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Crisis Standards of Care
Topic Collection
July 11, 2019

Topic Collection: Crisis Standards of Care

Were you redirected from ASPR’s Communities of Interest (COI) site? After years of housing foundational crisis standards of care (CSC) and allocation of scarce resources (ASR) information and sample plans shared by HPP awardees, the ASPR CPO site has been removed from PHE.gov, and  all contents were transferred to ASPR TRACIE. This Topic Collection includes links to a number of CSC and ASR resources, and we encourage users to direct all future CSC and ASR inquiries to askasprtracie@hhs.gov.

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.   

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 can help emergency medical system (EMS) medical directors and EMS systems planners and hospital emergency planners to 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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Centers for Disease Control and Prevention. (2017). Framework for Expanding EMS System Capacity During Medical Surge.
This framework can help community planners better understand the role of emergency medical services in medical surge planning and crisis standard of care adaptations, which falls under four strategies: Tiered Dispatch; Modified Treatment and Transport Strategies; Coordinated Transport to Alternate Destinations; and Support for Rapid Implementation of Patient Interventions.
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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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Geiling, J., Burkle, F., Amundson, D., et al. (2014). Resource-Poor Settings: Infrastructure and Capacity Building. Chest. 146(4 Suppl):e 156S–e167S.
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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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 11:04:52 PM
Hick, J.L., Hanfling, D., and Cantrill, S.V. (2012). Allocating Scarce Resources in Disasters: Emergency Department Principles. Annals of Emergency Medicine. 59(3): 177-187.
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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Minnesota Department of Health, Center for Emergency Preparedness and Response, Minnesota Healthcare Preparedness Program. (2014). 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 Preparednes. (2018). 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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State of Michigan, Department of Community Health, Office of Public Health Preparedness. (2012). Guidelines for Ethical Allocation of Scarce Medical Resources and Services During Public Health Emergencies in Michigan.
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


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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* Levin, D., Cadigan, R. O., Biddinger, P., et al. (2009). Altered Standards of Care During an Influenza Pandemic: Identifying Ethical, Legal, and Practical Principles to Guide Decision Making. (Abstract only.) Disaster Medicine and Public Health Preparedness. 3(SUPPL.2):S132-S140.
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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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 Preparednes. (2018). 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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Public Engagement Pilot Project on Pandemic Influenza (PEPPPI). (2005). Citizen Voices on Pandemic Flu Choices: A Report of the Public Engagement Pilot Project on Pandemic Influenza. University of Nebraska Public Policy Center.
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


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. (2007). Part 3 (A). The Most Difficult Healthcare Decisions. The University of Arizona, Arizona Bioethics Program.
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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Iserson, K. (2007). Part 3 (B). Who Allocates Scarce Healthcare Resources? The University of Arizona, Arizona Bioethics Program.
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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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


American Medical Association. (n.d.). Allocating Limited Health Care Resources. (Accessed 12/3/18.)
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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ASPR TRACIE. (2016). Drug Shortages and Disasters.
This factsheet supplements the Pharmacy Topic Collection and includes recent resources that provide an overview of the situation and how it can worsen during emergencies. These resources can help healthcare providers prepare for and respond to shortages and other pharmaceutical-related challenges that may arise during and after a disaster using crisis standards of care principles.
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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 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 can help emergency medical system (EMS) medical directors and EMS systems planners and hospital emergency planners to 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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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.
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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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Centers for Disease Control and Prevention (2015). Community Planning Framework for Healthcare Preparedness.
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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Challen, K., Bentley, A., Bright, J., and Walter, D. (2007). Clinical Review: Mass Casualty Triage – Pandemic Influenza and Critical Care. Critical Care. 11(2): 212.
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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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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Emergency Nurses Association. (2017). ENA Topic Brief: Crisis Standards of Care.
This topic brief is geared towards emergency nurses and provides an overview of Crisis Standards of Care (CSC), including background, criteria for activation, exercise, and related considerations.
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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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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 11:04:52 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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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 suggest using a three-level surge capacity taxonomy (conventional capacity, contingency capacity, and crisis capacity) to bolster hospital surge planning.
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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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Hick, J.L., and O’Laughlin, D.T. (2006). Concept of Operations for Triage of Mechanical Ventilation in an Epidemic. Academic Emergency Medicine. 13(2): 223-9.
This report was the first published concept of operations for triage of mechanical ventilation in epidemic situations and discusses some of the ethical principles and pitfalls of such systems.
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Hick, J.L., Hanfling, D., and Cantrill, S.V. (2012). Allocating Scarce Resources in Disasters: Emergency Department Principles. Annals of Emergency Medicine. 59(3): 177-187.
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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Hick, J.L., Rubinson, L., O'Laughlin, D.T., and Farmer, J.C. (2007). Clinical Review: Allocating Ventilators during Large-Scale Disasters—Problems, Planning, and Process. Critical Care. 11(3): 217.
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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* Minnesota Department of Health, Office of Emergency Preparednes. (2018). 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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New York State Task Force on Life & the Law, New York State Department of Health. (2015). Ventilator Allocation Guidelines.
This resource includes ventilator allocation guidelines for adults, children, and neonates, and also includes discussion of legal issues related to ventilator allocation, using pandemic influenza as the planning scenario. The ethical framework supporting the guidelines is also described, and includes five components: duty to care; duty to steward resources; duty to plan; distributive justice; and transparency.
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Oregon Health Authority. (2018). Oregon Crisis Care Guidance.
Representatives from across the state convened a series of stakeholder workgroups to develop this document, which provides strategies for allocating resources during two main types of disasters: severe outbreaks of infectious disease (such as an influenza pandemic), and mass trauma events (such as a major earthquake). General principles and planning strategies, as well as guidance by healthcare sector, are discussed. The portal site hosts the state’s updated crisis care guidance and implementation toolkit, along with other resources.
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Phillips, S.J. and Knebel, A. (eds.). (2007). Mass Medical Care with Scarce Resources: A Community Planning Guide. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality.
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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Powell, T., Christ, K.C., and Birkhead, G.S. (2008). Allocation of Ventilators in a Public Health Disaster. Disaster Medicine and Public Health Preparedness. 2(01): 20-26.
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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State of Michigan, Department of Community Health, Office of Public Health Preparedness. (2012). Guidelines for Ethical Allocation of Scarce Medical Resources and Services During Public Health Emergencies in Michigan.
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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The Center for Health Policy, Columbia University School of Nursing. (2008). Adapting Standards of Care under Extreme Conditions: Guidance for Professionals during Disasters, Pandemics, and Other Extreme Emergencies. American Nurses Association.
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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Thompson, A. (2006). Stand on Guard for Thee. University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group.
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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White, D.B., Katz, M.H., Luce, J.M., and Lo, B. (2009). Who Should Receive Life Support During a Public Health Emergency? Using Ethical Principles to Improve Allocation Decisions. Annals of Internal Medicine. 150:132-138.
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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* 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


