Nursing Surge Capacity Strategies for Management of Critically Ill Adults with COVID-19

Background: There is a vital need to develop strategies to improve nursing surge capacity for caring of patients with coronavirus (COVID-19) in critical care settings. COVID-19 has spread rapidly, affecting thousands of patients and hundreds of territories. Hospitals, through anticipation and planning, can serve patients and staff by developing strategies to cope with the complications that a surge of COVID-19 places on the provision of adequate intensive care unit (ICU) nursing staff—both in numbers and in training. Aims: The aim is to provide an evidence-based starting point from which to build expanding staffing models dealing with these additional demands. Design/Method: In order to address and develop nursing surge capacity strategies, a five-member expert panel was formed. Multiple questions directed towards nursing surge capacity strategies were posed by the assembled expert panel. Literature review was conducted through accessing various databases including MEDLINE, CINAHL, Cochrane Central, and EMBASE. All studies were appraised by at least two reviewers independently using the Joanna Briggs Institute JBI Critical Appraisal Tools. Results: The expert panel has issued strategies and recommendation statements. These proposals, supported by evidence-based resources in regard to nursing staff augmentation strategies, have had prior success when implemented during the COVID-19 pandemic. Conclusion: The proposed guidelines are intended to provide a basis for the provision of best practice nursing care during times of diminished intensive care unit (ICU) nursing staff capacity and resources due to a surge in critically ill patients. The recommendations and strategies issued are intended to specifically support critical care nurses incorporating COVID-19 patients. As new knowledge evidence becomes available, updates can be issued and strategies, guidelines and/or policies revised. Relevance to Clinical Practice: Through discussion and condensing research, healthcare professionals can create a starting point from which to synergistically develop strategies to combat crises that a pandemic like COVID-19 produces.


Introduction
The recent viral outbreak initiated from Wuhan, China, has now crossed all borders and has spread into more than 224 countries [1]. The outbreak is caused by a novel strain of coronavirus the hospital levels such as developing triage protocol to reallocate human and medical resources to equitably meet the needs of patients [13,14]. Triage process often starts by inventory of potential ICU resources, such as ventilatory capacity in the hospital, and then follows an algorithm for screening and admission [13]. Periodic patient assessment is necessary to check if there is any change in patients' needs in order to transfer, admit, or discharge patients [14]. Triage protocols may also be developed at a regional level to allow for communication and resource sharing among all hospitals in one region [14]. This strategy gives more opportunities for better utilization of resources [14].
The goal of nursing surge capacity is to find wise ways to augment and extend the hospital workforce; to allocate healthcare resources in an ethical, rational, and organized method to do the greatest good for the greatest possible number of patients [14]. In order to combat the complications that the pandemic threatens to level of care, a decision was made to develop nursing surge capacity recommendations and strategies for management of critically ill patients with COVID-19 in the ICU. The objectives of these strategies are to provide guidance and recommendations in order to help nursing administrators and leaders to prepare for a COVID-19 pandemic in ICU.

Data Sources
The search strategy aimed to find published studies in MEDLINE, CINAHL, Cochrane Central, and EMBASE from December 2019 through March 2020 ( Figure 1). The keywords used were: COVID-19, coronavirus 2019, ICU surge capacity, nursing surge capacity, and strategies. The filters applied included "humans", "last 10 years", and "English language". The unpublished studies were searched in ProQuest and MEDNAR. Nurs. Rep. 2020, 1, FOR PEER REVIEW 3 potential ICU resources, such as ventilatory capacity in the hospital, and then follows an algorithm for screening and admission [13]. Periodic patient assessment is necessary to check if there is any change in patients' needs in order to transfer, admit, or discharge patients [14]. Triage protocols may also be developed at a regional level to allow for communication and resource sharing among all hospitals in one region [14]. This strategy gives more opportunities for better utilization of resources [14]. The goal of nursing surge capacity is to find wise ways to augment and extend the hospital workforce; to allocate healthcare resources in an ethical, rational, and organized method to do the greatest good for the greatest possible number of patients [14]. In order to combat the complications that the pandemic threatens to level of care, a decision was made to develop nursing surge capacity recommendations and strategies for management of critically ill patients with COVID-19 in the ICU. The objectives of these strategies are to provide guidance and recommendations in order to help nursing administrators and leaders to prepare for a COVID-19 pandemic in ICU.

