Design for Implementation of a System-Level ICU Pandemic Surge Staffing Plan

Abstract

Background: The current coronavirus disease 2019 pandemic is causing significant strain on ICUs worldwide. Initial and subsequent regional surges are expected to persist for months and potentially beyond. As a result of this, as well as the fact that ICU provider staffing throughout the United States currently operate at or near capacity, the risk for severe and augmented disruption in delivery of care is very real. Thus, there is a pressing need for proactive planning for ICU staffing augmentation, which can be implemented in response to a local surge in ICU volumes. Methods: We provide a description of the design, dissemination, and implementation of an ICU surge provider staffing algorithm, focusing on physicians, advanced practice providers, and certified registered nurse anesthetists at a system-wide level. Results: The protocol was designed and implemented by the University of Pittsburgh Medical Center’s Integrated ICU Service Center and was rolled out to the entire health system, a 40-hospital system spanning Pennsylvania, New York, and Maryland. Surge staffing models were developed using this framework to assure that local needs were balanced with system resource supply, with rapid enhancement and expansion of tele-ICU capabilities. Conclusions: The ICU pandemic surge staffing algorithm, using a tiered-provider strategy, was able to be used by hospitals ranging from rural community to tertiary/quaternary academic medical centers and adapted to meet specific needs rapidly. The concepts and general steps described herein may serve as a framework for hospital and other hospital systems to maintain staffing preparedness in the face of any form of acute patient volume surge.

Description of a Multi-faceted COVID-19 Pandemic Physician Workforce Plan at a Multi-site Academic Health System

“…Despite rapid expansion of COVID-19-related literature, limited data exist to guide specific health system adaptations to the pandemic. In critical care settings, published reports have outlined disaster response strategies, including teambased models that incorporate non-expert physicians under supervision of trained physicians, [24][25][26][27] adequate PPE supply and training, 15,24,26,[28][29][30] and clear algorithms for efficient evidence-based clinical care. 24 Outside of critical care, recent reports describe COVID-19 pandemic plans within academic health systems with high-level staffing model descriptions in the context of broader care delivery strategies.…”

Mechanical-Ventilation Supply and Options for the COVID-19 Pandemic. Leveraging All Available Resources for a Limited Resource in a Crisis

“…Experienced critical care physicians working as telemedicine attending physicians may also serve at the top of these pyramids, especially in community models. Such models have been seen in both multicenter academic-medical-center collaborations across a large city ( 76 ) and multistate hospital systems ( 77 ).…”

“…With telemedicine attending physicians or critical care teams caring for a high volume of critically ill patients, bedside procedures should be designated to specialized teams to optimize efficiency of the native team ( 76 , 77 ). That workload should be distributed to the most efficient team members by creating dedicated procedure teams.…”

“…Every critically ill patient with COVID-19 should have oversight by an attending intensivist, whether in person or via telemedicine. Physician leads on ICU teams generally follow a pyramid model with the most experienced critical care physician at the top of the pyramid overseeing a large number of critical-care experienced physicians such as fellows and residents or nurse practitioners and physician assistants75,76,77 . These experienced but less senior providers may oversee another tier of extenders who have less critical care experience, such as physicians from other specialties or other advanced practice providers.…”

“…Experienced critical care physicians working as telemedicine attendings may also serve at the top of these pyramids, especially in community models. Such models have been seen in both multi-center academic medical center collaborations across a large city76 , and multi-state hospital systems77 .With telemedicine attendings or critical care teams caring for a high volume of critically ill patients, bedside procedures should be designated to specialized teams in order to optimize efficiency of the native team76,77 . That workload should be distributed to the most efficientteam members by creating dedicated procedure teams.…”