Going Nuclear: Crisis Standards of Care

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Splitting vents, DIYing facemask, and having a blanket DNR are nuclear options that agencies and providers cannot immediatly jump to because there is a shortage or pandemic. Organizations and providers that carte blanche change the standards of care without strong planning and consideration can face serious legal ramifications. The process to develop crisis standards of care takes considerable planning to ensure that the healthcare system can provide reasonable care to limit the morbidity and mortality for the public at large.

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It’s important to be mindful that the experience and resources may vary widely among geographical areas and systems. Noticing that some hospitals within NYC are splitting ventilators doesn’t mean that your agency can do that at this time. Utilize their experience as an indicator to begin discussions and planning on developing and implementing crisis standards of care (CSC). 

Standard of Care Spectrum

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Conventional: capacity states that the space, supplies, and staff are consistent with daily practices operations, business as usual. The goal is to provide individuals with the best care possible.

Contingency capacity is not consistent with daily practices, but is functionally equivalent. Contingency capacity is our disaster triage plans that are implemented when demand exceeds community resources. Currently this contingency capacity would include not transporting low risk COVID-19 patients or reusing PPE.

Crisis capacity states that even the adaptive space, staff, and supplies are not consistent with daily operations, but sufficient to provide care to the population and requires a significant adjustment to the standards of care. Some examples would be utilizing DIY mask, splitting ventilators, or reallocating life-sustaining resources. CSC is an extreme option that cannot be utilized because of fear and is only utilized when the healthcare system is forced to. The goal is to provide the population with the best care possible.

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The spectrum may be in contingency mode while others are in conventional. An example is that your ambulances are staffed but providers are reusing PPE for the cycle.

States, and agencies even within the state, may vary on what stage of the spectrum they are at. The healthcare system should work toward recovery and getting back to conventional standards of care as soon as possible.

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Other Terms

When planning it is important to utilize specific indicators and triggers to enter into CSC. The indicators would could be predictors of change or availability of resources. Triggers are decision points about making adaptations. Developing the appropriate indicators and triggers allows agencies and systems to move between standards of care with the appropriate communication, resources, and legal defense.

5 elements of Crisis Standards of Care

These 5 elements have several associate components to them which are explained in further detail in the Crisis Standards of Care Guidance. Meeting these elements ensures that the CSC are ethical, legal, and consistent across localities and states. To meet these elements the healthcare system needs to develop a consensus among public health, hospitals, EMS, primary care, and healthcare coalitions. Some states may have very clear guidance such as Minnesota.

  1. A strong ethical grounding that enables a process deemed equitable and just based on its transparency, consistency, proportionality, and accountability;
  2. Integrated and ongoing community and provider engagement, education, and communication;
  3. The necessary legal authority and legal environment in which CSC can be ethically and optimally implemented;
  4. Clear indicators, triggers, and lines of responsibility; and
  5. Evidence-based clinical processes and operations.

There are many more resources available at ASPR Tracie and through your state’s public health department. Be tempered in your response. 

Moving to Crisis Standards of Care is by force not by will or fear.


60 Second Read "Paddling the STEMI"

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As a kid I loved getting into the cookie jar. I thought I was pretty sneaky, but I would always get caught. To make it worse, when mom asked me if I had gotten into the cookie jar - I lied and said no. As a result of fibbing I got a paddling. Really mom just used a plastic spoon until one day it broke when she was paddling my brother (he deserved it).

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After identifying a STEMI (OMI) I place my pads in the AP position, which requires me to take off at least V1 and V2, possibly V3 and V4 depending on the style of your pads. Doing this one move can save you precious seconds if the patient goes into VF. 

Patients identified to have a STEMI within the field have around a 4-6% likelihood of going into a VF arrest while under the care of pre-hospital providers (Felder, 2019).

This allows providers to be very sensitive, but not specific, by placing pads on all STEMIs. That’s okay in my book because we decrease the amount of time to defibrillation in those 4-6% of patients.

Two studies looked at the pads on strategy. Osei-Ampofo et al (2016) published a case review of two patients. The pads-off strategy took 2 min 42 sec from arrest to shock. The pads-on strategy took 27 seconds. Both people woke up very shortly after being defibrillated.

The second study by Felder et al (2019) did a retrospective chart review. There were 446 patients identified as a STEMI within the field. 11 people went into cardiac arrest. The pads-off strategy averaged 72 seconds while the pads-on took 17 seconds.


The shocking thing was out of both studies only two people showed any signs of decompensation. 11 out of 13 people appeared stable just prior to going into cardiac arrest. Providers were unable to differentiate which people were going to code. 

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To be sensitive (and caring) provider should consider premptively placing defib pads on all patients where occlusion myocardial ischemia/infarction is suspected.


Felder, S., VanAarsen, K., & Davis, M. (2019). Decreasing time to first shock: Routine application of defibrillation pads in prehospital STEMI. CJEM, 1–4.

Osei-Ampofo, M., Cheskes, S., Byers, A., Drennan, I., Buick, J., & Verbeek, P. (2015). A Novel Approach to Improve Time to First Shock in Prehospital STEMI Complicated by Ventricular Fibrillation. Prehospital Emergency Care20(2), 278–282.

Ryan, D., Craig, A. M., Turner, L., & Verbeek, P. R. (2013). Clinical Events and Treatment in Prehospital Patients with ST-segment Elevation Myocardial Infarction. Prehospital Emergency Care17(2), 181–186.

Siudak, Z., Birkemeyer, R., Dziewierz, A., Zmudka, K., Dubiel, J., & Dudek, D. (2011). Out-of-hospital cardiac arrest in patients treated with primary PCI for STEMI. Long-term follow up data from EUROTRANSFER registry. Resuscitation,83(3), 303–306.


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