Study Methodology

This study was conducted to investigate hospital preparedness for mass-casualty—specifically biological—emergencies in America’s rural communities. Rural counties are defined as non-metropolitan counties, as determined by the Office of Management and Budget (OMB). Non-metropolitan counties have no urban centers and are not economically dependent upon adjacent or nearby urban centers. 52 In order to be classified as an urban area upon which another county can be characterized as dependent, the U.S. Census Bureau requires a population density of 1,000 persons per square mile. 53

Within rural communities, and for the purpose of this study, hospitals were selected that had one or more vulnerability factors that may increase a community’s value as a strategic terrorist target. Vulnerability factors included proximity to military installations, nuclear or chemical plants, large-scale agricultural production, an international border, or major waterways. Additionally, hospitals were selected to represent five geographic regions of the country: the Northwest, Southwest, Northeast, Southeast, and Midwest.

To ensure diversity and national representation among participating organizations, this study enrolled rural hospitals from each of the five major regions of the United States.

The intent of this study was to visit and gather data from one hospitals in each of these geographic regions. An initial pool of eleven hospitals was selected, and each hospital was mailed a letter of introduction explaining the study. After subsequent phone calls assessing levels of interest among the hospitals, five were selected for participation. For security reasons, all participating hospitals were promised that they would not be identified by name or location in any final or summary reports, and that comments would not be attributed to specific participants. All site visits and meetings were conducted during December 2003.

Two-day site visits at each hospital included meetings with decision-making personnel (such as chief executive officers, chief operating officers, chief medical officers, and facility directors), department personnel (such as trauma coordinators and emergency department medical and nursing directors, elected officials), and representatives from the traditional responder community (such as firefighters, police officers, and emergency medical technicians, or EMTs). These meetings were supplemented by a tour of the hospital facility to clarify information discussed in the interviews.

The interview was designed to consist of only open-ended, discussion-based questions. Follow-up questions that were aimed at elucidating specifics of the bioterrorism preparedness plans were posed by the Principle Investigator as needed through the course of the conversation. The interview instrument was tested and refined prior to use, and employed consistently for all five visits. Specific probative questions were noted in typed transcripts of the interviews. Each hospital CEO was given the opportunity to review for accuracy and approve his/her written hospital profile.

Hospitals were provided an honorarium for their role in coordinating meetings with hospital and non-hospital participants and to cover the costs of refreshments supplied during the meetings.

52. Dependence is said to be established when 25 percent of the employed population of a county commutes to an urban center or when 25 percent of a county’s working population is comprised of residents of an urban center.
53. Economic Research Service, USDA. “Measuring Rurality: What is rural”? Available at http://www.ers.usda.gov/briefing/rurality/WhatisRural/.