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The Increasing Demand for Critical Care Beds—
Recommendations for Bridging the RN Staffing Gap

Tener Goodwin Veenema, PhD, MPH, MS, RN; Christopher R. Friese, PhD, RN, AOCN;
and Diane Meyer, RN, MPH  | March 30, 2020

There are more than 3.8 million registered nurses nationwide, making them one of the largest components of the healthcare workforce.1 With their clinical roles and scope of practice, they are critical contributors to national health security. They are vital in the ongoing response to the COVID-19 outbreak, where nurses across the United States are currently or likely will be involved in identifying, triaging, isolating, and treating suspected and confirmed cases. However, the United States is already witnessing a shortage of critical care nurses in the COVID-19 response. In this post, we discuss potential ways to bridge this staffing gap.

The rapid surge in COVID-19 cases over the past 2 weeks highlights that, despite concerted efforts in the field, our healthcare system will be strained beyond imaginable expectations. Currently, health systems in Washington State, California, New York, and the greater Boston area are exceeding their critical care bed capacity and face shortfalls in ventilators and personal protective equipment (PPE). The Italian experience portends what the US is already beginning to see: seriously ill patients requiring care in a healthcare system that has no additional capacity, critical equipment shortages, and the real risk of a depleted healthcare workforce due to employment-acquired COVID-19.2 Sadly, earlier this month, New York nurse Kious Kelly died of COVID-19 amid reports that his hospital had run out of protective equipment and had resorted to trash bags as gowns.3 Difficult, painful decisions may potentially lie ahead regarding allocation of scarce resources. We are in the “acceleration phase” of the COVID-19 pandemic in the United States. We recognize the fluidity of the current situation, the urgent needs, and the absence of high-quality evidence on many essential topics.

Although the federal government has deployed the Strategic National Stockpile (SNS), allowed for extended use, and relaxed regulations, the supplies delivered to the states are insufficient to meet the expected need. Recently, the president stated his intention to invoke the Defense Production Act to direct manufacturers to repurpose their factories to produce ventilators, PPE, pulse oximeters, and other equipment necessary to care for critically ill patients. Healthcare facilities across the United States have begun to surge bed capacity to try to accommodate the expected influx of COVID-19 patients, including in New York, which is setting up temporary satellite hospitals that can hold up to 4,000 patients.4 While the increase in supplies and bed capacity will greatly help the country’s ability to respond to the growing pandemic, what is less clear is how the healthcare workforce will be expanded to staff these beds. This includes the nursing workforce, which is largely responsible for the day-to-day tasks of caring for patients. Equally important is the need to keep these healthcare workers safe while taking care of documented or presumed COVID-19 patients.

More aggressive policy and practical actions to surge the nursing workforce while simultaneously protecting them (and all healthcare workers) from infection need to be taken now. Building on key facts known about COVID-19, historical data from similar public health emergencies, and the imperative to save lives, we identify below what nursing competencies are needed for nurses to care for COVID-19 patients, the training and PPE necessary to keep nurses safe, and strategies for surging the nurse workforce.

COVID-19–related Nursing Roles and Responsibilities

COVID-19 has created challenges in the healthcare setting that require nurses to restructure traditional workplace practices and rethink roles and responsibilities. At a minimum, in order to prioritize nurse safety, all nurses who will likely come in contact with COVID-19 patients should acquire training and demonstrate competence in the following areas:

