Mass Critical Care Surge Response During COVID-19

BACKGROUND: After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world.RESEARCH QUESTION: A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality.STUDY DESIGN AND METHODS: TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, "gray" evidence from lay media sources, and anecdotal experiential evidence.RESULTS: Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs.INTERPRETATION: A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19. CHEST 2022; 161(2):429-447
The COVID-19 pandemic confronted hospitals with unprecedented surges of seriously ill patients. [bib_ref] Hospital preparedness for COVID-19: a practical guide from a critical care perspective, Griffin [/bib_ref] [bib_ref] Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in..., Richardson [/bib_ref] In 2014, the Task Force for Mass Critical Care (TFMCC) developed consensus statement suggestions for the provision of care during pandemics in collaboration with the American College of Chest Physicians. [bib_ref] Introduction and executive summary: care of the critically ill and injured during..., Christian [/bib_ref] The concepts of increasing critical care bed numbers and augmenting staff, equipment, supplies, and describe operational strategies to scale up surge staffing effectively and maintain contingency-level medications ("space, stuff, staff") provided an effective framework for hospitals confronted by COVID-19 [fig_ref] Figure 1 -: Diagram showing a framework for critical care surge capacity planning outlining the... [/fig_ref]. [bib_ref] Surge capacity principles: care of the critically ill and injured during pandemics..., Hick [/bib_ref] [bib_ref] Surge capacity logistics: care of the critically ill and injured during pandemics..., Einav [/bib_ref] It is disappointing that these were not operationalized to the degree necessary to prevent adverse outcomes. [bib_ref] Association of intensive care unit patient load and demand with mortality rates..., Bravata [/bib_ref] [bib_ref] Intensive care unit strain and mortality risk among critically ill patients with..., Rubinson [/bib_ref] As foreseen, supply chain disruptions led to shortages of key medications, consumables, and personal protective equipment. [bib_ref] A California hospital's response to COVID-19: from a ripple to a tsunami..., Bader [/bib_ref] [bib_ref] It takes a village . . . : contending with drug shortages..., Burry [/bib_ref] Hospital space became a premium as critically ill patients overflowed from full ICUs into postanesthesia care units, EDs, operating rooms, intermediate and monitored units, flat-space areas, and even temporary or tent facilities, with up to 25% of COVID-19 deaths attributable to increased hospital surge caseload. [bib_ref] Hospital preparedness for COVID-19: a practical guide from a critical care perspective, Griffin [/bib_ref] [bib_ref] Association between caseload surge and COVID-19 survival in 558, Kadri [/bib_ref] The prolonged course of COVID-19 has led to contingency conditions becoming the norm for months. More than 3,600 US health care workers (HCWs) have died.Contingency responses refer to increasing hospital resources by repurposing equipment and supplies, augmenting the clinical workforce, and expanding care to nontraditional areas of the hospital while maintaining functionally equivalent standards of care. [bib_ref] Surge capacity principles: care of the critically ill and injured during pandemics..., Hick [/bib_ref] [bib_ref] Surge capacity logistics: care of the critically ill and injured during pandemics..., Einav [/bib_ref] demonstrates the transition from contingency to crisis where contingency level care is not sustainable and care is prioritized or limited, leading to substantial risk of adverse outcomes and potential triage of scarce resources. [bib_ref] Introduction and executive summary: care of the critically ill and injured during..., Christian [/bib_ref] [bib_ref] Triage of scarce critical care resources in COVID-19: an implementation guide for..., Maves [/bib_ref] Notably, no so-called bright line exists between risk levels that separates contingency from crisis, and it is imperative that neighboring hospitals adopt similar strategies.
Ten new suggestions are presented in this interim report emphasizing specific operational strategies intended to prolong the contingency state, thereby avoiding crisis and the need for triage of scarce resources. These suggestions are based upon data and experiences from COVID-19 surge mitigation that, when implemented, will maintain contingency-level care and will prevent or delay transition to crisis.

# Methods
The TFMCC is composed of a interdisciplinary group of disaster professionals including physicians, nurses, pharmacists, respiratory therapists, and health system leaders experienced in the management of critically ill patients with COVID-19. The TFMCC adopted a modified version of established rapid guidelines from the World Health Organization [bib_ref] Developing WHO rapid advice guidelines in the setting of a public health..., Garritty [/bib_ref] and Guidelines International Network-McMaster Guideline Development Checklist 14 with our previous methodology. [bib_ref] Methodology: care of the critically ill and injured during pandemics and disasters:..., Ornelas [/bib_ref] Subcommittee members voted on initial suggestions using a five-point Likert scale, derived from the Grading of Recommendations Assessment, Development and Evaluation grid. [bib_ref] Use of GRADE grid to reach decisions on clinical practice guidelines when..., Jaeschke [/bib_ref] [bib_ref] Methodologies for the development of CHEST guidelines and expert panel reports, Lewis [/bib_ref] Three distinct areas of surge preparedness and management related to the COVID-19 pandemic were prioritized and include (1) communication and coordination, (2) staffing and resilience, and (3) communications and technology. See e-Appendix 1 for complete methodology.

## Data extraction
The TFMCC members believe it is urgent to distribute the most important and relevant information widely based on preliminary work, generating this interim communication. Each subcommittee conducted a literature review of published evidence relevant to their respective area. Studies published since 2020 were prioritized for inclusion due to direct evidence addressing COVID-19. Key narrative statements deemed relevant were extracted and arranged into overarching themes. The TFMCC members also met weekly to share anecdotal evidence from their own experiences managing COVID-19 surge. The statements extracted from the literature review were combined with the anecdotal evidence for each theme, when applicable, to arrive at initial suggestions for each subcommittee.

# Results
The TFMCC members identified four issues requiring urgent attention to address future surges including staffing, load-balancing, communications, and technology, resulting in 10 suggestions with corresponding operational strategies [fig_ref] TABLE 1 ]: Summary of 10 Suggestions and Operational Strategies [/fig_ref].

## Staffing suggestions
During the COVID-19 pandemic, patients have died from the lack of staffed ICU beds. [bib_ref] Facing Covid-19 in Italy-ethics, logistics, and therapeutics on the epidemic's front line, Rosenbaum [/bib_ref] Rapid bed expansion must balance staff safety and quality of care, impact on providers, and impact outside of ICUs. [bib_ref] Adult ICU triage during the coronavirus disease 2019 pandemic: who will live..., Sprung [/bib_ref] The risks of repurposing and augmenting staff include (1) lower-quality care without adequate training, [bib_ref] Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in..., Richardson [/bib_ref] excessive duty times and workload, (3) moral injury, (4) the costs of training new staff, and (5) the costs of cancelling time-sensitive but nonemergent care with associated potential adverse consequences. chestjournal.org experienced physician) managing up to 24 patients in collaboration with non-ICU skilled physicians and advanced practice providers (including nurse practitioners, physician assistants, and similar professionals), delivering care to more patients than ICU staff could achieve alone [fig_ref] Figure 3 -: Diagram showing critical care adult physician or provider staffing model for expanding... [/fig_ref]. Further staffing can be expanded by use of specialized procedure teams (eg, for central venous catheterization, intubations, and assistance in care activities such as prone positioning) and telemedicine coverage. The suggested nursing model expands the reach of one ICU-trained nurse to four patients by teaming with two nurses focused on the non-ICU aspects of care after a period of focused training . Both models account for staffing up to 100% above normal baseline patient levels, consistent with previous TFMCC suggestions for the upper limit of contingency care, 4 but can be scaled proportionately to the level of surge. Achieving these ratios requires extensive clinical experience and may need to be modified for those with less training.
Pediatric ICUs can effectively care for adult patients with consultative support from adult teams, either in person or via telemedicine, mitigating the loss of time for training new staff in the basics of critical care medicine, while expanding system capacity due to lower pediatric ICU use experienced during the pandemic [fig_ref] Figure 5 -: Diagram showing model for staffing and support of PICUs embedded in facilities... [/fig_ref]. [bib_ref] Changes in pediatric ICU utilization and clinical trends during the coronavirus pandemic, Zee-Cheng [/bib_ref] [bib_ref] Critical care for coronavirus disease 2019: perspectives from the PICU to the..., Joyce [/bib_ref] [bib_ref] A hybrid model of pediatric and adult critical care during the coronavirus..., Deep [/bib_ref] Suggestion 2: We suggest limiting overtime to less than 50% above normal for all HCWs to minimize the risk of burn-out and exhaustion.
There are limits to how long a clinical team can remain effective in the setting of increased workloads. Experience with deployed military surgical teams found them to be ineffective after 48 continuous hours. [bib_ref] The impact of sleep deprivation in military surgical teams: a systematic review, Parker [/bib_ref] Team effectiveness may be preserved by limiting shift durations to 12 h, mandating rest periods every 24 h, naps, "sleep banking," and consistent schedules to prevent circadian desynchronization. [bib_ref] The impact of sleep deprivation in military surgical teams: a systematic review, Parker [/bib_ref] Staffing plans must also account for surges of weeks to months. Limiting overtime should be an operational strategy to minimize the risk of burnout.
Suggestion 3: We suggest that the mental health needs of all HCWs are priorities for maintaining an effective response and staffing capacity.
HCWs are secondary victims of the COVID-19 pandemic. [bib_ref] Stress and fear: clinical implications for providers and patients (in the time..., Karnatovskaia [/bib_ref] -Diagram depicting the spectrum of surge from minor through major. The magnitude of surge is illustrated by the alterations in the balance between demand (stick figures) and supply (medication boxes). As surge increases, the demand-supply imbalance worsens. Conventional, contingency, and crisis responses are used to respond to the varying magnitude of surge. Varying response strategies are associated with each level of response. As the magnitude of the surge increases, the strategies used to cope with the response gradually depart from the usual standard of care (default defining the standards of disaster care) until such point that even with crisis care, critical care is no longer able to be provided. (Reprinted with permission from Christian et al. [bib_ref] Introduction and executive summary: care of the critically ill and injured during..., Christian [/bib_ref] burnout (28%), depression (24%), posttraumatic stress disorder (13%), [bib_ref] Impact of viral epidemic outbreaks on mental health of healthcare workers: a..., Serrano-Ripoll [/bib_ref] and suicide. [bib_ref] COVID-19 related suicide among hospital nurses; case study evidence from worldwide media..., Rahman [/bib_ref] Identification of factors that place HCWs at risk of moral injury or exhaustion [fig_ref] TABLE 2 ]: Risk Factors for Health Care Workers Expe-Inadequate access to personal protective