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When Standards of Care Change in Mass‐Casualty Events

Veenema, Tener Goodwin PhD, MPH, MS, CPNP; Toke, Joanna MPH

AJN, American Journal of Nursing: September 2007 - Volume 107 - Issue 9 - p 72A–72F
doi: 10.1097/01.NAJ.0000287515.53876.03
Hospital & Critical Care

Keep in mind the safety of nurses and patients in planning a response.

Tener Goodwin Veenema is an associate professor of clinical nursing at the University of Rochester School of Nursing, an assistant professor of emergency medicine at the University of Rochester School of Medicine and Dentistry, and an adjunct faculty member at the Center for Disaster Medicine and Emergency Preparedness at the University of Rochester Medical Center, Rochester, NY; in 2004–2007 she participated in the Robert Wood Johnson Executive Nurse Fellows Program. Joanna Toke is a student at Boston College Law School and lives in Brighton, MA.

Contact author: Tener Goodwin Veenema,

A mass-casualty event results in a significant number of deaths and a sudden surge of extremely injured patients. The Agency for Healthcare Research and Quality (AHRQ) defines such an event as “an act of bioterrorism or other public health or medical emergency involving thousands, or even tens of thousands, of victims.”1 These events can be categorized as having either an immediate impact (as with bombings or earthquakes) or a slowly developing impact (as with an influenza pandemic).2

Mass-casualty events often disrupt communication systems, interrupt transportation of patients and supplies, and overwhelm the resources and personnel of responding agencies.1 Health care infrastructures may also be devastated, as they were in New Orleans after Hurricane Katrina in 2005.

Because a disaster places such heavy demands on health care systems and personnel, advance preparations must be made to ensure that care will be delivered to the greatest possible number of people. Nurses may need to considerably change accepted standards. The moral, ethical, and legal implications of doing so must be considered beforehand, as should the emotional fallout for nurses. This article gives nurses an overview of issues they must consider when planning a response to a mass-casualty event.

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After the terrorist attacks of September 11, 2001, many states and health care organizations instituted emergency-preparedness protocols designed to increase their capacity to handle a sudden surge of patients.1 Their challenges were many. To save as many lives as possible during a mass-casualty event, facilities will have to allocate scarce resources according to need if the health care system is to function.2 Nurses, already in short supply nationwide, will become an even more precious resource, and may not even be able to respond if they are needed at their workplaces or if they are ensuring their own and their family's safety.3 And when there's a sudden surge of acutely ill patients, the availability of too few health care workers experienced in dealing with mass casualties and of too few supplies may result in patients being inadequately treated.4

To help guide planning efforts, in August 2004 the AHRQ and the Office of the Assistant Secretary for Public Health Emergency Preparedness (now called the Office of the Assistant Secretary for Preparedness and Response) within the U.S. Department of Health and Human Services (HHS) convened a meeting of experts in bioethics, emergency medicine, emergency management, health administration, health law and policy, and public health. The panel developed the following principles for ensuring that when a large-scale disaster requires it, standards of care are changed in ways that permit adequate care to be given.1

Maximize the number of lives saved. Instead of treating the sickest or the most injured first, disaster triage must identify and treat those most likely to survive. Victims with minor injuries may receive no care at all.5, 6

Employ disaster-triage models. Protocols for triage should be flexible enough to adapt to the number of people who need care and the speed with which the event occurs. (About six mass-casualty triage systems are in place around the world, but very little research has been done to validate them.7)

Allocate resources. In seeking to care for the greatest possible number of patients, clinicians may use facilities for a variety of purposes. For example, ICUs may become surgical suites and medical units may become isolation wards. Supplies may be used after their expiration dates, and personal protective equipment such as an N95 respirator may be reused.1 Because many infectious and bioterrorism agents cause respiratory failure and a large-scale outbreak would increase the demand for mechanical ventilation, triage criteria must be established for allocating the necessary resources to those most likely to benefit.8

Identify acceptable alterations to the standards of care. Health care systems must determine in advance the ways in which standards of care may be altered when responding to a mass-casualty event.1

Make decisions ethically. Resource allocation must be based on clinically sound principles and a decision-making process that's inclusive, transparent to the public, and judged to be fair. An ethical framework for decision making, such as the one proposed by the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group, must be used.9 In 2007 the AHRQ released Mass Medical Care with Scarce Resources: A Community Planning Guide, which addresses six critical areas for community planning: prehospital care, hospital and acute care, alternative care sites, palliative care, ethical considerations, and legal matters.2 The report outlines ethical principles that can be used when giving care under such circumstances (see Guiding Principles from the AHRQ, at left).

