CRISIS STANDARDS OF
CARE
Mississippi State Department of Health
Office of Emergency Planning and Response
Approved: 21 February 2017
Crisis Standards of Care
TABLE OF CONTENTS
INTRODUCTION ........................................................................................................... 1
PURPOSE.............................................................................................................................. 1
SCOPE ................................................................................................................................... 1
CONCEPT OF OPERATIONS ...................................................................................... 2
Ethical Framework .................................................................................................. 3
Mass Casualty Event .............................................................................................. 4
LEGAL AUTHORITY .................................................................................................... 4
ACRONYMS ................................................................................................................. 5
REFERENCES .............................................................................................................. 6
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INTRODUCTION
Mississippi has previous experience with a devastated health system. The aftermath of
Hurricane Katrina in 2005 presented challenges in a shortage of the resources
required to have a functioning healthcare delivery system.
During the 2015 Ebola Virus Disease event, it was necessary to review the state’s
capacity to respond to new and/or re-emerging infectious disease outbreaks in order to
establish an updated mechanism for providing care under the current standards of
care with limited availability of appropriate personal protective equipment to protect
healthcare providers. In light of these threats to public health and our experience with
both real and potential catastrophic events, it was recommended that a more formal
review of current best practices be conducted and a guidance document be developed
to address the issue from an all-hazards perspective.
The Mississippi Pandemic Influenza Steering Committee, sponsored by the Mississippi
State Department of Health (MSDH), took the initiative during the H1N1 virus event to
begin a review of current literature and evidence-based practices relating to the need
to respond to a public health emergency in which thousands of Mississippians would
seek and require medical care.
PURPOSE
The purpose of the MSDH Crisis Standard of Care (CSC) guidelines is to provide a
clinical framework for emergency medical services, healthcare systems, and facilities to
plan, prepare for and respond to emergencies which present in resource limited
environments. In addition, this document provides a guide for making informed
decisions based on the premise of the CSC which is to do the greatest good for the
greatest number of persons. The overarching goal is to achieve the most advantageous
allocation of patient care during all phases of a public health or medical emergency.
Adaptation of the MSDH CSC guidelines will empower clinicians at the point of care
during emergencies and allow for more informed decision making.
SCOPE
It is the intention of the MSDH CSC document to provide background and planning
guidance for developing a consistent approach to understanding the circumstances,
indicators and triggers that could result in the need to implement altered standards of
care, whether the precipitating event is the result of an act of bioterrorism, public health
or medical emergency involving large numbers of victims, a mass casualty event
(MCE), or inadequate resources available to maintain the current standard of care.
While the initial focus of development of the MSDH CSC guidance was a pandemic
influenza response plan, the guidelines outlined are consistent ethical approaches to
catastrophic events of any nature where it would become necessary to allocate scarce
resources. Making optimal decisions concerning the allocation of scarce resources is
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essential in determining the degree to which healthcare systems continue to function.
Ultimately it could mean saving many thousands of lives. (Phillips SJ, Knebel A, eds.
Mass Medical Care with Scarce Resources: A Community Planning Guide (2007).
CONCEPT OF OPERATIONS
When an emergency declaration is made, it changes the legal environment and enables
specific legal and regulatory powers and protections for public health and healthcare
providers concerning their actions and omissions associated with allocating and utilizing
scarce medical resources and implementing crisis standards of care (CSC). This
guidance provides a delineated continuum of care from normal operations to eventual
CSC. The continuum involves the scarcity of all other resource options until it is no
longer feasible to provide normal care, including strategies to reduce demand, optimize
existing resources, and augment existing resources.
Core ethical precepts in medicine permit some actions during crisis situations that
would not be acceptable under ordinary circumstances, such as implementing
resource allocation protocols that could preclude the use of certain resources on some
patients when others would derive greater benefit from them. Healthcare professionals
are obligated always to provide the best care they reasonably can to each patient in
their care, including during crises. When resource scarcity reaches catastrophic levels,
clinicians are ethically justified and are ethically obligated to use the available
resources to sustain life and well-being to the greatest extent possible.
