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COVID-19 Crisis Standards of Care Resources
Topic Collection
November 23, 2022

Topic Collection: COVID-19 Crisis Standards of Care Resources

This Topic Collection focuses on plans, tools, templates, and other immediately implementable resources to help with COVID-19 preparedness, response, recovery, and mitigation efforts, focusing on crisis standards of care (CSC). Implementing CSC in a hospital setting should be a last resort when all other surge strategies have failed and no other regional resources are available. Planners need to account for three domains:

·       Concept of operations – What is the process for making decisions? Who makes the decisions? How is this integrated with the incident command system?

·       Criteria – What will the decisions be based upon? Using the best evidence available, primarily  prioritizing interventions on the basis of prognosis and duration of use.

·       Coordination – How does the facility coordinate with others in the area through healthcare coalition/ other constructs to assure consistency of care and decision making?

The following are selected best practices designed for quick reference and application.

Please refer to CDC’s Coronavirus Disease 2019 webpage for the most up-to-date clinical guidance on COVID19 outbreak management.

If you have COVID-19 best or promising practices, plans, tools, or templates to share with your peers, please visit the ASPR TRACIE Information Exchange COVID-19 Information Sharing Page (registration required) and place your resources under the relevant topic area. Resources specific to CSC can be placed under the COVID-19 Crisis Standards of Care Resources Topic.

