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Crisis Standards of Care
Topic Collection
April 14, 2025

Topic Collection: Crisis Standards of Care

The provision of medical care under catastrophic disaster conditions or conditions of extreme shortages of supplies that place patients at substantial risk requires considerable planning, along with the recognition that the delivery of healthcare services will likely change due to the potential scarcity of required resources. Beginning in 2009, ASPR has focused significant attention on “crisis standards of care,” spearheaded by the issuance of three reports by the Institute of Medicine/ National Academies of Medicine. This work provides a roadmap for medical decision-making during events where allocation or triage decisions are necessary. Coordination of emergency response system planning is critical to limit patient morbidity and mortality in an environment of collective rather than individual priorities. The standards of care proposed under the delivery of such conditions must represent a “reasonable” approach to healthcare service delivery merging public health, ethical, and medical care demands, albeit under unique and challenging conditions.

Note the Sequential Organ Failure Assessment (SOFA) score has been a popular basis for triage systems for critical care in the past. Based on findings highlighted in articles from 2010 to present, the use of SOFA as a major or sole criterion is not ethically justifiable. This Topic Collection includes plans that have adjusted their criteria to a comparative use but also notes this limitation for a few otherwise excellent plans. For more information, access Christian et al. (2014) and the ASPR TRACE document SOFA Score: What it is and How to Use it in Triage. Current hospital planning should de-emphasize scoring systems in favor of individual prognostic assessment. ASPR TRACIE has developed a template for hospital crisis decision-making that may be helpful.

For additional information on the ethical basis for CSC decision-making and other ethical issues in disaster medicine, access the Disaster Ethics Topic Collection.

Note: Some resources included in this Collection were published more than 10 years ago and are included because they include foundational findings, strategies, and/or considerations.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

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Must Reads

ASPR TRACIE. (2024). 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. (2024). Crisis Standards of Care Considerations: Summary.
In this series of tipsheets, ASPR TRACIE provides brief summaries of specific areas of concern specific to crisis standards of care for healthcare providers and their facilities/health systems. These considerations were designed to inform and support the challenging decisions that occur under contingency and crisis conditions.
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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. Note some specific triage recommendations are dated but this is an excellent overview.
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Hanfling, D., Altevogt, B.M., Viswanathan, K., and Gostin, L.O. (eds.). (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Institute of Medicine. National Academies Press.
This foundational report of crisis standards of care philosophy and planning was designed to help authorities operationalize the concepts first developed in the 2009 Institute of Medicine Report titled, “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report.” It provides practical templates and toolkits for the emergency response disciplines and emphasizes the importance of a systems framework. This report also includes a “public engagement” template specifically to guide communities in hosting meetings and encourages the inclusion of citizens in their policy process.
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  • John Hick The IOM report looks intimidating, but is broken into sections based on discipline - one of the best ways to approach it is to look at the end of your relevant section at the outline of the 'functions' - if you're already done with some of them you can move on to the next and reference back in the text for further details on ones where you haven't made enough progress
    8/1/2015 11:04:53 PM
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. Discussion Paper, National Academy of Medicine, Washington, DC..
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? 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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Kelen, G., Marcozzi, D., Marx, J., and Kachalia, A.. (2023). Criteria for Declaring Crisis Standards of Care: A Single, Uniform Model. (Abstract only.) NEJM Catalyst.
The authors created criteria and related threshold triggers (based on eight categories) that allow acute care hospital staff to declare and terminate Crisis Standards of Care (CSC) and may serve as a regional model to help define when crisis care is occurring.
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Minnesota Department of Health, Center for Emergency Preparedness and Response, Minnesota Healthcare Preparedness Program. (2020). Patient Care Strategies for Scarce Resource Situations.
This card set can help facilitate an orderly approach to resource shortfalls at a healthcare facility. It is a decision support tool to be used by key personnel, along with incident management, who are familiar with ethical frameworks and processes that underlie these decisions.
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Minnesota Department of Health, Office of Emergency Preparedness. (2020). Crisis Standards of Care.
This website includes links to several critical crisis standards of care (CSC) resources and tools including the MN CSC Framework (released in November 2018) which provides an overview of the actions the state will take in response to a CSC situation. The framework also includes operational annexes for Ethics, Legal, EMS, Hospitals, and Public Engagement. The site also contains other resources including a summary report on community engagement, pandemic, and other resources.
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Wynia, M. (2020). Crisis Triage-Attention to Values in Addition to Efficiency. JAMA Network Open. 3(12):e2029326.
Researchers examined the use of two triage models on 2014/2015 data from 208 U.S. hospitals to determine their utility, consistency (i.e., whether both protocols rate patients as low or high priority), and accuracy (the number of patients with lowest priority that died prior to discharge). Researchers found that both protocols would likely be of limited utility in a catastrophic disaster with a shortage of ventilators, as each prioritized patients differently. The author emphasizes the need to incorporate additional principles into triage, particularly in the event of a pandemic.
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Community and Provider Engagement

