Critical Care Staffing in the Time of the Pandemic

Preparing for and responding to the surge of COVID-19 patients has required healthcare systems to develop and implement new strategies to deal with shortages. Resources that have been in scarce supply include personal protective equipment, ventilators, ICU beds, medications, and IV fluids. Sadly, the resource that is most challenging to recruit in adequate numbers is that of ICU clinical staff.

The acuity of ventilator-dependent patients who often require carefully titrated vasoactive IV infusions, and who may develop multi-organ failure, require low clinician/patient ratios. The pandemic-related “no visitor” policy has required clinical staff to adapt to virtual communication strategies with patients’ families. Adding to the staffing crisis, each day at work, those who care for COVID-19- infected patients are themselves exposed to the risk of infection. This risk is very real.

In the April 14, 2020 edition of Morbidity and Mortality Weekly Review, it was reported that there have been 9282 COVID-19 infections in healthcare professionals with 27 deaths. This grim statistic further decreases the pool of critical care physicians and nurses.

Who can help alleviate the shortage of critical care staff?

Supplementation of current critical care staff may include retired clinicians (less than ideal because their retirement age confers risk of worse clinical outcomes if infected), qualified professional volunteers from other states (if they can be quickly credentialed), and graduating physicians and nurses who have not yet completed credentialing exams. Physicians and nurses who work in hospital areas other than critical care may also be deployed, in particular, because their own areas of practice (like elective surgery, or family practice clinics) may not be operational or at capacity during the pandemic.

In an “all hands on deck” situation like this, ideally, clinical staff from areas outside of the ICU are redeployed based on their skills and comfort level.

The Society of Critical Care Medicine has recommended a “tiered staffing strategy” for such a pandemic in which a crisis model of care is led by an intensivist who oversees a number of teams. The teams are comprised of ICU advanced practice providers who work side by side with non-ICU physicians who have the requisite knowledge and skills to function in the ICU as part of these teams..

Non-ICU physicians shifting to critical care could include:

• Anesthesiologists
• Hospitalists
• Non-ICU nurses can likewise be paired with experienced ICU nursing staff to safely contribute to the care of these critically ill patients using a team approach.

Not all physicians and nurses available to work are prepared to work in the ICU. Clinicians who have long practiced in the outpatient setting may be called to help care for non-ICU hospitalized patients at a lower acuity level or may contribute their skills in outpatient testing centers or staffing telemedicine appointments.

An April 7 editorial in JAMA recommended that for the mental well-being of clinicians, health systems must provide redeployed staff the requisite “rapid training to support a basic critical knowledge base, appropriate backup and access to experts.”

The authors went on to reinforce the importance of “clear and unambiguous communication” and the ongoing reassurance that team members must have a trusting reliance on each other as they provide care and make difficult decisions together.