Introduction¹

The United States faces the real possibility of a catastrophic public health event that involves tens of thousands or hundreds of thousands of victims. Public health emergencies—such as the 2009 H1N1 pandemic, an intentional anthrax release, infectious disease threats such as severe acute respiratory syndrome (SARS), fires, floods, earthquakes, and hurricanes—highlight the ever-changing threats posed by acts of terrorism and other public health emergencies, while also underscoring the pressing reality of these events. A tremendous effort has been made over the past decade to prepare for public health emergencies. Many states and healthcare organizations have developed preparedness plans that include enhancing surge capacity to increase and maximize available resources and to manage demand for healthcare services in response to a mass casualty event.

During a wide-reaching catastrophic public health emergency or disaster, however, these surge capacity plans may not be sufficient to enable healthcare providers to continue to adhere to normal treatment procedures and follow usual standards of care. This is a particular concern for emergencies that may severely strain resources across a large geographic area, such as a pandemic influenza or the detonation of a nuclear device. Healthcare organizations and providers may face overwhelming demand for services, severe scarcity of material resources, insufficient numbers of qualified providers, and too little patient care space. Under these circumstances, it may be impossible to provide care according to the standards of care used in non-disaster situations, and, under the most extreme circumstances, it may not even be possible to provide basic life-sustaining interventions to all patients who need them.

In recent years, a number of federal, state, and local efforts have taken place to develop crisis standards of care protocols and policies for use in conditions of overwhelming resource scarcity. Those involved in these efforts have begun to carefully consider these difficult issues and to develop plans that are ethical, consistent with the community’s values, and implementable during a crisis. These planning efforts are essential because, absent careful planning, there is enormous potential for confusion, chaos, and flawed decision making in a catastrophic public health emergency or disaster.

However, although these efforts have accomplished a tremendous amount in just a few years, a great deal remains to be done in even the most advanced plan. Furthermore, the efforts have mainly been taking place independently, leading to a lack of consistency across neighboring jurisdictions and unnecessary duplication of effort. Lastly, many states have not yet substantially begun to develop policies and protocols for crisis standards of care during a mass casualty event.

These issues prompted the Institute of Medicine’s (IOM’s) Forum on Medical and Public Health Preparedness for Catastrophic Events (Preparedness Forum) to organize a series of regional workshops on this topic. These workshops were held in Irvine, CA; Orlando, FL; New York, NY; and Chicago, IL, between March and May of 2009.