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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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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Institute of Medicine. (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. The National Academies Press.
This foundational document summarizes expert guidance specific to providing healthcare during a public health emergency or in the aftermath of a disaster, when resources are scarce. It is separated into seven volumes: Introduction and CSC Framework; State and Local Government; EMS; Hospital; Alternate Care Systems; Public Engagement; and Appendices.
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Li-Vollmer, M., Beebe, A., Kite, H., et al. (2009). Public Engagement Project on Medical Service Prioritization during an Influenza Pandemic. Public Health-Seattle & King County.
Public Health-Seattle & King County hosted four public engagement forums to discuss the rationing of scarce resources during a severe pandemic influenza. This report summarizes themes that emerged from the forums.
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* Minnesota Department of Health, Office of Emergency Preparedness. (2020). Crisis Standards of Care.
This website includes links to several critical crisis standards of care (CSC) resources and tools including the MN CSC Framework (released in November 2018) which provides an overview of the actions the state will take in response to a CSC situation. The framework also includes operational annexes for Ethics, Legal, EMS, Hospitals, and Public Engagement. The site also contains other resources including a summary report on community engagement, pandemic, and other resources.
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Education and Training

Hick, J., Witte, C., Hanfling, D., and Raheem, M. (2018). Crisis Standards of Care-Panel Presentation.
The speakers provide a definition and legal overview of crisis standards of care (CSC), illustrate how the principles of CSC apply to disaster medical care, and share how to apply CSC into emergency planning. An overview of ethics and disaster response is also included, as are lessons learned from recent incidents (e.g., Hurricane Maria, the 2014 Ebola outbreak, and the earthquake that struck Haiti in 2010).
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Iserson, K. (2007). Part 1: Resource Allocation – The Ethical Justification. The University of Arizona, Arizona Bioethics Program.
In this webinar, the speaker discusses when healthcare resources should be rationed, why healthcare resources should be rationed, and the ethical justification for rationing resources.
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Iserson, K. (2007). Part 2: How to Ration Healthcare Resources. The University of Arizona, Arizona Bioethics Program.
Webinar participants will learn more about: 1) what triggers indicate that healthcare resource rationing is necessary, 2) what actions can be taken to ration healthcare resources, 3) what general treatment priorities should be implemented, and 4) why stakeholder validation is vital.
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Iserson, K. (2016). Improvised Medicine: Providing Care in Extreme Environments. (Book available for purchase.)
Healthcare providers can use this information to increase their knowledge and ability to perform medicine in overwhelming scenarios (e.g., mass casualty incidents, and resource-poor/ austere environments). The author shares that he tested the methods and equipment in clinical practice in the U.S. and abroad.
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* McCulley, K., Lozon, M., Hodge, J., and DeBruin, D. (2024). Pediatric Crisis Standards of Care. Pediatric Pandemic Network.
Speakers emphasized the need to include pediatric patients in crisis standards of care planning and highlighted strategies for addressing related legal and ethical considerations. Access the slides here: https://files.constantcontact.com/332bf3d1601/99af8e0d-cc58-42ca-85f3-ceb416f3abd7.pdf
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Simulation Use for Global Away Rotations. (2018). Procedural Education for Adaptation to Resource Limited Settings (PEARLS).
The videos on this page can teach healthcare providers to perform traditional procedures (e.g., lumbar punctures, burn dressing) without the typical supplies on hand.
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Wynia, M. (2021). Ethics Talk: Rationing Critical Care During COVID Surge.
The speaker shares his experiences and challenges associated with implementing crisis standards of care during patient surge.
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Guidelines and Strategies

