Frequently Asked Questions: Medical Response and Surge Exercise (MRSE)

The Medical Response and Surge Exercise (MRSE) is an annual Hospital Preparedness Program (HPP) Cooperative Agreement requirement and officially replaces both the Coalition Surge Test (CST) and the Hospital Surge Test (HST). As of HPP Budget Period 3 (starting on July 1, 2021 and ending June 30, 2022), HCCs must complete the MRSE annually. Previously, the Hospital Surge Test was used for hospitals located in approved jurisdictions or officially classified as an isolated frontier hospital. Now hospitals located in approved jurisdictions (American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Republic of Palau, Republic of the Marshall Islands, Guam, and the United States Virgin Islands) or officially classified as an isolated frontier hospital must also complete the MRSE.

The MRSE is a functional exercise. Federal Emergency Management Agency (FEMA) Homeland Security Exercise and Evaluation (HSEEP) guidelines describe a functional exercise as "an operations-based exercise designed to test and evaluate capabilities and functions while in a realistic, real-time environment." HCCs are welcome to use MRSE as a full-scale event, provided all MRSE requirements are met and that the HCC can report the data required to calculate the MRSE performance measures.

There are several differences between the CST/HST and the MRSE. Some of the salient changes include: 

• Removal of the low- or no-notice requirement

• Removal of a time limit for the exercise (previously 90 minutes)

• Including flexibility for the HCC to define its surge scenario

• Enabling greater linkages to other program components (e.g., Hazard Vulnerability Analysis (HVA), each HCC's individual response plan)

• Increasing opportunity to meet non-HPP exercise requirements such as those required by Centers for Medicare and Medicaid Services (CMS), the Joint Commission, and state/local authorities

• Use of only five required bed types in the 20% surge calculation, rather than all HCC staffed beds. Additional bed types may be added by your HCC depending upon your surge scenario

• Increasing the ability of HCCs to utilize a qualifying real-world incident in lieu of the MRSE

Some aspects of the CST/HST have been maintained. These include:

• HCCs are required to complete the exercise annually

• The exercise remains a source of performance data for HPP

• HCCs are required to enter exercise data into the Coalition Assessment Tool (CAT) annually to comply with HPP reporting requirements

All steps of planning for and completing the MRSE are outlined in the following tools:

• Situation Manual – The core document provided to all participants in an exercise. It provides in-depth instructions for how to plan and conduct the MRSE. 

• Evaluation Plan – The document that outlines the goals and purpose of exercise evaluation for an HCC and guides the Exercise Evaluator through assisting during the exercise, gathering information, and facilitating the After-Action Review. The Evaluation Plan helps the Exercise Evaluator turn information collected during the exercise into a meaningful After-Action Review and Improvement Plan in concert with exercise participants. 

• Exercise Planning and Evaluation Tool – This tool is organized to walk HCCs through conducting the exercise and collecting all exercise data. All required exercise data collection – including data for HPP Cooperative Agreement MRSE performance measures – will be completed in the Exercise Planning and Evaluation Tool.

Data from the MRSE must be submitted by HCCs into the Coalition Assessment Tool (CAT). HCCs are required to submit MRSE performance measure information and to upload the MRSE Exercise Planning and Evaluation Tool into the CAT.

HPP allows HCCs to utilize a real-world incident in lieu of conducting the Medical Response and Surge Exercise. The MRSE Situation Manual provides HCCs with guidance and parameters for using real-world incidents. HCCs are asked to use their judgment in selecting an appropriate real-world incident. Some criteria have been provided to help HCCs determine what is an appropriate use of a real-world incident. These criteria are listed below:

• The real-world surge incident must impact greater than or equal to 20% of the required staffed bed types and other scenario-specific staffed bed types used in the MRSE (see the Calculating the Scale of the Surge section in the MRSE Situation Manual)

• At least one of each of the HCC core members must participate in the real-world incident response

• At least one executive from each of the participating core member organizations must participate in the After-Action Review (AAR)

• The HCC must be able to capture the data points required to report all MRSE performance measures. To strengthen the possibility of meeting this requirement, HCCs can pre-identify resource needs for a range of surge incident types (e.g., from the HCC Hazard Vulnerability Analysis) as explained in the Identifying Anticipated Resources Required for the Surge section in the MRSE Situation Manual 

• The HCC must use the Exercise Planning and Evaluation Tool to document the real-world incident and provide data required by HPP (e.g., performance measures)

• The HCC must submit an AAR and Improvement Plan to HPP after the real-world incident in line with the reporting requirements of the HPP Cooperative Agreement for both exercises and real-world incidents. The real-world surge incident must have a discrete beginning and end ('bookends') rather than a slow build up. Preferred real-world incidents to be used in lieu of the MRSE last no more than one week. Generally speaking, the COVID-19 response cannot be used in lieu of conducting the MRSE unless there is a specific COVID-19 surge event lasting less than one week. Ongoing COVID-19 surge, therefore, is not an appropriate real-world incident to use in lieu of the MRSE. However, a four-day surge of pediatric COVID-19 cases may be an appropriate scenario if the four-day surge is greater than or equal to 20% of the current staffed beds and the timeframe of the real-world surge incident occurs in less than a week. 