equipment... [/fig_ref] should be a central operational priority, with a focus on prevention by leadership, managing expectations, and proactive guidance for changes to clinical care. [bib_ref] Impact of viral epidemic outbreaks on mental health of healthcare workers: a..., Serrano-Ripoll [/bib_ref] [bib_ref] Symptoms of anxiety, depression, and peritraumatic dissociation in critical care clinicians managing..., Azoulay [/bib_ref] [bib_ref] Burnout and psychological distress amongst Australian healthcare workers during the COVID-19 pandemic, Dobson [/bib_ref] [bib_ref] Psychological impact of an epidemic/pandemic on the mental health of healthcare professionals:..., Stuijfzand [/bib_ref] [bib_ref] The relationship between psychological resilience, burnout, stress, and sociodemographic factors with depression..., Yoruk [/bib_ref] [bib_ref] Occupational burnout syndrome and post-traumatic stress among healthcare professionals during the novel..., Raudenska [/bib_ref] Globally, the health care workforce is composed predominantly of women in diverse roles, including critical custodial, food service, laboratory, and Load-balancing 7. We suggest that early transfer of patients before a hospital is overwhelmed promotes the effective conservation of resources and less deviation from routine care standards.
Transfer (load-balance) patients early before a hospital is overwhelmed to maintain contingency-level care.
Load-balancing 8. We suggest earlier utilization of regional transfer centers for load-balancing during surge for patient transfers and placement. We also suggest having intensivist or hospitalist availability to help prioritize transfers and provide support to bedside clinicians when transfers are delayed.
Implement regional transfer centers to improve bed access and assure efficient ICU bed use through active management and load-balancing of admissions across all hospitals in a state or region. On-call intensivist or hospitalist support should be available as a resource.
Load-balancing 9. We re-emphasize that designated clinicians who are actively engaged in clinical work (especially intensivists and hospitalists) actively participate in hospital incident command structure; this group should provide updates to clinical staff for improving situational awareness, ensuring bidirectional communication.
Establish formal communication structures between incident command and frontline clinicians, such as PCSS or PCCS team to ensure bidirectional communication and situational awareness.
Communication 10. We suggest hospitals apply telemedicine technology to augment critical care early and in the broadest sense possible.
Use telemedicine technology to support bedside critical care, to connect specialty clinicians to distant sites, and to support visitation needs of families.
Technology HCW 14 health care worker; PCSS 14 physician clinical support supervisor.
chestjournal.org radiographic technicians and direct patient care by nurses, advanced practice providers, and physicians. Of nurses in the United States, 87.4% are women who may find themselves bearing a disproportionate amount of the stresses of both workplace and home during the pandemic.A survey of > 12,000 US nurses reported that workplace strategies that best promoted well-being during the pandemic included talking with colleagues (47%), expressions of gratitude (37%), and accurate information about the virus (34%) [bib_ref] The relationship between critical care work environment and professional quality of life, Monroe [/bib_ref] ; only 5% identified employee assistance programs or formal counseling as helpful.The Healthy Work Environment Standards [fig_ref] TABLE 3 ]: Resilience Letters or cards from community members and local school children show... [/fig_ref]. [bib_ref] The relationship between critical care work environment and professional quality of life, Monroe [/bib_ref] Concerns such as childcare, reduced family contact, significant change in daily life, and work-life balance place individuals at high risk for burnout. [bib_ref] Impact of viral epidemic outbreaks on mental health of healthcare workers: a..., Serrano-Ripoll [/bib_ref] [bib_ref] Symptoms of anxiety, depression, and peritraumatic dissociation in critical care clinicians managing..., Azoulay [/bib_ref] [bib_ref] Burnout and psychological distress amongst Australian healthcare workers during the COVID-19 pandemic, Dobson [/bib_ref] [bib_ref] Psychological impact of an epidemic/pandemic on the mental health of healthcare professionals:..., Stuijfzand [/bib_ref] [bib_ref] The relationship between psychological resilience, burnout, stress, and sociodemographic factors with depression..., Yoruk [/bib_ref] [bib_ref] Occupational burnout syndrome and post-traumatic stress among healthcare professionals during the novel..., Raudenska [/bib_ref] Suggestion 4: During surge, we suggest minimizing redundant clinical documentation requirements to focus on core elements directly relevant to bedside care.
The TFMCC believes it is an effective operational strategy to reduce documentation requirements to maximize staff time for bedside care during public health emergencies. Clinician documentation should focus mainly on critical care provided and limitations due to resource challenges and should address issues (3) the presence of telemedicine support. Higher acuity patients (as is typical with patients with COVID-19 in the ICU) may impact capacity negatively by demanding greater resources to maintain contingency-level care. Other clinician team members may include non-ICU skilled physicians and ICU or non-ICU skilled practitioners, or both; training institutions trainees (residents and fellows) also may be team members. Finally, this model is focused on resources for direct patient care only, and sufficient resource needs for overnight staffing and cross-coverage also should be factored and scaled up appropriately with increasing surge.
related to diagnoses for billing; templated notes and dictation services are supportive. Nursing documentation changes may include exemptions from repetition of documented care plans or extended time windows for signatures on telephone orders.Streamlining facility-specific documentation and focused patient assessments may further assist in decreasing documentation requirements. Authorities should provide general approvals for streamlined documentation during a public health emergency to help facilities avoid the burden of requesting individual waivers.