Data Sources
The search strategy aimed to find published studies in MEDLINE, CINAHL, Cochrane Central, and EMBASE from December 2019 through March 2020 ( Figure 1). The keywords used were: COVID-19, coronavirus 2019, ICU surge capacity, nursing surge capacity, and strategies. The filters applied included "humans", "last 10 years", and "English language". The unpublished studies were searched in ProQuest and MEDNAR.

Quality Assessment of Extracted Data
Initially, all titles and abstracts were screened independently by at least two reviewers. All full texts of the studies which passed through the initial stage were retrieved and assessed against the review inclusion criteria in detail. These eligible studies were again appraised by at least two reviewers independently using the Joanna Briggs Institute JBI Critical Appraisal Tools [15]. The JBI appraisal has different checklists to be applied against different study designs. The instrument consists of 10 items that assess the methodological quality of a study and determines the extent to which a study has addressed the possibility of bias in its design, conduct, and analysis. The results of the JBI appraisal have been taken into full account and used to inform the synthesis and interpretation of the results of the recommendations (Figure 1).

Quality Assessment of Extracted Data
Initially, all titles and abstracts were screened independently by at least two reviewers. All full texts of the studies which passed through the initial stage were retrieved and assessed against the review inclusion criteria in detail. These eligible studies were again appraised by at least two reviewers independently using the Joanna Briggs Institute JBI Critical Appraisal Tools [15]. The JBI appraisal has different checklists to be applied against different study designs. The instrument consists of 10 items that assess the methodological quality of a study and determines the extent to which a study has addressed the possibility of bias in its design, conduct, and analysis. The results of the JBI appraisal have been taken into full account and used to inform the synthesis and interpretation of the results of the recommendations (Figure 1).
A total of 220 studies were retrieved. After reading the titles and abstracts, 150 studies were excluded. After reading the full articles, a total of 53 articles were excluded and 17 articles were included which met the inclusion criteria ( Figure 2). All identified publications were collated and fed into Endnote X10 software. The evidence-based strategies issued are to support critical care nurses to manage critical patients in the intensive care unit during the COVID-19 pandemic. Four recommendations and rationales were issued by the expert panel based on evidence.
Nurs. Rep. 2020, 1, FOR PEER REVIEW 4 A total of 220 studies were retrieved. After reading the titles and abstracts, 150 studies were excluded. After reading the full articles, a total of 53 articles were excluded and 17 articles were included which met the inclusion criteria ( Figure 2). All identified publications were collated and fed into Endnote X10 software. The evidence-based strategies issued are to support critical care nurses to manage critical patients in the intensive care unit during the COVID-19 pandemic. Four recommendations and rationales were issued by the expert panel based on evidence.

Recommendation 1: Regular Patient-to-Nurse Ratio
When able to, recommend nursing staffing (1:1 or 1:2) in the ICU during the COVID-19 pandemic to provide high-quality patient care, improve safety, have fewer complications, and better outcomes ( Figure 3). This should be followed until such time that the surge is felt. At that time, progression to Recommendation 2 will be made.

Recommendation 1: Regular Patient-to-Nurse Ratio
When able to, recommend nursing staffing (1:1 or 1:2) in the ICU during the COVID-19 pandemic to provide high-quality patient care, improve safety, have fewer complications, and better outcomes ( Figure 3). This should be followed until such time that the surge is felt. At that time, progression to Recommendation 2 will be made.
Nurs. Rep. 2020, 1, FOR PEER REVIEW 4 A total of 220 studies were retrieved. After reading the titles and abstracts, 150 studies were excluded. After reading the full articles, a total of 53 articles were excluded and 17 articles were included which met the inclusion criteria ( Figure 2). All identified publications were collated and fed into Endnote X10 software. The evidence-based strategies issued are to support critical care nurses to manage critical patients in the intensive care unit during the COVID-19 pandemic. Four recommendations and rationales were issued by the expert panel based on evidence.

Recommendation 1: Regular Patient-to-Nurse Ratio
When able to, recommend nursing staffing (1:1 or 1:2) in the ICU during the COVID-19 pandemic to provide high-quality patient care, improve safety, have fewer complications, and better outcomes ( Figure 3). This should be followed until such time that the surge is felt. At that time, progression to Recommendation 2 will be made.

