key questions and example indicators and triggers for the major components of the emergency response system: emergency management, public health, behavioral health, EMS, hospital and acute care, and out-of-hospital. The toolkit is designed to be scalable for use at multiple levels, from the facility, organization, and agency levels up through the whole community’s emergency response system. Discussions need to occur at all levels so they include the level of detail about organizational capabilities that is needed for operational decision making, within the context of integrative planning for a coordinated response. These discussions will help the stakeholders develop the capabilities described in both the Hospital Preparedness Program (HPP) and the Public Health Emergency Preparedness (PHEP) cooperative agreements (ASPR, 2012a; CDC, 2011).


At the request of the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services (HHS), the National Highway Traffic Safety Administration (NHTSA) in the Department of Transportation, and the Veterans Health Administration, in the fall of 2012 the IOM convened the Committee on Crisis Standards of Care: A Toolkit for Indicators and Triggers. The task was to prepare a conversation toolkit to guide stakeholders through the process of developing indicators and triggers that may govern their health system’s transition across the continuum of care, from conventional standards of care to contingency surge response and standards of care to crisis surge response and standards of care, and back to conventional standards of care. Box 1-1 presents the statement of task.

This committee was made up of experts in the fields and sectors responsible for implementing CSC, including public health, emergency medicine, nursing, pediatrics, EMS, emergency management, and disaster behavioral health. Appendix C contains biosketches of the committee members. The work of the current committee builds on the work of a previous IOM committee, the Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations (IOM, 2009, 2012). The work of that committee is described below.

To gather stakeholder input, the current committee held an open meeting in January 2013. Panelists from different stakeholder perspectives were invited, including public health, emergency management, EMS, health care coalitions, home health, long-term care and nursing homes, behavioral health, specialty burn care, and information management. The committee also sought input on the task from representatives of the federal government, including ASPR and NHTSA. The committee met in closed session in conjunction with the open meeting and once again in March 2013 to review the evidence and draft the report.

In addition, the committee reviewed relevant literature. The MEDLINE/PubMed and Scopus databases were searched using the following terms (in a variety of combinations): indicator, metric, measure, trigger, predictor, warning, precipitating factors, health system indicator, health system trigger, and health system measure, combined with the terms disaster, surge capacity, surge capability, medical surge, crisis standards of care, and allocation of scarce resources.2 Abstracts were reviewed and selected for relevance to the topic at hand. Finally, the committee examined previous efforts to determine indicators and triggers in publicly available state and local crisis standards of care plans.


2 The committee would like to thank Alicia Livinski of the National Institutes of Health Library for her help in conducting these searches.

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