Take an all-hazards approach. An effective plan should take into account factors common to all hazards (such as the need for qualified providers), as well as factors that are hazard specific (such as guidelines for containing an outbreak of infectious disease). The federal government delegates emergency-planning authority to states; the Federal Emergency Management Agency (FEMA) and the Department of Homeland Security advocate an all-hazards approach to disaster planning.10

Overlap providers' roles. There may be a shortage of available staff, so certain jobs may need to overlap, with additional training being provided.11 When there's a sudden surge of patients, the nurse's role may need to expand. For example, according to the AHRQ, “nurses may function as physicians and physicians may function outside their specialties.”1 The nursing shortage may greatly limit any mass-casualty response, and organizations should plan accordingly.1 A large-scale disaster such as a terrorist bombing will require many adjustments to established roles.12

Accommodate delays in care. A mass-casualty event may create a backlog of patients waiting for medical care. There may also be delays in laboratory processing, and treatments may be determined based on physical examinations and clinical judgment rather than laboratory results. Nurses may not be able to assess patients comprehensively; patient education, case management, and discharge planning may be nonexistent.

Protect workers. This may mean giving providers and their families personal protective equipment and instituting other measures such as staff rotation and stress management programs to prevent burnout.

Delegate authority to sanction the alteration of standards. It's important to identify which organizations and individuals will have the authority to sanction the use of altered standards of care and under what conditions. The AHRQ offers the following questions as a guide1:

* What circumstances will trigger a call for altered standards of care?

* Who is authorized to make that call, and at what level (site, community, regional, state, or federal) should it be made?

* Under what legal statutory authority should the call be made?

* Once the call is made, who assumes responsibility for directing emergency actions?

Defer care or treatment. Elective procedures may have to be cancelled, inpatients may need to be discharged early or transferred, and certain lifesaving efforts may have to be discontinued.1 “Reverse triage”—“the safe discharge of current inpatients and refocus of hospital resources to those in even greater need”13—may be performed. Less critically ill patients, such as those undergoing cardiac monitoring, might be discharged to their home or to a nursing home to make room for more critically ill and injured patients.

Postpone documentation. Providers may not have time to obtain patients' informed consent or fully document the care they're providing. Death certificates and other forms may not be filled out according to established guidelines. Nurses' documentation might be abbreviated, taped for transcription at a later date, or eliminated altogether.

Consider privacy. Since treatment will be given to a large number of people in crowded and possibly inadequate settings, patients' right to privacy will likely be violated.1 Under the Health Insurance Portability and Accountability Act (HIPAA) of 1996, regulations protect patients' health information in certain circumstances. In July 2006 the HHS released HIPAA Privacy Rule: Disclosures for Emergency Preparedness—A Decision Tool, an interactive tool to be used in determining HIPAA compliance planning for emergencies (available online at

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Comprehensive national initiatives need to be developed for educating nurses in disaster response. These initiatives must address considerations such as competency-based standards, legal and policy issues (such as reciprocity of nursing licensure and registrations), release from work, professional liability, and mandatory vaccination. Both the American Nurses Association (ANA) and the Emergency Nurses Association have issued position statements related to work release for disaster response (see and, respectively). It is the profession's responsibility to determine exactly which changes to nursing practice standards will be acceptable. Without an agreed-upon plan, nurses will find that other disciplines are deciding on standards for us. The ANA has convened a task force that will explore the issues surrounding altering standards of nursing practice during disasters.

Education. Competencies for public health emergency preparedness have been defined14, 15 and those specific to nursing have been identified.16 Educational models for preparing health care workers for disaster response are available,17, 18 and several nursing initiatives are under way to expand academic curricula and continuing education. Jane Morgan, director of Disaster Health Services at the American Red Cross, said that the American Red Cross has adopted the ReadyRN curriculum for Disaster Nursing and Emergency Preparedness to train its nurses in all phases of disaster planning. ReadyRN, which one of us (TGV) wrote and developed, consists of 22 competency-based modules designed specifically for nurses. (MC Strategies, a part of the publisher Elsevier, has published ReadyRN online. Go to and click on the “Nursing Programs” box.)

Preparation. Clinicians, hospitals, and public health agencies should be prepared to deal with the health and behavioral effects—and the high number of fatalities—that follow mass-casualty events.19 The AHRQ has a questionnaire that facilities can use to assess their readiness for these events. Go to and click on the questionnaire and instruction downloading links.