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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ASPR TRACIE. (2016). The Exchange, Issue 1. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
The inaugural issue of the ASPR TRACIE newsletter focuses on mass casualty incident response and crisis standards of care (CSC). It includes articles written by authors with experience in local, state, and federal CSC planning.
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ASPR TRACIE. (2018). Considerations for Oxygen Therapy in Disasters.
This ASPR TRACIE fact sheet provides information on the types of oxygen therapy and the types of oxygen supplies generally available as oxygen therapy was a limiting factor in many hospitals during the pandemic. It also provides information on the typical sizes and length of use of various oxygen storage methods. Conservation methods are also described.
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ASPR TRACIE. (2024). 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. (2024). Crisis Standards of Care Considerations: Summary.
In this series of tipsheets, ASPR TRACIE provides brief summaries of specific areas of concern specific to crisis standards of care for healthcare providers and their facilities/health systems. These considerations were designed to inform and support the challenging decisions that occur under contingency and crisis conditions.
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ASPR TRACIE. (2024). Medical Operations Coordination Centers.
Healthcare systems were pushed to the brink during the pandemic, and many continue to experience abnormal levels of strain that often impact patient census, bed availability, and the ability of tertiary care centers to accept transfers. Many states primarily use two techniques to ensure patients have the best possible access to care: load balancing and transfer management systems. This brief describes the centers that provide these services (Medical Operations Coordination Centers, or MOCCs) that help avoid or mitigate crisis conditions.
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ASPR TRACIE and ASTHO. (2017). Clinicians and Coalitions: A Conversation about Finding Solutions for Medication Shortages.
The speakers in this webinar: provided an overview of the medication shortages and their clinical impact; described coping strategies for scarce resources; and discussed the decision- making strategies states, coalitions, and healthcare facilities have used based on crisis standards of care principles. Speakers also responded to questions received from participants in a facilitated discussion (available here: https://files.asprtracie.hhs.gov/documents/aspr-tracie-medication-shortage-webinar-discussion-questions.pdf)."
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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. Note some specific triage recommendations are dated but this is an excellent overview.
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Dries, D., Reed, M., Kissoon, N., et al. (2014). Special Populations: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. Chest. 146(4 Suppl):e75S–e86S.
The panel developed 14 suggestions specific to caring for critically ill or injured populations during public health emergencies or disasters. Suggestions are categorized under the following: “defining special populations for mass critical care, special population planning, planning for access to regionalized service for special populations, triage and resource allocation of special populations, therapeutic considerations, and crisis standards of care for special populations.”
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Einav, S., Hick, J., Hanfling, D., et al. (2014). Surge Capacity Logistics: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. Chest. 146(4_supplement):e17S–e43S.
The authors list 22 suggestions specific to surge capacity and mass critical care under the following topics: stockpiling of equipment, supplies, and pharmaceuticals; staff preparation and organization; patient flow and distribution; deployable critical care services; and using transportation assets to support surge response.
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Geiling, J., Burkle, F., West, T., et al. (2014). Resource-Poor Settings: Response, Recovery, and Research: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. Chest. 146(4 Suppl):e168S-77S.
The "Resource-Poor Settings panel" developed 33 suggestions in response to five questions about providing care in resource poor settings during public health emergencies and disasters. This chapter is part II (of II) and focuses on response, recovery, and research.
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Hanfling, D., Altevogt, B.M., Viswanathan, K., and Gostin, L.O. (eds.). (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Institute of Medicine. National Academies Press.
This foundational report of crisis standards of care philosophy and planning was designed to help authorities operationalize the concepts first developed in the 2009 Institute of Medicine Report titled, “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report.” It provides practical templates and toolkits for the emergency response disciplines and emphasizes the importance of a systems framework. This report also includes a “public engagement” template specifically to guide communities in hosting meetings and encourages the inclusion of citizens in their policy process.
Favorite:
1
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  • John Hick The IOM report looks intimidating, but is broken into sections based on discipline - one of the best ways to approach it is to look at the end of your relevant section at the outline of the 'functions' - if you're already done with some of them you can move on to the next and reference back in the text for further details on ones where you haven't made enough progress
    8/1/2015 11:04:53 PM
Hanfling, D., Hick, J., and Stroud, C. (2013). Crisis Standards of Care: A Toolkit for Indicators and Triggers. (Free registration required.) Institute of Medicine: 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. Chapter 7 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 (detailed specifically for emergency medical services using slow-onset and no-notice scenarios).
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Hanfling, D., Hick, J., and Stroud, C. (2013). Crisis Standards of Care: A Toolkit for Indicators and Triggers Table 7-1. Institute of Medicine, Washington, DC: National Academies Press.
Table 7.1 provides specific indicators, triggers, and tactics for EMS to use along the continuum of care during the COVID-19 pandemic.
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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. 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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Hermelin, D., Alcorn, K., Gammon, R., et al. (2024). Futility and Potentially Inappropriate Treatment in Massive Transfusion. Blood Bulletin. 24(2).
These considerations can help healthcare providers determine potentially inappropriate treatment in massive transfusion, particularly during severe blood shortages (e.g., during a public health emergency or mass casualty incident).
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Hick, J. L., Barbera, J. A., and Kelen, G.D. (2009). Refining Surge Capacity: Conventional, Contingency, and Crisis Capacity. (Abstract only.) Disaster Medicine and Public Health Preparedness. 3(2 Suppl): S59-67.
In this article, the authors provide the original description of the the three-level surge capacity taxonomy (conventional capacity, contingency capacity, and crisis capacity) to bolster hospital surge planning. This construct has been used by the National Academies of Medicine and other organizations.
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Hick, J., Einav, S., Hanfling, D., et al. (2014). Surge Capacity Principles: Care of the Critically Ill and Injured During Pandemics and Disasters. Chest. 146(4_supplement): e1S–e16S.
This article presents 10 suggestions pertaining to the principles that should guide surge capacity and capability planning for mass critical care in disasters or pandemics.
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* Maves, R., Downar, J., Dichter, J., et al. (2020). Triage of Scarce Critical Care Resources in COVID-19: An Implementation Guide for Regional Allocation. Chest Journal. 158(1):212-225.
This expert panel report by the Task Force for Mass Critical Care and the American College of Chest Physicians offers a framework to equitably meet the clinical needs of the greatest number of patients when resources are scarce.
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* McCulley, K., Lozon, M., Hodge, J., and DeBruin, D. (2024). Pediatric Crisis Standards of Care. Pediatric Pandemic Network.
Speakers emphasized the need to include pediatric patients in crisis standards of care planning and highlighted strategies for addressing related legal and ethical considerations. Access the slides here: https://files.constantcontact.com/332bf3d1601/99af8e0d-cc58-42ca-85f3-ceb416f3abd7.pdf
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* Minnesota Department of Health, Office of Emergency Preparedness. (2020). Crisis Standards of Care.
This website includes links to several critical crisis standards of care (CSC) resources and tools including the MN CSC Framework (released in November 2018) which provides an overview of the actions the state will take in response to a CSC situation. The framework also includes operational annexes for Ethics, Legal, EMS, Hospitals, and Public Engagement. The site also contains other resources including a summary report on community engagement, pandemic, and other resources.
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* National Academies of Sciences, Engineering, and Medicine. (2020). Crisis Standards of Care: Ten Years of Successes and Challenges – Proceedings of a Workshop.
This report synthesizes the conversations from a 2019 workshop where participants reviewed the successes and gaps over the last decade of crisis standards of care work to help plan future work.
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Network for Public Health Law. (2025). Crisis Standards of Care.
This webpage provides links to resources, guidance, and information on crisis standards of care, state invocations, liability, and other related topics.
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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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Phillips, S.J., Knebel, A., and Johnson, K.. (2007). Mass Medical Care with Scarce Resources: A Community Planning Guide.
Chapter VI of this guide provides an overview of the issues surrounding non-federal, non-hospital-based alternative care sites (ACS). Different types of ACS are described, and factors associated with decision making during mass casualty events are highlighted. Sample case studies are also included including several from Hurricane Katrina.
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* Sharpe, V., Berkowitz, K., Cecire, R., et al. (2010). Meeting the Challenge of Pandemic Influenza: Ethical Guidance for Leaders and Health Care Professionals in the Veterans Health Administration. U.S. Department of Veterans Affairs.
This guidance document is divided into five sections on ethical preparedness and response in a healthcare system: 1) an overview of ethical challenges; 2) workforce capacity and responsibility; 3) resource allocation; 4) hospice and palliative care; and 5) limiting personal liberty to preserve public health. The document also includes a checklist for implementing the plan guidance.
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* Zaza, S., Koonin, L., Ajao, A., et al. (2016). A Conceptual Framework for Allocation of Federally Stockpiled Ventilators During Large-Scale Public Health Emergencies. (Registration required.) Health Security. 14(1):1-6.
The authors describe a conceptual framework for the distribution of ventilators stockpiled by the federal government during a large-scale emergency. They identify necessary planning steps to aid in the optimal allocation of ventilators to individual hospitals.
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Lessons Learned

