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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Page R10
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Crisis Standards of Care: Ten Years of Successes and Challenges: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25767.
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    PREPUBLICATION COPY: UNCORRECTED PROOFS     Crisis  Standards  of  Care:  Ten  Years  of   Successes  and  Challenges   PROCEEDINGS OF A WORKSHOP   Megan Snair, Aurelia Attal-Juncqua, and Scott Wollek, Rapporteurs Forum on Medical and Public Health Preparedness for Disasters and Emergencies Board on Health Sciences Policy Health and Medicine Division    

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported jointly by contracts between the National Academy of Sciences and Administration for Children and Families (HHSP233201400020B/HHSP23337065), the Assistant Secretary for Preparedness and Response (HHSO100201850012A), the Centers for Disease Control and Prevention (200-2011-38807/75D30119F00077), the Food and Drug Administration (75F40120P00067), and the National Institutes of Health (HHSN263201800029I/HHSN26300026). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25767 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Crisis standards of care: Ten years of successes and challenges: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/25767.   PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

PREPUBLICATION COPY: UNCORRECTED PROOFS Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

v PREPUBLICATION COPY: UNCORRECTED PROOFS PLANNING COMMITTEE ON CRISIS STANDARDS OF CARE: TEN YEARS OF SUCCESSES AND CHALLENGES1 JOHN L. HICK (Co-Chair), Professor of Emergency Medicine and Medical Director of Emergency Preparedness, Hennepin Healthcare, University of Minnesota SUZET M. MCKINNEY (Co-Chair), Executive Director and Chief Executive Officer, Illinois Medical District BROOKE COURTNEY, Senior Regulatory Counsel, Office of Counterterrorism and Emerging Threats, Food and Drug Administration JAMES HODGE, JR., Professor of Law, Sandra Day O’Connor College of Law, Arizona State University NIRANJAN (TEX) KISSOON, Executive Medical Director, Children’s and Women’s Global Health; UBC and BCCH Professor in Acute and Critical Care –Global Child Health, British Columbia Children’s Hospital Research Institute NICOLETTE LOUISSAINT, Executive Director, Healthcare Ready ANITA PATEL, Senior Special Advisor, Pandemic Medical Care and Countermeasures Lead, Centers for Disease Control and Prevention PETER PONS, Associate Director of Emergency Medicine, Denver Health Medical Center COLLEEN RYAN, Staff Surgeon, Shriners Burns Hospital; Professor of Surgery, Harvard Medical School UMAIR SHAH, Executive Director, Harris County Public Health STEVEN WARD, Director, Operational Medicine Readiness, Policy and Oversight, U.S. Air Force MATTHEW K. WYNIA, Director, Center for Bioethics and Humanities, University of Colorado Denver Health and Medicine Division Staff SCOTT WOLLEK, Senior Program Officer CAROLINE CILIO, Associate Program Officer (until October 2019) KIMBERLY SUTTON, Senior Program Assistant ANDREW M. POPE, Senior Director, Board on Health Sciences Policy Consultants LAURA RUNNELS, LAR Consulting MEGAN SNAIR, Science Writer 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

FORUM ON MEDICAL AND PUBLIC HEALTH PREPAREDNESS FOR DISASTERS AND EMERGENGIES2 DAN HANFLING (Co-Chair), Vice-President, Technical Staff, In-Q-Tel SUZET M. MCKINNEY (Co-Chair), Chief Executive Officer, Illinois Medical District STACEY J. ARNESEN, Branch Chief, Disaster Information Management Research Center, National Library of Medicine, National Institutes of Health JOHN BENITEZ, Medical Director, Emergency Preparedness, Tennessee Department of Health ERIC BLANK, Senior Director, Public Health Programs and Systems, Association of Public Health Laboratories DUANCE C. CANEVA, Chief Medical Officer, Department of Homeland Security MARY CASEY-LOCKYER, Senior Associate, Disaster Health Program Development, American Red Cross BROOKE COURTNEY, Senior Regulatory Counsel, Office of Counterterrorism and Emerging Threats, Food and Drug Administration JOHN J. DREYZEHNER, Director, Center for Preparedness and Response, Centers for Disease Control and Prevention DAVID EISENMAN, Associate Professor, David Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles BRUCE EVANS, Fire Chief, Upper Pine River Fire Protection District JAMES R. FICKE, Robert. A. Robinson Professor and Director, Department of Orthopaedic Surgery, Johns Hopkins Medicine NATALIE GRANT, Director, Office of Human Services Emergency Preparedness and Response, Administration for Children and Families, Department of Health and Human Services LORI GRUBSTEIN, Program Officer, Health Care Group, Robert Wood Johnson Foundation JOHN L. HICK, Professor of Emergency Medicine and Medical Director of Emergency Preparedness, Hennepin Healthcare, University of Minnesota ROBERT KADLEC, Assistant Secretary for Preparedness and Response, Department of Health and Human Services THOMAS KIRSCH, Professor of Military and Emergency Medicine, Director, National Center for Disaster Medicine and Public Health, Uniformed Services University of the Health Sciences NICOLETTE A. LOUISSAINT, Executive Director, Healthcare Ready FREDA GAIL LYON, Vice President, Emergency Services, WellStar Health System PHILLIP MAYTUBBY, Director, Public Health Protection, Oklahoma City-County Health Department BIRGITTE MESSERSCHMIDT, Director of Applied Research, National Fire Protection Association AUBREY K. MILLER, Senior Medical Advisor, Office of the Director, National Institute of Environmental Health Sciences, National Institutes of Health BARBARA MULACH, Director, Office of Science Coordination and Program Operations, National Institute of Allergy and Infectious Diseases, National Institutes of Health 2 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. vii PREPUBLICATION COPY: UNCORRECTED PROOFS