Rationale
Matching patient needs with adequately trained nurses and maintaining safe patient-to-nurse ratio is essential to ensure the provision of safe and high-quality patient care. As such, nurse staffing ratios in critical care units is an important aspect when planning care [16]. The literature on nursing ratios in ICU has confirmed the relationship between ICU nurse staffing and patient outcomes. The reviewed studies confirm that a higher number of registered nursing staff to patient ratio (1:1 or 1:2) is highly associated with improved patient safety and better outcomes [13]. In the U.S. and Canada, the nurse-to-patient ratio in ICU stays close to (1:1.5) at both time points. Western Europe and Latin America had lower nurse staffing, especially at night, with an overall ratio of (~1:1.8) [17]. Note that this is the preferable situation when applicable or during non-pandemic times.
Additionally, critically ill patients require the care of nurses who have specialized knowledge and skills and who are given enough time to provide that care safely. Appropriate staffing ensures effective pairing of patient/family needs with the assigned nurse's knowledge, skills, and abilities. In fact, evidence confirms that the likelihood of serious complications and mortality rates increase when fewer registered nurses (RNs) are assigned to care for patients [13,18,19]. Similarly, a considerable amount of research indicates healthy work environments and better patient outcomes when a higher percentage of patient care tasks are provided by RNs [20].

Rationale
Most countries that have already been hit hard by COVID-19, attempted to increase the supply of healthcare. Having care directed by trained and experienced ICU nurses is an effective way to provide high-quality care for critically ill patients [21]. However, during crisis times, the number of ICU nurses cannot accommodate a large number of patients. Additional personnel can be identified internally through the scale-back of elective and non-urgent services in the hospital. As elective surgeries are placed on hold, nurses from areas like the Surgical ICU, Endoscopic units, Step-down units, Post Anesthesia Care Unit (PACU), and Pre-Op become available for ICU staffing needs. These nurses should be the first choice to augment ICU staffing and expand ICU beds during pandemics such as COVID-19, as their skills are most readily transferable, thereby having the potential to increase the critical care capacity of the hospital in the safest way possible. To expand the staffing capacity further, hospitals may consider external searching resources to identify and recruit ICU nurses who had transitioned to ambulatory care settings and other nurses from community care settings to support ICU staff during the crisis [7]. Additionally, other qualified medical professionals can be recruited to safely manage the care of mechanically ventilated patients. Anesthesiologists and physicians who have ventilator management experience are potential resources to supplement ICU care teams. With minimal orientation, they can easily support respiratory therapists and nurses to achieve safe ventilatory support to those requiring it [7]. Other potential caregiver support could include students in medical, nursing, and other health education programs who are nearing the end of their studies. Many would be suitable for providing services to patients or helping to respond to public concerns through telephone hotlines [21].  The team is led by an ICU physician who works with a respiratory therapist trained in critical care and 2 ICU nurses who supervised 3 step-down nurses. Each team provides care for 15 patients [12].    The team is led by an ICU physician who works with a respiratory therapist trained in critical care and 2 ICU nurses who supervised 3 step-down nurses. Each team provides care for 15 patients [12].    The team is led by an ICU physician who works with a respiratory therapist trained in critical care and 2 ICU nurses who supervised 3 step-down nurses. Each team provides care for 15 patients [12].  The team is led by an ICU physician who works with a respiratory therapist trained in critical care and 2 ICU nurses who supervised 3 step-down nurses. Each team provides care for 15 patients [12].
In this model, one experienced ICU physician oversees 4 teams composed of ICU physicians, respiratory therapist, and nurses supported by other hospital professionals to take care of 24 patients each [10].

