Critical Findings on COVID-19 Select Publications from the National Academies of Sciences, Engineering, and Medicine (2021) / Chapter Skim
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Rapid Expert Consultation on Staffing Considerations for Crisis Standards of Care for the COVID-19 Pandemic (July 28, 2020)
Rapid Expert Consultation on Staffing Considerations for Crisis Standards of Care for the COVID-19 Pandemic (July 28, 2020)
Pages 84-99
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From page 84... ...
Kadlec: Attached please find a rapid expert consultation that was prepared by the co-conveners of the Crisis Standards of Care (CSC) 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.
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From page 85... ...
Fineberg, M.D., Ph.D. 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.
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From page 86... ...
health care system–specific strategies. The first set of efforts may include: • Reducing the burden of disease by implementation of non-pharmaceutical interventions whenever possible; • Transferring patients at capacity-strained facilities to facilities with a lower census so as to "load balance" the delivery of services whenever possible; • Curtailing the delivery of elective services, including the scheduling of routine care visits in the outpatient setting; and • Ensuring support efforts are in place in order to meet the social and psychological needs of the existing health care workforce.
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From page 87... ...
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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From page 88... ...
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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From page 89... ...
Relying on commonly used assumptions about ICU beds being available for only cases of shock or ventilator-dependent patients in a mass casualty would result in a significant variance between assumed and actually available ICU beds. 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.
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From page 90... ...
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. An example of this is the COVID Watch system created at the University of Pennsylvania, which allowed seven full-time nurses to manage 1,000 less acute 7 National Academies of Sciences, Engineering, and Medicine.
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From page 91... ...
Alignment of public health messaging; interactive, virtual care tools; and the teams at outpatient specialty facilities could help protect vulnerable patients and potentially free up staff for other roles. 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.
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From page 92... ...
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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From page 93... ...
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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From page 94... ...
In particular, rapid intervention and airway teams have been in high demand in facilities experiencing surges, often responding to multiple calls each hour. CRNAs have been used successfully in several hospitals to provide staffing for these intervention teams along with other anesthesia and emergency medicine staff.
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From page 95... ...
While there is no substitution for bedside care delivered by nurses, technicians, and other health professionals, telemedicine could be used to manage some of the concerns related to real-time patient care physician oversight and allow community hospitals to broaden their scope of services and allow them to more effectively assist with "load balancing" ventilated patients who require continued respiratory support and weaning. 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.
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From page 96... ...
Based on the information above, the following could assist health care coalitions and other entities considering a large number of staffing needs versus a small number of deployable staff by helping to consider what has already been done and exploring any potential adjustments to be made locally that will inform the specific needs for staffing assistance. • Has the community implemented maximal disease control measures to reduce future cases?
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From page 97... ...
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 Copyright National Academy of Sciences. All rights reserved.
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From page 98... ...
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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From page 99... ...
• 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) results reach a experts in workplace stress in point where units are extreme situations unable to maintain staffing; Implement changes in • patients are transferred to personnel policies and other facilities, personnel practices refuse to come to work; • unable to give workers time off between shifts, at least equal to shift length APPENDIX B Acknowledgment of Reviewers The following individuals served as reviewers: Mahshid Abir, RAND Corporation; David Asch, University of Pennsylvania; Christine Cassel, University of California, San Francisco, Kaiser Permanente School of Medicine; Bernard Lo, University of California, San Francisco; and Nicole Lurie, CEPI.
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