NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

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.

Cover of Crisis Standards of Care

Crisis Standards of Care: Summary of a Workshop Series.

Show details

Continuum of Surge Capacity and Standards of Care

Many workshop participants stressed that making changes to usual standards of care is not an all-or-none situation. The changes required depend on the nature and extent of the disaster, the existing capabilities of the community, and the particular resources that become scarce, among many other variables. Several participants emphasized that the response to the disaster should be proportional, and changes to standards of care should be the minimum necessary given the circumstances.

Efforts to define a common taxonomy and framework for discussion are a first step to ensuring a proportional response, to developing protocols that are sufficiently detailed so as to be implementable, and to begin the discussion of exactly when healthcare providers and facilities should implement crisis standards of care.

Conventional, Contingency, and Crisis Standards of Care

John Hick, associate medical director for EMS and medical director of emergency preparedness at Hennepin County Medical Center, MN, presented a framework from an article published in the June 2009 issue of the Journal of Disaster Medicine and Public Health Preparedness (Hick et al., 2009). Hick and his coauthors described three categories of surge capacity: conventional capacity, contingency capacity, and crisis capacity (Box 3). The description resonated strongly with workshop participants and came to define the discussions of care at each of the workshops. The recent IOM committee on crisis standards of care also adopted this terminology and framework (IOM, 2009).

Box Icon


Continuum of Conventional, Contingency, and Crisis Capacity. 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 (more...)

“Conventional capacity is really about providing patient care without any change in daily practice,” said Hick. Most hospitals and other healthcare resources can face small surges in demand, but still operate within the conventional framework. They may cancel elective surgeries, or accelerate the discharge of healthy patients, but they will still perform invasive procedures in standard operating rooms, follow standard protocols, and generally operate in a business-as-usual mindset. Staff may be asked to pitch in and support different areas of the hospital—a trauma surgeon may be pulled into the emergency room—but staff will not be operating outside of their bounds of expertise.

“As you move into contingency modes of reaction, you’re starting to … change practice a little, but it still really doesn’t have any significant impact on the care delivered or on the outcomes achieved,” said Hick.

Contingency care might mean using rooms of the hospital for different kinds of clinical care than usual, such as using post-anesthesia care rooms or procedure areas for care that would usually be delivered in an intensive care unit (ICU). Practitioners may start conserving supplies by, for example, not providing precautionary oxygen to patients who under normal circumstances would receive it, but who can survive and recover without it.

“As we move into the crisis level, we’re really starting to make some pretty substantial changes to the way we provide care, and there are some implications for patient outcomes,” said Hick. “We’re trying to do the best we can with the resources available.”

In crisis situations, staff may be asked to practice outside of the scope of their usual expertise. Supplies may have to be reused and recycled. In some circumstances, resources may become completely exhausted. Family members may be asked to provide basic patient hygiene and other aspects of care that do not require medical expertise.

“Crisis capacity is really defined as adapting spaces, staff, and resources so that … you’re doing the best you can with what you have,” said Dan Hanfling, special advisor to the Inova Health System in Falls Church, VA, on matters related to emergency preparedness and disaster response. “You’re providing the best possible care under the circumstances.”

As Hick noted, the goal is always to avoid entering contingency or crisis care. However, if that becomes unavoidable and a facility is operating under contingency or crisis care, the goal is “to get back to a conventional footing.” Hick discussed strategies of preparation, substitution, adaptation, conservation, reuse, and finally, reallocation. Strategies that have a lesser impact on clinical care, such as substitution, should be used first, and strategies such as reallocation should be used only when other strategies have not been sufficient to address the resource shortage. He highlighted a set of informational cards for healthcare providers and institutions that he and others developed in Minnesota that lays out patient care strategies for scarce resource situations (Minnesota Department of Health, 2008). The card set lists appropriate substitution, adaptation, conservation, reuse, and reallocation strategies for oxygen, medication administration, hemodynamic support and IV fluids, mechanical ventilation, nutrition, and staffing.

Stages of Care in the North Dakota Plan

Officials in the state of North Dakota have also outlined incremental changes to standards of care. During the Chicago workshop, Tim Wiedrich, chief of emergency preparedness and response for the North Dakota Department of Health, presented their work on outlining levels of care (Box 4).

Box Icon


Stages of Care in North Dakota’s Plan. STAGE 1: SMALL OUTCOME IMPACT Tighter admission criteria

Stage 1 involves a small shift in patient care that may inconvenience some patients, but will not have a measurable impact on patient care. It is akin to the “conventional” care category outlined by Hick.

As an event escalates, North Dakota moves into Stage II, taking steps that limit the quality of care and may impact patient outcomes. Doctors and nurses are asked to operate slightly outside their normal bounds of expertise, retired caregivers are called back onto the job, and changes are made in standard operating procedures such as charting and checking vital signs.

Stage III is akin to the crisis care scenario outlined by Hick and others. In a Stage III emergency, the North Dakota system operates under a “best efforts” basis that attempts to stretch the medical response to serve as many patients as possible. At Stage III, the impact on care is severe. A decision such as “no CPR” has real consequences, but in this scenario is deemed necessary to ensure the best possible care is delivered to the maximum number of people.

Copyright © 2010, National Academy of Sciences.
Bookshelf ID: NBK32751


  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (1.0M)

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...