Crisis Standards of Care: Summary of a Workshop Series (2010)

At the request of the Office of the Assistant Secretary for Preparedness and Response in the Department of Health and Human Services, the Institute of Medicine convened the Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations to develop guidance that state and local public health officials can use to establish and implement standards of care that should apply in disaster situations—both naturally occurring and manmade—under scarce resource conditions. Specifically, the committee was asked to identify and describe the key elements that should be included in crisis standards of care protocols, to identify potential indicators and triggers, and to develop a template matrix that can be used by state and local public health officials as a framework for developing specific guidance for healthcare provider communities to develop and implement crisis standards of care. This appendix provides a summary of the committee’s recommendations, findings, and practical guidance. A complete copy of the report is available through www.iom.edu/disasterstandards.

Based on a review of the currently available state standards of care protocols, published literature, and testimony provided at its workshop, the committee concluded that there is an urgent and clear need for a single national set of guidance for states with crisis standards of care that can be generalized to all crisis events and is not specific to a certain event. However, the committee recognizes that within such a single general framework, individual disaster scenarios may require specific considerations, such as differences between no-notice events and slow-onset events, while the key elements and components remain the same.

For the purpose of developing recommendations for situations in which healthcare resources are overwhelmed, the committee defined the

level of health and medical care capable of being delivered during a catastrophic event as “crisis standards of care.”

The committee emphasized that, in an important ethical sense, entering a crisis standard of care mode is not optional—it is a forced choice, based on the emerging situation. Under such circumstances, failing to make substantive adjustments to care operations—that is, not to adopt crisis standards of care—is very likely to result in greater death, injury, or illness.

In order to ensure that patients receive the best possible care in a catastrophic event, the nation needs a robust system to guide the public, healthcare professionals and institutions, and governmental entities at all levels. To achieve such a system of just care, the committee set forth the following vision for crisis standards of care:

• Fairness—standards that are, to the highest degree possible, recognized as fair by all those affected by them (including the members of affected communities, practitioners, and provider organizations); evidence based; and responsive to specific needs of individuals and the population focused on a duty of compassion and care, a duty to steward resources, and a goal of maintaining the trust of patients and the community

• Equitable processes—processes and procedures for ensuring that decisions and implementation of standards are made equitably

  • Transparency—in design and decision making

  • Consistency—in application across populations and among individuals regardless of their human condition (e.g., race, age, disability, ethnicity, ability to pay, socioeconomic status, preexisting health conditions, social worth, perceived obstacles to treatment, past use of resources)

  • Proportionality—public and individual requirements must be commensurate with the scale of the emergency and degree of scarce resources

  • Accountability—of individuals deciding and implementing standards, and of governments for ensuring appropriate protections and just allocation of available resources

• Community and provider engagement, education, and communication—active collaboration with the public and stakeholders for their input is essential through formalized processes

• The rule of law

  • Authority—to empower necessary and appropriate actions and interventions in response to emergencies

  • Environment—to facilitate implementation through laws that support standards and create appropriate incentives

Throughout the report, the committee emphasized the need for states to develop and implement consistent crisis standards of care protocols both within the state and through work with neighboring states, in collaboration with their partners in the public and private sectors. The committee’s intent was to provide a framework that allows consistency in establishing the key components required of any effort focused on crisis standards of care in a disaster situation. It also hoped that by suggesting a uniform approach, consistency will develop across geographic and political boundaries so that the guidance will be useful in contributing to a single, national framework for responding to crises in a fair, equitable, and transparent manner.

The report also contains guidance to assist state public health authorities in developing these crisis standards of care. This guidance includes criteria for determining when crisis standards of care should be implemented, key elements that should be included in the crisis standards of care protocols, and criteria for determining when these standards of care should be implemented. The five key elements that should be included in crisis standards of care protocols, along with associated components, are summarized in Table B-1.

The letter report states that “state authorities have the political and constitutional mandate to prepare for and coordinate the response to disaster situations throughout their state jurisdictions” and outlines a process by which states should begin to develop crisis standards of care protocols. These steps include the following:

1. Outline Ethical Considerations: Convene a “Guideline Development Working Group” of appropriate stakeholders to establish ethical principles that will serve as the basis for the crisis standards of care.

2. Review Legal Authority for Implementation of Crisis Standards of Care: Review existing legal authority for the implementation of crisis standards of care and address legal issues related to the successful implementation of these standards, such as liability

protections or temporary changes in licensure or certification status or scope of practice.

