Crisis Standards of Care for the COVID-19 Pandemic: An Essential Resource for the PALTC Community

  • Jim Wright
    Address correspondence to Jim Wright, MD, PhD, CMD, AMDA Ethics Subcommittee, SNF/LTC Partners of Virginia, 1415 Hermitage Rd, Manakin-Sabot, Richmond, VA 23103, USA.
    AMDA Ethics Subcommittee, SNF/LTC Partners of Virginia, Richmond, VA, USA
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Published:December 07, 2020DOI:


      In 2020, April was indeed the cruelest month for nursing homes. By the mid-month, more than 7000 residents and workers had died of the COVID-19 virus, with more than 36,500 people infected in 4100 facilities.
      • Stockman F.
      • Richtel M.
      • Ivory D.
      • Smith M.
      “They're death pits”: virus claims at least 7,000 lives in U.S. Nursing Homes.
      Post-acute and long-term care (PALTC) providers were all involved in local and/or national discussions about best practices for managing an unprecedented crisis: How are you supplying your staff with PPE (personal protective equipment)? From where are you obtaining nurses? Are you using steroids or nebulizers? How are you isolating patients? It was a time of the unimaginable—unimaginable suffering for residents and families, unimaginable stress for all front-line workers, but also a time of great kinship and support from fellow PALTC providers. Into this milieu came a request from Dr Arjun Srinivasan, Associate Director for Healthcare Associated Infection Prevention Programs at the Centers for Disease Control and Prevention (CDC). Would AMDA–The Society for Post-Acute and Long-Term Care be willing to take the lead on devising a COVID-19 Crisis Standards of Care (CSC) document for PALTC providers?
      At the request of Christopher Laxton, executive director of AMDA, the workgroup was initially composed of members of AMDA's Ethics Subcommittee. It quickly expanded, however, to include other leaders from AMDA as well as representatives from the National Association of Directors of Nursing Administration and the American Association of Post-Acute Care Nursing. These individuals in conjunction with representatives from CSC Workgroups from the Institute of Medicine and the Department of Health and Human Services truly made for an interdisciplinary workgroup. We were very fortunate to benefit from the steady hand of Abigail Viall, from the Health Systems and Worker Safety Task Force at the Centers for Medicare and Medicaid Services (CMS). Through her office, we were able to take advantage of some common components found in CSC documents for other health care settings such as hospitals and Emergency Medical Services (EMS).
      Our first task was to determine exactly what we had been tasked to do. Few of us had heard of a CSC document or understood the need for it. We of course knew about “crisis care”—those decisions an individual provider or facility makes in the face of an overwhelming crisis such as COVID-19. Up to this point, the decisions we had been making were based on a variety of sources—AMDA recommendations, CDC guidelines, and anecdotal reports from our fellow PALTC providers, for example. What we were missing, though, was a compendium of best practices and trusted resources, specific to the PALTC setting, which would enable us to implement crisis care for patients with COVID-19 on a systemwide level. The Institute of Medicine had published general guidelines for Crisis Standards of Care in 2001,
      and a CSC specific for COVID-19 was in development for EMS. It was time for a COVID-19–specific CSC for the PALTC setting. This is what the Nursing Home Crisis Standards of Care Workgroup set about to do.
      “COVID-19: Considerations, Strategies, and Resources for Crisis Standards of Care in Post-Acute and Long-Term Care (PALTC) Facilities” is organized into 5 parts ( The document starts with an overview of the general considerations involved in forming standards for crisis management: How to navigate the continuum of care, resources for preparedness, legal waivers for Medicare and other programs, ethical considerations (expanded in Appendix 1), and advance care planning and communications (see Appendix 2 for a detailed discussion on Crisis Communication Teams). Our colleagues, Alexis Roam and Amy Stewart from the American Association of Post-Acute Care Nursing (AAPACN), artfully crafted a table of examples and resources to help providers move through the continuum of care from conventional to contingency to crisis, and steps to mitigate this progression.
      Following the “overview,” you will find 4 sections of detailed information on the components of implementing Crisis Standards of Care in the setting of COVID-19:
      • “Response and Operations” (and the associated Appendix 3) detail the steps in forming an “Incident Command System,” a way to address staffing shortages, limited resources, crisis communication, and coordination with local agencies and health care systems.
