Five Key Principles for Transitioning to Crisis Standards of Care in EMS
“The Chinese use two brush strokes to write the word 'crisis.' One brush stroke stands for danger; the other for opportunity. In a crisis, be aware of the danger, but recognize the opportunity”—John F. Kennedy.
In late September 2024, western North Carolina was battered by Hurricane Helene. The rain and the storm surge were too much, causing massive flooding, destroying homes and businesses.
The EMTs and paramedics in the region were drawn to help. Some contributed to a GoFundMe account to help individuals or communities. Others responded on USAR or DMAT teams to provide direct relief and assistance. What they didn’t know is this event will also affect them directly.
One of the businesses devastated by this event is Baxter, a company that is well known for a host of medical product and services, but one product in particular—IV fluids—will affect the entire country. Baxter manufacturers and sells roughly 50% of the IV fluids used in the U.S. This affects the use of Ringer’s lactate, normal saline, D5W, and D10W, commonly used in EMS to treat diabetic patients.
Standards of Care
Normal day-to-day operations for any EMS service or health care system is the conventional standard of care. We have enough staff, supplies, and ambulances (or in a hospital, space) to manage operations. Sometimes we need to resort to contingency standards of care; for example, when there was a shortage of 50% dextrose we might switch to 25% dextrose or glucagon. If you have an usual number of sick-outs, you might resort to overtime or switch from 8-hour shifts to 10-hour shifts.
A shift to crisis standards of care happens in situations in which we have no alternatives. The supplies and equipment we use, the staff to respond and provide care, the ambulances, all or any combination of items are in short supply or nonexistent. We still need to respond to patients, but the care we provide is to the level possible given the challenges we have. The care we provide in this instance may be below any acceptable standard, but given the circumstances there were no other choices left. For example, during the COVID-19 pandemic, there were EMS agencies that resorted to using shower curtains for personal protective equipment (PPE). During the Las Vegas Route 91 Harvest music festival shooting in 2017, victims were transported in the back of pickup trucks without bleeding control.
Contingency and crisis standards of care are implemented during times of disaster, either natural or man-made. Sometimes EMS agencies must shift to contingency or crisis standards of care because we have shortages of essential pieces of pharmaceuticals, equipment, or supplies.
When It’s a Crisis
A switch to crisis standards of care may develop slowly in the case of incidents that evolve over a long period of time. Agencies start off in contingency standard of care, and know if the incident doesn’t resolve, it will proceed into a crisis. We can see the train wreck on the horizon, but it may take us a bit to arrive.
The type of incident that triggers a crisis standard of care may be intense and short term. For example, the Las Vegas shooting saw more 400 people shot and 60 fatalities. There were more victims than there were EMTs, paramedics, ambulances, and supplies to treat them. Many patients were transported by private automobiles. The critical strain on EMS resources and the hospital surge were limited to the time around the event, but did resolve in a few hours.
Sometimes incidents may be more long term. The COVID response resulted in tremendous shortages in personal protective equipment, specifically N95 masks. EMTs and other health care professionals re-used masks, attempted to disinfect them, or resorted to making masks out of coffee filters. This went on for almost a year. During spikes in outbreaks of COVID in Queens, New York, the crush of patients was apocalyptic, going on for weeks.
The transition to a crisis standard of care is not optional; it’s forced upon an agency based on situations over which we have no control. Trying to maintain normal operations is a fool’s errand, and will result in greater incidences of death, injury, or illness.
If we are in a contingency phase of our operations, and a crisis is inevitable, we should look to develop a crisis plan of care immediately. If you proceed directly into a crisis spool up and respond, re-examine and recalibrate your plan as you move forward. While you are still in the contingency phase see if you can extend the shelf life on expired medications. Change to saline locks as opposed to starting IVs. If you are using D10W for the treatment of hypoglycemia switch to D50 or D25.