1. Develop Guidance for Provision of Medical Care Under State Crisis Standards of Care: Establish an “Advisory Committee” that will find a comprehensive set of materials to inform its deliberations in the “Indicators and Triggers” and “Clinical Process and Operations” sections of the report.

2. Conduct a Public Stakeholder Engagement Process: Although representatives of various healthcare and other interested professional groups and the public have been involved in drafting the ethical principles and crisis standards of care, a robust engagement process is also necessary to provide an opportunity for review and comment by the provider and public community at large. Particular attention should be paid to conduct outreach to and gather input from vulnerable populations, including those with medical special needs.

3. Establish a Medical Disaster Advisory Committee: During a disaster, this committee will provide ongoing advice to the state authority regarding changes to the situation and potential corresponding changes in the implementation of crisis standards of care.

An ethical framework serves as the bedrock for public policy and cannot be added as an afterthought. Hence, ethical principles underlie the committee’s vision for crisis planning, outlined above. In addition, ethically and clinically sound planning will aim to secure fair and equitable resources and protections for vulnerable groups. The committee concluded that core ethical precepts in medicine permit some actions during crisis situations that would not be acceptable under ordinary circumstances, such as implementing resource allocation protocols that could preclude the use of certain resources on some patients when others would derive greater benefit from them. But even here, it is the situation that changes during disasters, not ethical standards per se. The context of a disaster may make certain resources unavailable for some or even all patients, but it does not provide license to act without regard to professional or legal standards. Healthcare professionals are obligated always to provide the best care they reasonably can to each patient in their care,

including during crises. When resource scarcity reaches catastrophic levels, clinicians are ethically justified—and indeed are ethically obligated—to use the available resources to sustain life and well-being to the greatest extent possible. As a result, the committee concluded that ethics permits clinicians to allocate scarce resources so as to provide necessary and available treatments preferentially to those patients most likely to benefit when operating under crisis standards of care. However, operating under crisis standards of care does not permit clinicians to ignore professional norms nor to act without ethical standards or accountability.

The committee strongly recommended extensive engagement with community and provider stakeholders. Such public engagement is necessary not only to ensure the legitimacy of the process and standards, but more importantly to achieve the best possible result. The letter report discusses considerations for engaging with community and provider stakeholders prior to the event, during the event, and after the event. The report also notes that although there are likely to be substantive population-level mental health risks from a mass casualty public health emergency that requires crisis standards of care, there is also an opportunity to promote resilience at the individual and population levels to mitigate these risks. Thus it is important to develop a national platform to support resilience that can customized by communities at the local level. The report also emphasizes that building trust is particularly important in more vulnerable populations, including those with preexisting health inequities and those with unique needs related to race, ethnicity, culture,

immigration, limited English proficiency, and lower socioeconomic status.

The letter report also addressed issues related to the implementation of crisis standards of care, including legal considerations. Questions of legal empowerment of various actions to protect individual and communal health are pervasive and complicated by interjurisdictional inconsistencies. The law should clarify prevailing standards of care and create incentives for actors to respond to protect the public’s health and respect individual rights.

An important consideration regarding the framework for the implementation of crisis standards of care in a disaster includes the recognition that it will never be an “all or none” situation. Disasters will have varying impacts on communities, based on many different variables that might affect the delivery of health care during such events. Response to a surge in demand for healthcare services will likely fall along a continuum ranging from “conventional” to “contingency” and “crisis” surge responses (Figure B-1; Hick et al., 2009). Conventional patient care uses usual resources to deliver health and medical care that conforms to the expected standards of care of the community. The delivery of care in the setting of contingency surge response seeks to provide patient care that remains functionally equivalent to conventional care. Contingency care adapts available patient care spaces, staff, and supplies as part of the response to a surge in demand for services. Although this may introduce minor risk to the patient compared to usual care (e.g., substituting less familiar medications for those in short supply, thereby potentially leading to medication dosage error), the overall delivery of care remains mostly consistent with community standards. Crisis care, however, occurs under conditions in which usual safeguards are no longer possible. Crisis care is provided when available resources are insufficient to meet usual care standards, thus providing a transition point to implementing crisis standards of care.

FIGURE B-1 Continuum of incident care and implications for standards of care.

NOTE: Post-anesthesia care unit (PACU); intensive care unit (ICU).

^aUnless temporary, requires state empowerment, clinical guidance, and protection for triage decisions and authorization for alternate care sites/techniques. Once situational awareness achieved, triage decisions should be as systematic and integrated into institutional process, review, and documentation as possible.