ASPR TRACIE. (2024). Crisis Standards of Care: Lessons From the COVID-19 Pandemic.
Dr. John Hick describes how the crisis standards of care concept and practice has changed since the COVID-19 pandemic.
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ASPR TRACIE. (2025). Crisis Standards of Care-Insights from COVID-19 and Pharmaceutical Supply Challenges Webinar.
The speakers in this webinar shared signs of crisis standards of care, indicators that signal this transition, considerations for managing care to ensure ethical and efficient decision-making, and lessons learned from recent staffing and supply challenges.
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Butler, C.R., Wightman, A., Taylor, J.S., et al. (2023). Experiences of US Clinicians Contending With Health Care Resource Scarcity During the COVID-19 Pandemic, December 2020 to December 2021.. JAMA Network Open. 6(6):e2318810
The authors interviewed 23 practitioners to better understand the effects of extreme resource scarcity on their experiences during the pandemic. Many reported losing a sense of motivation and purpose over time, particularly when they experienced little institutional support. The authors encourage the inclusion of healthcare practitioners in the institutional resource scarcity planning process.
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Devereaux, A., Yang, H., Seda, G., et al. (2020). Optimizing Scarce Resource Allocation During COVID-19: Rapid Creation of a Regional Health-Care Coalition and Triage Teams in San Diego County, California.
The authors describe the rapid development of a healthcare coalition in response to the COVID-19 pandemic with a crisis care committee and other workgroups focused on sharing scarce resources, developing and training triage teams, and providing situational awareness.
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Dichter, J., Brown, D., Zamorano, C., et al. (2024). The Minnesota Critical Care Working Group 1: Monitoring and Coordinating Statewide Critical Care Surge Response in the COVID-19 Pandemic, March 2020 through July 1, 2021. (Abstract only.) CHEST (in press).
This article details the formation of the working group and how they collaborated to develop a statewide response to the COVID-19 pandemic that can serve as a model for future events.
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* Dudzinski, D., Hoisington, B., and Brown, C. (2020). Ethics Lessons from Seattle's Early Experience with COVID-19. American Journal of Bioethics. 20(7):67-74.
The authors describe UW Medicine's ethical decision-making related to preparations for and early response to the COVID-19 pandemic. It includes the health system's contributions to healthcare coalition activities as the Regional COVID-19 Coordination Center and participation of faculty in drafting and revising the Northwest Healthcare Response Network's guidance for the region.
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Fink, S. (2018). PrepTalks: Triage, Ethics and Operations - Healthcare Emergency Preparedness and Response. Federal Emergency Management Agency.
The speaker shares stories from two disasters and emphasizes the importance of planning for crisis standards of care operations, to include scarce resource allocation.
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Fong, K., Summers, C., and Cook, T. (2024). NHS Hospital Capacity during COVID-19: Overstretched Staff, Space, Systems, and Stuff. BMJ. 385:e075613.
The authors offer lessons learned from the COVID-19 pandemic about how intensive care units in the United Kingdom managed patient surge. They note that while ICUs were able to expand their space, they lacked the staffing and supplies to use it effectively; patient surge occurred unevenly throughout the country but there was strain throughout the health care system; redeployment of staff to ICUs led to surgical backlogs; and health care workers became infected disproportionately and faced significant psychological harm. The authors encourage future responses to assess surge capacity and strain in other than numerical counts and to protect the well-being of staff.
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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 Toner E. (2021). Crisis Standards of Care and COVID-19: What Did We Learn? How Do We Ensure Equity? What Should We Do? 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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Kadri, S., Sun, J., Lawandi, A., et al. (2021). Association Between Caseload Surge and COVID-19 Survival in 558 U.S. Hospitals, March to August 2020. (Abstract only.) Annals of Internal Medicine. 174(9).
The authors assessed the effects of hospital surge on COVID-19 mortality through a retrospective cohort study of administrative hospital data. They found an association between surge and mortality risk and suggested that nearly one in four COVID-19 deaths studied could be attributed to hospital surge illustrating that many hospitals were in crisis conditions that may have not been well-recognized.
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Kesler, S., Bastin De Jong, C., Chell, C., et al. (2024). The Minnesota Critical Care Working Group 2: Crisis Conditions during the COVID-19 Pandemic, July 2021 through March 2022. (Abstract only.) CHEST (in press).
The authors describe how a statewide working group analyzed real-time evidence to identify crisis conditions (using group consensus on operating conditions; federal tele-Tracking data; MOCC patient placement data; and two surveys created and distributed to hospitals and healthcare professionals). Despite successfully gathering these data and engaging leadership, the group "had a limited impact on care processes;" the authors share recommendations for researchers and policymakers to boost impact.
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Leider, J.P., Lim, S., DeBruin, D., et al. (2023). Using a Web Platform for Equitable Distribution of COVID-19 Monoclonal Antibodies: A Case Study in Resource Allocation. Frontiers. 11.
The authors of this article sought to incorporate ethical considerations into distribution of monoclonal antibodies (mAbs) for COVID-19. The centralized access platform (state website) assessed patient criteria compared with the mAbs emergency use authorization and created a scoring system to prioritize eligible patients in times of scarcity.
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Merin, O., Nachman, A., Levy, G., et al. (2010). The Israeli Field Hospital in Haiti — Ethical Dilemmas in Early Disaster Response. The New England Journal of Medicine. 362(e38).
The authors share experiences with field hospital issues in an austere environment and how healthcare practitioners addressed resource dilemmas. They describe their triage protocols and how they managed ethical dilemmas.
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* National Academies of Sciences, Engineering, and Medicine. (2020). Crisis Standards of Care: Ten Years of Successes and Challenges – Proceedings of a Workshop.
This report synthesizes the conversations from a 2019 workshop where participants reviewed the successes and gaps over the last decade of crisis standards of care work to help plan future work.
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New Hampshire Department of Health and Human Services. (2022). State of New Hampshire Crisis Standards of Care Guidance.
This document describes how the State of New Hampshire addressed the need for an all-hazards approach to crisis standards of care in the event of a “catastrophic or pervasive public health crises.”
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Toner, E., Mukherjee, V., Hanfling, D., et al. (2020). Crisis Standards of Care: Lessons from New York City Hospitals' COVID-19 Experience. Johns Hopkins Bloomberg School of Public Health, Center for Health Security.
The authors explore how crisis standards of care (CSC) were implemented in New York City during the COVID-19 pandemic. In the future, they recommend that clinicians be more involved in CSC planning, and that CSC be formally and quickly declared with resource-specificity.
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Wynia, M. (2020). Crisis Triage-Attention to Values in Addition to Efficiency. JAMA Network Open. 3(12):e2029326.
Researchers examined the use of two triage models on 2014/2015 data from 208 U.S. hospitals to determine their utility, consistency (i.e., whether both protocols rate patients as low or high priority), and accuracy (the number of patients with lowest priority that died prior to discharge). Researchers found that both protocols would likely be of limited utility in a catastrophic disaster with a shortage of ventilators, as each prioritized patients differently. The author emphasizes the need to incorporate additional principles into triage, particularly in the event of a pandemic.
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Pandemic-Specific Planning

