*3.4. Recommendation 4: Training Model for ICU Tiered Sta*ffi*ng Strategy for COVID-19 Pandemic*

Illustrated in this model (Figure 7) is a team composed of two ICU nurses; each nurse trains one re-assigned nurse and together they provide care for two critically ill patients. Training should only be added for the re-assigned nurse to care for two patients (hopefully, at least one of which is ventilated) under the direction of an ICU-trained nurse. This will orient the re-assigned nurse as well as orient the ICU-trained nurse as to what tasks and responsibilities will be assigned, divided, and shared. In the training, ventilator management should be the main focus, including modalities, high PEEP considerations, O2 saturations, ABG interpretation, suctioning, proning, sedation, paralytics, and pain control, though sedation vacations must be reviewed by medical staff as to risk versus benefit.

**Figure 7.** Training preparation for tiered staffing strategy for COVID-19 pandemic preparation.

#### Rationale

A significant number of critically ill patients will be admitted to intensive care units during the COVID-19 pandemic. Staffing will be further strained by the threat of experienced ICU staff nurses becoming ill [26]. During the COVID-19 pandemic, it is anticipated that the projected shortfall of well-trained ICU nurses will impact the care of critically ill ventilated patients. Consequently, the focus should not be only to increase the numbers of mechanical ventilators but must also address the number of trained critical care nurses required to care for mechanically ventilated COVID-19 patients, alongside non-COVID-19 patients requiring ICU care [25,26]. Assigning hospital nurses to work immediately in ICU during crisis time without enough training may put the nurse and patients at high risk. Therefore, planning for appropriate nursing staff prior to such a pandemic is required. Augmenting critical care nursing staff is one innovative way to scale up staffing capacity during a pandemic. Individual healthcare organizations must modify their strategies thereby aligning ICU staffing with their patient needs and with available resources [25,26]. In this strategy, consideration should be made to have already chosen and delegated non-ICU-trained nurses to be stationed in the ICU and be assigned to an ICU nurse in order to form a controlled baseline training prior to the actual surge. This will establish roles and responsibilities and form the foundation to build an expanding team when a surge becomes evident.