Nursing Roles and ResponsibilitiesCompetencies
Case identificationDemonstrate ability to identify individuals who are suspected of or confirmed as having COVID-19.
Case isolationDemonstrate ability to isolate individuals who are suspected of or confirmed as having COVID-19, including setting up separate, well-ventilated triage areas, placing patients in private rooms with door closed and private bathroom (as possible), prioritizing AIIRs for patients undergoing aerosol-generating procedures.
Selection and use of personal protective equipment (PPE)Demonstrate selection and proper use (donning and doffing) of PPE, including gloves, gown, respiratory protection that is at least as protective as a fit-tested NIOSH-certified disposable N95 filtering face piece respirator or facemask—if a respirator is not available—and eye protection (ie, goggles or disposable face shield that covers the front and sides of the face).
Collection of diagnostic respiratory specimensDemonstrate proper selection and use of PPE N-95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown; limit number of people in the room; close door; clean and disinfect room surfaces as soon as possible; ensure proper handling and transport of specimens.
Infection prevention and control measuresDemonstrate competence in proper hand washing and respiratory hygiene practices; manage patients infected with COVID-19; employ environmental and administrative controls; and use safe injection practices.
Workflow redesign to optimize safetyDescribe strategies to optimize workplace safety, such as hand hygiene, barriers to limit contact with patients at triage, cohorting of COVID-19 patients, limits to the numbers of staff providing their care, prioritization of respirators and AIIRs for aerosol-generating procedures, and implementation of PPE optimization strategies to extend supplies.5
Direct patient careNursing procedures that are likely to induce coughing (eg, sputum induction, open suctioning of airways) should be performed cautiously and avoided if possible. If performed, demonstrate use of proper selection and use of PPE: wear an N95 or higher-level respirator, eye protection, gloves, and a gown. Limit number of healthcare workers to only those essential for patient care and procedure support. Clean and disinfect procedure room surfaces promptly

Training

As the United States looks to surge the nursing workforce in response to the outbreak, additional training will be necessary to strengthen these competencies to prevent healthcare worker infection, to reduce further nosocomial and community transmission, and to maintain the continuity and availability of the nursing workforce. Healthcare facilities should:

  • Implement virtual training (available on demand) that covers the basic epidemiology and transmission principles of the SARs-CoV 2 virus. This should include current guidance on case identification and isolation, proper infection prevention and control (eg, handwashing, respiratory hygiene, etc), PPE use (including PPE selection, donning, and doffing), specimen collection, and disinfection and decontamination. Such training should be updated as new data emerge.
  • Conduct in person just-in-time training on PPE selection, donning, and doffing with all nursing staff. Each nurse should be observed and signed off by a colleague to ensure proper adherence to guidelines.
  • Review with the nursing staff the basics of good hand washing and conduct hand washing audits to ensure compliance.
  • Consider deploying infection control and critical care nurses from large health systems and urban hospitals to rural and critical access hospitals to provide needed expertise.

Increasing PPE Supplies

To fulfill the nursing competencies needed to care for COVID-19 patients, it is necessary for nurses and all healthcare workers to have access to rigorously tested and manufactured PPE to protect themselves, reduce transmission, and ensure continuity of the RN workforce. Strategies include:

  • Expand regional donation drives of relevant PPE from construction, labor, and other industrial sectors that use PPE. Counties (or similar functional units) can distribute to their local healthcare providers based on need. Social media is an effective channel to mount and coordinate this activity. Healthcare facilities should set guidelines for what is acceptable and not acceptable to donate.
  • Secure supplies of reusable elastomeric half-mask respirators now. The National Academy of Medicine published a consensus study report on the use of elastomeric respirators as an adjunct to surge during a pandemic.6 Elastomeric filtering face piece respirators are used in other fields routinely (eg, nuclear power, environmental mitigation) and can be used in the healthcare setting. First responders used elastomeric respirators during the 9/11 attack recovery efforts. These masks are reusable after routine cleaning and disinfection. This approach would provide healthcare workers with immediate access to respiratory protection with comparable efficacy. They may be particularly well-suited for critical care teams working on cohorted wards with COVID-19 patients.
  • The Biomedical Advanced Research and Development Authority should begin now to contract with manufacturers to develop and produce next-generation, truly reusable PPE.
  • The president should use his authority under the Defense Production Act to direct industry partners to apply advanced manufacturing processes, including 3-dimensional printing, to mass produce PPE and other essential equipment.
  • Direct the National Institute for Occupational Safety and Health to test novel products and materials that may not meet N95 filtering standards but provide some degree of acceptable filtration.
  • Adopt ultraviolet light7 or similarly tested methods to decontaminate N95 respirators to enable reuse.
  • Minimize PPE waste. In this crisis, we have observed healthcare personnel misusing PPE, such as workers wearing both an N95 and a powered-air purifying respirator, and double gloving when it is not indicated. Reduce the number of personnel entering rooms.

Surge Staffing

Additional nursing staff will be required to handle the large increase in critical care beds that is expected to occur over the coming days and months. To surge the workforce to meet this demand, additional nurses will need to be trained in critical care nursing (eg, ventilator management), and strategies will be required to reduce exposure to infectious patients.

  • Health system leaders and local authorities should pool existing rosters of registered healthcare workers and solicit availability for emergency reactivation.
  • Develop rapid cross-training programs so registered nurses can partner with experienced critical care nurses to learn basic nursing care of ventilated patients.
  • Reverse triage (discharge) patients to lower level healthcare facilities (rehabilitation hospitals) or home whenever it is safe to do so to create additional hospital beds and to free up nursing staff.
  • Cohort COVID-19 patients and staff. Divide unit staff into cohorts and establish a consistent staffing pattern to facilitate strong teamwork. Rotate cohorts of nurses to care for confirmed COVID-19 patients. Schedule cohorts to work together (eg, Monday, Thursday, and Sunday) with standardized rest periods. In the event of workplace exposure, consistent teams may limit the spread of infection across more workers.
  • Redesign duties to reduce face-to-face patient contact and the potential for healthcare worker infection. Reduce nonessential checking of vital signs; draw labs once a day or reduce blood draws in stable patients. Reconsider traditional patient assignment procedures or assign only key personnel to care for patients (eg, assign nursing assistants to specific patients who require their care, not entire cohorts). Deploy extended length intravenous tubing and keep infusion pumps outside of isolation rooms. De-prescribe nonessential medications. Schedule medication administration at specified times. Deploy communication strategies (walkie-talkies, intercoms, baby monitors) to reduce traffic into isolation rooms.
  • Implement digital health applications and telehealth capabilities for all nursing care using these technologies, limiting the time nurses are in contact with patients. Nursing should be aggressively advocating for the implementation of telehealth and digital resources in the clinical setting.
  • Large health systems and urban hospitals should consider deploying infection control and critical care nurses to rural and critical access hospitals to train staff on proper infection prevention and control and on care of critically ill and ventilated patients.

The ongoing COVID-19 epidemic in the United States will require agile, innovative, and evidence-informed strategies to safely accommodate the surge in critically ill patients. We are dedicated to our roles as nurses but expect access to the training and resources needed to do our job safely while delivering quality and compassionate care.

  1. American Association of Colleges of Nursing. Nursing Fact Sheet. Updated April 1, 2019. https://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Fact-Sheet. Accessed March 27, 2020.
  2. Livingston E, Bucher K. Coronavirus disease 2019 (COVID-19) in Italy. JAMA 2020. https://jamanetwork.com/journals/jama/fullarticle/2763401.
  3. Sengupta S. A N.Y. nurse dies. Angry co-workers blame a lack of protective gear. New York Times March 26, 2020. https://www.nytimes.com/2020/03/26/nyregion/nurse-dies-coronavirus-mount-sinai.html. Accessed March 27, 2020.
  4. New York State. Amid ongoing COVID-19 pandemic, Governor Cuomo announces initial delivery of equipment and supplies for Javits Center temporary hospital. March 23, 2020. https://www.governor.ny.gov/news/amid-ongoing-covid-19-pandemic-governor-cuomo-announces-initial-delivery-equipment-and-supplies. Accessed March 27, 2020.
  5. Centers for Disease Control and Prevention. Strategies to optimize the supply of PPE and equipment. Updated March 26, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html. Accessed March 27, 2020.
  6. National Academies of Sciences, Engineering, and Medicine. Study on the Use of Elastomeric Respirators in Health Care. Washington, DC: National Academies Press; 2019. https://www.nationalacademies.org/our-work/study-on-the-use-of-elastomeric-respirators-in-health-care. Accessed on March 27, 2020.
  7. Lowe J, Paladino KD, Farke JD, et al. N95 Filtering Facepiece Respirator Ultraviolet Germicidal Irradiation (UVGI) Process for Decontamination and Reuse. Nebraska Medicine; undated. https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf. Accessed March 27, 2020.