Rapid Expert Consultation on Staffing Considerations for Crisis Standards of Care for the COVID-19 Pandemic (July 28, 2020) (2020) / Chapter Skim
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Rapid Expert Consultation
Rapid Expert Consultation
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working group, Dan Hanfling and John Hick, and conducted under the auspices of the National Academies of Sciences, Engineering, and Medicine's Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats. Building on prior National Academies reports on CSC and the rapid expert consultation on March 28, 2020, the aim of this rapid expert consultation is to focus on staffing needs for the care of COVID patients, including the deployment and allocation of expert clinical staff during COVID-19.
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Chair Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats PROBLEM STATEMENT AND SCOPE The availability of qualified staff, particularly for respiratory therapy and critical care nursing, is restricting many hospitals and states from meeting patient care needs as COVID-19 cases increase in their jurisdiction. Inconsistent staffing models across hospitals and jurisdictions highlight the importance of a fair and equitable process to meet staffing needs.
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Thousands of federal and out-of-state providers have responded to the needs of states, such as New York, in an attempt to help meet a surge in need. However, as the crisis continues unabated, with nearly 40 of 50 states with "hotspots" (defined by rising case counts, rising hospitalizations, and decreasing bed availability in hospital intensive care units [ICUs]
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The use of health care coalitions and Medical Operations Coordination Centers (MOCCs) 3 as "level-loading" mechanisms should be in place to ensure that all available inpatient capacity is leveraged.
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As with patient transfers, some hospitals in an area may wish to continue elective procedures while others have to curtail them. The role of health care coalitions and jurisdictional public health, emergency management, and executive officers is important to maintain a coordinated approach so that the surge is able to be absorbed.
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In addition to hospital capacity and resource data, it is essential that MOCCs and healthcare coalitions, especially those that cross jurisdictional boundaries, share common definitions and reporting criteria for public health data. Community data such as testing capacity and results and infection incidence are needed in concert with hospital-collected data to best understand the impact of disease in the community and to assist in projecting resource requirements.
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Implement Innovative Strategies to Increase Support to Patients in the Community and Reduce Emergency Department and Inpatient Loading While much of the focus of CSC discussions is on critical inpatient populations, the support and management of less critical patients in the community can have a substantial impact on the resources available. The utilization of digital health technology and remote patient monitoring to create interactive systems that provide real-time "virtual care" and medical oversight should be considered for implementation.
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HEALTH CARE SYSTEM STRATEGIES Obtain Additional Staffing Health care coalitions can play an important role in obtaining additional staff from within the coalition or from neighboring coalitions. Existing staff-sharing agreements may be leveraged to move staff from one facility to another.
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For example, an intermediate care nurse works in the ICU, a nurse from a cardiac rehabilitation unit staffs in intermediate care, a floor nurse staffs cardiac rehab, and a pre-induction surgical nurse with prior inpatient experience provides floor care. These "step ups" should be accompanied by appropriate training and orientation, ideally anticipated and provided before such a transition is needed both to improve acceptance and ensure appropriate job performance as well as work through any associated collective bargaining and administrative issues.
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manage the bedside care, orders, and medications. This principle is illustrated below by a figure from the Society of Critical Care Medicine 11 in which non-ICU nurses provide care at a 1:2 ratio with 1 critical care nurse supervising 6 patients, a hospitalist or other physician supervising 24 patients, and a critical care physician reviewing care and troubleshooting with the four "team" physicians to effectively supervise care for 96 patients.
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CRNAs have been used successfully in several hospitals to provide staffing for these intervention teams along with other anesthesia and emergency medicine staff. Respiratory therapists (RTs)
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Wearables and other digital health technologies could also be used to support the out-of-hospital management of infected patients who may not need hospitalization, but still require close medical monitoring. ASSESSING IMPLEMENTATION OF STRATEGIES Many facilities will make staffing requests based on conventional staffing ratios while some will make requests based on adjusted ratios or changed practices such as a tiered staffing model.
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Current providers should receive just-in-time education on the "step up" knowledge and roles that they will need. Hospitals and health care coalitions should proactively manage inpatient volumes across their catchment area and also should share information to ensure that staffing strategies across their area are consistent.
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Practical Examples and Indicator or Trigger Response Tactics Resources Increasing staff requirements Tailor responsibilities to ASPR TRACIE: in the face of increasing expertise, diverting COVID-19: Healthcare demand nontechnical or nonessential System Operations Strategies care to others and Experiences Lack of qualified staff for specific cases Hospital Roles and Responsibilities in Healthcare Coalitions 14
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Establish remote consultation University of Pennsylvania of specialized services such COVID Watch as telemedicine, phone triage, etc., if possible Leveraging Digital Health Technologies During Large Scale Epidemics Out-of-hospital sector staff Adjust staffing hours and US ICU Resource are being asked to volunteer routines to accommodate Availability for COVID-19 (e.g., MRC) to provide care more patients to higher acuity patients (e.g., alternate care sites and Implement "step-up" staffing hospital surge)
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psychological first aid) • productivity and function problems due to personnel Continue regular and accurate issues cause service surveillance of stress-related disruption; issues • role conflict (relative priorities of home and Explore specialized family well-being and job consultation from content function)
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