Response Resource Availability and
Crisis Standards of Care

Resource continuum:		Normal	Good	Fair/Poor
Operating conditions:		Normal/usual operating conditions, with normal "space, staff, and supplies"	Care functionally equivalent to normal but with constrained resources	Austere operating conditions: care with insufficient "space, staff, and/or supplies"
Response resource adequacy	Space	Usual patient care space fully utilized	—Patient care areas re-purposed (PACU) —Monitored units for ICU-level care	Facility damaged/unsafe, or, Non-patient care areas (e.g. classrooms, etc. ) used for patient care
	Staff	Usual staff called in and utilized	Staff extension: —Brief deferrals of non-emergent service —Supervision of broader group of patients —Change in responsibilities, documentation, etc.	Trained staff unavailable or unable to adequately care for volume of patients even with extension techniques
	Supplies	Cached and usual supplies used	Conservation, adaptation, and substitution of supplies with occasional re-use of select supplies	Critical supplies lacking, possible re-allocation of life-sustaining resources
Standard of care continuum:		Medical Standards of Care
		Conventional care1: usual care	Contingency Care2	Crisis standards of care3: austere operating conditions
Indicator: potential need to implement "crisis standards of care" Trigger: "crisis standards of care"

Incident demand / resource imbalance increases

Risk of morbidity / mortality to patient increases

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1 "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 that triggers activation of the facility emergency operations plan."
2 "Contingency capacity: The spaces, staff, and supplies used are not consistent with daily practices but provide care that is functionally equivalent to usual patient care practices. These spaces or practices may be used temporarily during a major mass casualty incident or on a more sustained basis during a disaster (when the demands of the incident exceed community resources)."
3 "Crisis capacity: Adaptive spaces, staff, and supplies are not consistent with usual standards of care, but provide sufficient of care in the setting of a catastrophic disaster (i.e., provide the best possible care to patients given the circumstances and resources available). Crisis capacity activation constitutes a significant adjustment to standards of care."

* Adapted from:
Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, a Letter Report (Institute of Medicine of the National Academies, 2009, see especially pages 52-54).

See also:

• Guidance for Emergency Response Dosimetry (NCRP Report No. 179), National Council on Radiation Protection and Measurements, Bethesda, MD, 2017.
  • Key table from Report No. 179 showing how to manage worker dosimetry issues with decreasing resources in large mass casualty radiation incident
  • Implementation Guidance for Emergency Response Dosimetry (NCRP, Commentary No. 28, 2018): provides details about NCRP Report No. 179)

More about Crisis Standards of Care:

