Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19

J Racial Ethn Health Disparities. 2021 Aug;8(4):824-836. doi: 10.1007/s40615-020-00840-5. Epub 2020 Aug 13.


Background: Crisis Standards of Care (CSC) provide a framework for the fair allocation of scarce resources during emergencies. The novel coronavirus disease (COVID-19) has disproportionately affected Black and Latinx populations in the USA. No literature exists comparing state-level CSC. It is unknown how equitably CSC would allocate resources.

Methods: The authors identified all publicly available state-level CSC through online searches and communication with state governments. Publicly available CSC were systematically reviewed for content including ethical framework and prioritization strategy.

Results: CSC were identified for 29 states. Ethical principles were explicitly stated in 23 (79.3%). Equity was listed as a guiding ethical principle in 15 (51.7%); 19 (65.5%) said decisions should not factor in race, ethnicity, disability, and other identity-based factors. Ten states (34.4%) allowed for consideration of societal value, which could lead to prioritization of health care workers and other essential personnel. Twenty-one (72.4%) CSC provided a specific strategy for prioritizing patients for critical care resources, e.g., ventilators. All incorporated Sequential Organ Failure Assessment scores; 15 (71.4%) of these specific CSC considered comorbid conditions (e.g., cardiac disease, renal failure, malignancy) in resource allocation decisions.

Conclusion: There is wide variability in the existence and specificity of CSC across the USA. CSC may disproportionately impact disadvantaged populations due to inequities in comorbid condition prevalence, expected lifespan, and other effects of systemic racism.

Keywords: COVID-19; Crisis Standards of Care; Equity; Infectious disease; Pandemic.

Publication types

  • Systematic Review

MeSH terms

  • COVID-19 / ethnology*
  • Health Care Rationing / ethics*
  • Health Care Rationing / organization & administration*
  • Health Equity*
  • Humans
  • Standard of Care*
  • United States / epidemiology