Crisis Standards of Care
Topic Collection
October 17, 2024
Topic Collection: Crisis Standards of Care
The provision of medical care under catastrophic disaster conditions requires considerable pre-event 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 of the National Academies. Work performed under this topic area provides a roadmap for medical decision-making during catastrophic events. Coordination of emergency response system planning is critical to successful health and medical outcomes under chaotic “crisis” conditions, which 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 that many state plans use Sequential Organ Failure Assessment (SOFA) score thresholds (e.g., >11) to make decisions. Based on findings highlighted in articles from 2010 to present, this 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 current frameworks, access Christian et al. (2014) and the ASPR TRACE document SOFA Score: What it is and How to Use it in Triage.
For additional information on the ethical basis for CSC decision-making and other ethical issues in disaster medicine, access the Disaster Ethics Topic Collection. For CSC-related lessons learned and promising practices during the pandemic, access the COVID-19 Resources Page.
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.
Must Reads
This ASPR TRACIE white paper (developed after a national expert roundtable) can help emergency medical system (EMS) medical directors and EMS systems planners to understand and plan for key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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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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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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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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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 I of II and focuses on infrastructure and capacity building.
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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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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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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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The authors summarize key elements contained in the Institute of Medicine work on crisis standards of care. Written for the emergency medicine community, this paper is intended to be a useful adjunct to support discussions related to the planning for large-scale disaster events.
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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).
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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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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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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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This document provides comprehensive operational guidance on scarce resource allocation criteria and implementation protocols for emergency medical services and medical control authorities, and hospitals and other healthcare facilities. Related legal guidance is also included.
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Community and Provider Engagement
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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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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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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This paper discusses a series of stakeholder workgroups (comprising ethicists, lawyers, clinicians, and local and state public health officials, as well as community members) conducted by the Massachusetts Department of Public Health-Harvard Altered Standards of Care Working Group in 2006 to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. The planning process and principles for equitable allocation of resources identified by the project may be helpful to other organizations/jurisdictions developing altered standards of care plans.
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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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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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This report describes the Public Engagement Pilot Project on Pandemic Influenza, the objectives of which were twofold: 1) to discuss and rank goals for a pandemic influenza vaccination program, and 2) to pilot test a model for engaging citizens in vaccine-related policy decisions.
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Education and Training
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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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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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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This webinar covers four topics about resource allocation: 1) who allocates scarce healthcare resources during a crisis, 2) how crisis triage officers are selected and trained, 3) how crisis triage officers should function, and 4) how the use of risk communication techniques can help maintain the trust of healthcare workers and the public.
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More information on the use of risk communication during a crisis in which scarce resources need to be rationed is provided in this webinar.
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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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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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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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Guidelines and Strategies
This webpage briefly describes the 4 main principles for allocating limited health care resources discussed in the American Medical Association’s Code of Medical Ethics Opinion 11.1.3.
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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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This ASPR TRACIE fact sheet provides information on the types of oxygen therapy and the types of oxygen supplies generally available. It also provides information on the typical sizes and length of use of various oxygen storage methods.
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This ASPR TRACIE white paper (developed after a national expert roundtable) can help emergency medical system (EMS) medical directors and EMS systems planners to understand and plan for key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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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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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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Healthcare systems were pushed to the brink during the COVID-19 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).
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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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This slide presentation by a hospital CMO discusses ethical considerations for making resource allocation decisions during a disaster, and provides practical guidance for plan development and implementation. Descriptions of the respective composition and roles of resource distribution teams used by the author’s facility are included.
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This document includes information to help planners enhance and/or develop a community's medical surge plans. It is organized into chapters, such as: Building Planning Teams and Coalitions; Models of Healthcare Delivery; Alternate Care Systems; Essential Healthcare Services; and Crisis Standards of Care. The chapter on coalitions defines roles and responsibilities for planning teams and coalitions, and the steps necessary to determine a community's healthcare needs.
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This article describes how contingency planning should be multi-faceted and involve a robust health command structure. This structure should provide the facility with the capability to expand critical care provision in terms of space, equipment, staff, and cohorting of affected patients in the early stages. The authors note that despite the expansion of critical care in the event of a pandemic, demand for services will likely exceed supply and a process for triage will need to be developed.
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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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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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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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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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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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This presentation reviews key considerations, and provides recommendations for, the development of crisis standards of care, using Illinois as an example.
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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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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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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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In this article, the authors suggest using a three-level surge capacity taxonomy (conventional capacity, contingency capacity, and crisis capacity) to bolster hospital surge planning.
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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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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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The authors summarize key elements contained in the Institute of Medicine work on crisis standards of care. Written for the emergency medicine community, this paper is intended to be a useful adjunct to support discussions related to the planning for large-scale disaster events.
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The authors discuss the complex issues of finding acceptable alternatives to using durable medical devices such as mechanical ventilators during disaster and share decision-making support tools.