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General Resources

American Medical Association. (2020). Crisis Standards of Care: Guidance from the AMA Code of Medical Ethics.
This document highlights guidance from the AMA Code of Medical Ethics relevant to physicians making decisions about the allocation of scarce resources during the COVID-19 pandemic.
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American Nurses Association. (2020). Crisis Standards of Care: COVID-19 Pandemic.
This document provides guidance to registered nurses and institutions about the provision of patient care during extreme circumstances such as the COVID-19 pandemic.
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American Public Health Association and National Academy of Medicine. (2020). Crisis Standards of Care During COVID-19.
This webinar was the fourth in a series of COVID-19 Conversations. Presenters offered an overview of crisis standards of care, discussed adapting them during the COVID-19 pandemic, and highlighted practical and ethical considerations of enacting crisis standards of care. The webinar recording, transcript, and presenter slides are available for review.
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Antiel, R., Curlin, F., Persad, G., et al. (2021). Should Pediatric Patients be Prioritized When Rationing Life-Saving Treatments during the COVID-19 Pandemic? Pediatrics. doi: 10.1542/peds.2020-012542..
This article addresses the ethical underpinnings of considering the needs of children versus adults during the COVID-19 pandemic when resources may be scarce.
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ASPR TRACIE. (2020). COVID-19 Patient Surge and Scarce Resource Allocation.
The resources on this page can help healthcare and emergency management planners prepare for surges of COVID-19 patients.
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ASPR TRACIE. (2020). Crisis Standards of Care and COVID-19: What’s Working and What Isn’t (Webinar).
The speakers in this webinar discussed clinical consultation versus triage support, systems-level information sharing, coalition-level coordination activities, and recent publications/resources to help with crisis standards of care planning efforts.
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ASPR TRACIE. (2020). Crisis Standards of Care and Infectious Disease Planning.
This ASPR TRACIE Technical Assistance response covers Crisis Standards of Care (CSC) for infectious diseases.
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ASPR TRACIE. (2021). Innovations in COVID-19 Patient Surge Management (Tip Sheet).
This ASPR TRACIE tip sheet summarizes four healthcare executives’ experience with statewide patient surge management during COVID-19 and lessons learned gleaned from other resources. (Access the full report here: https://files.asprtracie.hhs.gov/documents/innovations-in-covid-19-patient-surge-management-final-508.pdf)
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ASPR TRACIE. (2022). ASPR TRACIE Crisis Standards of Care Briefs-Summary.
This resource includes links to quick sheets on crisis standards of care (CSC) considerations. Topics include principles of CSC, information for planners and healthcare providers, clinical allocation decisions, public messaging, and roles and responsibilities.
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ASPR TRACIE. (2022). Hospital Strain Mitigation Strategies.
This ASPR TRACIE technical assistance response describes strategies for addressing strain on U.S. hospitals (due in part to increases in seasonal respiratory viruses and issues with available space and staffing), including specific data points and operational strategies.
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ASPR TRACIE. (2022). Issue 15: Ethics in Healthcare during Disasters.
The articles in this issue focus on ethical dilemmas during and beyond COVID-19, ethical issues specific to COVID-19 treatment and vaccination, crisis standards of care, and patient load balancing.
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Biddison, E., Gwon, H., Schoch-Spana, M. et al. (2018). Scarce Resource Allocation During Disasters: A Mixed-Method Community Engagement Study. Chest. 153(1):187-195.
The authors conducted a series of 15 discussions with 324 members of the public and health-related professionals to characterize the public's values regarding how scarce mechanical ventilators should be allocated during an influenza pandemic, and to inform a statewide scare resource allocation framework. They concluded that awareness of how “the values expressed by the public and front-line clinicians sometimes diverge from expert guidance in important ways,” should inform policy making.
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Christian, M., Sprung, C., King, M., et al. (2014). Triage: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement.
The 11 suggestions highlighted in this article can help those involved in large-scale pandemics or disasters with multiple critically ill or injured patients (e.g., front-line clinicians and hospital administrators) make more informed decisions about critical care triage.
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COVID-19 Healthcare Resilience Task Force. (2020). COVID-19: Considerations, Strategies, and Resources for Emergency Medical Services Crisis Standards of Care.
This document provides an overview of general considerations, potential strategies, and existing resources that emergency medical services (EMS) agencies may use to inform changes to their operations and standards of care to preserve and effectively allocate EMS during the COVID-19 pandemic.
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COVID-19 Healthcare Resilience Working Group. (2020). COVID-19: Considerations, Strategies, and Resources for Crisis Standards of Care in Post-Acute and Long-Term Care (PALTC) Facilities.
This document provides select healthcare entities (e.g., nursing homes, assisted living facilities, Intermediate Care Facilities for Individuals with Intellectual Disabilities, long-term acute care hospitals, inpatient rehabilitation facilities, and dedicated hospice facilities) an overview of general considerations, potential strategies, and existing resources they may use to inform changes to their COVID-19 related operations and crisis standards of care (CSC) processes. It is intended to complement, not replace, existing state and/or local guidance and plans for implementing CSC.
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Devereaux, A., Tosh, P., Hick, J., et al. (2014). Engagement and Education. Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. Chest. 146(4 Suppl):e 118S–e133S.
This panel of experts reviewed the literature and developed 23 suggestions into four categories related to clinician engagement and education: situational awareness, clinician roles and responsibilities, education, and community engagement.
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Dichter, J., Devereaux, A., Sprung, C., et al. (2021). Mass Critical Care Surge Response during COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings from the Task Force for Mass Critical Care. (Added 9/9/2021) Chest Journal .
This article presents ten new suggestions from the Task Force for Mass Critical Care based on the response to COVID-19 to help hospitals and communities operationalize strategies to avoid crisis standards of care. These suggestions focus on staffing, load-balancing, communications, and technology.
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Emanuel, E., Persad, G., Upshur, R., et al. (2020). Fair Allocation of Scarce Medical Resources in the Time of COVID-19. The New England Journal of Medicine.