Rationale
To overcome the anticipated shortage of ICU staff during the COVID-19 pandemic, hospitals are recommended to adopt a team-based approach. In the Ontario Health Plan for an Influenza Pandemic Care Team Approach, and the Society of Critical Care Medicine (SCCM) Tiered Staffing Strategy for a Pandemic are recommended models for ICU staff augmentation strategies during pandemics such as COVID-19. Both strategies have similar concepts and applications. They focus on the utilization of non-experienced healthcare workers to work in collaboration (in teams) with experienced staff to increase the capacity of care for critically ill patients. This strategy demonstrated to work effectively in pandemic situations [7,21].
The tiered staffing strategy combines experienced ICU nurses with reassigned hospital nurses. Instead of the regular care delivery model where each ICU nurse provides care for one to two patients (Figure 2), in this strategy, each ICU-trained nurse will supervise and direct other two re-assigned nurses who have useful skills but lack experience in the ICU setting to ultimately provide care for four critically ill patients. ICU physician(s) trained in critical care or those who regularly manage ICU patients will oversee all nurse teams ( Figure 3) [12,13,21,22].
As the situation unfolds, teams can be expanded to care for more patients such as six or eight or more as required. Tiered staffing models are not set standards and each hospital must determine the best combination of staff based on their resources [11,23,24]. Combining experienced and non-experienced ICU-trained nurses will help to ensure adequate levels of care and not overwhelm ICU-trained staff. When implementing the current strategy and combining inexperienced team members, it is recommended to maintain effective communication among the team. This can be achieved through utilizing different ways such as team huddles at the start of each shift and at regular intervals, such as every 4 hours, to discuss team assignments, patient care goals, and red flags that should be reported immediately to the team leader [25]. This will ensure effective communication and allows each team member to discuss his/her patients' needs and get the experts' opinion. If a physical huddle is difficult, virtual huddles can be applied to enhance patients' safety and to keep all team members aware of all updates and changes in the unit [25].

Applications of a Team-Based Approach
The report of the Ontario Health Plan for an Influenza Pandemic presented an example of a tiered strategy and called it Care Team Model (Figure 4). In this model, healthcare workers who have useful skills but lack experience in critical care can work in teams supervised by experienced staff and collectively care for a larger group of patients. In place of an individual specialized nurse caring for one to two patients, a team of mixed experienced nurses provides the care for a group of patients. This is possible because in combination, they have the complete skills set and pertinent experience required to care for expanded patient numbers. In this example, one intensivist can supervise three teams, each composed of one physician, one respiratory therapist and two ICU nurses who supervised three step-down nurses. Each one of the 3 teams will take care of 5 patients and the 3 teams together will provide care to 15 patients [10,11]. The care team model focuses on the provision of care by a team of healthcare workers. Teams would be created with feedback loops and operate under this designated hierarchy and guided by expected job functions and responsibilities. This model has proven to be effective in past emergencies [10,11,15,16].
The SCCM presented an expanded example of the applications of tiered staffing strategy for pandemics with a larger number of healthcare workers and larger capacity for care provision ( Figure 5). It suggests that one ICU-experienced physician oversees the care of 4 teams, and each team provides care for 24 patients. Each one of these teams is supervised by an ICU physician or non-ICU physician such as an anesthesiologist, pulmonologist, surgeon, or hospitalist, who does not frequently perform ICU care but has some ICU training. Each team is composed of an experienced respiratory therapist and other clinicians such as physicians, nurse anesthetists, or pharmacists who are experienced in managing ventilated patients. There are four ICU nurses in each team; each nurse is responsible for supervising the other three re-assigned nurses and each re-assigned nurse will care for two patients. Ultimately each team will provide care for 24 patients and the four teams together will provide care for 96 patients [16]. This strategy is an alternative strategy that may be implemented as ICU-trained nurses fall ill and ICU-trained nurses become less available to care for patients.

Recommendation 4: Training Model for ICU Tiered Staffing Strategy for COVID-19 Pandemic
Illustrated in this model (Figure 7) is a team composed of two ICU nurses; each nurse trains one re-assigned nurse and together they provide care for two critically ill patients. Training should only be added for the re-assigned nurse to care for two patients (hopefully, at least one of which is ventilated) under the direction of an ICU-trained nurse. This will orient the re-assigned nurse as well as orient the ICU-trained nurse as to what tasks and responsibilities will be assigned, divided, and shared. In the training, ventilator management should be the main focus, including modalities, high PEEP considerations, O2 saturations, ABG interpretation, suctioning, proning, sedation, paralytics, and pain control, though sedation vacations must be reviewed by medical staff as to risk versus benefit.
Nurs. Rep. 2020, 1, FOR PEER REVIEW 8 respiratory therapist and other clinicians such as physicians, nurse anesthetists, or pharmacists who are experienced in managing ventilated patients. There are four ICU nurses in each team; each nurse is responsible for supervising the other three re-assigned nurses and each re-assigned nurse will care for two patients. Ultimately each team will provide care for 24 patients and the four teams together will provide care for 96 patients [16]. This strategy is an alternative strategy that may be implemented as ICU-trained nurses fall ill and ICU-trained nurses become less available to care for patients.

