other entities have embarked on developing crisis standards of care (CSC) plans and guidance. As this body of work continues to evolve, the need for guidance on how to develop indicators and triggers that aid decision making about the provision of care in disasters has been identified as a gap. Indicators are measurements or predictors of change in demand for health care service delivery or availability of resources. An example indicator could be emergency department wait time. Triggers are decision points that are based on changes in the availability of resources that require adaptations to health care services delivery along the care continuum.1 An example trigger could be emergency department wait time exceeds X hours, which would trigger a variety of response tactics such as increased staffing.

Advance planning about indicators and triggers involves considering what information about demand and resources is available across the health care spectrum (from prehospital to end-of-life care), how this information is shared and integrated, how this information drives actions, and what actions might be taken to provide the best health care possible given the situation. Because of the stress, complexity, and uncertainty inherent in a crisis situation, it is particularly important that these conversations occur in advance. Planning for indicators and triggers has to occur at the level of the specific organization, agency, or community, because it depends on the usual resources and demand. For example, a tornado that touches down in a small, rural community may automatically warrant activation of the health care organization disaster plan, whereas additional information about the size and location of the tornado may be required before making this decision in a larger community with a higher ability to absorb a surge in demand.

At the request of the Assistant Secretary for Preparedness and Response at the Department of Health and Human Services, the National Highway Traffic Safety Administration 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 the 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.


Chapter 1 provides background on crisis standards of care. Chapter 2 discusses key concepts, limitations, and systems-level considerations related to developing indicators and triggers. Chapters 3-9 constitute a discussion toolkit designed to help stakeholders have discussions about indicators and triggers. Chapter 3 provides the overarching framework for the toolkit and should be read by everyone. Chapters 4 through 9 are customized for each major component of the emergency response system: emergency management (Chapter 4), public health (Chapter 5), behavioral health (Chapter 6), emergency medical services (EMS) (Chapter 7), hospital and acute care (Chapter 8), and out-of-hospital care (Chapter 9).2 Because


1 “The surge capacity following a mass casualty incident falls into three basic categories, depending on the magnitude of the incident: conventional, contingency, and crisis. These categories also represent a corresponding continuum of patient care delivered during a disaster. As the imbalance increases between resource availability and demand, health care—emblematic of the health care system as a whole—maximizes conventional capacity; then moves into contingency; and, once that capacity is maximized, moves finally into crisis capacity. A crisis situation may lead to an overwhelming demand for services and result in shortages of equipment, supplies, pharmaceuticals, personnel, and other critical resources, necessitating operational adjustments” (IOM, 2012, p. 1-6)

2 The out-of-hospital care delivery system includes diverse ambulatory care environments (public, private, tribal, veterans health, military), home health and hospice, assisted living and skilled nursing, specialty care and resources, and others.

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