Mass Critical Care Surge Response During COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings From the Task Force for Mass Critical Care

Abstract

Background: After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world.

Research question: A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality.

Study design and methods: TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, "gray" evidence from lay media sources, and anecdotal experiential evidence.

Results: Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs.

Interpretation: A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.

Keywords: COVID-19; contingency; conventional; crisis levels; critical clinical prioritization; incident command system; load-balancing; mass critical care; staffing; surge; telemedicine; tiered staffing.

Graphical abstract

Figure 1

Diagram showing a framework for critical care surge capacity planning outlining the conventional, contingency, and crisis surge responses. PACU = post-anesthesia care unit. (Reprinted with permission from Christian et al.³)

Figure 2

Diagram depicting the spectrum of surge from minor through major. The magnitude of surge is illustrated by the alterations in the balance between demand (stick figures) and supply (medication boxes). As surge increases, the demand-supply imbalance worsens. Conventional, contingency, and crisis responses are used to respond to the varying magnitude of surge. Varying response strategies are associated with each level of response. As the magnitude of the surge increases, the strategies used to cope with the response gradually depart from the usual standard of care (default defining the standards of disaster care) until such point that even with crisis care, critical care is no longer able to be provided. (Reprinted with permission from Christian et al.³)

Figure 3

Diagram showing critical care adult physician or provider staffing model for expanding surge coverage., , , , , , , This model assumes all ICU care teams have at least one intensivist or other skilled ICU physician (red circle-and-diamond figures) to surge while maintaining contingency level care. An intensivist or skilled ICU physician may manage up to 12 patients in a 12-h shift when providing only direct hands-on care, and up to 24 patients when combining hands-on care with support and collaboration for up to four other clinician team members (blue circle-and-diamond figures). The factors that effectively increase an ICU team’s capacity to expand coverage while maintaining contingency level care include (banners at the top of graph): (1) team members with more ICU experience, (2) the presence of procedure teams (for placing invasive lines or other procedures, for intubations, for other care such as prone positioning), and (3) the presence of telemedicine support. Higher acuity patients (as is typical with patients with COVID-19 in the ICU) may impact capacity negatively by demanding greater resources to maintain contingency-level care. Other clinician team members may include non-ICU skilled physicians and ICU or non-ICU skilled practitioners, or both; training institutions trainees (residents and fellows) also may be team members. Finally, this model is focused on resources for direct patient care only, and sufficient resource needs for overnight staffing and cross-coverage also should be factored and scaled up appropriately with increasing surge.

Figure 4

Diagram showing critical care surge capacity team nursing staffing model.^, One ICU-trained RN working with two non-ICU-trained RNs can expand ICU level care to four patients by having each focus using their own skill sets. CHG = change; ETT = endotracheal tube; NGT = nasogastric tube; OGT = orogastric tube; OT = occupational therapy; PT = physical therapy; RN = registered nurse; tPA = tissue plasminogen activator.

Figure 5

Diagram showing model for staffing and support of PICUs embedded in facilities that routinely care for adult patients to support adult surge., , Adult RNs, pharmacists, and physicians can provide brief daily and as-needed in-person or teleconsultation for pediatric ICUs of varying sizes providing care for critically ill adults starting with younger patients with less comorbidities, but with upper age of 70 years or older as needed to meet increasing demands. This model is supported most easily in facilities that also routinely care for adults because of existing logistic (“stuff”) and system capabilities. PICU = pediatric ICU; RN = registered nurse.

Figure 6

Diagram showing the American Association of Critical Care Nurses Healthy Work Environment Standards. The six standards have been shown to correlate with burnout among critical care nurses. The Healthy Work Environment Standards have been demonstrated to apply to the interdisciplinary team and to noncritical care areas. Authentic leadership and meaningful recognition are shown to correlate most strongly with compassion satisfaction, which counteracts compassion fatigue and enhances professional quality of life.

Figure 7

Diagram showing an example of a nine-hospital system illustrating daily levels of strain during a severe pandemic surge. Using clinical leaders’ assessment and strain criteria each of nine hospitals (left margin, top frame) assesses their daily level of ICU surge for the first 10 days (shown across the top); the levels of daily strain are illustrated in the colored legend below. For health system leadership, the ebb and flow of daily level of strain for each hospital helps to determine where hospital resources need to be directed, where resources are available to transfer patients, or both. PACU = post-anesthesia care unit.

Figure 8

Case study of CCP. CCP = critical clinical prioritization.

Figure 9

Diagram showing critical clinical prioritization. As resource strain approaches crisis levels, ICU clinicians may need to adapt, substitute, conserve, or even initiate rationing of resources. This transition zone immediately preceding crisis level is termed critical clinical prioritization and is illustrated on the lower panel, “Basis of Clinical Management.”

Figure 10

Diagram showing regional and statewide patient placement centers. Transfer centers interface with all hospital and health systems in a region or state and typically may be engaged after routine referral sources are no longer accepting transfers. Their role is to facilitate patient transfers quickly to an appropriate hospital setting including ICU and medical or surgical beds, while efficiently and effectively using capacity at both larger and smaller hospitals. The ability to pay should never be a criterion regarding transfer, and transfer centers should have policy authority to rotate transfers if required. Transfer distances may require a combination of ground and air transport. Intensivists and hospitalists may help to prioritize transfers based on both the type of (specialized) care needed and urgency of transfer, and they may be able to provide clinical advice to onsite clinicians whose patients may not be able to be transferred immediately.

Figure 11

Diagram showing the role of the PCSS. PCSS = physician clinical support supervisor.

Figure 12

Diagram showing telemedicine and tele-ICU technology. Telemedicine and tele-ICU technology with portable applications can augment both the delivery of clinical expertise to virtually any hospital bedside in support of ICU care and specialty consultation support and can provide families virtually unlimited audiovisual access to their loved ones who are hospitalized patients (right side of diagram). This technology also functions by helping decompress hospital surge by outpatient care reach support for patients at home and preventing disease exposure from unnecessary office visits (left side of diagram).

Figure 13

Diagram showing the impact of triage in crisis surge response to balance demand and capacity, demonstrating different levels of triage depending on the degree of demand in relationship to system capacity. LTC = long-term care. (Reprinted with permission from Maves et al.¹²)