**1. Introduction**

The recent viral outbreak initiated from Wuhan, China, has now crossed all borders and has spread into more than 224 countries [1]. The outbreak is caused by a novel strain of coronavirus which is very much similar to the SARS-CoV that resulted in the SARS outbreak [2]. Initially, this new

coronavirus was named as 2019-nCoV and then was renamed as Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses (ICTV) [1]. The World Health Organization (WHO) has termed COVID-19 for the disease associated with the infection caused by SARS-CoV-2 [3–5]. The coronavirus has been the focus of global attention after its first report in Wuhan, China, in December 2019. COVID-19 has rapidly spread all over the globe [6]. According to the WHO, as of July 13th, 2020, there were 12,880,565 confirmed cases of COVID-19 including 568,573 reported deaths globally [6].

SARS-CoV-2 transmission of the virus from human to human has become evident and documented in multiple published studies [7]. The mode of transmission for COVID-19 virus was initially thought to occur through droplets of saliva or discharge from the nose when an infected person coughs, sneezes, or speaks [8]. Recent studies have shown that the virus may remain suspended in the air, in the form of aerosols, for upwards of several hours [8]. However, the WHO maintains that these studies do not replicate typical cough conditions as they were produced with high-powered jet nebulizers and they have not altered their recommendations as of the date of this article submission [9]. Although maintaining at least one-meter of distancing is recommended by the WHO, it has been suggested by a recent study published in *The Lancet,* that more protection can be had if that distance is extended to two meters or more if possible. The avoidance of large gatherings, the wearing of masks, wearing of eye protection and regular hand-washing or use of alcohol-based hand rub is important to stop the transmission cycle and minimize the risk of infection [8]. Until now, there are no approved specific vaccines or treatments for COVID-19 [7]. Maintaining at least one-meter distance among individuals and regular hand-washing or using alcohol-based hand rub is important to stop the transmission cycle and minimize the risk of infection [10]. The most common symptoms of COVID-19 include fever, dry cough, and tiredness [7]. An infected person may develop some less common symptoms such as pain, sore throat, loss of taste or smell, headache, and diarrhea [7]. In critical cases, serious symptoms may appear as difficulty breathing, chest pain, and loss of speech or movement [7]. The foremost problem with COVID-19 is that a major proportion of infected persons do not exhibit or experience symptoms and hence serve as asymptomatic carriers. COVID-19 virus can transmit from symptomatic and asymptomatic carriers to other people and cause the disease [10].

Frontline healthcare workers in general, and nursing staff more specifically, as the backbone of any healthcare system, face additional burdens and hazards as they respond to the current COVID-19 pandemic. These burdens include exposure to pathogens, physical and psychological distress, fatigue, long working hours, and burnout [11]. The COVID-19 pandemic denotes a unique challenge to intensive care services. During a pandemic, the principal difficulties surround the preparation of intensive care units (ICU) and healthcare workers for the expected surge in caseload [11]; likely, complicated by workforce challenges including potential difficulty in maintaining standard staffing ratios [11]. In fact, frontline workers tend to get more severely ill than patients and it is not based on expectation of their ages [12]. This could be due to higher viral load exposure but also the high level of stress acting to depress the immune systems of overtaxed frontline healthcare workers [12]. Healthcare workers may experience severe symptoms and lose their ability to work due to admission or death, or they may experience mild symptoms and go under self-isolation for 14 days or more [12]. In both cases, healthcare facilities are expected to lose a considerable number from their manpower and functionality at this critical time [12]. The COVID-19 pandemic has placed a huge strain on health systems due to the increasing number of patients requiring acute and critical health care, staff, hospital beds, supplies, and resources [12].

To deal with this crisis, some countries developed plans and guidelines for crisis management [3]. The management is targeting the scarcity of staff, space, beds, and supplies [3]. Some of these plans were made by the national (governmental) level such as inviting all healthcare professionals to re-join the workforce, relaxing some of the licensing requirements, and accelerating credentialing processes to rapidly incorporate healthcare workers into working in hospitals [11]. Other plans were made at the hospital levels such as developing triage protocol to reallocate human and medical resources to

equitably meet the needs of patients [13,14]. Triage process often starts by inventory of potential ICU resources, such as ventilatory capacity in the hospital, and then follows an algorithm for screening and admission [13]. Periodic patient assessment is necessary to check if there is any change in patients' needs in order to transfer, admit, or discharge patients [14]. Triage protocols may also be developed at a regional level to allow for communication and resource sharing among all hospitals in one region [14]. This strategy gives more opportunities for better utilization of resources [14].

The goal of nursing surge capacity is to find wise ways to augment and extend the hospital workforce; to allocate healthcare resources in an ethical, rational, and organized method to do the greatest good for the greatest possible number of patients [14]. In order to combat the complications that the pandemic threatens to level of care, a decision was made to develop nursing surge capacity recommendations and strategies for management of critically ill patients with COVID-19 in the ICU. The objectives of these strategies are to provide guidance and recommendations in order to help nursing administrators and leaders to prepare for a COVID-19 pandemic in ICU.