Berlinger, N., Wynia, M., Powell, T., et al. (2020). Ethical Framework for Health Care Institutions & Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic - The Hastings Center.. The Hastings Center.
This document identifies ethical challenges associated with care of COVID-19 patients, specifies three ethical duties of health care leaders, provides examples of policies and processes for review, and offers guidelines for institutional ethics services.
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DeBruin, D.A., Marshall, M.F., Parilla, E., et al. (2010). Implementing Ethical Frameworks for Rationing Scarce Health Resources in Minnesota During Severe Influenza Pandemic.
This companion report (to For the Good of Us All: Ethically Rationing Health Resources in Minnesota in a Severe Influenza Pandemic, included in this collection) analyzes the issues related to the implementation of ethical frameworks for rationing. This document includes considerations for state policies, legal issues, prioritization for healthcare workers, and other policy issues and can help inform state planners responsible for the allocation of scarce resources in an emergency situation.
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* Dudzinski, D., Hoisington, B., and Brown, C. (2020). Ethics Lessons from Seattle's Early Experience with COVID-19. American Journal of Bioethics. 20(7):67-74.
The authors describe UW Medicine's ethical decision-making related to preparations for and early response to the COVID-19 pandemic. It includes the health system's contributions to healthcare coalition activities as the Regional COVID-19 Coordination Center and participation of faculty in drafting and revising the Northwest Healthcare Response Network's guidance for the region.
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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. Discussion Paper, National Academy of Medicine, Washington, DC..
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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* Maves, R., Downar, J., Dichter, J., et al. (2020). Triage of Scarce Critical Care Resources in COVID-19: An Implementation Guide for Regional Allocation. Chest Journal. 158(1):212-225.
This expert panel report by the Task Force for Mass Critical Care and the American College of Chest Physicians offers a framework to equitably meet the clinical needs of the greatest number of patients when resources are scarce.
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Miller Institute of Medicine Institute for Bioethics and Health Policy. (2020). Pandemic Ethics Resources.
The Florida Department of Health prepared this guidance document to help medical and healthcare entities statewide prepare for scarce resource allocation in the event of a pandemic influenza. While the triage criteria is slightly dated, the roles and responsibilities are outlined well within a replicable framework.
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Solomon, M., Wynia, M., and Gostin, L. (2020). Covid-19 Crisis Triage - Optimizing Health Outcomes and Disability Rights. New England Journal of Medicine. 383(5):e27.
In this editorial, the authors emphasize assessment of short-term survival and outline many potential legal and ethical pitfalls associated with triage decisions incorporating underlying disability.
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Vawter, D.E., Garrett, E.J., Gervais, K.G., et al. (2010). For the Good of Us All: Ethically Rationing Health Resources in Minnesota in a Severe Influenza Pandemic. (Free registration required.) Minnesota Center for Health Care Ethics and the University of Minnesota Center for Bioethics.
This report—developed for the state of Minnesota—contains and describes the reasoning behind the creation of ethical frameworks for rationing antiviral medications, N95 respirators, surgical masks, vaccines and mechanical ventilators during a pandemic that met nine specific assumptions. The guidelines can be adopted and tailored by other states.
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Plans, Tools, and Templates

