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).