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What are Crisis Standards of Care?

While Washington state has not needed to implement Crisis Standards of Care, a second surge of COVID-19 cases could require our state officials to revisit these standards.

During the COVID-19 crisis, planning has included examining Crisis Standards of Care in the event the health care system is overwhelmed by the volume and needs of patients. Washington state has to date successfully flattened the curve, and the potential need for surge capacity was not realized although lack of adequate PPE and concerns about the reuse of PPE continue to be a major concern. While Washington state has not needed to implement Crisis Standards of Care, a second surge of COVID-19 cases could require our state officials to revisit these standards.

Watkins Sally WSNA

Sally Watkins

In the event of a large-scale disaster, either a no-notice event such as a natural disaster or a prolonged situation such as a pandemic like COVID 19, there is potential for an overwhelming number of critically ill or injured patients. In these situations, certain medical resources may become scarce. Prioritization of care may need to be considered. The surge in medical care needs is a complex event, and the response needed is equally complex. In an effort to better manage this surge in care needs, it is essential to have an overall guiding framework.

In 2009, the Institute of Medicine (now the National Academy of Medicine) published a landmark report, “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situation: A Letter Report.” In this report, Crisis Standards of Care was defined as follows:

“A substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g. pandemic influenza) or catastrophic (e.g. earthquake, hurricane) disaster. This change in the level of care delivered is justified by specific circumstances and is formally declared by a state government in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory power and protections for healthcare providers in the necessary task of allocating and using scarce medical resources and implementing alternate care facility operations.”

A framework for managing surge capacity was defined as a continuum from conventional to contingency, and finally crisis:

"Conventional Capacity: The spaces, staff, and supplies used are consistent with daily practices within the institution. These spaces and practices are used during a major mass casualty incident that triggers activation of the facility emergency operations plan.

"Contingency Capacity: The spaces, staff, and supplies used are not consistent with daily practices but provide care that is functionally equivalent to usual patient care. These spaces or practices may be used temporarily during a major mass casualty incident or on a more sustained basis during a disaster (when the demands of the incident exceed community resources).

"Crisis Capacity: Adaptive spaces, staff, and supplies are not consistent with usual standards of care, but provide sufficiency of care in the context of a catastrophic disaster (i.e., provide the best possible care to patients given the circumstances and resources available). Crisis capacity activation constitutes a significant adjustment to standards of care.”

The Institute of Medicine also stressed the importance of an ethically grounded system to guide decision-making in crisis to ensure the most appropriate use of resources. These ethical principles are defined as:

  • 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.
  • Duty to care – standards are focused on the duty of health care professionals to care for patients in need of medical care.
  • Duty to steward resources – health care institutions and public health officials have a duty to steward scarce resources, reflecting the utilitarian goal of saving the greatest possible number of lives.
  • 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 individual decisions and implementation standards and of governments for ensuring appropriate protections and just allocation of available resources.

This framework has been nationally accepted and adopted and has been used in the development of various tools and products, including Scarce Resource Cards (SRC), representing a specific resource critical to patient care that may become scarce during times of medical surge; Critical Care triage algorithms, including in-depth clinical consideration worksheets; and Triage Team Guidelines, including composition, roles and responsibilities.

The American Nurses Association also recently provided a guidance document on the issue of crisis standards of care for nurses:

    Guidance to registered nurses

    • Professional nurses have a duty to care during crises like pandemics. Their employers and supervisors have a corresponding duty to reduce risks to nurses’ safety, plan for competing priorities like childcare, and address moral distress and other injuries to personal and professional integrity such crisis events can cause.
    • No crisis changes the professional standards of practice, Code of Ethics, accountability for clinical competence or values of the registered nurse. However, the specific balance of professional standards and crisis standards of care will be based on the reality of the specific situation, such as the presence or absence of necessary equipment, medications or colleagues.
    • Decision-making during extreme conditions can shift ethical standards to a utilitarian framework in which the clinical goal is the greatest good for the greatest number of individuals, but that shift must not disproportionately burden those who already suffer health care disparities and social injustice. Sacrifices in desired care must be fairly shared. This means that care decisions are not about “the best that can be done” under normal conditions. They are necessarily constrained by the specific conditions during the crisis.
    • ANY move to crisis standards of care MUST be done within the institution’s response structure and ideally in collaboration with other health care professionals, policymakers and the community.
    • Registered nurses may be asked to delegate care to others, such as students, staff displaced from another institution, or volunteers. This will require a rapid assessment of the skills of the others available to assist in patient care. Nurses must continue to emphasize patient safety and appropriate delegation.
    • An increased reliance on a nurse’s own or the collective accumulated competence may be needed, as the usual range of colleagues, experts or support services may not be available.

    More information can be found at: