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Coronavirus: Tiered Staffing Recommended to Bolster Critical Care

Analysis  |  By Christopher Cheney  
   March 23, 2020

A crucial element of creating new ICUs during a pandemic is combining experienced critical care staff with reassigned non-ICU personnel.

The Society of Critical Care Medicine (SCCM) is recommending a tiered staffing model for hospitals opening new ICUs in response to the novel coronavirus (COVID-19) pandemic.

To avoid rationing of critical care services, which has been reported in China and Italy, U.S. hospitals are scrambling to find ventilators and critical care staff to expand ICU beds for treatment of high-acuity COVID-19 patients. Severe hypoxic respiratory failure requiring mechanic ventilation is the most common reason that COVID-19 patients are being admitted to ICUs globally, according to a recent SCCM report.

"As large numbers of critically ill patients are admitted to ICU, step-down, and other expansion beds, it must be determined who will care for them. Having an adequate supply of beds and equipment is not enough. Based on AHA 2015 data, there are 28,808 privileged and 19,996 full-time equivalent intensivists in the United States; however, 48% of acute care hospitals have no intensivists," the SCCM report says.

ICU tiered staffing model for COVID-19 pandemic

To address the anticipated shortage of ICU staff during the COVID-19 pandemic, SCCM is proposing that U.S. hospitals adopt a tiered staffing model that integrates experienced ICU personnel with reassigned hospital staff members. The integrated ICU personnel would be used to staff non-traditional ICUs created in repurposed hospital spaces such as post-anesthesia care units, Lewis Kaplan, MD, president of SCCM and professor of surgery at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, told HealthLeaders last week.

An SCCM graphic of the proposed tiered staffing model is not absolute—each hospital will have to determine the best combination of staff members based on available resources, Kaplan says.

"The graphic is a helpful guide to see how you could do things, where you might begin to deploy your resources or education, and what the staffing model could look like. There will be some hospitals that have a different way of looking at their staffing model—there can be several successful approaches that reflect the unique elements of a hospital's capabilities and staffing," he says.

In the SCCM graphic, one trained or experienced critical care physician would supervise four ICU teams, with each team providing care to 24 mechanically ventilated COVID-19 patients. Each team would have four tiers:

  • At the top tier, each ICU team could be led by an experienced ICU advanced practice practitioner or a reassigned non-ICU physician.
  • The second tier would focus on mechanical ventilation and could be staffed by a combination of experienced and reassigned doctors, respiratory therapists, advanced practice practitioners, certified registered nurse anesthetists (CRNAs), and certified anesthesiologist assistants (CAAs).
  • The third tier could be staffed by experienced ICU nurses.
  • The fourth tier could be staffed by reassigned non-ICU nurses.

Tiered staffing model keys to success

Four actions are necessary for a tiered ICU staffing model to function effectively during the COVID-19 pandemic, Kaplan says.

1. Limiting elective surgeries frees up acute and ICU care beds, staff members, and ventilators. On the staffing front, reducing elective surgeries increases the availability of anesthesiologists, OR nurses, OR technicians, CRNAs, and CAAs. "Anesthesiologists and CRNAs are very good at managing mechanical ventilation and helping to care for people with acute illness," Kaplan says.

Reducing elective surgeries also increases the availability of ventilators, he says. "OR anesthesia machines are in fact ventilators that happen to have several other features such as delivering anesthetic gases."

2. Training of non-critical care staff who are reassigned to ICU duty is essential. The training should focus on education for new skills as well as refreshing staff members on any earlier critical care training. "People who are being trained or refreshed in conjunction with staff members who know how to care for patients with acute illness can work together in a repurposed space," Kaplan says.

3. Combining experienced and inexperienced ICU staff helps ensure an adequate level of care. "When you put people in a space where they don't typically work, it can be very trying. So, you need to have a partner system where the new ICU is not entirely composed of many people who have never worked in an ICU. … This will ultimately allow inexperienced staff members to have a buddy who can help them, guide them, or provide comfort," he says.

4. Public health measures limit viral transmission and viral spread, which slows down the rate at which COVID-19 patients present for hospital care. "This is the so-called flattening of the curve," Kaplan says.

Christopher Cheney is the CMO editor at HealthLeaders.


Increasing the supply of critical care staff and ventilators will play a pivotal role in avoiding the rationing of care in the United States during the COVID-19 pandemic.

With a tiered ICU staffing model, one trained or experienced critical care physician could supervise four ICU teams, according to the Society for Critical Care Medicine.

Keys to success for a tiered ICU staffing model include limiting elective surgeries and training reassigned non-ICU personnel.

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