Standards for clinical practice. The three phases of mass-casualty care are triage, evacuation to hospitals, and clinical management.6 Triage provides responders with the best opportunity to do the greatest good for the greatest number of people. But it may involve withholding care from those with little chance of surviving. Consequently, triage nurses may suffer significant anxiety and distress,20 which can be compounded by their own personal losses in the disaster.21

The basic principles of mass-casualty nursing include20

* rapid assessment of the nursing care needed.

* self-protection, including using personal protective equipment.

* triage and initiation of lifesaving measures.

* adaptation of basic nursing skills to emergency situations.

* mitigation or removal of environmental health hazards.

* prevention of further injury or illness.

* decontamination.

* realistic realignment of care goals in light of the event.

* leadership in triage, care, and transport.

* education and supervision of auxiliary personnel and volunteers.

* provision of emotional support to victims.

Legal, financial, and ethical issues. The ANA's Code of Ethics for Nurses with Interpretive Statements can be used in discussion of ethical issues. It states, “The nurse's primary commitment is to the patient, whether an individual, family, group, or community.”22 The ANA's Nursing: Scope and Standards of Practice can also be used to discuss these issues within the profession.23

The Center for Law and the Public's Health at Georgetown and Johns Hopkins Universities drafted a model law, the Model State Emergency Health Powers Act (MSEHPA), to give state governments a clear legal framework for handling a public health crisis, particularly one caused by an act of bioterrorism (see Under the MSEHPA, a mass-casualty event would result in temporary modification of regulations and requirements at all levels of government. States are free to adopt and amend this model law. By July 2006, 38 states and the District of Columbia had passed bills based on the MSEHPA; six more states have had bills introduced.24

Legal and financial concerns can hinder care in a disaster in several ways. Concerns about liability, for example, may cause a provider not to participate in disaster relief efforts; not having proof of insurance may cause patients to delay seeking care. The following are the most salient legal issues that may arise.

Mandatory reporting of disease. Nurses should already be aware of their state and local governments' reporting requirements; in the event of a disaster, they will need to keep current on any additional reporting requirements.

Isolation and quarantine. The MSEHPA permits temporary isolation and quarantine without notice if delay would “significantly jeopardize the public health authority's ability to prevent or limit the transmission of a contagious or possibly contagious disease to others.”25 After exercising this emergency power, the public health authority would be required to petition a court within 10 days to continue the isolation or quarantine. The public health authority would also be authorized to seek isolation or quarantine through a judicial proceeding that would provide notice to and a hearing for the people involved.25

Patient privacy. The MSEHPA addresses the issue of confidentiality in two ways. First, access to the health information of a patient who has had medical testing, treatment, or vaccination or who has been involved in isolation, quarantine programs, or “efforts by the public health authority during a public health emergency” is limited to those who will provide treatment, conduct epidemiologic research, or investigate the causes of transmission.25 Second, disclosure of health information cannot be made without patient consent, except when it's divulged to the individual or immediate family or to appropriate federal authorities according to federal law; disclosure can also be made to avert danger to an individual's or the public's health and to identify a person who has died or to determine the cause of death.25

Nurses' obligation to protect patients' privacy and confidentiality is not absolute.22 This duty may be superseded by the obligation to protect a patient from imminent harm (as with a suicidal patient), protect innocent people (as with mandatory reporting of child abuse), and protect the public health (as with mandatory disclosure of infectious disease outbreaks).22 Especially in cases of bioterrorism, the nurse would be ethically obligated to disclose identifiable patient information to local public health officials.

Vaccination. In a public health crisis, a state or local government may require immunization of the general populace against an infectious agent. This authority may come from the state legislature, or it may be a more general granting of authority to specific government agencies to protect the public's health. In addition, the MSEHPA would specifically grant state public health agencies the power to require vaccination in the event of a declared emergency.25

Reimbursement. Sources exist for funding recovery efforts, such as those provided by FEMA's Robert T. Stafford Disaster Relief and Emergency Assistance Act (see, but local, state, and private sources should also be used. Agreements among insurance companies, providers, and health care organizations should be established in advance of a mass-casualty event to identify each party's expectations and requirements for reimbursement. A comprehensive plan should establish who is responsible for reimbursement, how reimbursement occurs, and which services are reimbursed and how much is paid.

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Guiding Principles from the AHRQ

The following “guiding principles” are taken directly from Mass Medical Care with Scarce Resources: A Community Planning Guide, a recent report from the Agency for Healthcare Research and Quality.

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

Principle #2: Planning [for] a public 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.

Phillips SJ, Knebel A, editors. Mass medical care with scarce resources: a community planning guide. Rockville, MD: Agency for Healthcare Research and Quality; 2007 Feb.

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© 2007 Lippincott Williams & Wilkins, Inc.