## Load-balancing and patient transfers
Load-balancing is the process of coordinating emergency response by sharing resources, transferring patients amongst hospitals, or both. [bib_ref] Changes in pediatric ICU utilization and clinical trends during the coronavirus pandemic, Zee-Cheng [/bib_ref] [bib_ref] Critical care for coronavirus disease 2019: perspectives from the PICU to the..., Joyce [/bib_ref] [bib_ref] A hybrid model of pediatric and adult critical care during the coronavirus..., Deep [/bib_ref] Adult RNs, pharmacists, and physicians can provide brief daily and as-needed in-person or teleconsultation for pediatric ICUs of varying sizes providing care for critically ill adults starting with younger patients with less comorbidities, but with upper age of 70 years or older as needed to meet increasing demands. This model is supported most easily in facilities that also routinely care for adults because of existing logistic ("stuff") and system capabilities. PICU 14 pediatric ICU; RN 14 registered nurse.
chestjournal.org hospital mortality increasing when bed capacity was exceeded. [bib_ref] Association of intensive care unit patient load and demand with mortality rates..., Bravata [/bib_ref] [bib_ref] Intensive care unit strain and mortality risk among critically ill patients with..., Rubinson [/bib_ref] [bib_ref] Broadening the scope of healthcare operations: expanding capacity strain hospital-wide, Kohn [/bib_ref] [bib_ref] Higher ICU capacity strain is associated with increased acute mortality in closed..., Wilcox [/bib_ref] Effective load-balancing first involves knowledgeable ICU strain monitoring and mindful resource management by frontline clinical leaders. It next involves the organized transfer of patients from overburdened to lesser burdened hospitals facilitating a balance, so that no single institution enters crisis and that consistent level of care is provided within and across regions. Patient transfers within a single health care network are helpful, but insufficient. Regional mechanisms to share information and load-balance across facilities may be the most important factor in mitigating crisis care situations.Suggestion 5: We suggest that resource strain level be actively monitored and determined by frontline clinical leaders based upon assessment of available resources and conditions. ICU strain is defined as a discordance between demand for and availability of ICU resources and is assessed with objective criteria. [bib_ref] Hospital preparedness for mass critical care during SARS-CoV-2 pandemic, Wurmb [/bib_ref] [bib_ref] Intensive care role in disaster management critical care clinics, Hossain [/bib_ref] [fig_ref] TABLE 4 ]: Strain Indicator Limits Defining Conventional, Contingency, and Crisis Levels of Resources Typically... [/fig_ref] suggests ICU strain indicators that are resources ICU clinicians and leaders assess during routine ICU management and include staffed ICU beds, patient acuity, queuing time to admission, available equipment, supplies, and ICU staff. [bib_ref] Hospital preparedness for COVID-19: a practical guide from a critical care perspective, Griffin [/bib_ref] [bib_ref] Surge capacity principles: care of the critically ill and injured during pandemics..., Hick [/bib_ref] [bib_ref] Surge capacity logistics: care of the critically ill and injured during pandemics..., Einav [/bib_ref] [bib_ref] Refining surge capacity: conventional, contingency, and crisis capacity, Hick [/bib_ref] [bib_ref] Intensive care role in disaster management critical care clinics, Hossain [/bib_ref] Strain is defined further based on conventional, contingency, and crisis care surge levels. The TFMCC suggests the criteria for crossing from conventional to contingency threshold be when two or more conventional strain criteria are exceeded and the criteria for crossing form contingency to crisis be when any crisis strain criterion is met [fig_ref] TABLE 4 ]: Strain Indicator Limits Defining Conventional, Contingency, and Crisis Levels of Resources Typically... [/fig_ref]. We suggest strain indicators be updated continuously and available in an electronic database.
As an operational strategy, the TFMCC suggests bedside clinician leaders, including ICU directors and service chiefs, be empowered to determine ICU surge level (especially contingency and crisis) based on their real-time assessment and in conjunction with strain indicators [fig_ref] Figure 7 -: Diagram showing an example of a nine-hospital system illustrating daily levels of... [/fig_ref]. Hospital and system leadership may sustain contingency-level care by expanding ICU care areas, supplementing staff, and distributing equipment, transferring patients to load-balance, or a combination thereof.