Arizona Department of Health Services. (2020). Arizona Crisis Standards of Care Plan: A Comprehensive and Compassionate Response.
This comprehensive plan is the result of years of collaboration between the state public health, healthcare, legal, ethical, and emergency management disciplines and can serve as a model for others. Sections include: Statewide Concept of Operations; Clinical Concept of Operations; Organization and Assignment of Responsibilities; Direction, Control, and Coordination; Information Collection, Analysis, and Dissemination; Communications; Administration, Finance, and Logistics; and Legal Considerations. Note that the specific triage tools are dated as they use SOFA as a primary determinant.
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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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ASPR TRACIE. (2023). Mass Casualty Hospital Capacity Expansion Toolkit (PDF).
Mass casualty incidents (MCIs) generally occur without warning. A concise, scalable surge response template can be a helpful quick reference to the hospital personnel tasked with expanding care capacity in the first hours of an MCI and can minimize ad hoc and potentially conflicting decisions about prioritization of space and strategies. This optional toolkit includes four sections to guide emergency department, general inpatient, and critical care space expansion and basic additional staffing needs in the event of patient surge including crisis situations. Access the Word version of this toolkit here: https://files.asprtracie.hhs.gov/documents/mass-casualty-hospital-capacity-expansion-toolkit---word-version.docx
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ASPR TRACIE. (2024). ASPR TRACIE Hospital Mass Casualty Response Plan Considerations.
The term “mass casualty incident” (MCI) refers to the combination of patients and care requirements that require mobilization of additional resources to meet the demand. MCIs generally occur without warning and a concise plan is needed to ensure rapid and efficient response. The considerations in this document can assist hospitals in developing a new—or vetting an existing— MCI plan.
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ASPR TRACIE. (2024). Template - Hospital Crisis Standards of Care Resource Allocation Annex.
This template can help hospital emergency managers and medical directors develop an annex to their Emergency Operations Plans (EOPs) that complements existing surge capacity plans. It includes specific decision processes for allocation of resources and the triage of patients for the provision of critical care when shortages of equipment or therapeutics pose a significant risk to patient outcomes. Access the Word version of the template here: https://files.asprtracie.hhs.gov/documents/template-hospital-csc-resource-allocation-annex.docx
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Centers for Disease Control and Prevention. (2018). Allocating and Targeting Pandemic Influenza Vaccine During an Influenza Pandemic. U.S. Department of Health and Human Services.
This document provides guidance on the allocation of influenza vaccine during the early stages of a pandemic when demand may exceed production capacity. It offers general principles on pandemic vaccination and a framework based on targeted groups and pandemic severity.
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  • Sheran Kaplan-Hicks This link is broken and does not provide access to this document.
    10/15/2019 12:32:50 PM
Colorado Department of Public Health and Environment. (2022). Annex B: Colorado Crisis Standards of Care Plan. CDPHE All Hazards Internal Emergency Response and Recovery Plan.
This deactivated crisis standards of care plan outlines state-level process and decision making and resource allocation were used or proposed for situations that surpassed 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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Gravely, S. and Whaley, E. (2008). Critical Resource Shortages: A Planning Guide. Virginia Department of Health and Virginia Hospital and Healthcare Association Altered Standards of Care Workgroup.
This document provides guidance on managing shortages of critical resources during the preparedness, response, and recovery phases of a disaster. Pandemic influenza is used as the planning scenario.
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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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Illinois Department of Public Health. (2018). Catastrophic Incident Response Annex.
This annex describes and guides Illinois' state-level response and care of patients, including crisis care and resource allocation, during a catastrophic incident that incapacitates the local, regional, and/or state health care system and prevents the ability to provide conventional and/or contingency care. It includes a concept of operations and sections on roles, responsibilities, resource requirements, and recovery. Attachment 6 has specific recommendations for EMS adaptations during catastrophic incidents.
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Kelen, G., Marcozzi, D., Marx, J., and Kachalia, A.. (2023). Criteria for Declaring Crisis Standards of Care: A Single, Uniform Model. (Abstract only.) NEJM Catalyst.
The authors created criteria and related threshold triggers (based on eight categories) that allow acute care hospital staff to declare and terminate Crisis Standards of Care (CSC) and may serve as a regional model to help define when crisis care is occurring.
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Michigan Department of Health and Human Services. (2021). Michigan Guidelines for Implementation of Crisis Standards of Care and Ethical Allocation of Scarce Medical Resources and Services.
These guidelines are intended to assist decision-makers with resource and service allocation and prioritization during public health emergencies.
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Minnesota Department of Health, Center for Emergency Preparedness and Response, Minnesota Healthcare Preparedness Program. (2020). Patient Care Strategies for Scarce Resource Situations.
This card set can help facilitate an orderly approach to resource shortfalls at a healthcare facility. It is a decision support tool to be used by key personnel, along with incident management, who are familiar with ethical frameworks and processes that underlie these decisions.
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* Minnesota Department of Health, Office of Emergency Preparedness. (2020). Crisis Standards of Care.
This website includes links to several critical crisis standards of care (CSC) resources and tools including the MN CSC Framework (released in November 2018) which provides an overview of the actions the state will take in response to a CSC situation. The framework also includes operational annexes for Ethics, Legal, EMS, Hospitals, and Public Engagement. The site also contains other resources including a summary report on community engagement, pandemic, and other resources.
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Nevada Division of Public and Behavioral Health. (2017). Nevada Crisis Standards of Care (CSC) Plan.
This state crisis standards of care plan supports state medical surge capacity and capability planning and provides a mechanism for expanding medical surge operations. It includes sections on: Statewide Concept of Operations, Clinical Concept of Operations, Healthcare Sector Adaptations and Considerations, Public Information, Communications Plans and Protocols, Legal Considerations, Plan Development and Maintenance, and several helpful appendices. While this plan serves as a replicable example of coordination, the critical care triage criteria uses SOFA cutoff levels; these need to be updated.
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Oregon Health Authority. (2018). Crisis Care Guidance.
This guidance document was designed to help Oregon communities and health systems improve their ability to respond to public health emergencies. The document includes an overview of guidance strategies and specific strategies by healthcare sector (e.g., health care at home, alternate care sites, and critical care).
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Orlando Health and Corfield, J. (2024). Crisis Standards of Care Plan-Orlando Health.
The crisis standards of care plan template can be used by hospital incident command responders and clinical providers to manage substantial acute or long-term changes to healthcare operations that impact the level of patient care provided. Access the compliant PDF here: https://files.asprtracie.hhs.gov/documents/crisis-standards-of-care-plan-orlando-health.pdf
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* Sharpe, V., Berkowitz, K., Cecire, R., et al. (2010). Meeting the Challenge of Pandemic Influenza: Ethical Guidance for Leaders and Health Care Professionals in the Veterans Health Administration. U.S. Department of Veterans Affairs.
This guidance document is divided into five sections on ethical preparedness and response in a healthcare system: 1) an overview of ethical challenges; 2) workforce capacity and responsibility; 3) resource allocation; 4) hospice and palliative care; and 5) limiting personal liberty to preserve public health. The document also includes a checklist for implementing the plan guidance.
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Studies and Reports