Please consult the Evaluation Plan to learn more about MRSE performance measures. If, after reading the MRSE Situation Manual's guidance for real-world events and the Evaluation Plan, you still have questions about the appropriateness of using a real-world incident or how to report the data, please consult your recipient and your HPP Field Project Officer (FPO) or reach out to the MRSE Support Team at MRSE@hhs.gov.

Currently, all HCCs are required to conduct the MRSE in each budget period beginning with BP3 of the current cooperative agreement project period. Currently, there are no exemptions. National Healthcare Preparedness Programs (NHPP) leadership continuously monitors impacts of the COVID-19 response on recipients and sub-recipients. HPP understands that the current situation in many hospitals and other member organizations is challenging and will continue to be challenging. However, we at HPP believe there are many risks to our health care system that remain while we battle COVID-19. HCCs have until June 30, 2022 to complete this exercise. If you have additional questions specific to your situation, you can work with your recipient and your HPP FPO.

No. This is not a requirement for the MRSE. Core members of the HCC are required participants in the MRSE. Although HPP encourages all core members to participate in every exercise, the HCC should include at least one participant from each of the four core member types. Participation beyond the one representative of each type is dependent on the exercise scenario designed by the HCC.

Yes. In fact, HPP strongly encourages HCCs to consult members during the Phase I: Plan & Scope phase to understand member exercise needs and to then customize the MRSE to meet those needs. Provided the requirements of the MRSE are met, HCCs may use the MRSE to meet other exercise requirements of their members. Combining exercise requirements not only reduces burden on HCCs and their members, but also encourages participation in the MRSE.

The specialty surge annex tabletop/exercise requirements are intended to facilitate discussion among HCC partners, and they must only be completed once for each specialty surge annex. HCCs can combine these two exercises, as long as the functional aspects of the MRSE and the facilitated discussion components of the response annexes are integrated. For example, if conducting a medical surge exercise that includes a burn surge component, HCCs must be able to report the required data for the MRSE performance measures through this combined exercise and must respond to questions in the Coalition Assessment Tool (CAT) for the specialty surge annex exercise.

HPP is interested in your experience planning and exercising combined exercises. If you would like to, please share your approach with us by sending an email to the MRSE Support Team at MRSE@hhs.gov.

The MRSE, like the CST, will need to be conducted in alignment within state plans and guidance. HPP recognizes that many HCC and jurisdictional preparedness and response plans identify and incorporate unique positions, plans, and processes based on existing state laws, organizational structures, and policies. As a result, increased flexibility was added to the MRSE. HCCs can now tailor exercise play to align with various local, state, and regional plans. The MRSE also allows HCCs to incorporate the use of additional exercise roles for both facilitators and players to further align with existing exercise and response structures. For more assistance with planning and execution of the MRSE, please contact your recipient and HPP FPO.

During execution of the MRSE, the use of SimCells should be limited to the provision of ongoing situational awareness related to the incident scene, resource availability outside of the state, and other factors that may impact the continued execution of the HCC's response plan. SimCells should not be utilized to represent unavailable HCC core members or other critical exercise participants. Please submit your feedback and recommendations on the future use of SimCells to the MRSE Design Team at MRSE@hhs.gov.

Although there is a technical definition of 'Incident Management Team' in the glossary of the MRSE Situation Manual, there is no requirement for an HCC to use an incident management team in the MRSE. An incident management team may not be applicable to all HCCs. The HCC should use the coordination model defined in its response plan. Table 1 of the Situation Manual provides the required roles for conducting the MRSE.

According to the 2017 – 2022 Health Care Preparedness and Response Capabilities, health care executives are defined as "health care organization senior executives with institutional decision-making authority. Titles of health care executives may include, but are not limited to, President, Chief Executive Officer, Chief Operating Officer, Chief Medical Officer, Chief Nursing Officer, and Medical Director."

Although executives are not required to participate in Phase I: Plan & Scope or Phase II: Exercise, HPP requires that at least one executive from each HCC core member organization participates in the Review phase's After-Action Review. HPP also encourages executives from other member types to participate, especially if the member played a key role in the MRSE. The HCC Readiness and Response Coordinator should ensure participation of executives in the review by confirming their participation in advance.

The MRSE is an HCC-level program requirement and there is no required role for the recipient in the exercise itself. However, HPP encourages broad participation in program exercises, including recipients. This is especially true if the HCC is participating in a statewide or regional exercise which meets MRSE requirements. After the exercise is conducted and data are reported through the Coalition Assessment Tool (CAT), the recipient will utilize the HCC-reported information to report on HPP end-of-year performance measures. If a recipient desires to combine other exercises with the MRSE to help HCCs meet additional exercise requirements, they are encouraged to do so and to help HCCs to participate in these combined exercises.

