Table 1.
Summary of 10 Suggestions and Operational Strategies
| Suggestions | Operational Strategy | Category |
|---|---|---|
| 1. We suggest graded staff-to-patient ratios with consideration to experience level, resources, and patient acuity to optimize contingency care and avoid crisis care (Figs 3, 4, 5). | Three staffing models are presented to scale up surge staffing effectively to maintain contingency-level care. | Staffing |
| 2. We suggest limiting overtime to less than 50% above normal for all HCWs to minimize the risk of burn-out and exhaustion. | Limit overtime to < 50% more than normal for all staff to minimize risk of burnout. | Staffing |
| 3. We suggest that the mental health needs of all HCWs are priorities for maintaining an effective response and staffing capacity. | Identify HCWs at risk of moral injury or exhaustion, address necessary preventative changes to clinical care, and promote an informed supportive culture. | Staffing |
| 4. During surge, we suggest minimizing redundant clinical documentation requirements to focus on core elements directly relevant to bedside care. | Responsibly streamline documentation requirements. | Staffing |
| 5. We suggest that resource strain level be actively monitored and determined by front line clinical leaders based upon assessment of available resources and conditions. | Clinical leaders, ICU directors, and service chiefs should be empowered to determine local resources including strain indicators as being conventional, contingency, or at crisis levels. | Load-balancing |
| 6. We suggest there is a transition zone toward the limits of contingency care when increasingly scarce resources are modified beyond routine standards of care to preserve life. This critical clinical prioritization level precedes triage of scarce resources and is a powerful indicator for needed resources to maintain contingency-level care. (case study Fig 8) | Educate clinicians to recognize critical clinical prioritization to request resources or patient transfers; prepare decision support for potential crisis scenarios; prioritize communication systems for rapid access to ethical, legal, and administrative counsel when triage of scarce resources is encountered. | Load-balancing |
| 7. We suggest that early transfer of patients before a hospital is overwhelmed promotes the effective conservation of resources and less deviation from routine care standards. | Transfer (load-balance) patients early before a hospital is overwhelmed to maintain contingency-level care. | Load-balancing |
| 8. We suggest earlier utilization of regional transfer centers for load-balancing during surge for patient transfers and placement. We also suggest having intensivist or hospitalist availability to help prioritize transfers and provide support to bedside clinicians when transfers are delayed. | Implement regional transfer centers to improve bed access and assure efficient ICU bed use through active management and load-balancing of admissions across all hospitals in a state or region. On-call intensivist or hospitalist support should be available as a resource. | Load-balancing |
| 9. We re-emphasize that designated clinicians who are actively engaged in clinical work (especially intensivists and hospitalists) actively participate in hospital incident command structure; this group should provide updates to clinical staff for improving situational awareness, ensuring bidirectional communication. | Establish formal communication structures between incident command and frontline clinicians, such as PCSS or PCCS team to ensure bidirectional communication and situational awareness. | Communication |
| 10. We suggest hospitals apply telemedicine technology to augment critical care early and in the broadest sense possible. | Use telemedicine technology to support bedside critical care, to connect specialty clinicians to distant sites, and to support visitation needs of families. | Technology |
HCW = health care worker; PCSS = physician clinical support supervisor.