Butler, C.R., Webster, L., and Diekama, D. (2024). Staffing Crisis Capacity: A Different Approach to Healthcare Resource Allocation for a Different Type of Scarce Resource. Journal of Medical Ethics. 50(9):647-649.
Managing a staffing shortage during a crisis requires a different ethical framework. The authors encourage healthcare providers to both prioritize the worst off (and restricting access to critical care hospitals to those who need it most) and prioritize interventions that provide the highest short-term benefits.
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Dichter, J., Devereaux, A., Sprung, C., et al. (2022). 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. Chest. 161(2):429-447.
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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Hodge, J.G., Hanfling, D. and Powell, T. (2013). Practical, Ethical, and Legal Challenges Underlying Crisis Standards of Care. (Free registration required.) Journal of Law, Medicine, and Ethics. 41(Suppl 1): 50-55.
The authors discuss law and policy issues anticipated to arise during implementation of crisis standards of care. Table 1 lists select related legal issues by subject (e.g., organization of personnel, patients' interests, allocation of resources, and reimbursement).
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Kanter, R.K. and Moran, J.R. (2007). Pediatric Hospital and Intensive Care Unit Capacity in Regional Disasters: Expanding Capacity by Altering Standards of Care. (Abstract only.) Pediatrics. 119(1):94-100.
The authors used a simulation to determine how altered standards of care during a large-scale emergency or disaster could expand pediatric intensive care unit (PICU) beds and non-ICU beds. Modeling showed that altered standards could increase capacity, but that ICU beds would still be insufficient during large disasters.
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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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MacMartin, M., Zeng, A., Chelen, J., et al. (2023). 'The Burden of Wanting to Make It Right': Thematic Analysis of Semistructured Interviews to Explore Experiences of Planning for Crisis Standards Of Care and Ventilator Allocation during the COVID-19 Pandemic in the USA. BMJ Open. 13(11):e076674.
Healthcare planners experienced psychological burdens when planning for resource scarcity, according to interviews the authors conducted in spring/summer 2021. The amount and nature of burden depended on the institutional and government leadership specific to crisis standards of care planning; the actual planning process; the nature of (and level of tension surrounding) the institution’s policies; and the role of collaboration/healthcare provider input in planning for the future.
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Riggan, K.A., Nguyen, N.V., Ennis, J.S., et al. (2024). Behind the Scenes: Facilitators and Barriers to Developing State Scarce Resource Allocation Plans for the COVID-19 Pandemic. (Abstract only.) Humanities: Original Research. 166(3):561-571.
The authors interviewed 36 providers from 34 states to gather lessons learned from the state scarce resource allocation plan development process. Overall findings emphasized the need to include providers and the broader community in the plan development/update process.
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Romney, D., Fox, H., Carlson, S. et al. (2020). Allocation of Scarce Resources in a Pandemic: A Systematic Review of U.S. State Crisis Standards of Care Documents. (Abstract only; email askasprtracie@hhs.gov for access to the full article.) Disaster Medicine and Public Health Preparedness.
The authors reviewed crisis standards of care documents to determine how many contained all five elements recommended by the Institute of Medicine and how those elements were incorporated. Out of 31 documents they included in their analysis, five contained all five elements.
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Yek, C., Wang, J., Fintzi, J., et al. (2023). Impact of Surge Strain and Pandemic Progression on Prognostication by an Established COVID-19-Specific Severity Score. Critical Care Explorations. 5(12):e1021.
The authors of this article analyzed the modified 4C (m4C) score, a tool that predicted hospital capacity during the COVID-19 pandemic. They found that mortality prediction according to m4C was more robust during patient surges and less effective during later waves. They conclude that crisis standards of care guidelines should be frequently reassessed to ensure resources are allocated adequately.
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* Zaza, S., Koonin, L., Ajao, A., et al. (2016). A Conceptual Framework for Allocation of Federally Stockpiled Ventilators During Large-Scale Public Health Emergencies. (Registration required.) Health Security. 14(1):1-6.
The authors describe a conceptual framework for the distribution of ventilators stockpiled by the federal government during a large-scale emergency. They identify necessary planning steps to aid in the optimal allocation of ventilators to individual hospitals.
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Agencies and Organizations

