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Heat early warning systems and action plans use temperature thresholds to trigger warnings and risk communication. In this study, we conduct multistate analyses, exploring associations between heat and all-cause and cause-specific hospitalizations, to inform the design and development of heat–health early warning systems. We used a two-stage analysis to estimate heat–health risk relationships between heat index and hospitalizations in 1,617 counties in the United States for 2003–2012. The first stage involved a county-level time series quasi-Poisson regression, using a distributed lag nonlinear model, to estimate heat–health associations. The second stage involved a multivariate random-effects meta-analysis to pool county-specific exposure–response associations across larger geographic scales, such as by state or climate region. Using results from this two-stage analysis, we identified heat index ranges that correspond with significant heat-attributable burden. We then compared those with the National Oceanic and Atmospheric Administration National Weather Service (NWS) heat alert criteria used during the same time period. Associations between heat index and cause-specific hospitalizations vary widely by geography and health outcome. Heat-attributable burden starts to occur at moderately hot heat index values, which in some regions are below the alert ranges used by the NWS during the study time period. Locally specific health evidence can beneficially inform and calibrate heat alert criteria. A synchronization of health findings with traditional weather forecasting efforts could be critical in the development of effective heat–health early warning systems.

Recent climate studies have predicted a future with longer, more intense, and more frequent heat events. Evolving challenges presented by this paradigm necessitate an assessment of current efforts to warn for extreme heat events. NOAA’s National Weather Service (NWS) Weather Forecast Offices (WFOs) issue Excessive Heat Watch, Excessive Heat Warning, and Heat Advisory products as conditions warrant. In the fall of 2013 the NWS conducted an internal assessment with its WFOs to 1) document variations in the usage of heat-based watch, warning, and advisory hazard messages (products) across the country; 2) learn about the degree to which locally developed criteria are applied to forecaster decision-making processes in issuing these products; and 3) gather ideas for enhancing communication of expected excessive heat events in general. Survey responses indicate that WFOs selectively use one or a combination of products, and that various methodologies are used to develop criteria for issuing heat products. Given that forecasters use meteorological and nonmeteorological factors when deciding to issue heat products, forecaster judgment is a crucial element of the warning process. Results also revealed partner confusion due to inconsistent heat product issuance criteria. Suggestions were made for eliminating or revising existing products and policies, or creating new products, policies, or issuance criteria. Results of the survey led the NWS to investigate approaches for achieving higher levels of consistency in heat product issuance criteria, and to engage health partners to examine how heat product issuance criteria could incorporate the known health impacts of heat exposure.