## Suggestion 6:
We suggest there is a transition zone toward the limits of contingency care when increasingly scarce resources are modified beyond routine standards of care to preserve life. This critical clinical prioritization level precedes triage of scarce resources and is a powerful indicator for needed resources to maintain contingency-level care. 54 (Case study [fig_ref] Figure 8 -: Case study of CCP [/fig_ref] Although guidance exists for formal triage, clinicians may encounter situations of severe strain that fall short of this need, where clinical judgement is needed to determine optimal use of available resources. [bib_ref] Triage of scarce critical care resources in COVID-19: an implementation guide for..., Maves [/bib_ref] [bib_ref] Triage: care of the critically ill and injured during pandemics and disasters:..., Christian [/bib_ref] [bib_ref] Intensive care role in disaster management critical care clinics, Hossain [/bib_ref] The use of advanced therapies is not strictly binary; resources may be shared in some cases. Continual renal replacement therapy systems can be shared by two or more patients on 6-to 12-h alternating schedules; the choice of ventilator for a given patient can be based on the severity of lung disease; and patients with severe hypoxemia often may be managed with noninvasive respiratory support in an intermediate or ward setting instead of the ICU. These strategies are a form of resource conservation, but border on crisis care and are termed critical clinical prioritization (CCP) ; a case study is illustrative [fig_ref] Figure 8 -: Case study of CCP [/fig_ref].Clinicians should recognize CCP when they are on the verge of transitioning from contingency to crisis and should alert leadership and request urgent support, including more resources (if available) or patient transfers (load-balance) to less-strained facilities. If neither of these are available, health systems are left resorting to triage and allocation processes dynamically based on available resources. Ideally, these strategies should be consistent across a region's hospitals.
Operational strategies include educating clinicians in advance to recognize and respond to CCP, preparing decision support for potential crisis scenarios, and prioritizing communication systems for rapid access to ethical, legal, and administrative counsel when the potential need for triage of scarce resources is encountered.
Suggestion 7: We suggest that early transfer of patients before a hospital is overwhelmed promotes the effective conservation of resources and less deviation from routine care standards.
The mortality of patients rises as pandemic surge increases. Early transfer of patients is an operational strategy to help mitigate proactively the effects of surge and to prevent crisis care conditions. 10,67 Patients awaiting ICU admission have an increased mortality with longer-duration queuing times, and patients in the ED are at great risk [fig_ref] TABLE 5 ]: Risk for Patients Waiting for ICU Admission vs the Risks of Transfer,... [/fig_ref]. [bib_ref] Intensive care role in disaster management critical care clinics, Hossain [/bib_ref] [bib_ref] Interhospital transfer: an independent risk factor for mortality in the surgical intensive..., Arthur [/bib_ref] [bib_ref] Patient safety incidents during interhospital transport of patients: a prospective analysis, Lyphout [/bib_ref] [bib_ref] The interhospital medical intensive care unit transfer instrument facilitates early implementation of..., Malpass [/bib_ref] Strategies to mitigate risks during transfer include assuring respiratory and hemodynamic stability and transferring patients with minimal organ failure and at shorter times and distances as possible [fig_ref] TABLE 5 ]: Risk for Patients Waiting for ICU Admission vs the Risks of Transfer,... [/fig_ref]. [bib_ref] Intensive care role in disaster management critical care clinics, Hossain [/bib_ref] [bib_ref] Interhospital transfer: an independent risk factor for mortality in the surgical intensive..., Arthur [/bib_ref] [bib_ref] Patient safety incidents during interhospital transport of patients: a prospective analysis, Lyphout [/bib_ref] [bib_ref] The interhospital medical intensive care unit transfer instrument facilitates early implementation of..., Malpass [/bib_ref] We suggest patient transfer be considered when hospitals reach the threshold for contingency care surge level (suggestion 5).
Despite transfer risks, load-balancing before a site becomes overwhelmed, including the transfer of convalescent patients to less-acute settings, promotes effective conservation of resources before reaching the limits of contingency care. [bib_ref] Association of intensive care unit patient load and demand with mortality rates..., Bravata [/bib_ref] 

