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: