Planning for a COVID-19 Pandemic – Workforce and Staffing

ANZICS recommends the use of a risk assessment matrix (e.g. CDNA risk matrix Appendix 6) for any COVID-19 exposure. In more advanced phases of the pandemic with vaccinated staff it may be that revisions of the quarantine period (in conjunction with local jurisdictions) is necessary with regular testing to allow staff to return to work as appropriate.

We recognise there may be exceptional circumstances where quarantine periods for health care workers (HCWs) are adjusted with appropriate testing and infection control measures (e.g. organ retrieval, specialised procedures).

We recommend an efficient and operationally effective surveillance program for health care workers caring for COVID-19 patients to support workforce maintenance and safety.

We recommend ICUs maintain and update regularly a database (with standard confidentiality) of staff availability and other places or work. This should include categories i.e. general sick leave, COVID infection, COVID exposure/isolation, annual or other leave.

ANZICS recommends in order to facilitate and maintain a sustainable critical care workforce that additional recognition and support is considered which may include special leave or additional remuneration for medical, nursing, allied health and ancillary staff working in ICU.

ANZICS strongly supports the need for a long term sustainable nursing workforce. It is essential that nurse managers, nurse educators and staff development nurse positions are maintained and expanded to support nurses working clinically as well as educate and provide training to post-graduate student nurses.

We recommend that nursing staff capable of caring for critically ill patients be identified.

This includes:

• Nursing staff with formal critical care training or experience, but not currently working in ICU (e.g. redeployed, in administrative or non-clinical roles, recently left workforce)
• Paediatric ICU nursing staff
• Nursing staff with experience of critically ill patients in other areas of the hospital (e.g. coronary care nurses)
• Nursing staff in departments with reduced clinical activity who are familiar with a critical care environment (e.g. anaesthetic nurses).

We recommend a formal rapid orientation and training program is provided.

A database of who has completed the training program should be created at each ICU. These nurses should work under the supervision of an experienced ICU nurse.

We recommend that all current casual or part-time ICU nursing staff be encouraged to increase hours and that examination of roster patterns occur to maximise workforce availability whilst maintaining staff well-being.

We recommend that changes to models of care be explored, particularly models utilising team based care with increased ancillary and allied health staff to support ICU nurses (e.g. pharmacists assisting with checking and drawing up of medications).

We strongly recommend that changes to models of care for nursing only occur in advanced phases of the pandemic and that ICUs prioritise nursing staff welfare and patient care. Altered models of care with higher patient to nurse ratios are associated with increased mortality and should only be explored as a last resort in the black phase of the pandemic and only initiated at a state/jurisdictional level.

Wearing PPE for prolonged periods can increase fatigue and hence shorter shifts or more regular breaks should be considered. For periods where patients are stable and not receiving interventions, models of care may be altered to facilitate additional breaks. Local union participation is recommended as shift modifications may be impacted by relevant state nursing awards.

If a change in model of care is required, we recommend that an experienced ICU nurse should supervise a maximum of 4 up-skilled nurses, and not take on a patient load themselves, to ensure adequate patient safety and staff protection.

We recommend that nurses without critical care experience may be suitably trained and redeployed to assist with the following:

• Supervision of staff and visitors donning/doffing of PPE
• Routine nursing care – turning, washing
• Liaison between treating team and family (e.g. daily updates, facilitate video calls)
• Re-supply, storage and inventory of equipment
• Medication delivery and checking
• Documentation
• Maintaining bed management and patient flow information
• Supporting essential pandemic research projects.

We recommend additional medical staffing for the ICU should be sourced by considering:

• Senior medical staff with critical care training, but not currently working in ICU
• Anaesthetic staff (expected reduction in surgical activity)
• Junior medical staff with critical care experience
• Career medical officers with critical care experience.

We recommend medical staff should be deployed in a manner that is aligned with their current scope of practice.

• Anaesthetic staff may be deployed as hospital ‘resuscitationists’, making up intubation teams, to lead rapid response teams or to assist in intensive care ideally under the supervision of intensive care specialists. Hospitals may have to perform their own interhospital transfers due to the limited capacity of retrieval services. Anaesthetic staff may also perform this role.
• Medical staff with critical care training may be deployed to manage HDU patients in repurposed clinical areas physically separate from the ICU, under the supervision of more experienced ICU staff.
• Junior medical staff with little to no ICU training may assist with documentation and non-ICU clinical activities.