^bInstitutions consider impact on the community of resource use (consider “greatest good” versus individual patient needs—e.g., conserve resources when possible), but patient-centered decision making is still the focus.

^cInstitutions (and providers) must make triage decisions balancing the availability of resources to others and the individual patient’s needs—shift to community-centered decision making.

SOURCES: Adapted from Hick et al. (2009); Wynia (2009).

The goal for the health system is to increase the ability to stay in conventional and contingency categories through preparedness and anticipation of resource needs prior to serious shortages, and to return as quickly as possible from crisis back across the continuum to conventional care (Tables B-2 and B-3).

In major disaster and emergencies, there will also be a surge of psychological casualties among those directly affected, including responders, healthcare practitioners, and members of the population who have not experienced direct impact. Mass psychological casualties and morbidity will occur in those who experience an aggravation of a prior or concurrent mental health condition. New substantial burdens of clinical disorders, including posttraumatic stress disorder, depression, and substance abuse may also arise among those with no prior history. Even in those with no formal disorder, there may be significant distress at a population level, resulting in unparalleled demands on the mental health system. Therefore, it is necessary to use a mass casualty disaster mental health concept of operations in order to enable a crisis standard of disaster mental health care through the use of currently available, evidence-based mental health rapid triage and incident management systems. Additional details can be found in the complete letter report.

Providing a treatment category of “palliative care” for those not likely to survive will be an important service option for responders and triage officers. Acknowledging that a patient is not likely to survive typically leads to discussions regarding the goals of care, appropriateness of interventions, and efforts to help the patient and family begin to say good-bye (Matzo, 2004). Prognostication, aided by a risk index or scale, enables healthcare practitioners to plan clinical strategies during a crisis situation. These tools may be helpful in determining whether a patient’s illness has reached a terminal phase (Box B-1) (Matzo, 2004).

Resources that are likely to be scarce in a crisis care environment and may justify specific planning and tracking include the following:

• Ventilators and components

• Oxygen and oxygen delivery devices

• Vascular access devices

• Intensive care unit (ICU) beds

• Healthcare providers, particularly critical care, burn, and surgical/anesthesia staff (nurses and physicians) and respiratory therapists

• Hospitals (due to infrastructure damage or compromise)

• Specialty medications or intravenous fluids (sedatives/analgesics, specific antibiotics, antivirals, etc.)

• Vasopressors/inotropes

• Medical transportation

The committee discussed the need to consider both indicators and triggers:

Prior to implementation of formal resource triage, the following conditions must be met or in process (Devereaux et al., 2008):

• Identification of critically limited resources and infrastructure

• Surge capacity fully employed within healthcare facility

• Maximal attempts at conservation, reuse, adaptation, and substitution performed

• Regional, state, and federal resource allocation insufficient to meet demand

• Patient transfer or resource importation not possible or will occur too late to consider bridging therapies

• Request for necessary resources made to local and regional health officials

• Declared state of emergency (or in process)

Triage occurs routinely in medicine, when resources are not evenly distributed or temporarily overwhelmed. These decisions are generally ad hoc, based on provider expertise, and have minimal effects on patient outcome. Thus standards of care are routinely adjusted to resources available to the provider without requiring a formal process or declarations. However, the situation in disasters is more complex, as services may not be available due to demand, with severe consequences to the patient who does not receive these resources. Reactive triage involves the ad hoc decisions made by clinical or administrative personnel to an exigent circumstance to allocate available resources in the face of an unanticipated shortfall. These decisions must be accountable to general principles of ethical resource allocation, but do not follow a structured, systematic process. Situational awareness is not available. Proactive triage involves systematic decisions made by clinical or administrative personnel to a situation requiring resource triage where situational awareness is available and the decision making is accountable to the incident management process. Additional details about reactive and proactive triage are available in the letter report.

The implementation of crisis standards of care and fair and equitable resource allocation requires attention to the core elements of incident management, including situational awareness, incident command, and adequate communication and coordination infrastructure and policies. Without this foundation, medical care will be inconsistent, and resources will not be optimally used (Hick et al., 2009). All healthcare systems must also understand how their incident management system interacts with that of jurisdictional emergency management and any coalition hospital response partners, including the process for obtaining assistance during an emergency (Figure B-2).

FIGURE B-2 Overview of relationships among agencies, committees, and groups.

NOTE: Depending on the organization of the state, the functional layout, details, and relationships among the units might vary.

