CHESTGuidelines & Topic CollectionsCOVID-19 Resource CenterSurge Priority Planning COVID-19: Critical Care Staffing and Nursing Considerations

Surge Priority Planning COVID-19: Critical Care Staffing and Nursing Considerations

Anne Marie Martland, MS, ACNP-BC; Meredith Huffines, MS, BA, RN; and Kiersten Henry, DNP, ACNP-BC


Effective management of critically ill patients infected with the COVID-19 virus is dependent upon the efficient provision of evidence-based care. Ensuring the safety and resilience of nursing staff during pandemic-related surge capacity is an essential component of disaster preparedness. The suggestions in this article are focused on nursing leadership and administrative considerations, strategies for optimizing staffing resources, and maintaining staff safety and resilience. The suggestions in this article are important for hospital administrators, nursing leaders, and bedside nursing personnel.

Summary of suggestions

Identifying alternate staffing resources

We suggest that hospitals consider alternate sources of staffing to supplement existing critical care nursing staff. These may be internal or external resources.

Internal Resources

  1. Identify alternate staffing resources within the facility who may have prior critical care experience. These include advanced practice nurses (Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Nurse Practitioners), as well as nurses in procedural areas (such as the post- anesthesia care unit, cardiac catheterization lab, electrophysiology lab, and operating room).
  2. Identify nurses in progressive care units (intermediate care, telemetry, or stepdown units) who could contribute to team-based care with the guidance and expertise of a critical care nurse.
  3. Identify staff who could provide support to both associates and patients, such as psychiatric counselors and social workers.

External Resources

  1. Identify critical care nurses who have transitioned to ambulatory settings but have only been out of critical care environment for less than 3 years.
  2. Consider partnering with prehospital resources to support the ICU care team.1,2
    • Local emergency medical services (EMS) to utilize paramedics or emergency medical technicians for appropriate patient care skills as part of the critical care team approach
    • Neighboring medical practices (RNs and medical assistants) and urgent care facilities3
  3. Consider utilizing telemedicine, particularly in community facilities with limited specialist support. E-ICU monitoring (remote monitoring of patients by critical care nurses and providers at an offsite facility) is also a potential means of force expansion to provide support to on-site staff.4,5
  4. Utilize additional established resources through the US Department of Health and Human Services Assistant Secretary of Preparedness Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) at

Develop a team-based approach for critical care patient management

A team-based approach with critical care registered nurses (RNs) supported by additional staff members would increase the capacity for care of critically ill patients. Utilizing the unique skill set of each team member in a collaborative approach would provide force multiplication. This team-based approach has been demonstrated to work effectively in both aeromedical transportation and disaster medicine settings. Role definition is an essential component of this approach to patient care.1,4

  1. To establish group norms, we recommend utilizing the principles of highly reliable organizations (HRO) and the American Association of Critical-Care Nurses’ Healthy Work Environment Standards.6
    • HRO principles include preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise. Determining the skill set and expertise of each team member will support staff comfort with deference to expertise.7
    • The Healthy Work Environment Standards include skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.
  2. Utilize 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 critical care RN. This will enhance communication, optimize patient care activities, and allow each team member to discuss their clinical strengths and address any concerns. Huddles at regular intervals throughout the shift will inform all team members of changes in plan of care and provide the opportunity to address any concerns.8
  3. Determine appropriate tasks for team members without critical care training, designating the critical care RN as team lead for each patient care team. Examples include paramedics performing intubation, IV starts, and nebulizer treatments. RNs without critical care experience could be utilized to document vital signs, perform appropriate nursing interventions, such as routine medication administration, vital sign monitoring, and assisting with patient care activities.

Administrative Considerations for Nurse Staffing

Critical care surge capacity secondary to infectious disease presents unique nursing administrative concerns. These include patient placement, addressing visitor policies, providing adequate amounts of advised personal protective equipment, and determining staff who should not be involved in direct care of COVID-19 infected patients. Formally addressing topics such as the potential need for staff isolation and compensation at the onset of surge will assist in mitigating staff concerns.

  1. Visitation policies should be adapted based on exposure risk and patient population. We recommend that administrators clearly communicate changes to visitation policies, and ensure this information is available to patients and their families. Consider options for video communication so that patients do not feel isolated from their family members during this time and families are provided reassurance and regular updates.
  2. We recommend that leadership provide just-in-time training to reinforce knowledge of COVID-19 symptoms, transmission, and other important clinical information. This training should include a review of donning and doffing of appropriate personal protective equipment (PPE). A brief but standardized orientation for outside health-care providers assisting in surge management should also be developed to ensure compliance with pertinent policies.9
  3. The Centers for Disease Control and Prevention indicate that there is limited information on COVID-19 in pregnancy. High fever can increase the risk of birth defects in the first trimester of pregnancy. There are also documented cases of pregnancy loss with other related coronaviruses (SARS-CoV and MERS-CoV). We recommend that administrators consider limiting exposure of pregnant nurses from care of patients with COVID-19, particularly during high risk procedures that increase exposure.
  4. Administrators should also evaluate other high-risk staff (those who are immunocompromised or have respiratory illness) to determine their risk of exposure and ability to wear the required personal protective equipment for the required duration.
  5. Staff members with potential exposure to COVID-19 may be placed on isolation. Those staff may have concerns regarding lodging, as well as compensation. We recommend that facilities develop a plan for housing and compensating staff who need to isolate away from family members and are unable to return to work during their isolation period.

Nursing Leadership Concerns

Nursing literature on the SARS epidemic identified challenges faced by nursing leadership during a period of patient surge related to infectious disease.10 Five stages experienced by nurse leaders were identified as facing shock and chaos, sourcing for reliable sources to clarify myths, developing and adjusting nursing care, supporting nurses and their clients, and rewarding nurses.

  1. We recommend that nurse leaders collaborate with hospital administrators to develop consistent and regularly scheduled methods of updating staff on operating conditions, safety concerns, and other issues related to surge capacity.
  2. Nurse leaders should be prepared to assist staff in managing internal conflict between personal and professional responsibilities.
  3. We recommend that nurse leaders identify resources for assistance in mitigating internal conflicts among staff working under surge conditions, such as social workers and mental health personnel.
  4. We recommend that even in times of surge, nurse leaders provide meaningful recognition to staff engaged in patient care efforts. This recognition promotes a healthy work environment and reinforces staff resilience.

Nurse Safety and Resilience

We suggest that facilities implement proactive strategies to prevent staff attrition due to fatigue or illness. These include the provision of mental health support, ensuring safe utilization of personal protective equipment to prevent staff infection, and maintaining a healthy work environment. Perceived organizational support had an impact on predicting burnout in Canadian nursing staff during the SARS crisis.11

  1. We recommend implementation of a safety officer role to monitor PPE and staff exposure risk as part of a total staff safety model. This individual could be an Emergency Medical Technician or Nursing Technician familiar with PPE, or another identified individual who is trained in PPE utilization. The safety officer could provide just-in-time training for those not comfortable with donning and doffing of PPE, and, intermittently, audit PPE utilization.
  2. We recommend that each care team designate a team safety officer to ensure team members are taking routinely scheduled breaks for hydration, rest, toileting, and refreshments. Staff should also be assessed for skin breakdown related to extended time periods in PPE.13
  3. Provide staff with resources to plan with their family in advance of reporting to their first shift.
  4. Promote a team culture, particularly if staff are staying on-site during their off time. This may include team meals, team exercise sessions, or other bonding activities.14
  5. Provide access to mental health support for staff feeling overwhelmed or concerned. SARS team nurses in Taiwan demonstrated worry about infecting family and colleagues. Utilization of video communication with family members reduced nurse worry.8
  6. We recommend that hospital administration maintain visibility with impacted patient care areas to provide support. Mechanisms should be in place for addressing staff concerns about psychosocial issues and working conditions. Meaningful recognition of staff providing support during the surge effort should be provided at regular intervals.11,15


  1. Centers for Disease Control and Prevention. Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health. Atlanta, GA: U.S. Department of Health and Human Services; 2018.
  2. Brannman S, Nieratko J, Patnosh J, et al. Engaging healthcare partners in the disaster healthcare delivery system. Washington, DC: U.S. Health and Human Services Office of the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). partners-in-the-disaster-healthcare-delivery-system-508.pdf . Accessed March 14, 2020.
  3. Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). Medical Surge and the Role of Urgent Care Centers. Washington, DC: ASPR TRACIE; 2018.
  4. Arizman I. Field organization and disaster medical assistance teams. Turk J Emerg Med. 2015;15(Supp 1):11-19.
  5. Greenwald PW, Hsu H, Sharma R. Planning for future disasters: telemedicine as a resource. Ann Emerg Med. 2018:71(3):435-436.
  6. The American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2nd ed. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2016.
  7. Provost SM, Lanham HJ, Leykum LK, McDaniel RR, Pugh J. Health care huddles: managing complexity to achieve high reliability. Health Care Manage Rev. 2015;40(1):2-12.
  8. Lee SH, Juang YY, Su YJ, Lin YH, Chao CC. Facing SARS: psychological impacts on SARS team nurses and psychiatric nurses in a Taiwan general hospital. Gen Hosp Psychiatry. 2005;27(5):352-358.
  9. Joshi N. Just in time training. 2013. Available from: Accessed March 14, 2020.
  10. Shih FJ, Turale S, Lin YS, et al. Surviving a life-threatening crisis: Taiwan’s nurse leaders’ reflections and difficulties fighting the SARS epidemic. J Clin Nurs. 2009;18(24):3391-3400.
  11. Marjanovic Z, Greenglass ER, Coffey S. The relevance of psychosocial variables and working conditions in predicting nurses’ coping strategies during the SARS crisis: an online questionnaire survey. Int J Nurs Stud. 2007;44(6):991-998.
  12. Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). Tips for Retaining and Caring for Staff After a Disaster. Washington, DC: ASPR TRACIE; 2018.
  13. U.S. Fire Administration. Emergency Incident Rehabilitation. Washington, DC: International Association of Firefighters; 2008.
  14. Substance Abuse and Mental Health Services Administration. Tips for Disaster Responders: Preventing and Managing Stress. Washington, DC: U.S. Department of Health and Human Services; 2014.
  15. Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). Disaster behavioral health. The Exchange. 2017;2(1).