Examine Operations
EMS agencies have an opportunity to examine operations before a crisis unfolds. Think clearly about strategy for when you need to transition to a crisis plan. Regardless of whether or not we are talking about staff, supplies, or space (ambulances), keep these five key principles in mind.
1. Ethical Allocation of Resources
Crisis standards of care require prioritizing resources based on the greatest benefit to the most people. This involves using established triage protocols to make difficult decisions, such as which patients receive critical interventions and which do not. Ethical principles, such as fairness, duty to care, and transparency, must guide these decisions to maintain public trust.
2. Adaptive and Flexible Decision-Making
Transitions to crisis standards demand adaptive leadership that can respond to rapidly changing conditions. Incident commanders, EMS coordinators, and health care leaders must adjust protocols based on real-time data, including personnel shortages, ambulance availability, and supply constraints. This dynamic approach ensures that care delivery remains aligned with situational realities, minimizing harm even under constrained circumstances.
3. Interagency and Multi-Disciplinary Coordination
Successful crisis response hinges on effective collaboration between EMS, hospitals, law enforcement, public health agencies, and other emergency responders. Coordination ensures optimal use of available resources, streamlined communication, and unified protocols across agencies, reducing redundancy and improving patient outcomes. Regional disaster plans and mutual aid agreements often serve as the framework for this collaboration. Capitalize on the use of medical operations coordination centers and health care coalitions. EMS must have a seat at the table.
4. Maintain Documentation and Accountability
Even in crisis situations, documentation remains essential to ensure continuity of care and post-event evaluations. EMS command staff must record key decisions, resource allocation, and patient care metrics to maintain accountability and support legal, ethical, and operational review after the event.
5. Ensure Provider and Staff Well-being
A crisis response is sustainable only if EMS personnel can continue to function effectively. Your staff wants to provide the best care possible. They will be stressed knowing that they can’t provide the conventional standard of care. Supporting the mental health and physical well-being of staff through mechanisms such as psychological first aid, peer support, and rotating shifts ensures that personnel can operate safely and with resilience. This principle is especially critical in prolonged events, such as pandemics, where burnout and compassion fatigue pose significant risks.
These five principles are foundational in any transition to crisis standards of care. Regardless of whether the stressor is a shortage of personnel, supplies, or ambulances, these principles ensure that EMS systems can provide care as safely and equitably as possible under extraordinary circumstances.
Strategies for the Future
How can we mitigate this problem in the future? When pharmaceuticals or IV fluids are in short supply, remember vendors allot supplies to their customers based on who purchases with them on a regular basis. If you haven’t made purchase in six or more months they won’t ship to you.
In that case, we can manage our logistics better. One of the things we can learn from IV fluid allocation is to use multiple vendors for supplies. In the Meigs & Meigs textbook Accounting: the Basis for Business Decisions, the authors state that you should use a 40% to 60% split between vendors for ordering supplies, or even better, a 30%-30%-40% breakdown between three different suppliers. This can help alleviate problems when suppliers switch to an allotment system.
Hospitals and health care systems have priority on any shortage of medical supplies or pharmaceuticals. If you work to establish safe harbor contracts with health care systems, when medications and other critical supplies are in shortage, you can help your EMS service lessen the blow from allotments. By establishing safe harbor agreements with hospitals, EMS services can purchase needed supplies without running afoul of federal anti-kickback statutes, as long as the supplies are purchased at the same rate as what the hospital paid.
Resources
Gostin LO, Viswanathan K, Altevogt BM, Hanfling D, eds. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response: Volume 1: Introduction and CSC Framework. Vol 3. National Academies Press; 2012.
Hick JL, Barbera JA, Kelen GD. Refining surge capacity: Conventional, contingency, and crisis capacity. Disaster Med Public Health Prep. 2009;3(2 Suppl):S59-S67. doi:10.1097/DMP.0b013e31819f1ae2
Meigs RF. Accounting: The Basis for Business Decisions. McGraw-Hill; 1996.Title 42 CFR §1001.952(ii)(2).