Recommendation 4: Training Model for ICU Tiered Staffing Strategy for COVID-19 Pandemic
Illustrated in this model ( Figure 7) is a team composed of two ICU nurses; each nurse trains one re-assigned nurse and together they provide care for two critically ill patients. Training should only be added for the re-assigned nurse to care for two patients (hopefully, at least one of which is ventilated) under the direction of an ICU-trained nurse. This will orient the re-assigned nurse as well as orient the ICU-trained nurse as to what tasks and responsibilities will be assigned, divided, and shared. In the training, ventilator management should be the main focus, including modalities, high PEEP considerations, O2 saturations, ABG interpretation, suctioning, proning, sedation, paralytics, and pain control, though sedation vacations must be reviewed by medical staff as to risk versus benefit. Rationale A significant number of critically ill patients will be admitted to intensive care units during the COVID-19 pandemic. Staffing will be further strained by the threat of experienced ICU staff nurses becoming ill [26]. During the COVID-19 pandemic, it is anticipated that the projected shortfall of welltrained ICU nurses will impact the care of critically ill ventilated patients. Consequently, the focus should not be only to increase the numbers of mechanical ventilators but must also address the number of trained critical care nurses required to care for mechanically ventilated COVID-19 patients, alongside non-COVID-19 patients requiring ICU care [25,26]. Assigning hospital nurses to work immediately in ICU during crisis time without enough training may put the nurse and patients at high risk. Therefore, planning for appropriate nursing staff prior to such a pandemic is required. Augmenting critical care nursing staff is one innovative way to scale up staffing capacity during a pandemic. Individual healthcare organizations must modify their strategies thereby aligning ICU staffing with their patient needs and with available resources [25,26]. In this strategy, consideration should be made to have already chosen and delegated non-ICU-trained nurses to be stationed in the ICU and be assigned to an ICU nurse in order to form a controlled baseline training prior to the actual surge. This will establish roles and responsibilities and form the foundation to build an expanding team when a surge becomes evident.

Conclusions
In anticipation of COVID-19 demands upon nursing staff and subsequent potential weakening of care levels in the provision of patient care, specifically in the ICU setting, a panel was formed to raise and answer critical concerns. The nursing surge capacity of critically ill patients with COVID- Rationale A significant number of critically ill patients will be admitted to intensive care units during the COVID-19 pandemic. Staffing will be further strained by the threat of experienced ICU staff nurses becoming ill [26]. During the COVID-19 pandemic, it is anticipated that the projected shortfall of well-trained ICU nurses will impact the care of critically ill ventilated patients. Consequently, the focus should not be only to increase the numbers of mechanical ventilators but must also address the number of trained critical care nurses required to care for mechanically ventilated COVID-19 patients, alongside non-COVID-19 patients requiring ICU care [25,26]. Assigning hospital nurses to work immediately in ICU during crisis time without enough training may put the nurse and patients at high risk. Therefore, planning for appropriate nursing staff prior to such a pandemic is required. Augmenting critical care nursing staff is one innovative way to scale up staffing capacity during a pandemic. Individual healthcare organizations must modify their strategies thereby aligning ICU staffing with their patient needs and with available resources [25,26]. In this strategy, consideration should be made to have already chosen and delegated non-ICU-trained nurses to be stationed in the ICU and be assigned to an ICU nurse in order to form a controlled baseline training prior to the actual surge. This will establish roles and responsibilities and form the foundation to build an expanding team when a surge becomes evident.

Conclusions
In anticipation of COVID-19 demands upon nursing staff and subsequent potential weakening of care levels in the provision of patient care, specifically in the ICU setting, a panel was formed to raise and answer critical concerns. The nursing surge capacity of critically ill patients with COVID-19 in the ICU was addressed through searching available evidence. Substantiation was retrieved from a variety of databases inclusive of published and unpublished studies. The retrieved studies were then reviewed by a minimum of two reviewers independently using JBI critical appraisal tools. The recommendations in the recent guidelines covered ICU nursing surge capacity strategies. We recommend that hospitals implement the evidence-based strategies that have been shown to be effective such as a team-based approach, and to establish other innovative strategies for ICU nursing staff surge capacity in the COVID-19 pandemic. As new evidence presents itself, further updates of the guideline will be issued.