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.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 and the ASPR TRACE document.For additional information on the ethical basis for CSC decision-making and other ethical issues in disaster medicine, access the 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).
Consequently, all nurses will also have to reflect on the ethical issues related to their duty as nursing professionals in the face of a global crisis, such as a pandemic. Table 1: Web Site Addresses for Additional Information on Pandemic Flu. A crisis can interrupt an organization’s routine business, bring threats to public safety or lead to financial and reputation loss. This lesson addresses prominent ethical issues in crisis situations. They include responsibility and accountability, and the ethics of humanistic care.
Resources marked with an asterisk (.) appear in more than one category. Hanfling, D., Altevogt, B.M., Viswanathan, K., and Gostin, L.O.
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. Minnesota Department of Health, Office of Emergency Preparednes. (2018).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. Biddison, E., Gwon, H., Schoch-Spana, M. 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.
Levin, D., Cadigan, R. O., Biddinger, P., et al. (2009).(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. Minnesota Department of Health, Office of Emergency Preparednes. (2018).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. Centers for Disease Control and Prevention. (2015).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. Challen, K., Bentley, A., Bright, J., and Walter, D.
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. Dries, D., Reed, M., Kissoon, N., et al. 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.”. Hanfling, D., Altevogt, B.M., Viswanathan, K., and Gostin, L.O. 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.
Hanfling, D., Hick, J., and Stroud, C. (2013).(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). Minnesota Department of Health, Office of Emergency Preparednes. (2018).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. New York State Task Force on Life & the Law, New York State Department of Health. (2015).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. Oregon Health Authority. (2018).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. White, D.B., Katz, M.H., Luce, J.M., and Lo, B. 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. Ytzhak, A., Sagi, R., Bader, T., et al. (2012).(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. Arizona Department of Health Services.
(2015).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. District of Columbia Emergency Healthcare Coalition.
(2013).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. Hanfling, D., Hick, J., and Stroud, C. 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. Minnesota Department of Health, Office of Emergency Preparednes.
(2018).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. Nevada Division of Public and Behavioral Health.
(2017).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.
Levin, D., Cadigan, R. O., Biddinger, P., et al. (2009).(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. Timbie, J., Ringel, J., Fox, D., et al. 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? This ASPR TRACIE Topic Collection was refreshed and comprehensively reviewed in November 2018 by the following subject matter experts (listed in alphabetical order):Eric Alberts, BS, CEM, CHEP, CHPP, FPEM, FPEM-HC, SEM, Orlando Health, Inc.