## Meaningful recognition
Be recognized and recognize others for the value each brings to the work of the organization

## Authentic leadership
Fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.

## Skilled communication
Be as proficient in communication skills as you are in clinical skills

## Healthy work environment
Resilience Well-Being Suggestion 8: We suggest earlier utilization of regional transfer centers for load-balancing during surge for patient transfers and placement. We also suggest having intensivist or hospitalist availability to help prioritize transfers and provide support to bedside clinicians when transfers are delayed.In the TFMCC 2014 guidance, evacuation of hospitals for surge mitigation was highlighted [bib_ref] Evacuation of the ICU: care of the critically ill and injured during..., King [/bib_ref] ; however, hospitals have been challenged by management of patient transfers during prolonged surges. The COVID-19 pandemic demonstrated increasing mortality associated with increasing surge, 6,10 and load-balancing through large-volume patient transfer centers has been proven both practical and effective. [bib_ref] In Imperial County, medical air teams work around the clock to move..., Vives [/bib_ref] Health systems have developed their own regional placement centers designed to improve access and patient flow through active management techniques. [bib_ref] Use of systems engineering to design a hospital command center, Kane [/bib_ref] [bib_ref] Use of high-reliability principles in the evolution of a hospital command centre, Collins [/bib_ref] Several states rapidly developed pandemic placement centers to transfer patients to any available ICU bed, optimizing statewide access and preventing hospitals from reaching crisis conditions. [bib_ref] Statewide real-time tracking of beds and ventilators during coronavirus disease 2019 and..., Merkel [/bib_ref] The operational strategy of having a command center is to improve Appropriate staffing Ensure sufficient rest between work periods Team staffing with clear delegation of responsibilities Team huddles at shift change and prescribed intervals Identify team leads with strong clinical skills, knowledge of organizational policy, and strong interpersonal skillsEffective decision-making Engage team members in discussion of policies and procedures that impact them
True collaboration Use just-in-time strategies for supporting the interdisciplinary team: Using "the pause" after a patient death: pausing for a moment of silence after resuscitation attempt or the expected death of a patient allows team members to reflect and honor the patient, providing a transition before returning to patient care After-shift huddles to review the events of the day, including challenges and wins PPE 14 personal protective equipment. The transition from conventional to contingency strain is triggered when any two conventional strain indicators are exceeded (any "no" answer in the conventional strain criteria column should be considered to have exceeded that strain criteria's conventional limit). The transition from contingency to crisis strain is triggered when any crisis strain criteria is met. CRRT 14 continual renal replacement therapy; HD 14 hemodialysis; HFNC 14 high flow nasal cannula; NIV 14 noninvasive ventilation; RN 14 registered nurse.
chestjournal.org access and assure efficient use of beds through active management and load-balancing of admissions across all hospitals to reduce ED boarding and diversion and to prevent extended waiting times for admission. [bib_ref] The positive impact of establishing an internal transfer center, Simmons [/bib_ref] The key elements of success include a call center with appropriate technology and personnel, participation of large health systems with transfer capacity, and agreements by participants to support the transfer center's processes with clear lines of communication between call center directors and state or health system leaders to resolve barriers rapidly [fig_ref] Figure 1 -: Diagram showing a framework for critical care surge capacity planning outlining the... [/fig_ref]. We also strongly suggest having intensivist or hospitalist assistance to help prioritize transfers and to provide assistance to bedside clinicians.
Best practices are under development. Technology from cell phones and paper intake forms should transition to secure electronic forms and telephone platforms. Oregon, [bib_ref] Statewide real-time tracking of beds and ventilators during coronavirus disease 2019 and..., Merkel [/bib_ref] Arizona,and Minnesota 59 use tools including electronic bed boards to report bed availability and calls requesting transfers. The most important success element was frequently updated electronic bed capacity data (even when hand-entered), although collaboration and teamwork among call center, state, and health care organizations is as important. [bib_ref] Statewide real-time tracking of beds and ventilators during coronavirus disease 2019 and..., Merkel [/bib_ref] Communications During Surge Suggestion 9: We re-emphasize that designated clinicians who are actively engaged in clinical work (especially intensivists and hospitalists) actively participate in hospital incident command structure; this group should provide updates to clinical staff for improving situational awareness, ensuring bidirectional communication.
As stated in 2014, tight coordination of resource management is a cornerstone of effective hospital incident command systems. [bib_ref] Surge capacity principles: care of the critically ill and injured during pandemics..., Hick [/bib_ref] decision-maker with authority to act quickly, the actions occurring in incident command often are opaque to HCWs tasked with their orders. It is strongly suggested as an operational strategy that formal communication structures be established to ensure bidirectional communication to update clinicians and provide

## Critical clinical prioritization: a case study from nych+h/bellevue hospital
The traditional model of supply: demand mismatch describes a progression from conventional to contingency to crisis care, with each transition representing care that deviates further from standard. Several authors (AU, VM, TH) experienced that the transition from contingency to crisis care can potentially be deferred, or fully prevented, through creative and novel methods managing resources. Resource management at this transition was primarily based on clinical decisions for how best to use available resources to sustain the entire population of patients requiring them and is distinct from crisis triage of scarce resources. We term this decision-making at the transition between contingency and crisis care Critical Clinical Prioritization (CCP).
To illustrate how CCP was utilized during the surge of critically ill COVID cases, we have provided real-life examples of strategies implemented by the authors.
Renal replacement: The high demand for continuous renal replacement therapy (CRRT) overwhelmed the capacity to deliver it in the standard way in many hospitals. A transition to crisis standards would mean choosing individual patients who would receive this therapy continuously over 24 hours while others would be denied. Instead, this standard approach was adjusted based on patient need with intervals adjusted down to 12 or even 6 hours per patient to facilitate rotation of a small number of machines amongst a larger patient pool to provide life sustaining care to all of them. When the limits of this strategy were reached, an emergency peritoneal dialysis (PD) program, which primarily takes place outpatient, was initiated for appropriate patients to further expand the breadth of renal replacement therapies offered inpatient.
Mechanical ventilators: When the demand for mechanical ventilation overwhelmed ventilator capacity, a transition to crisis standards would have meant determining which patients would or would not be candidates for a ventilator via committee-based resource triage. Instead, to maximize ventilator allocation, standard ICU ventilators were triaged to the most severe patients while ventilators not typically used for critically ill patients (such as transport, anesthesia, home/portable, and non-invasive ventilators retrofitted to provide invasive mechanical ventilation) were triaged to patients less severely ill. As severely ill patients improved, they were transitioned to the atypical ventilators as appropriate for their needs, making standard ICU ventilators available.

## Space:
The demand for ICU care overwhelmed the supply of primary and secondary ICU spaces. Instead of denying ICU care to patients, methods to maximize utilization of space were implemented from retrofitting non-ICU spaces to accommodate critical patients to placing two patients into rooms intended for one, while taking steps to mitigate the risks of doing this. Additionally, if available ICU bed space was identified in other regional hospitals, patients were transferred to load balance between hospitals.