The authors review health impacts of moderate to severe pandemics, health system capacity, and ethical values for rationing health resources in a pandemic. They offer six recommendations to address the question of who should get health resources during the COVID-19 pandemic: 1) maximizing benefits, 2) targeting critical interventions to those caring for ill patients and operating critical infrastructure first, 3) randomizing allocation for those with similar prognoses, 4) differing prioritization guidelines by intervention and altering those guidelines based on changing scientific evidence, 5) prioritizing interventions to reward those willing to assume personal risk by participating in safety and effectiveness research, and 6) allocating scarce resources to patients with COVID-19 and those with other conditions in the same way.
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Hick, J. (2020). Critical Care Planning - COVID-19 Quick Notes.
This two-pager summarizes critical care planning for COVID-19. It includes a figure depicting the expansion of critical care from conventional to contingency/crisis levels. The document offers key points to operationalize the concept in terms of space, staffing, supplies and to provide critical care.
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* Hick, J., Hanfling, D., and Wynia, M.. (2022). Hospital Planning for Contingency and Crisis Conditions: Crisis Standards of Care Lessons from COVID-19. The Joint Commission Journal on Quality and Patient Safety.
The authors highlight gaps in contingency and crisis standards of care planning uncovered during the COVID-19 pandemic and provide recommendations for hospitals that can help ensure an effective, fair response in the future.
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Hick, J., Hanfling, D., Wynia, M., and Pavia, A. (2020). Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2. National Academy of Medicine .
This discussion paper describes the application of crisis standards of care principles to clinical care challenges posed by a coronavirus or other epidemic or pandemic. The authors encourage healthcare facilities to develop a process for decision making based on the best available clinical information and built upon existing surge capacity plans.
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Hick, J., Hanfling, D., Wynia, M., and Toner E. (2021). Crisis Standards of Care and COVID-19: What Did We Learn? How Do We Ensure Equity? What Should We Do? (Added 8/30/2021.) National Academy of Medicine .
This discussion paper reviews some of the lessons learned related to crisis standards of care principles and practices during the COVID-19 pandemic and identifies issues and action steps for the future.
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Hodge, Jr, J.. (2020). Legal & Regulatory Challenges to Crisis Standards of Care (CSC) in Response to COVID-19. (Added 12/15/2020.) The Network for Public Health Law.
This brief overview of challenges to crisis standards of care applied in the early days of the COVID-19 pandemic links to related articles, letters and regulations.
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Keller, M., Want, J., Nason, M., et al. (2022). Preintubation Sequential Organ Failure Assessment Score for Predicting COVID-19 Mortality. (Abstract only.) Critical Care Medicine.
The authors reviewed a U.S. cohort of 15,000 ventilated patients with COVID-19 hospitalized between January 1, 2020, and February 14, 2021 to validate the predictive capacity of the preintubation SOFA score. They found the tool has low accuracy for predicting mortality and recommend reviewing triage pathways.
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Minnesota Department of Health. (n.d.). Health Care Considerations – Crisis Standards of Care. (Accessed 3/24/2020.)
This web page includes several resources that healthcare facilities may use to plan for medical surge caused by COVID-19.
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National Academies of Sciences, Engineering, and Medicine. (2020). Rapid Expert Consultation on Crisis Standards of Care for the COVID-19 Pandemic. The National Academies Press.
This rapid expert consultation articulates guiding principles, key elements, and core messages undergirding crisis standards of care decision making. The document is also available to read or download at https://www.nap.edu/catalog/25765/rapid-expert-consultation-on-crisis-standards-of-care-for-the-covid-19-pandemic.
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National Academies of Sciences, Engineering, and Medicine. (2020). Rapid Expert Consultation on Staffing Considerations for Crisis Standards of Care for the COVID-19 Pandemic (July 28, 2020).
This resource builds upon prior consultation (issued on March 28, 2020) and focuses on Crisis Standards of Care and staffing needs--including deployment and allocation of expert clinical staff--to ensure the care of COVID-19 patients.
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National Academy of Medicine and Others. (2020). Nine National Organizations Call for Action to Implement Crisis Standards of Care During COVID-19 Surge.
Nine national organizations call on leaders to implement crisis standards of care to "do the most good possible for the largest number of people with limited resources."
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National Hospice and Palliative Care Organization. (2020). Crisis Standards of Care in Hospice & Palliative Care Emergency Management.
This document defines and highlights the impact of crisis standards of care (CSC) on palliative and hospice care. It also includes a table with links to state-specific CSC information.
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NRCC Healthcare Resilience Task Force. (2020). Crisis Standards of Care and Civil Rights Laws.
This document highlights language that supports the adherence to civil rights laws and disability rights laws in the application of Crisis Standards of Care during resource-constrained emergencies, such as the COVID-19 pandemic.
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SCCM, AARC, ASA, APSF, AACN, and CHEST. (2020). Joint Statement on Multiple Patients Per Ventilator.
This consensus statement issued by the Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF), American Association of Critical-Care Nurses (AACN), and American College of Chest Physicians (CHEST) recommends that mechanical ventilators not be shared by multiple COVID-19 patients.
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Toner, E. (2021). Potential Solutions to the COVID-19 Oxygen Crisis in the United States.
This memoranda highlights findings from a virtual meeting held in January 2021 with frontline clinicians and public health officials from across the U.S. who discussed how they were meeting challenges associated with oxygen and supply shortages.
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Truog, R., Mitchell, C., and Daley, G. (2020). The Toughest Triage – Allocating Ventilators in a Pandemic. The New England Journal of Medicine.
Based on the currently available number of ventilators in the US in acute care hospitals and the Strategic National Stockpile, the authors of this perspective article estimate that each ventilator may be needed for a range of 1.4 to 31 patients during the COVID-19 pandemic. To prepare for the potential need to ration ventilators, the authors suggest establishing a committee excluding clinicians providing patient care to set the triage criteria and adjust those criteria as the overall situation changes. Additionally, they recommend proactive engagement with high-risk patients and their families about “do not intubate” orders and establishing a voluntary team with palliative care and emotional support expertise to withdraw mechanical ventilation rather than those clinicians caring for patients.
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Washington State Department of Health and Northwest Healthcare Response Network. (2020). Scarce Resource Management and Crisis Standards of Care: Overview and Materials.
This resource provides: background information on crisis standards of care, scarce resource cards for potentially limited resources, algorithms, worksheets, triage team guidelines, and implementation recommendations.
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Plans, Tools, and Templates

