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Crisis Standards
of Care
A Systems Framework for
Catastrophic Disaster Response
Introduction and CSC Framework
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Crisis Standards of Care
A Systems Framework for Catastrophic Disaster Response
Volume 1: Introduction and CSC Framework
Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations
Board on Health Sciences Policy
Dan Hanfling, Bruce M. Altevogt, Kristin Viswanathan, and Lawrence O. Gostin, Editors
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National
Research Council, whose members are drawn from the councils of the National Academy of Sciences, the
National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for
the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. HHSP23320042509XI between the National Academy of Sciences
and the Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations
expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations
or agencies that provided support for this project.
Library of Congress Cataloging-in-Publication Data
Crisis standards of care : a systems framework for catastrophic disaster
response / Committee on Guidance for Establishing Standards of Care for Use in
Disaster Situations, Board on Health Sciences Policy ; Dan Hanfling ... [et al.], editors.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-309-25346-8 (hardcover) — ISBN 978-0-309-25347-5 (pdf ) I. Hanfling, Dan.
II. Institute of Medicine (U.S.). Committee on Guidance
for Establishing Standards of Care for Use in Disaster Situations.
[DNLM: 1. Disaster Medicine—standards—United States. 2. Emergency
Medical Services—standards—United States. 3. Emergency Treatment—
standards—United States. WA 295]
363.34—dc23
2012016602
Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360,
Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2012 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since
the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carv-
ing from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2012. Crisis Standards of Care: A Systems Framework for Cata-
strophic Disaster Response. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished schol-
ars engaged in scientific and engineering research, dedicated to the furtherance of science and technology
and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in
1863, the Academy has a mandate that requires it to advise the federal government on scientific and techni-
cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy
of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in
the selection of its members, sharing with the National Academy of Sciences the responsibility for advising
the federal government. The National Academy of Engineering also sponsors engineering programs aimed
at meeting national needs, encourages education and research, and recognizes the superior achievements of
engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the
services of eminent members of appropriate professions in the examination of policy matters pertaining to
the health of the public. The Institute acts under the responsibility given to the National Academy of Sci-
ences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to
identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute
of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate
the broad community of science and technology with the Academy’s purposes of furthering knowledge and
advising the federal government. Functioning in accordance with general policies determined by the Acad-
emy, the Council has become the principal operating agency of both the National Academy of Sciences and
the National Academy of Engineering in providing services to the government, the public, and the scientific
and engineering communities. The Council is administered jointly by both Academies and the Institute
of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the
National Research Council.
www.national-academies.org
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COMMITTEE ON GUIDANCE FOR ESTABLISHING STANDARDS OF CARE
FOR USE IN DISASTER SITUATIONS
LAWRENCE O. GOSTIN (Chair), O’Neill Institute for National and Global Health Law, Georgetown
University Law Center, Washington, DC
DAN HANFLING (Vice-Chair), Inova Health System, Falls Church, VA
DAMON T. ARNOLD, Illinois Department of Public Health, Chicago (retired)
STEPHEN V. CANTRILL, Denver Health Medical Center, CO
BROOKE COURTNEY, Food and Drug Administration, Bethesda, MD
ASHA DEVEREAUX, California Thoracic Society, San Francisco, CA
EDWARD J. GABRIEL,* The Walt Disney Company, Burbank, CA
JOHN L. HICK, Hennepin County Medical Center, Minneapolis, MN
JAMES G. HODGE, JR., Center for the Study of Law, Science, and Technology, Arizona State University,
Tempe
DONNA E. LEVIN, Massachusetts Department of Public Health, Boston
MARIANNE MATZO, University of Oklahoma Health Sciences Center, Oklahoma City
CHERYL A. PETERSON, American Nurses Association, Silver Spring, MD
TIA POWELL, Montefiore-Einstein Center for Bioethics, Albert Einstein College of Medicine,
New York, NY
MERRITT SCHREIBER, University of California, Irvine, School of Medicine
UMAIR A. SHAH, Harris County Public Health and Environmental Services, Houston, TX
JOLENE R. WHITNEY, Bureau of Emergency Medical Services (EMS) and Preparedness, Utah
Department of Health, Salt Lake City
Study Staff
BRUCE M. ALTEVOGT, Study Director
ANDREW M. POPE, Director, Board on Health Sciences Policy
CLARE STROUD, Program Officer
LORA TAYLOR, Senior Project Assistant (until January 2012)
ELIZABETH THOMAS, Senior Project Assistant (since February 2012)
KRISTIN VISWANATHAN, Research Associate
RONA BRIER, Editor
BARBARA FAIN, Consultant for Public Engagement
* Resigned from the committee October 2011.