## Staff:
The peak of the pandemic pushed ICU staff to their limits with increased patient loads and extended work hours. To prevent a staffing crisis, tasks were offloaded to other non-ICU disciplines. Examples included integrating non-ICU personnel into ICU teams, senior critical care fellows assuming the role of attending physicians, anesthesia and general surgery teams managing procedures from airways to central and arterial line placement, orthopedic surgeons and operating room staff leading prone positioning teams, and ophthalmologists running PD teams. Other strategies included relaxing non-critical documentation requirements for all clinical staff. -Diagram showing critical clinical prioritization. As resource strain approaches crisis levels, ICU clinicians may need to adapt, substitute, conserve, or even initiate rationing of resources. [bib_ref] Refining surge capacity: conventional, contingency, and crisis capacity, Hick [/bib_ref] This transition zone immediately preceding crisis level is termed critical clinical prioritization and is illustrated on the lower panel, "Basis of Clinical Management." [fig_ref] Figure 1 -: Diagram showing a framework for critical care surge capacity planning outlining the... [/fig_ref] -Diagram showing regional and statewide patient placement centers. Transfer centers interface with all hospital and health systems in a region or state and typically may be engaged after routine referral sources are no longer accepting transfers. Their role is to facilitate patient transfers quickly to an appropriate hospital setting including ICU and medical or surgical beds, while efficiently and effectively using capacity at both larger and smaller hospitals. The ability to pay should never be a criterion regarding transfer, and transfer centers should have policy authority to rotate transfers if required. Transfer distances may require a combination of ground and air transport. Intensivists and hospitalists may help to prioritize transfers based on both the type of (specialized) care needed and urgency of transfer, and they may be able to provide clinical advice to onsite clinicians whose patients may not be able to be transferred immediately.
suggests respected clinical leaders are likely most effective. Town hall-type meetings, tiered huddles, and structured e-mails are other important communication vehicles [fig_ref] Figure 1 -: Diagram showing a framework for critical care surge capacity planning outlining the... [/fig_ref].