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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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This web page includes several resources that healthcare facilities may use to plan for medical surge caused by COVID-19.
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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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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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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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This guide provides planners (e.g., community, facility, state, and Federal) with valuable information that can help them plan for and respond to a mass casualty event. The authors share approaches and strategies to enable the audience to provide the most appropriate standards of care possible under the circumstances of a mass casualty event.
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This paper details one of the first efforts intended to identify a statewide approach to allocating mechanical ventilators in the setting of a large-scale respiratory emergency event. The authors highlight the ethical principles that govern such decision making, with an emphasis on the “duty to plan,” the “duty to care,” and the “duty to steward resources.”
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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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This document provides comprehensive operational guidance on scarce resource allocation criteria and implementation protocols for emergency medical services and medical control authorities, and hospitals and other healthcare facilities. Related legal guidance is also included.
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This policy paper is intended for professionals in a care giver or service provider role. It includes guidance on ethical principles in emergency care, meeting usual care expectations, and recommendations for emergency event care.
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The authors explore key ethical principles that may be invoked in the context of having to make scarce resource allocation decisions. They highlight strategies related to saving the most lives, maximizing the number of life years saved, and prioritizing patients who have had the least chance to live through life's stages. They emphasize the importance of applying such principles to all patients, not just to those at the extreme ages of the life cycle (very young, elderly) or those with functional impairments or chronic conditions.
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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
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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Dr. John Hick describes how the crisis standards of care concept and practice has changed since the COVID-19 pandemic.
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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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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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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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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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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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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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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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After the 2010 earthquake that struck Haiti, medical staff from the Israeli Defense Forces Medical Corps field hospital responded and was the only facility that had the capability to ventilate children and neonates during the first week after the disaster. The authors provide an overview of five case studies and the decision-making processes they went through using a tool developed for ventilator allocation during an influenza pandemic.
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Pandemic-Specific Planning
The authors describe how they applied a collaborative process using best evidence, expert panels, stakeholder consultations, and ethical principles to develop a triage protocol for prioritizing access to critical care resources, including mechanical ventilation, during an influenza pandemic.
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The authors “provide recommendations and standard operating procedures for intensive care unit (ICU) and hospital preparations for an influenza pandemic or mass disaster with a specific focus on critical care triage.”
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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 can help inform state planners responsible for the allocation of scarce resources in an emergency situation.
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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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Authors from the Indiana University Center for Bioethics provide recommendations on four specific areas of ethical concern: management of the healthcare workforce; resource allocation; changes to the standard of care provided by healthcare professionals; and allocating scarce vaccines and antiviral medications.
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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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In this presentation, the author shares a 15-point ethical guide for pandemic planning based in part on experiences with and study of the 2003 severe acute respiratory syndrome outbreak.
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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
This is the Situation Manual for a tabletop exercise focused on crisis standards of care (CSC) indicators, tactics, public information capacity, electronic information and triage systems, emergency operation center coordination, information sharing, and healthcare coalition and local jurisdiction involvement. It may be a valuable resource for other jurisdictions planning for similar exercises.
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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.
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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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During a pandemic or other emergency, healthcare facilities face significant challenges to quickly onboard additional healthcare providers when hospital admissions and ICU occupancy increase rapidly. This onboarding checklist can ensure new employees are compliant with administrative requirements, familiar with the mission and culture of the hospital, and understand expectations.
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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. 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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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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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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The authors share ethical principles and planning goals associated with pandemic influenza planning. Several templates are included as appendices.
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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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This deactivated COVID-19 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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This guidance document is in response to the directive for Healthcare PreparednessCapabilities: National Guidance for Healthcare System Preparedness (January 2012), Capability 10 (Medical Surge), Function 4 (Develop Crisis Standards of Care Guidance). The resource is intended to promote a consistent approach to emergency preparedness and response by the District’s healthcare organizations when the resources necessary to providing critical care are scarce.
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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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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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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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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).
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These guidelines are intended to assist decision-makers with resource and service allocation and prioritization during public health emergencies.
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This Word template may be used by healthcare facilities to develop a CSC plan.
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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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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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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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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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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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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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This all-hazards template (developed by a group of emergency management and disaster medicine experts from the U.S.) can provide hospital administrators a "snapshot" of current capacity and help improve planning by linking action items to institutional triggers across the surge capacity continuum.
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Studies and Reports
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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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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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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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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This paper discusses a series of stakeholder workgroups (comprising ethicists, lawyers, clinicians, and local and state public health officials, as well as community members) conducted by the Massachusetts Department of Public Health-Harvard Altered Standards of Care Working Group in 2006 to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. The planning process and principles for equitable allocation of resources identified by the project may be helpful to other organizations/jurisdictions developing altered standards of care plans.
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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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The authors created an evidence-based crisis standards of care triage allocation scheme specifically for children. Results gathered from studying virtual pediatric intensive care unit (PICU) subjects indicated improved population outcomes on "patients likely to benefit from short-duration ICU interventions."
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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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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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