v
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Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and techni-
cal expertise, in accordance with procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid and critical comments that will
assist the institution in making its published report as sound as possible and to ensure that the report meets
institutional standards for objectivity, evidence, and responsiveness to the study charge. The review com-
ments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish
to thank the following individuals for their review of this report:
Richard Alcorta, Maryland Institute for Emergency Medical Services Systems
Knox Andress, Louisiana Poison Center
Connie Boatright-Royster, MESH Coalition
Susan Cooper, Tennessee Department of Health
Lance Gable, Wayne State University Center for Law and the Public’s Health
Carol Jacobson, Ohio Hospital Association
Amy Kaji, Harbor-UCLA Medical Center
Jon Krohmer, Department of Homeland Security
Onora Lien, King County Healthcare Coalition
Suzet McKinney, The Tauri Group
Peter Pons, Denver Health Medical Center
Clifford Rees, University of New Mexico School of Law
Linda Scott, Michigan Department of Community Health
Robert Ursano, Uniformed Services University School of Medicine
Lann Wilder, San Francisco General Hospital and Trauma Center
Matthew Wynia, American Medical Association
Although the reviewers listed above have provided many constructive comments and suggestions, they were
not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before
vii
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its release. The review of this report was overseen by Dr. Georges Benjamin, American Public Health Asso-
ciation. Appointed by the Institute of Medicine, he was responsible for making certain that an independent
examination of this report was carried out in accordance with institutional procedures and that all review
comments were carefully considered. Responsibility for the final content of this report rests entirely with the
authoring committee and the institution.
viii REVIEWERS
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Contents
VOLUME 1: INTRODUCTION AND CSC FRAMEWORK
Acronyms ix
Summary 1-1
1 Introduction 1-15
Phase Two: Study Goals and Methods, 1-16
2009 Letter Report: Key Elements and Recommendations, 1-17
Impact of the 2009 Letter Report, 1-21
Organization of the Report, 1-28
References, 1-29
2 Catastrophic Disaster Response: Creating a Framework for Medical Care Delivery 1-31
Conceptualizing a Systems Approach to Disaster Response, 1-31
Fundamental Factors That Influence the Implementation of Crisis Standards of Care, 1-34
Guidance for Disaster Response Stakeholders, 1-41
Milestones for Crisis Standards of Care Planning and Implementation, 1-46
Implementation of the Disaster Response Framework, 1-47
Recommendation, 1-50
References, 1-52
3 Legal Issues in Emergencies 1-55
Medical and Legal Standards of Care, 1-55
The Changing Legal Environment in Declared Emergencies, 1-57
Legal Issues in Declared Emergencies, 1-58
Summary, 1-68
References, 1-69
ix
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4 Cross-Cutting Themes: Ethics, Palliative Care, and Mental Health 1-71
Ethical Framework, 1-72
Palliative Care, 1-78
Mental Health, 1-86
References, 1-94
VOLUME 2: STATE AND LOCAL GOVERNMENT 2-1
5 State and Local Government
VOLUME 3: EMS 3-1
6 Prehospital Care: Emergency Medical Services (EMS)
VOLUME 4: HOSPITAL 4-1
7 Hospitals and Acute Care Facilities
VOLUME 5: ALTERNATE CARE SYSTEMS 5-1
8 Out-of-Hospital and Alternate Care Systems
VOLUME 6: PUBLIC ENGAGEMENT 6-1
9 Public Engagement
VOLUME 7: APPENDIXES 7-1
Appendixes
x CONTENTS
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Acronyms
AHRQ Agency for Healthcare Research and Quality
AMA American Medical Association
APHA American Public Health Association
ASPR Assistant Secretary for Preparedness and Response
ASTHO Association of State and Territorial Health Officials
CDC Centers for Disease Control and Prevention
CONOPS concept of operations
CSC crisis standards of care
DHS Department of Homeland Security
DOD Department of Defense
EMAC Emergency Management Assistance Compact
EMS emergency medical services
EMTALA Emergency Medical Treatment and Active Labor Act
EOC emergency operations center
EUA emergency use authorization
FDA Food and Drug Administration
HCC health care coalition
HCF health care facility
HCPHES Harris County Public Health and Environmental Services
HHS Department of Health and Human Services
HICS hospital incident command system
HIPAA Health Insurance Portability and Accountability Act
HPP Hospital Preparedness Program
xi
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ICU intensive care unit
IOM Institute of Medicine
MAC medical advisory committee
MCE mass casualty event
MEMS Modular Emergency Medical System
MIMAL Model Intrastate Mutual Aid Legislation
MOU memorandum of understanding
MRC Medical Reserve Corps
MSCC Medical Surge Capacity and Capability
MSEHPA Model State Emergency Health Powers Act
NACCHO National Association of County and City Health Officials
NCCUSL National Conference of Commissioners on Uniform State Laws
NDMS National Disaster Medical System
NIMS National Incident Management System
NLE National Level Exercise
NRF National Response Framework
NSAID nonsteroidal anti-inflammatory drug
OSHA Occupational Safety and Health Administration
PACU postanesthesia care unit
PC palliative care
PHEP Public Health Emergency Preparedness
PPE personal protective equipment
PREP Public Readiness and Emergency Preparedness
PTSD posttraumatic stress disorder
RDMAC regional disaster medical advisory committee
RMCC regional medical coordination center
SARS severe acute respiratory syndrome
SDMAC state disaster medical advisory committee
SNS Strategic National Stockpile
SOFA Sequential Organ Failure Assessment
UEVHPA Uniform Emergency Volunteer Health Practitioners Act
VA Department of Veterans Affairs
VHP volunteer health practitioner
VPA Volunteer Protection Act
xii ACRONYMS