## Technological issues and solutions during surge management
Suggestion 10: We suggest hospitals apply telemedicine technology to augment critical care early and in the broadest sense possible.
Telemedicine was used to augment surge capacity and to provide family access for communication with hospitalized patients using straightforward and inexpensive technology including computers, electronic tablets, and conferencing software. Health care organizations used this technology to connect intensivists and specialists to distant rural sites and potentially to tele-triage. [bib_ref] Collaboration between tele-ICU programs has the potential to rapidly increase the availability..., Chandra [/bib_ref] [bib_ref] Rapid implementation of telecritical care support during a pandemic: lessons learned during..., Krouss [/bib_ref] Outpatient strategies include monitoring at-risk but stable patients remotely, home care for stable patients (hospital-at-home programs), and outpatient care [fig_ref] Figure 1 -: Diagram showing a framework for critical care surge capacity planning outlining the... [/fig_ref] , [bib_ref] Hospital surge capacity in a tertiary emergency referral centre during the COVID-19..., Carenzo [/bib_ref] Telemedicine and tele-ICU technology with portable applications can augment both the delivery of clinical expertise to virtually any hospital bedside in support of ICU care and specialty consultation support and can provide families virtually unlimited audiovisual access to their loved ones who are hospitalized patients (right side of diagram). This technology also functions by helping decompress hospital surge by outpatient care reach support for patients at home and preventing disease exposure from unnecessary office visits (left side of diagram).
chestjournal.org ones to care and provide decision-making goals, [bib_ref] Paved with good intentions: hospital visitation restrictions in the age of coronavirus..., Andrist [/bib_ref] [bib_ref] Association between visitation restriction during the COVID-19 pandemic and delirium incidence among..., Kandori [/bib_ref] and telemedicine was used to support the needs of families and patients. Operational strategies to facilitate family presence in the ICU includes video conferencing and conventional telephones with regular inclusion of multidisciplinary team members such as psychiatrists, palliative care specialists, social workers, and chaplains. Visitation policies also should include on-site strategies for families with limited access to technology Discussion Before the COVID-19 pandemic, mass critical care guidelines were tested infrequently under contingency or crisis conditions, and thus were underappreciated by planners. The impact of a prolonged public health emergency, leading to a state of chronic contingency care that would fluctuate unpredictably [fig_ref] Figure 1 -: Diagram showing a framework for critical care surge capacity planning outlining the... [/fig_ref] , [bib_ref] Triage of scarce critical care resources in COVID-19: an implementation guide for..., Maves [/bib_ref] has resulted in significant workforce stress. With increasing surge, mortality rises-sometimes dramatically-and it is likely many of our health care systems endured a chronic state of crisis conditions. 2,6,10 ICU clinicians recognized a highly dynamic zone of contingency care and intuitively developed ingenious strategies to identify and extend these boundaries, and the TFMCC focused on greater understanding of this contingency zone.
Sustaining a large operational workforce was a top priority. The three staffing strategies incorporate critical care-trained clinicians working with other professionals, combining skill sets and procedure teams and leveraging telemedicine ICU support and adult care in pediatric ICUs in needed proportions to sustain contingency-level care. They are adaptable and expandable based on surge levels. Also essential is supporting HCW resilience over months, including a reasonable ceiling of work hours, responsibly limiting required documentation, and addressing HCW's mental health needs through effective communication, adapting quickly to surge demands and promoting a healthy work environment (Tables 2, 3, [fig_ref] Figure 6 -: Diagram showing the American Association of Critical Care Nurses Healthy Work Environment... [/fig_ref].
Effectively managing surge resources and load-balancing is another priority. ICU pandemic strain was experienced poignantly by ICU clinician leaders, and their understanding of staff, bed, and supply resources in absolute amounts and imminent availability impacts the degree to which resources may be stretched to responsible limits during periods of CCP. The TFMCC strongly suggests clinical leadership be empowered to determine surge level and priorities, with the suggested communication strategies (suggestion 9) pivotal in keeping clinicians and administrative leaders aligned.
ICU strain indicators [fig_ref] TABLE 4 ]: Strain Indicator Limits Defining Conventional, Contingency, and Crisis Levels of Resources Typically... [/fig_ref] are suggested as adjuncts for clinician leader assessment in determining surge levels and priorities, are useful under routine conditions, and can be acquired electronically for ongoing use and predictive analysis. At present, ICU queuing time may be the most powerful strain indicator, given its strong correlation with mortality [fig_ref] TABLE 5 ]: Risk for Patients Waiting for ICU Admission vs the Risks of Transfer,... [/fig_ref] , [bib_ref] Intensive care role in disaster management critical care clinics, Hossain [/bib_ref] and among the most compelling reasons for early load-balancing to prevent overcrowding and crisis care during times of severe surge. [bib_ref] Association of intensive care unit patient load and demand with mortality rates..., Bravata [/bib_ref] [bib_ref] Association between caseload surge and COVID-19 survival in 558, Kadri [/bib_ref] Finally, transfer hubs proved an instrumental strategy in load-balancing hospitals at or near crisis to those with remaining capacity and a powerful process for maintaining contingency level care across regions and states, ranging from statewide support for individual centers to massive regional off-loading of specific sites. [bib_ref] In Imperial County, medical air teams work around the clock to move..., Vives [/bib_ref] Successful transfer centers demand relatively unsophisticated technology and software, but as a top priority require regional and statewide commitment, coordination, and above all teamwork among health care systems, professional associations, and health departments.
[fig] Figure 1 -: Diagram showing a framework for critical care surge capacity planning outlining the conventional, contingency, and crisis surge responses. PACU 14 post-anesthesia care unit. (Reprinted with permission from Christian et al. 3 ) [/fig]
[fig] Team: Composition, additional required personnel to care for increasing increments of patients ICU experienced physician (ICU-EP)Advanced practice providers, non-ICU trained clinicians, and other clinicians [/fig]
[fig] Figure 3 -: Diagram showing critical care adult physician or provider staffing model for expanding surge coverage.[22][23][24][25][26][27][28][29] This model assumes all ICU care teams have at least one intensivist or other skilled ICU physician (red circle-and-diamond figures) to surge while maintaining contingency level care. An intensivist or skilled ICU physician may manage up to 12 patients in a 12-h shift when providing only direct hands-on care, and up to 24 patients when combining hands-on care with support and collaboration for up to four other clinician team members (blue circle-and-diamond figures). The factors that effectively increase an ICU team's capacity to expand coverage while maintaining contingency level care include (banners at the top of graph): (1) team members with more ICU experience, (2) the presence of procedure teams (for placing invasive lines or other procedures, for intubations, for other care such as prone positioning), and [/fig]
[fig] Figure 5 -: Diagram showing model for staffing and support of PICUs embedded in facilities that routinely care for adult patients to support adult surge. [/fig]
[fig] Figure 6 -: Diagram showing the American Association of Critical Care Nurses Healthy Work Environment Standards.46 The six standards have been shown to correlate with burnout among critical care nurses. The Healthy Work Environment Standards have been demonstrated to apply to the interdisciplinary team and to noncritical care areas. Authentic leadership and meaningful recognition are shown to correlate most strongly with compassion satisfaction, which counteracts compassion fatigue and enhances professional quality of life.46 chestjournal.org numbers of sicker patients quickly when crisis conditions do occur.72 [/fig]
[fig] Figure 7 -: Diagram showing an example of a nine-hospital system illustrating daily levels of strain during a severe pandemic surge. Using clinical leaders' assessment and strain criteria each of nine hospitals (left margin, top frame) assesses their daily level of ICU surge for the first 10 days (shown across the top); the levels of daily strain are illustrated in the colored legend below. For health system leadership, the ebb and flow of daily level of strain for each hospital helps to determine where hospital resources need to be directed, where resources are available to transfer patients, or both. PACU 14 post-anesthesia care unit. [/fig]
[fig] Figure 8 -: Case study of CCP. CCP 14 critical clinical prioritization. [/fig]
[fig] Figure 11 -: Diagram showing the role of the PCSS. PCSS 14 physician clinical support supervisor. [/fig]
[fig] Figure 12 -: Diagram showing telemedicine and tele-ICU technology. [/fig]
[fig] Figure 13 -: Diagram showing the impact of triage in crisis surge response to balance demand and capacity, demonstrating different levels of triage depending on the degree of demand in relationship to system capacity. LTC 14 long-term care. (Reprinted with permission from Maves et al.12 ) [/fig]
[table] TABLE 1 ]: Summary of 10 Suggestions and Operational Strategies [/table]
[table] TABLE 2 ]: Risk Factors for Health Care Workers Expe-Inadequate access to personal protective equipment or essential supplies High perception of personal risk for infection Fear of being infected Fear of spreading the illness to family and friends Inability to care for one's family [/table]
[table] TABLE 3 ]: Resilience Letters or cards from community members and local school children show gratitude from the public; family and community support was a significant factor in nurse well-being during the COVID-19 pandemic as surveyed by the American Nurses Foundation 47 [/table]
[table] TABLE 4 ]: Strain Indicator Limits Defining Conventional, Contingency, and Crisis Levels of Resources Typically Encountered During the COVID-19 [/table]
[table] TABLE 5 ]: Risk for Patients Waiting for ICU Admission vs the Risks of Transfer, and Strategies to Help Mitigate [/table]