Table 2.

Challenges in infection prevention, ICU infrastructure, capacity, staffing, triage, and research

	Recommendations
Infection prevention
A global shortage of medical masks and respirators threatens efforts to prevent transmission	Consider reuse between patients and use beyond the manufacturer-designated shelf life
N95 respirators that do not fit facial contours might not provide the necessary protection	Conduct regular fit testing, preferably before outbreaks
Self-contamination often happens during removal of PPE	Train on both the donning and doffing of PPE
Viable virus on health-care workers' mobile phones and hospital equipment can cause nosocomial transmission	Conduct surface decontamination and consider wrapping mobile phones in disposable specimen bags
SARS-CoV-2 might be transmitted faecally	Practise immediate and proper disposal of soiled objects
ICU visits pose a risk of infection to visitors	Restrict or ban visits to minimise transmission; use video conferencing for communication between family members and patients or health-care workers
ICU infrastructure
Airborne infection isolation rooms with negative pressure are not universally available, especially in resource-limited settings	Consider adequately ventilated single rooms without negative pressure or, if necessary, cohort cases in shared rooms with beds spaced apart
ICU capacity
Surges in numbers of critically ill patients with COVID-19 can occur rapidly	Implement national and regional modelling of needs for intensive care
Low-income and middle-income countries have insufficient ICU beds in general, and even high-income countries will be put under strain in an outbreak like COVID-19	Consider whether increasing intensive care provision is an appropriate use of resources; if so, make plans for an increase in capacity, including providing intensive care in areas outside ICUs and centralising intensive care in designated ICUs
Increasing ICU capacity requires more equipment (eg, ventilators), consumables, and pharmaceuticals, which might be in short supply	Pay close attention to logistical support and the supply chain; reduce the inflow of patients who do not urgently require intensive care (eg, by postponing elective surgeries)
Ventilators are in short supply	Consider transport, operating theatre, and military ventilators
ICU staffing
Increasing ICU bed numbers and workload without increasing staff could result in increased mortality	Make plans for augmentation of staff from other ICUs or non-ICU areas, and provision of appropriate training (eg, with standardised short courses)
Risk of loss of staff to illness, medical leave, or quarantine after unprotected exposure to COVID-19, with a potentially devastating effect on morale, is high	Minimise risk of infection; consider segregation of teams and physical distancing to limit unprotected exposure of multiple team members, and travel restrictions to limit exposure to COVID-19, which is now global
Staff are especially vulnerable to mental health problems such as depression and anxiety during outbreaks	Reassure staff through infection prevention measures, clear communication, limitation of shift hours, provision of rest areas, and mental health support
ICU triage
ICUs can become overwhelmed as surge strategies might not be sufficient in an emerging pandemic like COVID-19	Consider implementing a triage policy that prioritises patients for intensive care and rations scarce resources
ICU research
The traditional pace of research might not match the pace of the outbreak	Use and adapt pre-approved research plans and platforms
Studies are often single-centre and underpowered	Collaborate through international research networks and platforms
Rapid conduct and sharing of research might compromise scientific quality and ethical integrity	Cautiously analyse the study methodology when interpreting the literature

COVID-19=coronavirus disease 2019. ICU=intensive care unit. PPE=personal protective equipment.