3.3.1. Rationale

To overcome the anticipated shortage of ICU staff during the COVID-19 pandemic, hospitals are recommended to adopt a team-based approach. In the Ontario Health Plan for an Influenza Pandemic Care Team Approach, and the Society of Critical Care Medicine (SCCM) Tiered Staffing Strategy for a Pandemic are recommended models for ICU staff augmentation strategies during pandemics such as COVID-19. Both strategies have similar concepts and applications. They focus on the utilization of non-experienced healthcare workers to work in collaboration (in teams) with experienced staff to increase the capacity of care for critically ill patients. This strategy demonstrated to work effectively in pandemic situations [7,21].

The tiered staffing strategy combines experienced ICU nurses with reassigned hospital nurses. Instead of the regular care delivery model where each ICU nurse provides care for one to two patients (Figure 2), in this strategy, each ICU-trained nurse will supervise and direct other two re-assigned nurses who have useful skills but lack experience in the ICU setting to ultimately provide care for four critically ill patients. ICU physician(s) trained in critical care or those who regularly manage ICU patients will oversee all nurse teams (Figure 3) [12,13,21,22].

As the situation unfolds, teams can be expanded to care for more patients such as six or eight or more as required. Tiered staffing models are not set standards and each hospital must determine the best combination of staff based on their resources [11,23,24]. Combining experienced and non-experienced ICU-trained nurses will help to ensure adequate levels of care and not overwhelm ICU-trained staff. When implementing the current strategy and combining inexperienced team members, it is recommended to maintain effective communication among the team. This can be achieved through utilizing different ways such as team huddles at the start of each shift and at regular intervals, such as every 4 hours, to discuss team assignments, patient care goals, and red flags that should be reported immediately to the team leader [25]. This will ensure effective communication and allows each team member to discuss his/her patients' needs and get the experts' opinion. If a physical huddle is difficult, virtual huddles can be applied to enhance patients' safety and to keep all team members aware of all updates and changes in the unit [25].

## 3.3.2. Applications of a Team-Based Approach

The report of the Ontario Health Plan for an Influenza Pandemic presented an example of a tiered strategy and called it Care Team Model (Figure 4). In this model, healthcare workers who have useful skills but lack experience in critical care can work in teams supervised by experienced staff and collectively care for a larger group of patients. In place of an individual specialized nurse caring for one to two patients, a team of mixed experienced nurses provides the care for a group of patients. This is possible because in combination, they have the complete skills set and pertinent experience required to care for expanded patient numbers. In this example, one intensivist can supervise three teams, each composed of one physician, one respiratory therapist and two ICU nurses who supervised three step-down nurses. Each one of the 3 teams will take care of 5 patients and the 3 teams together will provide care to 15 patients [10,11]. The care team model focuses on the provision of care by a team of healthcare workers. Teams would be created with feedback loops and operate under this designated hierarchy and guided by expected job functions and responsibilities. This model has proven to be effective in past emergencies [10,11,15,16].

The SCCM presented an expanded example of the applications of tiered staffing strategy for pandemics with a larger number of healthcare workers and larger capacity for care provision (Figure 5). It suggests that one ICU-experienced physician oversees the care of 4 teams, and each team provides care for 24 patients. Each one of these teams is supervised by an ICU physician or non-ICU physician such as an anesthesiologist, pulmonologist, surgeon, or hospitalist, who does not frequently perform ICU care but has some ICU training. Each team is composed of an experienced respiratory therapist and other clinicians such as physicians, nurse anesthetists, or pharmacists who are experienced in managing ventilated patients. There are four ICU nurses in each team; each nurse is responsible for

supervising the other three re-assigned nurses and each re-assigned nurse will care for two patients. Ultimately each team will provide care for 24 patients and the four teams together will provide care for 96 patients [16]. This strategy is an alternative strategy that may be implemented as ICU-trained nurses fall ill and ICU-trained nurses become less available to care for patients.
