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Crisis Standards of Care: A Framework for Responding to Catastrophic Disasters

Murray, John S. PhD, RN, CPNP, CS, FAAN

AJN, American Journal of Nursing: October 2012 - Volume 112 - Issue 10 - p 61–63
doi: 10.1097/01.NAJ.0000421030.94575.64
Disaster Care

What the new IOM guidelines mean for nurses.

What the new IOM guidelines mean for nurses.

John S. Murray has served in a variety of leadership, clinical, and research positions in both military and civilian health systems. Contact author: The author has disclosed no potential conflicts of interest, financial or otherwise.



Late one afternoon, a tornado hits your community. There was limited warning and the results are devastating. Roadways are impassable due to widespread debris and damage, all forms of communication are significantly disrupted, and the number of injured and dead is climbing rapidly. Your hospital, the only one operating in the community, is receiving mass casualties; patients are awaiting and receiving care in every conceivable space of the hospital, including the parking lot. Several hours into relief efforts, supplies and medications are running low. Outside help is hours away. Ten of the injured patients are in critical condition. There are only enough supplies and nurses to care for four of them. How do you decide which to care for? How should your team direct resources to benefit the greatest number of casualties?

Catastrophes both at home and abroad serve as a reminder of how quickly health care systems can be consumed when providing medical services to the ill and injured during these emergencies. Such disasters make headlines worldwide. In 2011, a deadly tornado devastated Joplin, Missouri, and a tsunami wreaked unimaginable destruction upon Japan.1 In 2012, an earthquake struck Chile, causing massive damage and displacing 1.5 million people.2 These events serve as sober reminders of the importance of establishing a framework that will help responders operate efficiently if disaster strikes.

Experts have long recognized that health care delivery systems are ill prepared to handle large-scale tragedies and have called for the establishment of a national framework for providing medical care during catastrophes.3 To provide such a plan, the Institute of Medicine (IOM) recently issued Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response.4 This article provides an overview of these new guidelines and examines how they affect nursing practice.

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Crisis standards of care (CSC) are guidelines designed to help organizations and health care professionals deliver the best possible care in circumstances in which resources are severely limited and health care standards are compromised. Developed by the IOM, by request of the U.S. Department of Health and Human Services, these guidelines offer a rigorous systems approach to providing disaster response. They are meant to be initiated only in the event of catastrophic disaster—an emergency that affects a community's entire infrastructure, impedes the functioning of local officials, interrupts routine community functions, and cuts off opportunities to receive immediate aid from outside resources.4

Because crisis care shifts the focus from patient-centered care to population-centered care, the IOM specifies that CSC should be initiated “only when no alternatives are possible.”4 An overarching objective of CSC is to save as many lives as possible by conserving and extending medical resources to benefit the greatest number of casualties. These standards of care might be needed in extreme disasters (natural or man-made) such as tornados, earthquakes, hurricanes, wildfires, or pandemics or bioterrorism. Additionally, these measures may be needed when medical resources (health care personnel, hospital supplies and equipment, medications, and blood products) are scarce.

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The CSC guidelines provide the framework for an integrated, interdisciplinary, and coordinated approach to disaster response by state and local governments, hospitals and health care professionals, and emergency medical services (EMS). Implementation of CSC will help to ensure that clinical protocols during a catastrophic event are ethical, efficient, and standardized. Once implemented, CSC guiding principles remain in effect until it's possible to return to normal operations.

CSC templates identify “the core functions and tasks for individuals and organizations involved in CSC planning and implementation.”4 Templates exist for

  • state and local government agencies.
  • emergency responders.
  • medical facilities.
  • community health care delivery systems.

The template for medical facilities, for example, outlines the core functions of hospitals and nursing staff in the implementation of CSC plans. It specifies that health care facilities' “disaster response plans should delineate protocols for a shift from conventional standards of care.”4

In addition to providing care in a crisis, facilities should also be able to receive and manage alerts from EMS, departments of public safety and public health, and the National Weather Service. Nursing roles and hours may change, as may the allocation of space and supplies.

During disasters, EMS personnel play a critical role in treating patients at the scene of the event as well as in transporting casualties to a higher level of care. Therefore, this group of experts has a key function in the development and implementation of state CSC plans. Local EMS departments are responsible for operating a communication system that enables the exchange of information among all responders; this allows participants to assess the scale of the incident as well as to identify resources the community requires.

EMS providers also play a critical role in planning for mass casualties and surge capacity, and have the ability to quickly mobilize resources to meet increased demands that occur during public health emergencies. For example, medics may be confronted with sheltering in place, transporting the injured to alternate care sites, modifying ambulance staffing configurations to accommodate care for greater numbers of patients, and implementing medically approved protocols for advanced care outside the hospital setting.

