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Institute of Medicine (US) Forum on Medical and Public Health Preparedness for Catastrophic Events. Crisis Standards of Care: Summary of a Workshop Series. Washington (DC): National Academies Press (US); 2010.

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Crisis Standards of Care: Summary of a Workshop Series.

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Related IOM Work on Crisis Standards of Care

This workshop series served as background for a subsequent Institute of Medicine letter report entitled Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations (IOM, 2009). This letter report was requested by the Office of the Assistant Secretary for Preparedness and Response (ASPR), Department of Health and Human Services (HHS). The workshop series was organized prior to the onset of the letter report and was not technically part of those efforts. However, the committee that authored the letter report was aware of the information discussed at the regional workshops and this information was subsequently used as one of the key background sources for the committee’s work. Consequently, the letter report helped to inform and advance many of the issues that were identified by participants at the workshops.

Unlike this workshop summary, the letter report offers a series of consensus committee recommendations. The report concludes that “[i]n an important ethical sense, entering a crisis standards 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—i.e., not to adopt crisis standards of care—is very likely to result in greater death, injury, or illness.” The committee also concluded that there is an urgent and clear need for a single national 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 recognized 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.

The report articulates current concepts and guidance that can assist state and local public health officials, healthcare facilities, and professionals in the development of systematic and comprehensive policies and protocols for crisis standards of care in disasters in which resources are scarce. The committee also identified a series of five key elements and associated components that should be included in all crisis standards of care protocols. Finally, in an extensive “operations” section, the report provides guidance to clinicians, healthcare institutions, and state and local public health officials on how those crisis standards of care should be implemented in a disaster situation. A summary of the committee’s recommendations, findings, and practical guidance is included in Appendix B. The complete letter report is available at http://www.iom.edu/disasterstandards.

Definition of “Crisis Standards of Care”

For purposes of developing recommendations for situations in which healthcare resources are overwhelmed, in the letter report the IOM committee defined the level of health and medical care capable of being delivered during a catastrophic event as “crisis standards of care”:

“Crisis standards of care” is defined as 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 powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations.

This definition was developed by the committee that authored the letter report after the workshops took place, and no formal definition was used for the purposes of the workshop. In addition, for consistency this workshop summary uses the term “crisis standards of care” even though this term was only adopted by the IOM after the workshops took place. The remainder of this document outlines the discussions and presentations that took place during the workshops.

Other Related Work

The IOM letter report and these regional workshops built on a series of previous efforts, many of which were mentioned during the workshops. Workshop attendees praised the work of the Agency for Healthcare Research and Quality (AHRQ) and the Office of the Assistant Secretary for Preparedness and Response for driving the discussion forward. The two agencies came together in 2004 to jumpstart the discussion by convening a panel with experts in the fields of bioethics, emergency medicine, emergency management, health administration, health law and policy, and public health. The result of that meeting was a critical document, Altered Standards of Care in a Mass Casualty Event, which served as a foundational document for communities approaching the issues of critical care (AHRQ, 2005).

Producing the document, however, was not easy. “When we first starting working on this subject in 2004, [hospital leaders] wouldn’t even agree to sit with us,” said Sally Phillips, director of public health emergency preparedness for AHRQ. “Their risk managers wouldn’t allow them to come.”

A subsequent report, published in 2007 and entitled Mass Medical Care with Scarce Resources: A Community Planning Guide, further advanced the field by providing an initial framework for developing policies and protocols for crisis standards of care (Phillips and Knebel, 2007).

Professional societies and academia also have made several recent efforts. Many workshop participants were involved with or highlighted the work undertaken through the American College of Chest Physicians, which resulted in a supplemental issue on the management of mass critical care in the journal Chest. This group brought together a multidisciplinary group of experts to provide an in-depth look at current U.S. and Canadian baseline critical care preparedness and response capabilities and limitations, and developed a framework for the development of mass critical care plans. Of particular interest to the workshop participants was the work on allocation of scarce critical care resources (Devereaux et al., 2008). The American Nurses Association (ANA) has also addressed this topic (ANA, 2008; Gebbie et al., 2009).

Copyright © 2010, National Academy of Sciences.
Bookshelf ID: NBK32749

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