As MRSE is a medical surge exercise, hospitals and EMS are critical participants. However, the MRSE provides many opportunities to involve other HCC member types. Their participation depends on the scenario designed by the HCC and the HCC's engagement with them during the exercise. HCCs may choose to allocate some surge patients to non-hospital facilities for treatment and/or admission in an appropriate, staffed bed. HCC members may be sources of resources such as personnel, medical equipment, supplies, and pharmaceuticals to be shared with other HCC members. Other public safety agencies may be needed to assist with logistics, security, or even transport of resources. The MRSE provides HCCs with considerable flexibility to design a scenario which involves any of its member types.

If HCCs do not have direct relationships or communication with EMS agencies' dispatch, they should follow the protocol established in their response plans to confirm EMS resource availability on the day of the exercise (e.g., through an EMS Council, Emergency Communication Center, local Emergency Operations Center, Public Safety Answering Point). Further, EMS participation is required in all three phases of the MRSE (as an HCC core group member), and any issues related to communication with EMS agencies' dispatch should be addressed during Phase I: Plan and Scope of the exercise.

Yes, a recipient can require all HCCs in their jurisdiction to perform the MRSE during a single state-wide exercise. However, one MRSE tool (with corresponding performance measure results) must be completed and uploaded in the Coalition Assessment Tool (CAT) for each HCC participating in the exercise. As the HPP MRSE performance measures are measured by each HCC - each HCC will have different results for the HPP performance measures and those must be captured even when conducting the MRSE exercise together.

The MRSE is an HCC-level HPP program requirement. However, HPP encourages collaboration between HCCs to mimic state-wide or regional medical surges. Provided each HCC in the recipient's jurisdiction is able to perform the exercise functions and meet the MRSE requirements (e.g., report HCC-level performance measures), HCCs are encouraged to design a joint exercise scenario for the MRSE. The total patient surge for the exercise will be 20% of beds from all HCCs. HPP strongly recommends you contact your HPP FPO prior to planning a multi-HCC exercise to meet your MRSE requirements.

If an HCC is divided into multiple sub-regions, requirements related to communications, notifications, and calculation of the 20% surge number apply to the entire HCC as a whole and not only to select sub-regions of an HCC.

At minimum, all core member types (acute care hospitals, public health, EMS, and emergency management) must participate in the MRSE. However, HCCs are encouraged to design scenarios which provide utility to a broader set of member types by identifying critical participants required to manage patient surge in the exercise scenario during the Plan and Scope Phase. We understand that circumstances may not allow all individual core members to participate. In that case, please proceed with the exercise and report participation as required in the MRSE Planning and Evaluation Tool. If you believe you will not have sufficient participation from your members, please contact your recipient and your HPP FPO to discuss options.

In Phase I: Plan & Scope, HCCs will determine their total number of staffed beds by bed type. HCCs may use their Surge Estimator Tool or another source of their choosing to assist with bed identification. HCCs enter the total number of staffed beds by type into the MRSE Planning and Evaluation Tool. Some bed types are required to be included in the 20% calculation for all exercises, while other optional bed types will be selected by the HCC as relevant for the scenario the HCC plans to exercise. For example, if the incident includes a surge of psychiatric patients, the HCC will likely select psychiatric unit beds to be included in the calculation. The tool will automatically calculate 20% of the required and selected optional bed types. Consult the MRSE Exercise Planning and Evaluation Tool and the MRSE Situation Manual for further details on this topic. If you have additional questions specific to your situation, you can work with your recipient and your HPP FPO.

Please refer to the MRSE Situation Manual, including Table 2: Required and Optional Staffed Bed Types Used by the Medical Response & Surge Exercise. 

It is acceptable to use a target of 20% of staffed beds based on an average census. If you use a number for planning purposes that does not exactly match the number on the day of the exercise, that is perfectly acceptable. HCCs will conduct their staffed bed census only in Phase I: Plan and Scope of the exercise. This will pre-set the 20% surge estimation for the exercise. On the day of the exercise, HCCs will already know how many surge patients they will have to manage based on the staffed bed census conducted in Phase I of the exercise.

The 20% bed calculation is based upon staffed beds.

It is not possible to fail the MRSE exercise. The MRSE is designed to examine and evaluate the ability of HCCs and other stakeholders to support medical surge. Placing stress on the health system is important for testing your current response systems, identifying gaps in preparedness, and informing improvement planning. You can document gaps and improvement actions in your After-Action Report and Improvement Plan in Phase III: Review of the exercise. In reporting, HPP will provide clear messaging that 'low' performance on performance measures related to the MRSE was anticipated and may indicate an area for future improvement for HCCs, recipients, and ASPR. HPP encourages HCCs to select and exercise scenarios that are most useful to the HCC rather than scenarios for which the HCC believes it can get 'full marks.'