Engaging the public in conversation about how communities should prepare for disasters is another central focus of CSC. This can also be a key role for nurses. The framework provides suggestions for what communities should know in the event of a disaster and addresses the mental health needs of individuals in crisis. As part of the disaster response community, nurses should help to develop crisis standards that are reflective of their community's values and priorities. For example, if a disaster strikes and there are limited resources, how should providers decide who receives them? Will they be provided on a first-come, first-served basis? Should a lottery system be used? Or will the most lives be saved by dispensing supplies to those who need them the most?

All citizens should trust that they'll have reasonable access to the best medical care possible under complicated conditions. Engaging in discussions beforehand and providing updates during a crisis are key actions that will support this goal. Conversations led by nurses regarding CSC can afford communities the opportunity to share ideas with local officials and disaster planning agencies. Of particular importance is addressing the needs of vulnerable, high-risk populations (children, immigrants, and the elderly, disabled, homeless, and geographically isolated).4-7 It's critical that the public understands that if a catastrophic event occurs, medical resources may be limited.

Ethical considerations during disaster response may be particularly challenging. An effective framework for large-scale disaster response can help guide the ethical delivery of care. The CSC framework is based on established medical ethics, reiterating the need for professionals to adhere to core values and behaviors in the context of disaster. Ethical standards and norms cannot be ignored because of disaster.

Plans and protocols during disasters shift the focus of patient care from the individual to the population at large. It can be difficult for health care providers, who are trained to treat individuals, to make that adjustment. The CSC framework acknowledges this and provides guidance to support the impartial allocation of scarce resources during response to catastrophic events. Additionally, it provides nurses responding to disaster with guidance on how best to adjust the delivery of care in light of harsh resource deficits. It also acknowledges the responsibilities of health care institutions to those in their employ, stating that they “have a reciprocal duty to… protect workers who face risks in providing care.”4

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Nurses play a critical role in disaster relief. Their expertise is essential in planning for emergencies, as well as during and after a catastrophic event. To ensure the greatest efficiency at each of these stages, the American Nurses Association (ANA) recommends that any disaster care protocols, such as the CSC, be designed to protect nurses “operating in extreme conditions and scarcities, and… ensure that the public receives the most adequate medical services possible.”8

To prepare for emergencies, nurses should familiarize themselves with CSC and work with their health care organizations and communities to optimize disaster response and recovery. In addition, the ANA has recommended that nurses plan for a potential disaster by preparing themselves and their families for extended stays away from home, understanding the legal implications of responding during emergencies, taking continuing education courses on emergency preparedness, participating in emergency drills, and notifying employers or volunteer organizations regarding “limitations on availability or any special skills… applicable to emergency conditions.”9

During and after catastrophic events, nurses are called upon to “provide the best care possible given the resources and physical conditions under which [they] are working.”9 The ANA recommends that during a crisis condition, nurses should clarify their roles and existing protocols, pay extra attention to communicating problems to the chain of command, and avail themselves of rapid training provided by the facility. After a disaster, nurses contribute by performing psychosocial needs assessments for disaster victims and communities, helping facilities return to normal operating conditions, and contributing to discussions evaluating services provided during the crisis.

Nursing ethics. If a disaster occurs, nurses may not be able to provide care to everyone, especially if supplies and resources are scarce. Uncertainty about alternative standards of care may prevail. The CSC guidelines provide direction on the ethical considerations often associated with disaster. The procedures they set forth are aimed at helping health care professionals provide the most acceptable care possible during extreme circumstances. Familiarization with the CSC guidelines will help nurses prepare for the stressful and ethically challenging situations that occur when disaster strikes.8

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2. Barrionuevo A, Robbins L. 1.5 million displaced after Chile quake. New York Times 2010 Feb 27.
3. Federal Emergency Management Agency. National response framework. Washington, DC; 2008 Jan. P-682.
4. Hanfling D, et al., editors. Crisis standards of care: a systems framework for catastrophic disaster response. Washington, DC: National Academies Press; 2012.
5. Murray JS. Disaster care: public health emergencies and children Am J Nurs. 2009;109(12):28–31
6. Murray JS. Disaster care: children of Hurricane Katrina Am J Nurs. 2011;111(8):52–5
7. Murray JS. Disaster preparedness for children with special healthcare needs and disabilities J Spec Pediatr Nurs. 2011;16(3):226–32
8. Brewer K. Who will be there? Ethics, the law, and a nurse's duty to respond in a disaster. Silver Spring, MD: American Nurses Association 2010 Jun. ANA issue brief;
9. Center for Health Policy, Columbia University School of Nursing. Adapting standards of care under extreme conditions: guidance for professionals during disasters, pandemics and other extreme emergencies. Silver Spring, MD: American Nurses Association; 2008 Mar.
© 2012 Lippincott Williams & Wilkins, Inc.