To ensure a sustainable workforce, we recommend the following:

• Streamlining of administrative processes (e.g. electronic health record training and healthcare practitioner credentialing) that may otherwise limit staffing flexibility and delay onboarding of new staff members
• Utilisation of furloughed staff for phone/telehealth support to decrease load on onsite/on call staff
• Accommodation for staff who are unable to return home e.g. because of vulnerable family members Debriefing and psychological support; staff morale may be adversely affected due to the increased workload, anxiety over personal safety and the health of family members (see section on Staff Wellbeing)
• The cancellation of pre-arranged annual leave during a pandemic should only be considered if absolutely necessary.

Physiotherapy is beneficial in the respiratory and physical rehabilitation of patients with COVID-19 in ICU. Clinical practice recommendations for COVID-19 and minimum standards for ICU physiotherapists have been published. We recommend that physiotherapists with critical care experience be identified by hospitals and facilitated to return to ICU during periods of increased demand.

Patients with COVID-19 are at risk of developing post-ICU impairments, including ICU acquired weakness (ICU-AW). ICU-AW has independently been associated with increased morbidity and mortality.

The risks of COVID-19 transmission from physiotherapy interventions should be weighed against the benefits of the treatment being undertaken. We recommend the involvement of senior physiotherapists and medical staff in these decisions.

We recommend that physiotherapists provide extended support to the critical care team in the following areas:

• Involvement in proning teams.
• Supporting any possible nursing workforce shortages where skills may overlap or require minimal additional training for critical care physiotherapists (e.g. respiratory care, ventilation management).
• Serving as a conduit between ICU and the ward e.g. advising and supporting ward colleagues with the physical rehabilitation in COVID-19 patients post-ICU.
• Reducing post-ICU disability through referral to existing programs such as pulmonary rehabilitation, or specialised ICU follow-up clinics or support groups.
• Developing local pathways for the identification and management of Post Intensive Care Syndrome.

The clinical responsibilities of ICU pharmacists include support of drug safety and prescribing, the reconciliation of patient admission medications and the procurement of important pharmaceuticals for patient management. These activities can be challenging during a pandemic, with the potential for medication shortages, changes to drug administration practices and rapidly evolving evidence.

We recommend that pharmacists with critical care experience be identified to manage any potential ICU pharmacy service shortfall (due to increased workplace demand or ill/quarantined staff).

The education, upskilling and support of these pharmacists is essential to assist the core ICU pharmacy service, with the aim of maintaining the recommended one pharmacist per ICU team/pod.

Social workers provide psychosocial care for patients and their support network during ICU admission. During periods of increased demand, we recommend social workers with critical care experience be made available to the intensive care unit with a focus on:

• Bereavement and grief support, including psychological first aid
• End-of-life care and planning
• Risk assessments for vulnerable patients (and those they care for)
• Determining the medical decision maker, particularly in situations of conflict
• Facilitating communication between health teams, patients and their loved ones, particularly during periods of restricted visitation
• Navigating the social care system including newly formed pandemic services.

Dietitians provide expertise in nutrition management for critically ill patients, many of whom may have complex clinical conditions. The long-term impact of a prolonged ICU stay due to COVID-19 infection on nutritional adequacy is unknown.

During periods of increased demand, we recommend that critical care specialised dietitians look after the sickest patients, triage workload and provide clinical supervision to staff. Non critical care dietitians may need to be redeployed to ICU, under the supervision of an experienced clinician. This may include the use of nutrition assistants to support clinical dietitians.

Existing models of care may need to be extended to overcome food service delivery for patients in isolation.

Speech Pathologists provide expertise in the diagnosis, management and rehabilitation of swallowing functions, for ventilated and non-ventilated patients.

Patients may have diverse communication needs during a pandemic, particularly during periods of isolation and limited family visitation. We recommend that speech pathologists be engaged early to enhance and promote effective patient communication with staff and family. This may include augmentative and alternative communication systems.

The commencement of early rehabilitation may reduce the risk of protracted dysphagia and communication disorders. Specific techniques should be employed to minimise the risk of aerosol generation.