• National Academies of Sciences, Engineering, and Medicine (NASEM)
  • Monographs: general information about mass casualty incidents
    • Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop (2020), (NASEM, 2020), updates the monographs listed below on this topic from 2009-2013
    • Crisis Standards of Care, A Toolkit for Indicators and Triggers, (NASEM, 2013), see page 17, page 97
    • Crisis Standards of Care, A Systems Framework for Catastrophic Disaster Response: Volume 1: Introduction and CSC Framework, (NASEM, 2012)
    • Crisis Standards of Care, Summary of a Workshop Series, (NASEM, 2010)
    • Guidance for Establishing Crisis Standards of Care for Use in Disaster Situation, A Letter Report (NASEM, 2009)
  • Crisis Standards of Care information: for COVID-19, some of which may pertain to large radiation incidents
    • Collection of NASEM assets
    • National Organizations Share Strategies to Improve Crisis Standards of Care Implementation During Future COVID-19 Surges and Beyond (National Academy of Medicine, May 13, 2021)
    • Call for Action to Implement Crisis Standards of Care (Dec 18, 2020)
      • List of specific action recommendations for governors, state health departments, hospital and health care systems, 2020
      • Links to other resources
• Other references on Crisis Standards of Care, not necessarily for radiation incidents
  • Pediatric
    • Lemmon ME, Truog RD, Ubel PA. Allocating Resources Across the Life Span During COVID-19-Integrating Neonates and Children Into Crisis Standards of Care Protocols. JAMA Pediatr. 2020 Dec 14. [PubMed Citation]
  • Adults
    • Minnesota Crisis Standards of Care Framework, Guidance and Strategies for State Agencies and Local Partners (PDF - 5 MB) (Minnesota Department of Health Center for Emergency Preparedness and Response, 7/20/2018)
    • Hick JL, Einav S, Hanfling D, Kissoon N, Dichter JR, Devereaux AV, Christian MD; Task Force for Mass Critical Care; Task Force for Mass Critical Care. Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014 Oct;146(4 Suppl):e1S-e16S. [PubMed Citation]
    • Maves RC, Downar J, Dichter JR, Hick JL, Devereaux A, Geiling JA, Kissoon N, Hupert N, Niven AS, King MA, Rubinson LL, Hanfling D, Hodge JG Jr, Marshall MF, Fischkoff K, Evans LE, Tonelli MR, Wax RS, Seda G, Parrish JS, Truog RD, Sprung CL, Christian MD; ACCP Task Force for Mass Critical Care. Triage of Scarce Critical Care Resources in COVID-19 An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians. Chest. 2020 Jul;158(1):212-225. [PubMed Citation]
      • See especially Table 1: Operational Steps to Implement a Triage System
    • Allocation of Scarce Critical Care Resources during a Public Health Emergency (PDF - 267 KB) (University of Pittsburgh Department of Critical Care Medicine, April 15 2020)
    • Cleveland Manchanda EC, Sanky C, Appel JM. Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19. J Racial Ethn Health Disparities. 2020 Aug 13:1–13. [PubMed Citation]
      • See especially Figure 2: map of Crisis Standards of Care regulation status in US states as of May 3, 2020.
    • Crisis Standards of Care: Lessons from New York City Hospitals’ COVID-19 Experience
      • Excellent report based on forum convened by Johns Hopkins Center for Health Security in which critical care physicians from NYC hospitals discussed their experiences with implementation of crisis standards of care.
    • Crisis Standards of Care and COVID-19: What’s working and What Isn’t (PDF - 4.04 MB) (HHS/ASPR/TRACIE, webinar slides from December 3, 2020)
    • Crisis Standards of Care during COVID-19: Public Messaging (PDF - 145 KB) (HHS/ASPR/TRACIE, Dec 2020)
    • Crisis Standards of Care During COVID-19: webinar (NASEM and APHA, April 15, 2020)
      • Although this webinar is about COVID-19, the principles outlined could apply to a large radiation incident like a nuclear detonation.
      • See both webinar and slides.
    • Crisis Triage and Disability Rights – these papers about the COVID-19 pandemic present issues that could be relevant for large radiation incidents
      • Solomon MZ, Wynia MK, Gostin LO. Covid-19 Crisis Triage - Optimizing Health Outcomes and Disability Rights. N Engl J Med. 2020;383(5):e27. [PubMed Citation]
      • Mello MM, Persad G, White DB. Respecting Disability Rights - Toward Improved Crisis Standards of Care. N Engl J Med. 2020;383(5):e26. [PubMed Citation]
      • Solomon MZ, Wynia MK, Gostin LO. Covid-19 Crisis Triage - Optimizing Health Outcomes and Disability Rights. N Engl J Med. 2020;383(5):e27. [PubMed Citation]
    • Rapid Expert Consultation on Crisis Standards of Care for the COVID-19 Pandemic (NASEM, March 28, 2020)
      • Although this monograph is about COVID-19, the principles outlined could apply to a large radiation incident like a nuclear detonation. See especially the "principles" noted and the Appendix.
    • Hantel A, Marron JM, Casey M, Kurtz S, Magnavita E, Abel GA. US State Government Crisis Standards of Care Guidelines: Implications for Patients With Cancer. JAMA Oncol. 2021 Feb 1;7(2):199-205. [PubMed Citation]
    • Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020 May 21;382(21):2049-2055. [PubMed Citation]
      • Although this paper is about COVID-19, the principles outlined could apply to a large radiation incident like a nuclear detonation.
    • Truog RD, Mitchell C, Daley GQ. The Toughest Triage - Allocating Ventilators in a Pandemic. N Engl J Med. 2020 Mar 23. [PubMed Citation]
      • Although this paper is about COVID-19, the principles outlined could apply to a large radiation incident like a nuclear detonation.
    • Ventilator Allocation Guidelines (PDF - 2.27MB) (New York State Task Force on Life and the Law, New York State Department of Health, November 2015, 272 pages)
      • Provides an ethical, clinical, and legal framework to assist health care providers and the general public in the event of a severe influenza pandemic.
      • Radiation incidents, especially nuclear detonations, would produce scarce resource environments that need to address the kinds of issues dealt with in detail in this guidance documents. The issues, are similar, although not identical.
    • Leider JP, DeBruin D, Reynolds N, Koch A, Seaberg J. Ethical Guidance for Disaster Response, Specifically Around Crisis Standards of Care: A Systematic Review. Am J Public Health. 2017 Sep;107(9):e1-e9. [PubMed Citation]
    • Timbie JW, Ringel JS, Fox DS, Pillemer F, Waxman DA, Moore M, Hansen CK, Knebel AR, Ricciardi R, Kellermann AL. Systematic review of strategies to manage and allocate scarce resources during mass casualty events. Ann Emerg Med. 2013 Jun;61(6):677-689.e101. [PubMed Citation]