The final determination as to the applicability of the information contained in the
classified Mississippi State Department of Health (MSDH) CSC planning document is
very dynamic by virtue of:
• The enormous variability of events
• The circumstances surrounding the event
• The information available at the time a decision was made in an evolving event
• The availability of adequately trained staff, medical supplies and equipment
• The locations and structures in which to provide care, etc.
Implementation of the MSDH CSC would entail following federal guidance by meeting
the following conditions:
• Identification of critically limited resources and infrastructure
• Surge capacity fully employed within healthcare facility
• Maximal attempts at conservation, reuse, adaptation, and substitution performed
• Regional, state, and federal resource allocation insufficient to meet demand
• Patient transfer or resource importation not possible or will occur too late to
consider bridging therapies
• Request for necessary resources made to local and regional health officials
• Declared state of emergency (or in process)
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MSDH Crisis Standards of Care
Ethical Framework
The Mississippi State Department of Health (MSDH) will follow the ethical framework
recommended by the Institute of Medicine in 2009 to address the issue of crisis
standards of care. One document utilized in development of this information is,
Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A
Letter Report, pages 1-23. This document was a summary report of four National
Regional meetings. The participants consisted of policy makers from state and local
public health departments, local and state government representatives, providers from
the healthcare community including relevant medical disciplines, nursing, emergency
medical services, palliative care, hospice, home health and their associated employee
unions, and healthcare and hospital administrators. There were several
recommendations:
• Develop consistent state crisis standards of care protocols
• Seek community and provider engagement
• Adhere to ethical norms during crisis standards of care (CSC)
• Provide necessary legal protections for healthcare practitioners and institutions
implementing CSC
• Ensure consistency in CSC implementation
• Ensure intrastate and interstate consistency among neighboring jurisdictions
Ethical features of the MSDH CSC will consist of:
• Fairness
• Duty to Care
• Duty to steward resources
• Transparency
• Consistency
• Proportionality
• Accountability
“Note: Utilizing a crisis standard of care may not be optional, as it could be a forced
choice based on the emerging situation. Under such circumstances, failing to make
substantive adjustments to healthcare operations, this is; not to adopt crisis standards
can result in increased morbidity and mortality.” (Hospital Preparedness Program,
Capability 10).
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Mass Casualty Event
The Mississippi State Department of Health (MSDH) Crisis Standards of Care (CSC)
guidance is being developed to assist in developing plans, policies and processes, and
to present healthcare providers and facilities with approaches and strategies for
providing the most optimal and appropriate standards of care possible during a mass
casualty event (MCE) and provide information on the circumstances communities likely
would face as a result of an MCE. The MSDH CSC will include:
• Key constructs, principles, and structures to be incorporated into the planning for
an MCE.
• Approaches and strategies that could be used to provide the most appropriate
standards of care possible under the circumstances.
• Examples of tools and resources available to help states and communities in
their planning process.
• Illustrative examples of how certain health systems, communities, or states have
approached certain issues as part of their MCE-related planning efforts.
LEGAL AUTHORITY
Legal Authority resides in the MSDH to develop plans, policies, and procedures to
protect the public health during events that would require public health or medical surge
capabilities.
The MSDH is charged with providing guidance and protocols on CSC in order to enable
a substantial change in routine healthcare operations including delivery of the optimal
level of patient care for a pervasive (e.g., pandemic influenza) or catastrophic (e.g.,
earthquake, hurricane) disaster. The need for crisis standards is justified by specific
circumstances and may or may not be triggered by a formal declaration of emergency,
disaster, or public health emergency (with input from locals, Healthcare Coalitions, and
regional authorities), in recognition that crisis operations will be in effect for a sustained
period.
The MSDH CSC planning documents are not intended to reflect the MSDH official
policy but to provide healthcare providers and healthcare facilities with options to
consider when planning their response to an event in which the decision to allocate
scarce resources in a manner that is different from usual circumstances but appropriate
to the situation.
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ACRONYMS
CSC Crisis Standards of Care
MCE Mass Casualty Event
MSDH Mississippi State Department of Health
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MSDH Crisis Standards of Care
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