Crisis Standards of Care: Are You Familiar?

by: Denise M. Danna, RN, DNS, NEA, BC, CNE. FACHE

Due to such disasters as Hurricane Katrina, the tornado in Joplin, and various other
catastrophic events across the country and globe, the Department of Health and Human Services (HHS) requested that the Institute of Medicine (IOM) create a committee to develop standards of care during disasters. As citizens, we frequently experience how our health care system and the infrastructure of a community can be overwhelmed in such catastrophic disasters.

Several reports were generated from the IOM committee on Crisis Standards of Care (CSC). The first report in 2009, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations developed a definition of crisis standards of care “as a substantial change in usual health care operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g. pandemic influenza) or catastrophic (e.g. earthquake, hurricane) disaster. This change in the level of care delivered is justified by specific circumstances and is formally declared by a state government, in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations” (IOM, 2009). The second report entitled, Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response (IOM, 2012) developed CSC templates to assist and guide individuals and organizations in CSC planning and implementation (IOM, 2012). Some of the main reasons that CSC protocols are needed in catastrophic disasters are to ensure that critical resources are provided to those individuals who will benefit the most, conserve limited resources, and ensure that all individuals receive the same access to the best possible care.

Nurses play a vital part in participating in the development of CSC. I was asked to participate in an interdisciplinary task force charged with developing crisis standards of care protocol. My section was writing “Delivery of Care Guidelines for Essential Inpatient Nursing Care” (Louisiana Department of Health & Hospitals, 2011). In developing the essential inpatient nursing care guidelines, the ANA report, Adapting Standards of Care Under Extreme Conditions: Guidance for Professionals During Disasters, Pandemics, and Other Extreme Emergencies (2008) was referenced. This report identified critical standards for healthcare providers that should always be maintained during a disaster (e.g. worker and patient safety, maintaining airway and breathing, circulation, control blood loss, and infection control (ANA, p. 16). Standards of care that could be adapted under extreme conditions included such activities as routine care (e.g. vital signs for non-acute patients), extensive documentation of care, and elective procedures (ANA, p. 16).

It is recommended that each hospital develop its own recommendations for providing essential nursing care during a catastrophic disaster that mirrors the community’s in which they live (Murray, 2012). Nurses serve an important role in disasters. Nurses should familiarize themselves with CSC and work within their organizations and communities to develop and implement CSC. During times of disasters, scarce resources may occur and nurses need to know how standards of care may be adapted while still providing safe, ethical and quality nursing care (Murray, 2012).


ANA (2008). Adapting Standards of Care Under Extreme Conditions: Guidance for
Professionals During Disasters, Pandemics, and Other Extreme Emergencies. Retrieved

Institute of Medicine (2009). Report Brief. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Retrieved from:

Click to access Guidance%20for%20Est%20CSC%20for%20Use%20in%20Disaster%20Situations%20A%20Letter%20Rpt.pdf

Institute of Medicine (2012). Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Retrieved from:

Louisiana Department of Health & Hospitals. ESF-8 Health & Medical Section. State Hospital Crisis Standard of Care Guidelines in Disasters (Version 1.2 September 2011).Retrieved from:

Click to access LA%20State%20Hospital%20CSC%20Guidelines%20in%20Disasters.pdf

Murray, J. (2012). Crisis Standards of Care: A framework for responding to catastrophic disasters. AJN, 112 (10), 61-63.


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  • Julie Bulson DNP, MPA, RN, NE-BC

    Disaster education at all levels is key! Crisis standards of care is a topic with which all nurses must be familiar. It will be challenging for staff to reconcile the allowable level of care in any crisis where it is necessary to implement crisis standards of care unless there is some familiarity. It will be just as important for healthcare emergency planners to work along with their ethics committees on the process for implementation and to identify the group of people that will be making difficult decisions. It is imperative that those difficult ethical care decisions are removed from those who giving the care. Lastly, during and after this type of situation, it will be important to include critical incident stress debriefing (CISM) opportunities for staff in an effort to care for our staff.

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