California Hospital Association, Emergency Preparedness Crisis Care.
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Minnesota Department of Health, Office of Emergency Preparedness. Crisis Standards of Care.
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Network for Public Health Law. Crisis Standards of Care.
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This ASPR TRACIE Topic Collection was comprehensively reviewed in 2025 by the following subject matter experts:

Dan Hanfling, MD, Clinical Professor of Emergency Medicine, George Washington University; John Hick, MD, Hennepin Healthcare and ASPR TRACIE; Vikramjit Mukherjee, MD, Associate Professor, NYU School of Medicine, Director, Critical Care, Bellevue Hospital, and Director, Special Pathogens Program, Bellevue Hospital; Bryan Wexler, MD, MPH, CHPCP, CHEC-III, Medical Director, Disaster Preparedness and Response, WellSpan Health, Director, Division of Disaster Medicine and Emergency Management, Department of Emergency Medicine, WellSpan, York Hospital, and Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine; and Matt Wynia, MD, MPH, Director, University of Colorado Center for Bioethics and Humanities and Professor, University of Colorado School of Medicine and Colorado School of Public Health.  

It was refreshed and comprehensively reviewed in November 2018 by: Eric Alberts, BS, CEM, CHEP, CHPP, FPEM, FPEM-HC, SEM, Orlando Health, Inc. (Hospital System); Virginia Ashby Sharpe, Ph.D., Acting Executive Director, National Center for Ethics in Health Care, Veterans Health Administration; Lynn Bergero, MHSA, Independent Consultant and CERT Volunteer; Barbara Citarella, RN, BSN, MS, CHCE, NHDP-BC, National Healthcare Disaster Professional, President, RBC Limited Healthcare & Management Consultants; Craig DeAtley, PA-C, Director, Institute for Public Health Emergency Readiness, MedStar Washington Hospital Center; John Hick, MD, HHS ASPR and Hennepin County Medical Center;  Mark Jarrett, MD, MBA, MS, SVP & Chief Quality Officer, Associate Chief Medical Officer, Northwell Health, Professor of Medicine, Zucker School of Medicine at Hofstra/Northwell; Jeff Rubin, PhD, CEM, Emergency Manager, Tualatin Valley Fire & Rescue; James Paturas, Director, Center for Emergency Preparedness and Disaster Response, Yale New Haven Heath System; Mary Russell, EdD, MSN, Healthcare Emergency Response Coalition, Palm Beach County FL; and Judy Seaberg, RN, PHN, MS, Health Care Preparedness Program Manager, Minnesota Department of Health.

It was originally comprehensively reviewed in June 2015 by: Dan Hanfling, MD (Panel Chair, Editor) Contributing Scholar, UPMC Center for Health Security, Member, InterAgency Board, Attending Physician, BestPractices, Inc. (a division of EmCare), and Clinical Professor of Emergency Medicine, George Washington University; and John Hick, MD, HHS ASPR and Hennepin County Medical Center. Additional assistance was provided by Alicia Livinski, Biomedical Librarian, HHS National Institutes of Health; and James Paturas, Director, Center for Emergency Preparedness and Disaster Response, Yale New Haven Heath System.

 

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