*3.2. Recommendation 2: Finding Alternate Sta*ff *from Internal and External Resources to Support ICU Sta*ff *during Crisis Time*

#### Rationale

Most countries that have already been hit hard by COVID-19, attempted to increase the supply of healthcare. Having care directed by trained and experienced ICU nurses is an effective way to provide high-quality care for critically ill patients [21]. However, during crisis times, the number of ICU nurses cannot accommodate a large number of patients. Additional personnel can be identified internally through the scale-back of elective and non-urgent services in the hospital. As elective surgeries are placed on hold, nurses from areas like the Surgical ICU, Endoscopic units, Step-down units, Post Anesthesia Care Unit (PACU), and Pre-Op become available for ICU staffing needs. These nurses should be the first choice to augment ICU staffing and expand ICU beds during pandemics such as COVID-19, as their skills are most readily transferable, thereby having the potential to increase the critical care capacity of the hospital in the safest way possible. To expand the staffing capacity further, hospitals may consider external searching resources to identify and recruit ICU nurses who had transitioned to ambulatory care settings and other nurses from community care settings to support ICU staff during the crisis [7]. Additionally, other qualified medical professionals can be recruited to safely manage the care of mechanically ventilated patients. Anesthesiologists and physicians who have ventilator management experience are potential resources to supplement ICU care teams. With minimal orientation, they can easily support respiratory therapists and nurses to achieve safe ventilatory support to those requiring it [7]. Other potential caregiver support could include students in medical, nursing, and other health education programs who are nearing the end of their studies. Many would be suitable for providing services to patients or helping to respond to public concerns through telephone hotlines [21].

*3.3. Recommendation 3: Implement a Team-Based Approach (Tiered Sta*ffi*ng Strategy or Care Team Model) to Manage Critically Ill Patients*

A Team-Based Approach Outlines Care Being Provided by Teams of Healthcare Professionals for Groups of Patients (Figures 4–6).

**Figure 4.** ICU tiered staffing strategy for COVID-19 pandemic; (1 ICU-trained nurse: 2 re-assigned nurses: 4 patients). This model can be expanded on a needs basis as pandemic scales up.

**Figure 6.** Expanded application of tiered staffing strategy for pandemic.

The team is led by an ICU physician who works with a respiratory therapist trained in critical care and 2 ICU nurses who supervised 3 step-down nurses. Each team provides care for 15 patients [12].

In this model, one experienced ICU physician oversees 4 teams composed of ICU physicians, respiratory therapist, and nurses supported by other hospital professionals to take care of 24 patients each [10].