When crisis care becomes necessary, a threshold has been crossed requiring that the affected institution(s) either quickly address the situation internally, or, more likely, appeal to partner facilities and agencies for assistance in either transferring patients to facilities with resources or bringing needed resources to the facility. If these strategies cannot be

carried out, or if partner facilities are in the same situation (e.g., a pandemic influenza scenario), then systematic implementation of crisis standards of care at the state level may become necessary in order to codify and provide guidance for triage of life-sustaining interventions as well as to authorize care provided in non-traditional locations (alternate care facilities).

The state has an obligation to ensure consistency of medical care to the highest degree possible when crisis care is being provided. Usual coordination and resource requests outlined above are used to minimize healthcare service disruption and/or to provide the most consistent level of care across the affected area and the state as a whole. When prolonged or widespread crisis care is necessary, the state should issue a declaration or invoke emergency powers empowering and protecting providers and agencies to take necessary actions to provide medical care and should accompany these declarations with clinical guidance, developed by the State Disaster Medical Advisory Committee, to provide a consistent basis for life-sustaining resource allocation decisions. The state, through its emergency powers, resource allocation, and provision of clinical guidance, attempts to “level the playing field” at the state level, as well as provide legal protections for providers making difficult triage decisions and provide relief from usual regulations that might impede coping strategies such as alternate care facilities.

Some hospital coalitions cover large metropolitan areas and thus the Regional Medical Coordination Center (RMCC) acts as liaison between the state and its constituents. The RMCC may be an agency, such as public health, or a hospital or other facility designated by the system. The RMCC attempts to ensure regional medical care consistency and may do so by acting as a resource “clearinghouse” between the healthcare facilities and emergency management and coordinating policy and information to meet regional needs. This may involve a Regional Disaster Medical Advisory Committee or at least a medical advisor or coordinator with access to technical experts in the area, particularly in large metropolitan areas because the specific needs of the area may not be well addressed by state guidance. However, the regional guidance cannot be inconsistent with that of the state.

Individual hospitals and healthcare facilities should work through tactical mutual aid agreements with other local facilities and at the regional level to ameliorate conditions that might force crisis standards of care. When these strategies have been exhausted, healthcare facilities, working through local public health authorities, should request a state

emergency declaration recognizing that crisis conditions are at hand, that a change in acceptable standards of care are required, and that crisis standards of care must be initiated.

The individual healthcare institution surge capacity plan should incorporate the use of a “clinical care committee” that is composed of clinical and administrative leaders who can focus a hospital or hospital system approach to the allocation of scarce, life-saving resources (Phillips and Knebel, 2007; Hick and O’Laughlin, 2006; O’Laughlin and Hick, 2008). A clinical care committee is activated by the facility incident commander when the facility is practicing contingency or crisis care due to factors that are not readily reversible. This committee is responsible for making prioritization decisions about the use of resources at the relevant healthcare institution (e.g., hospital, primary care, emergency medical services agency, and others). A sample institutional process is included in the letter report.

Although the most examined decision tools revolve around mechanical ventilation, guidance is also available for other core medical care components (medications, oxygen, etc.) and limited guidance is available for specific other resources, including blood products, elective surgery triage, trauma care, radiation, burn care, and cancer (Box B-2, Figure B-3). See the letter report for additional details.

FIGURE B-3 Triage algorithm process.

^aExample exclusion criteria include severe, irreversible organ failure (congestive heart failure, liver, etc.), severe neurologic compromise, extremely high or not improving SOFA scores, etc.

SOURCE: Adapted from Devereaux et al. (2008).

Finally, throughout the letter report, the committee emphasized the importance of consistent implementation of crisis standards of care in a disaster situation within and among states.

Crisis standards of care, as described in the report, will be required when the intent and ability to provide usual care is simply no longer possible due to the circumstances. As acknowledged by the committee, some governments have made great strides in determining how to approach resource scarcity, but much work remains to be done.

Indeed, the committee highlighted a number of areas worthy of further discussion, evaluation, and study. Some of these issues constitute real or perceived barriers that will make the implementation and operationalization of crisis standards of care difficult to achieve. Some simply reflect the fact that the study of this area of disaster medicine remains an evolving pursuit requiring multidisciplinary participation. Nonetheless, the discussion around this topic has matured tremendously in the past few years. Despite the gaps that remain, the committee was greatly encouraged by the search for solutions taking place.

In studying this issue, the committee’s intent was to provide a framework that allows consistency in describing the key components required by any effort focused on standards of care in a disaster. It also intended that, by suggesting such uniformity, consistency will develop across jurisdictions, regions, and states so that this guidance will be useful in contributing to a uniform national framework for responding to crisis in a fair, equitable, and transparent manner.

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