shuttered, some active uses, medically-related optimal.
    • Adequate structural integrity for safe use.
    • Relatively close to metropolitan area to facilitate patient transport.
    • Not targeted for teardown, conversion, or sale immediately or soon.
  • Contact current facility owners to discuss possible surge use and obtain permission for facility walkthrough.
  • Assemble facility inspection team:
    • Surge facility management/planning team representative.
    • Physician (emergency or field set-up experience preferred).
    • Nurse.
    • Facility Expert(s) (hospital knowledge preferred, HVAC-licensed, general knowledge of multiple facility issues, structural, plumbing, etc.).
    • Medical Gas System Verifier (locate at
    • Security Expert.
    • Hospital equipment and supplies procurement expert.
  • Conduct facility walkthroughs.
  • Select potential facility or facilities for surge use.
  • Management team experts begin readiness preparations in their area of focus: staffing, security, facility, etc.).

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4. Periodic Readiness Review

Description: Once readiness activities—such as arrangement of contracts and partner agreements, identification of providers, and procurement of limited equipment—have been completed, a periodic review must be conducted to ensure that readiness is maintained.

For example, over time staff or ownership of key partners or vendors may change, the target facility may be sold, or regulatory changes or technological advancements may have occurred that affect readiness plans. For this reason, surge facility plans and prearrangements must be reviewed periodically to ensure that they are active and appropriate.

Timeframe: Once surge facility preparedness plans and arrangements are finalized, they should be reviewed every 6 months. The management team should meet once a year to reassess the surge facility plans compared with current surge capacity needs and broad-scope regional emergency planning efforts.

Action Checklist

  • The management team leader contacts the target surge facility owners to check the facility status (any changes in condition, use, plans for the facility, or ownership).
  • If a new target surge facility or facilities are needed, the team will reassess the list of shuttered facilities and conduct new facility walkthroughs as needed.
  • The management team leader contacts each team member to check on plans for their focus area.
  • Each team member conducts a status check with all vendors or other providers for every advance contract or formal arrangement under their focus area. Partner organizations are contacted for a status check.
  • The team meets annually to review the overall surge facility plans and scenarios and assess the fit with current regional needs and broader emergency planning efforts.
  • Management team members are replaced as needed if a member changes jobs, is unable to fulfill his or her duties, etc.

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5. Ramp-Up

Description: Once the catastrophic event occurs, facility opening efforts will be under way through the efforts of individual management team members overseeing their area of focus (staffing, security, supplies, etc.). However, there should also be big-picture management team oversight to ensure that nothing is missed and to provide extra assistance as needed.

Timeframe: As soon as the catastrophic event occurs, through implementation of planned arrangements for opening the facility and the facility opening day.

Action Checklist

  • Management team leader checks in with each team member to ensure that facility opening activities are under way.
  • Management team leader assists with troubleshooting or procuring additional assistance or resources as needed.
  • The full management team (or designates) meets on-site at the beginning of opening day.

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6. Ongoing Operations

Description: Once needed staffing, equipment, and supplies are in place, and the facility has accepted patients, efforts will be needed to maintain fully operational status. Management team members will continue to oversee their area of focus. However, there should also be big-picture management team oversight to ensure that smooth operations are maintained, and to provide extra assistance as needed.

Timeframe: The operations activities listed below will begin on opening day and continue until the facility is closed.

Action Checklist

  • Management team leader conducts periodic checks with each team member to ensure continuation of effective facility operations. This should occur every few days at the beginning, and once a week as the facility continues operations.
  • Management team leader assists with troubleshooting or procuring additional assistance or resources as needed.

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7. Closure

Description: Shutdown of the surge facility will require removal of equipment and termination of ongoing contracts or arrangements. Management team members will oversee shut-down activities in their area of focus. However, there should also be big-picture management team oversight to ensure that facility shutdown occurs smoothly and quickly and to provide extra assistance as needed.

Timeframe: Once all patients can be discharged or transported back to the major hospital for continued care, and there is no ongoing surge capacity need, the facility can be closed. The shutdown should be expedited so that the facility can be returned to the control of the existing owners quickly and should be possible within a matter of days.

Action Checklist

  • Management team leader checks in periodically with each team member to ensure initiation and completion of shutdown activities in that member's area of focus.
  • Management team leader assists with problem troubleshooting or procuring additional assistance or resources as needed.
  • Management team leader or designate conducts a facility walkthrough with the facility owner when shutdown activities are completed to ensure that removal of equipment and supplies, cleaning, and other surge closure activities have been completed to the owner's satisfaction.

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8. Review/Replanning

Description: In the unfortunate event that a terrorist incident or disaster occurs, and the facility must be opened for surge use, valuable lessons will be learned during operations. This information should be captured so that surge facility readiness and operation plans can be improved in preparation for any future surge use.

Timeframe: Immediately following surge use of the facility.

Action Checklist

  • Conduct debriefs with line managers to identify any problems or suggested improvements.
  • Review usage of equipment and supplies to identify needed vendor contract modifications.
  • Review effectiveness of medical staffing levels to identify needed modifications.
  • Review patient transport problems or suggested improvements.
  • Review security problems or suggested improvements.
  • Review facility problems or suggested improvements.
  • Review outsourced services (food preparation, laundry, laboratory) for problems or suggested improvements or to see if in-house capacity should be developed for future surge use.

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This table summarizes the most important Federal and State regulations and identifies those that may require waivers and those that probably do not.

Issue Guidance/Waiver Likely Needed Responsible Entity
State/Local Government
Hospital administration   X X
Compliance with Federal, State and Local laws   X X
Governing body X X X
Quality Assessment Performance Improvement Program X X  
Services   X X
Pharmaceutical services   X X
Radiologic services   X X
Laboratory services X X X
Food and dietetic services   X X
Utilization review X X X
Physical environment   X X
Infection control   X X
Discharge planning X X X
Organ, tissue, and eye procurement X X  
Surgical services n/a    
Anesthesia services n/a    
Nuclear medicine n/a    
Outpatient services n/a    
Rehabilitation services n/a    
Respiratory care services n/a    
Staffing   X X
Medical staff   X X
Nursing services   X X
Medical records X X X
Pharmaceutical services X X X
Radiologic services   X X
Laboratory services X X X
Food and dietetic services   X X
Long-term Care Staffing   X  
Nursing   X  
Dietary   X  
Social services   X  
Patient Rights   X X
Notice of rights   X X
Exercise of rights   X X
Confidentiality of patient records   X X
Restraint for acute medical and surgical care   X  
Seclusion and restraint for behavior management   X  
Patient Information and Privacy Standards   X X
Organization and staffing   X X
Form and retention of records X X X
Health information privacy X X  
Other Issues   X X
Status of a new hospital X   X
Determination of need X   X
Construction plan approval for renovations X   X
Public safety and fire certificates X   X
Obtaining a license X   X
Medical personnel credentialing X   X
Complaints and incident reports     X
Sharps and disposal of medical waste     X
Reportable diseases, isolation, and quarantine     X
Authority to open a surge facility X   X
Operation and control of a surge facility X   X
Liability X X X
Medical personnel—crossing state lines X   X
Physician back-up by other healthcare providers   X X

For an extensive discussion of the legal and regulatory issues surrounding reopening a shuttered hospital, go to Appendix D in the Reopening Shuttered Hospital to Expand Surge Capacity report.

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Page last reviewed July 2018
Internet Citation: How to Use This Toolkit. Content last reviewed July 2018. Agency for Healthcare Research and Quality, Rockville, MD.