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Crisis Standards of Care and COVID-19: What Did We Learn? How Do We Ensure Equity? What Should We Do?

John L. Hick, Dan Hanfling, Matthew Wynia, and Eric Toner
Date posted:
August 30, 2021
Publication type:
NAM Perspectives
National Academy of Medicine
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COVID-19 has fundamentally challenged the delivery of health care services across the world, forcing difficult choices on health professionals and laying bare many preexisting health, medical, and public health sector frailties. Extreme shortages of key resources and worries that patients would not receive the care they needed were frequent features of the response beginning in the spring of 2020 and were recurrent during subsequent regional and national peaks.

Crisis standards of care (CSC) occur when the degree of resource shortage requires decisions that place a patient or provider at risk of a poor outcome. These situations arose in most jurisdictions and required a systematic, coordinated response [1]. Often, state and health care CSC plans were used or revised, or they did not apply to the situations encountered. In several critical instances, potentially useful CSC plans were ignored or actively subverted. The authors of this paper describe some of the successes and shortfalls of CSC principles and practices during COVID-19 and identify issues to be addressed for future events.

This paper focuses on hospital application of CSC, though emergency medical services (EMS) experienced similar issues. EMS and health care planning and response must be linked to ensure consistency of expectations as well as optimal patient distribution and redistribution. Both EMS and hospital resources and staff require stewardship during disasters, particularly ones that are protracted in nature. Recognition of clinical care interdependency (long-term care, EMS, hospitals, outpatient care) in planning and response is critical for avoiding CSC conditions and improving consistency across the spectrum of care as well as across any given geographic region.

Revision of CSC doctrine is needed and should be a focus for health care institutions and local, state, and federal governments alike to ensure that the best care possible is delivered when the next disaster strikes. In the following sections, the authors discuss some key CSC domains as well as successes, issues, and action steps.



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