ASPR TRACIE. (2020). SOFA Score: What it is and How to Use it in Triage.
The Sequential Organ Failure Assessment (SOFA) score was designed as a research tool so that groups of patients could be categorized based on their risk of death. This fact sheet includes an overview of the score, how it is calculated, and how it can be used in triage situations.
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Colorado Department of Public Health and Environment. (2020). Annex B: Colorado Crisis Standards of Care Plan. CDPHE All Hazards Internal Emergency Response and Recovery Plan.
This comprehensive crisis standards of care plan outlines state-level process and decision making and resource allocation during events that surpass available capacities and capabilities and provides a structure for clinical decisions (though some of the triage decision tools are not the most current). The plan also details a robust engagement and development process.
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Hanfling, D., Hick, J., and Stroud, C. (2013). Crisis Standards of Care: A Toolkit for Indicators and Triggers. Institute of Medicine, Washington, DC: National Academies Press.
This toolkit contains key concepts, guidance, and practical resources to help individuals across the emergency response system develop plans for crisis standards of care and respond to a catastrophic disaster. It includes sample indicators, triggers, and sample tactics for use in the transition from conventional surge to contingency surge to crisis surge, and a return from crisis response to conventional response including templates for no-notice and prolonged incidents.
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Hanfling, D., Hick, J., and Stroud, C. (2013). Crisis Standards of Care: A Toolkit for Indicators and Triggers – Table 8-1. (Free registration required.) Institute of Medicine, Washington, DC: National Academies Press.
Table 8.1 provides specific indicators, triggers, and tactics for hospitals to use along the continuum of care during the COVID-19 pandemic.
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* Hick, J., Hanfling, D., and Wynia, M.. (2022). Hospital Planning for Contingency and Crisis Conditions: Crisis Standards of Care Lessons from COVID-19. The Joint Commission Journal on Quality and Patient Safety.
The authors highlight gaps in contingency and crisis standards of care planning uncovered during the COVID-19 pandemic and provide recommendations for hospitals that can help ensure an effective, fair response in the future.
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Massachusetts General Hospital. (2020). Procedure to Maximize the Effectiveness of Ventilator Distribution Across States.
This document outlines a process states can use to gather hospital data needed to identify where ventilators are needed and deliver them directly to receiving hospitals.
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Minnesota Department of Health. (n.d.). Health Care Considerations – Crisis Standards of Care – Health Care Facility Scarce Resource Decision-Making Tree. (Accessed 3/24/2020.)
This decision tree is intended for use by healthcare facilities to guide triage planning during a CSC situation.
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Minnesota Department of Health. (n.d.). Health Care Considerations – Crisis Standards of Care – Template: Facility Crisis Standard of Care Plan. (Accessed 7/28/2022.)
This Word template may be used by healthcare facilities to develop a CSC plan.
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Various Authors. (2020). Model Hospital Policy for Fair Allocation of Scarce Medications to Treat COVID-19. University of Pittsburgh School of Medicine, Department of Critical Care Medicine.
This model offers a framework to make allocation decisions for COVID-19 medications when an insufficient supply is available. A trained allocation team – not the treating clinicians – would prioritize which eligible patients receive treatment using a lottery system weighted toward essential workers and individuals from disadvantaged areas.
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Western Regional Alliance for Pediatric Emergency Management. (2021). Pediatric Crisis Standards of Care Template.
This template provides background rationale and considerations for the use of crisis standards of care (CSC), examples of scoring systems, links to state CSC pediatric annexes, a pediatric CSC reference table, and legal decision factors.
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