      • “Daily Care and Life Enrichment” (and the associated Appendix 4) is a critical reminder to ensure that our patient-centered care goes beyond medical treatment, prompting us to find new ways to help residents remain physically, mentally, and socially active during the COVID-19 crisis.
      • “Medical Care and Treatment” follows with not only recommendations for COVID-19 treatment but how to enhance care by triaging operations, maximizing comfort and reducing transmission risk to front-line staff.
      • Finally, “Transport and Transfer” covers contingencies regarding both internal transfers (to isolation rooms, for example) and external transfers to hospitals as well as to alternative care sites.
      The Nursing Home Crisis Standards of Care Workgroup owes a debt of gratitude to all the health care professionals that contributed to the CSC document: Fatima Naqvi devoted a tremendous amount of time toward our sections on Advance Care Planning, Daily Care, Transport, and Medical Care; Diane Sanders-Cepeda contributed toward the sections on emergency preparedness and continuum of care; Dillard Elmore and Erin Vigne were instrumental in developing our sections on Communications; Ian Cordes brought valuable expertise to our recommendations on Response and Operations. We also are indebted to Swati Gaur and Naushira Pandya for contributing to our Medical Treatment section and to Cindy Fronning for the recommendations on Transport and Transfer. I was honored to have contributed toward the section on Ethics as well as the associated Appendix 1.
      This document is by no means exhaustive. It is, after all, written by providers who were in the midst of a crisis. What we hope that post-acute and long-term care professionals and policy makers will definitely find in “COVID-19: Considerations, Strategies, and Resources for Crisis Standards of Care in Post-Acute and Long-Term Care (PALTC) Facilities,” however, is a recognition of not only who we are as PALTC providers but a deep sense of obligation to the patients we serve. As opposed to CSC guidance in the hospital setting, we care for people that we have known for years and sometimes decades. We have already led our patients through other health crises and have earned their trust as a result. We recognize the deep honor in being an advocate for a patient population that has few advocates. Generally speaking, Crisis Standards of Care documents aim to deliver the most benefit for the most patients and for the health care system as a whole. There are times, however, when the best outcome for the system can result in hardship for an individual patient. Since our patients are quite often already disenfranchised by the American health care system, the last thing we wanted to do was to disenfranchise them further with a simple calculus that protects the majority at the expense of the individual. In this CSC, we remember that although our providers must keep the wider community in mind, we are a specialty who advocates for those who society can sometimes treat as if they are expendable. Our standards must keep in mind the needs of the few or even the one in times of crisis.
      In the early days of COVID, my team had just finished arguing with yet another emergency medical technician (EMT) who refused to come into our building. My administrator turned to me and said “Wow—we're really finding out who our friends are.” I responded, “I'm not sure we have any friends right now.” This is exactly why a CSC is needed for the PALTC setting. During emergencies such as COVID-19, your circle of friends will shrink. EMTs will refuse to enter your facility, hospitals will complain about yet another older adult occupying an intensive care unit bed, your supplier will divert N-95 masks to acute care settings, your governor will demand that you accept COVID-positive patients into your facility, ready or not. In conventional times, PALTC providers can feel as if the larger health care system views post-acute and long-term care as little more than an afterthought.
      During a crisis, society and the broader health care system can appear to be not only dismissive of our concerns but antagonistic to them. The members of the CSC Workgroup hope that this document will be a guide at a time when the friends of PALTC dwindle. It is also a reminder that although standards of care must shift during a crisis, there are still standards in place, precedence from which to learn and partners on whom to rely.
      The members of The Nursing Home Crisis Standards of Care Workgroup hope that you will find this guide helpful in navigating the COVID-19 crisis, and that it will serve as a reminder that you do not navigate it alone.


        • Stockman F.
        • Richtel M.
        • Ivory D.
        • Smith M.
        “They're death pits”: virus claims at least 7,000 lives in U.S. Nursing Homes.
        (New York Times, April 17, 2020. Available at:)
      1. Hanfling D. Altevogt B.M. Viswanathan K. Gostin L.O. Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations, Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. National Academies Press, Washington, DC2001