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Crisis standards of care

Pediatric Surge Crisis Standards of Care (module)
Patient Care Scarce Resource Strategies (Minnesota)
Crisis Standards of Care - Pediatrics (Nebraska)
Scarce Resource Management & Crisis Standards of Care Adult and Pediatrics (Washington Dept of Health)
Arizona Crisis Standards of Care Plan 2020 (Includes Pediatrics)


Rationale for degradation quotes

At some point in time following a catastrophe, it may become imperative to implement a crisis standard of care, thereby putting protocols, such as rationing of health care supplies and medications into action. The question is when? The letter report from IOM (US Institute of Medicine) stated that “in 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 - that is, not to adopt crisis standards of care - is very likely to result in greater death, injury, or illness.” 


Koenig KL, et al., Crisis Standard of Care: Refocusing Health Care Goals During Catastrophic Disasters and Emergencies, Journal of Experimental and Clinical Medicine (2011), doi:10.1016/j.jecm.2011.06.003 

Guiding Principles for Developing Altered Standards of Care in a Mass Casualty Event 


Principle 1: In planning for a mass casualty event, the aim should be to keep the health care system functioning and to deliver acceptable quality of care to preserve as many lives as possible. 


Principle 2: Planning a health and medical response to a mass casualty event must be comprehensive, community-
based, and coordinated at the regional level.

Principle 3: There must be an adequate legal framework for providing health and medical care in a mass casualty event.


Principle 4: The rights of individuals must be protected to the extent possible and reasonable under the circumstances. 

Principle 5: Clear communication with the public is essential before,
during, and after a mass casualty event. 

Altered Standards of Care in Mass Casualty Events, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services 540 Gaither Road. Publication No. 05-0043 April 2005 

Graceful Degradation 

Like the electrical utility that plans for “brown-outs”in order to avoid “black-outs”, hospitals and other provider organizations – when stretched beyond their limits, must begin to plan to engineer their failures. 


The goal of such efforts is to achieve “graceful degradation” of the health care system’s care capabilities as opposed to catastrophic failure of its services. Under such scenarios, patients may need to be treated and boarded in hallways. Their privacy will be compromised, but their wounds will still be treated. Care and access to caregivers may even become rationed. The goal of graceful degradation is to avoid having the health system become a victim of the assault – from becoming incapacitated and unable to deliver care of any kind. The hospital, in essence, must engineer its failures – those that it can allow – while maintaining its ability to provide care. 


At the same time that graceful degradation of health care services is occurring, the care providers and health care organizations must be exempted from the day-to-day rules of operation and regulations that otherwise would prohibit them from caring for patients in such fashions. Indeed, they must be legally protected from reciprocal actions that may occur, for instance, for violations of privacy or delivery of sub-standard care once a state of emergency has been declared. 


Health Care at the Crossroads. Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems 

Joint Commission on Accreditation of Healthcare Organizations, 2003.

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