IRA NEMETH, Chair, Disaster Medicine Section, American College of Emergency Physicians, Associate Medical Director for EMS and LifeFlight at UMass Memorial Hospital JOHN OSBORN, Operations Manager and Assistant Professor of Health Care Systems Engineering, Department of Surgery, Mayo Clinic College of Medicine TARA O’TOOLE, Senior Fellow and Executive Vice President, In-Q-Tel ANDREW T. PAVIA, George and Esther Gross Presidential Professor, Division of Pediatric Infectious Diseases, University of Utah School of Medicine LEWIS RADONOVICH, Chief of Research, National Personal Protective Technology Laboratory, National Institute for Occupational Safety and Health TERRY RAUCH, Deputy Assistant Secretary of Defense for Health Readiness Policy and Oversight, Office of the Assistant Secretary of Defense for Health Affairs, Department of Defense SARA ROSZAK, Vice President, Pharmacy Care and Health Strategy, National Association of Chain Drug Stores COLLEEN RYAN, Staff Surgeon, Shriners Burns Hospital, Professor of Surgery, Harvard Medical School ROSLYNE SCHULMAN, Director, Policy Development, American Hospital Association RICHARD SERINO, Distinguished Visiting Fellow, National Preparedness Leadership Initiative, Harvard T.H. Chan School of Public Health ALAN SINISCALCHI, Surveillance Coordinator for Influenza, Bioterrorism, and Public Health Preparedness, Connecticut Department of Public Health W. CRAIG VANDERWAGEN, Cofounder and Director, East West Protection, LLC TENER VEENEMA, Professor of Nursing, Johns Hopkins University JENNIFER WARD, President, Trauma Center Association of America GAMUNU WIJETUNGE, EMS Specialist, Office of Emergency Medical Services, National Highway Traffic Safety Administration, Department of Transportation MATTHEW K. WYNIA, Director, Center for Bioethics and Humanities, University of Colorado Denver Forum Staff SCOTT WOLLEK, Forum Director AURELIA ATTAL-JUNCQUA, Associate Program Officer MICHAEL BERRIOS, Research Associate KIMBERLY SUTTON, Senior Program Assistant ANDREW M. POPE, Senior Director, Board on Health Sciences Policy viii PREPUBLICATION COPY: UNCORRECTED PROOFS

ix PREPUBLICATION COPY: UNCORRECTED PROOFS Reviewers This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: VICTORIA ALBI, DC Department of Health NIRANJAN (TEX) KISSOON, Children’s and Women’s Global Health and Global Child Health Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by BOBBIE BERKOWITZ, Columbia University School of Nursing and University of Washington. She was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.

xi PREPUBLICATION COPY: UNCORRECTED PROOFS Contents 1 INTRODUCTION 1-1 Setting the Stage, 1-2 Workshop Background, 1-4 Organization of the Proceedings, 1-4 2 INFORMING THE NEXT STAGE OF CRISIS STANDARDS OF CARE 2-1 Terminology of Crisis Standards of Care and Implications, 2-1 Importance of Legal Frameworks, 2-2 Opportunities for the Future of Crisis Standards of Care, 2-3 3 ETHICAL AND LEGAL CONSIDERATIONS 3-1 Ethics in Real Life: Personal Experiences with Crisis Standards of Care, 3-1 Questions and Challenges of Research to Inform Crisis Standards of Care Decisions, 3-2 Individual Ethics Versus Population Ethics, 3-3 4 CRISIS STANDARDS OF CARE APPLICATION ACROSS SECTORS 4-1 Federal Planning and Response, 4-1 State-Level Planning, 4-4 Clinical Settings, 4-5 Supply Chain, 4-7 Discussion, 4-7 5 IMPLEMENTING CRISIS STANDARDS OF CARE ACROSS SECTORS 5-1 Emergency Medical Services, 5-1 State and Local Levels, 5-2 Health Care Settings, 5-4 Vendors, 5-6 Subspecialties, 5-7 Legal Environments, 5-8 Next Steps for the Overall System, 5-9 REFERENCES R-1 APPENDIXES A Workshop Agenda A-1 B Workshop Speaker Biographies B-1

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In 2009 the Institute of Medicine (IOM) began to assess the need for better-defined medical and public health crisis standards of care (CSC) for catastrophic disasters and public health emergencies. Over the next 10 years, the IOM defined templates for those stakeholders responsible for integrated CSC planning and implementation; created a tool kit with guidance on indicators and triggers; provided a discussion kit for stakeholders to use with their own communities to establish appropriate indicators and triggers to guide their planning; disseminated the messages and key concepts of CSC; and built on the initial efforts to refine certain elements and address remaining gaps. This current Proceedings of a Workshop captures the discussions from a 2019 workshop reviewing the successes and gaps over the last 10 years of CSC work, in order to inform the next phases of planning and implementation.

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