S UMMARY OF F EATURED S TUDY FROM THE N ATIONAL A CADEMIES OF S CIENCES , E NGINEERING , AND M EDICINE Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response

Foreword : We clearly recognize the tremendous havoc that ﬁ res, ﬂ oods, tornadoes, and hurricanes can have on a population, not to mention man-made disasters. A crisis can be found in a ﬂ ash just around the corner. And maybe your local hospital is at the bull ’ s eye of that disaster and out of commission. This is a summary of the centerpiece report of a three part series devoted to the management of care during crisis situations that demand special standards of care. The ﬁ rst report sets the stage and de ﬁ nes the need for such standards. The third in the series provides a tool kit for stake-holders and suggests indicators and triggers to institute the crisis standards at the community level. And the main report, summarized below, provides a framework for how to integrate roles, responsibilities, and resources at the federal, state, and local levels. Planning is key to providing the best possible care given the circumstances, and must be done with full cooperation and buy-in from all players at all levels. Do you know when to implement crisis standards in your community? and alternate care systems, prehospital and emergency medical services, and emergency management/public safety. Although these components are separate, they are interdependent in their contribution to the structure; they support and are joined by the roof, representing the overarching authority of local, state, and federal governments.


INTRODUCTION
Disasters, whether they occur suddenly and are unexpected or are caused by slow, sustained public health emergencies, can stress health care systems to the breaking point and disrupt delivery of vital medical services. Planning for these situations is necessary to provide the best possible health care during a crisis and, if needed, equitably allocate scarce resources.
The Department of Health and Human Services asked the Institute of Medicine of the National Academies of Sciences, Engineering, and Medicine to convene a committee of experts to develop guidance that health officials could use to establish and implement crisis standards of care (CSC) during disasters. In that 2009 report, "Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations-Letter Report," CSC was defined as a state of being that indicates a substantial change in health care operations and the level of care that can be delivered in a public health emergency, justified by specific circumstances. The committee developed national framework guidance on the key elements that should be included in standards of care protocols for disaster situations.
Following this report, the Department of Health and Human Services, the Department of Veterans Affairs, and the National Highway Traffic Safety Administration asked the expert committee to reconvene to provide concepts and guidance to help state and local officials apply the CSC framework. In its 2012 report, "Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response," the committee developed important templates to guide the efforts of professionals and organizations responsible for CSC planning and implementation. The committee found that integrated planning for coordinated response must be embraced by the full spectrum of disciplines that participate in an emergency response, including federal, state, and local governments; public health agencies; emergency medical services; emergency management and public safety agencies; and health care organizations and health care providers ( Fig. 1). At the core of a well-functioning CSC system are fundamental ethical values to ensure that all providers act with compassion and justice. Having a responsive legal and regulatory environment is also important. An effective and fair legal system encourages all health professionals and volunteers to perform their functions well while doi: 10.7205/MILMED-D-16-00226 also maximizing health resources and protecting patients from unnecessary harm.

DEFINING FEDERAL, STATE, AND LOCAL ROLES
The systems approach to catastrophic disaster response requires federal, state, and local government to work together to plan and implement CSC while acknowledging their differing authorities and access to resources. The federal government should provide national leadership by supporting and encouraging the establishment of guidelines for CSC for use in disasters. Co-ordination between state and federal partners is essential. State health departments are the most appropriate agencies to lead and coordinate CSC planning and response efforts at the state level and to brief state leaders. Effective local CSC efforts rely on the state's leadership, and state plans need to be adapted or folded into local planning efforts. Local government is uniquely positioned as a nexus connecting state government partners and local communities, so involvement of leaders of state and local government is paramount to ensure proper CSC planning and implementation.

HEALTH CARE FACILITIES' "DUTY TO PLAN"
During such crises, hospitals may be without power; trained staff may be unavailable; medicines, supplies, and hospital beds could be in short supply; and medical attention may need to be delivered in alternate care facilities. Making the necessary adjustments to the scope of practice, treatment options, ambulance staffing, and call center response all figure into state, local, and emergency medical services agency-specific crisis response plans. Among other duties, the state agency taking the lead in coordinating the response should establish triggers and thresholds that will signal the shift from conventional care to contingency care to crisis care. Public engagement should occur during the planning phase to ensure the plan reflects community values and priorities.
Hospitals, walk-in clinics, and private practices are all critical in the response framework, and they also need crisis response plans that designate the shift from conventional FIGURE 1. The foundation for CSC planning comprises ethical considerations and legal authority and environment, located on either side of the steps leading up to the structure. The steps represent elements needed to implement disaster response; education and information sharing are the means for ensuring that performance improvement processes drive the development of disaster response plans. The response functions are performed by each of the 5 components of the emergency response system: hospitals and acute care, public health, out-of-hospital and alternate care systems, prehospital and emergency medical services, and emergency management/public safety. Although these components are separate, they are interdependent in their contribution to the structure; they support and are joined by the roof, representing the overarching authority of local, state, and federal governments. standards of care to providing essential services during a disaster. During ordinary times, facilities providing acute medical care have a duty to serve patients; in anticipation of extraordinary times, such facilities have a "duty to plan" for catastrophic incidents, including planning for delivery of care along the continuum from conventional to crisis surge response.

CONCLUSION
If the entire emergency response system embraces and implements this framework, it will help ensure that the largest number of patients receive the best care possible during a public health emergency, while still ensuring that everyone receives fair and equitable care.
For more information about National Academies of Sciences, Engineering, and Medicine reports and activities relating to CSC, visit nationalacademies.org/crisisstandardsofcare. Copyright 2016 by the National Academy of Sciences. All rights reserved.