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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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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Ytzhak, A., Sagi, R., Bader, T., et al. (2012). Pediatric Ventilation in a Disaster: Clinical and Ethical Decision Making. (Abstract only.) Critical Care Medicine. 40(2).
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


Christian, M.D., Hawryluck, L., Wax, R.S., et al. (2006). Development of a Triage Protocol for Critical Care during an Influenza Pandemic. CMAJ. 175(11): 1377-81.
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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Emanuel, E.J., and Wertheimer, A. (2006). Public Health. Who Should Get Influenza Vaccine When Not All Can? Science. 312(5775): 854-5.
The authors discuss the ethical reasoning behind vaccine prioritization and include a table that illustrates tiers and rankings (as of 2006).
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Florida Department of Health, Pandemic Influenza Technical Advisory Committee. (2011). Pandemic Influenza: Triage and Scarce Resource Allocation Guidelines.
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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Meslin, E., Alyea, J., and Helft, P. (2007). Pandemic Flu Preparedness: Ethical Issues and Recommendations to the Indiana State Department of Health. Indiana University, Center for Bioethics.
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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Thompson, A. (2006). Stand on Guard for Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza. University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group.
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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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. 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


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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Arizona Department of Health Services. (2015). Arizona Crisis Standards of Care Tabletop Exercise Situation Manual.
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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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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Ball, R. and Schneider, P. (2009). South Carolina Prepares for Pandemic Influenza: An Ethical Perspective. South Carolina Department of Health and Environmental Control.
The authors share ethical principles and planning goals associated with pandemic influenza planning. Several templates are included as appendices.
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Centers for Disease Control and Prevention. (2017). Framework for Expanding EMS System Capacity During Medical Surge.
This framework can help community planners better understand the role of emergency medical services in medical surge planning and crisis standard of care adaptations, which falls under four strategies: Tiered Dispatch; Modified Treatment and Transport Strategies; Coordinated Transport to Alternate Destinations; and Support for Rapid Implementation of Patient Interventions.
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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. (2018). Annex B: Colorado Crisis Standards of Care Plan. CDPHE All Hazards Internal Emergency Response and Recovery Plan.
This comprehensive crisis standards of care plan outlines state-level process and decision making and resource allocation during events that surpass available capacities and capabilities and provides a structure for clinical decisions (though some of the triage decision tools are not the most current). The plan also details a robust engagement and development process.
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District of Columbia Emergency Healthcare Coalition (2013). Modified Delivery of Critical Care Services in Scarce Resource Situations.
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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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.
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Minnesota Department of Health, Center for Emergency Preparedness and Response, Minnesota Healthcare Preparedness Program. (2014). 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 Preparednes. (2018). 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. (n.d.). Crisis Care Guidance Implementation Toolkit. (Accessed 12/13/2018.)
This toolkit was designed to help Oregon communities and health systems improve their ability to respond to public health emergencies. The webpage includes links to several toolkit resources under three categories: Emergency Medical Services, Hospital Services, and Critical Care.
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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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Studies and Reports


The authors describe challenges and solutions identified by their hospitals with regard to the operationalization of critical care triage protocols developed by the Ministry of Health and Long-Term Care in Ontario, Canada.
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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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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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* Levin, D., Cadigan, R. O., Biddinger, P., et al. (2009). Altered Standards of Care During an Influenza Pandemic: Identifying Ethical, Legal, and Practical Principles to Guide Decision Making. (Abstract only.) Disaster Medicine and Public Health Preparedness. 3(SUPPL.2):S132-S140.
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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Timbie, J., Ringel, J., Fox, D., et al. (2012). Allocation of Scarce Resources During Mass Casualty Events. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality.
The authors of this report identified the best evidence-based strategies for allocating scarce resources during mass casualty incidents (MCIs). The following questions are addressed in the report: (1) What strategies are available to policymakers to optimize the allocation of scarce resources during MCIs? (2) What strategies are available to providers to optimize the allocation of scarce resources during MCIs? (3) What are the public’s key perceptions and concerns regarding the implementation of strategies to allocate scarce resources during MCIs? (4) What methods are available to engage providers in discussions regarding the development and implementation of strategies to allocate scarce resources during MCIs?
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Toltzis, P., Soto-Campos, G., Kuhn, E., et al. (2015). Evidence-Based Pediatric Outcome Predictors to Guide the Allocation of Critical Care Resources in a Mass Casualty Event. Pediatric Critical Care Medicine. 16(7): e207–e216.
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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* 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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