Forecasting nurse staffing during the initial spring 2020 COVID-19 patient surge within NewYork-Presbyterian (NYP) healthcare system required a great deal of teamwork and preparation. Comprised of 11 campuses, NYP has nine acute care campuses inclusive of two academic medical centers. The initial goal was to increase the capacity of critical care beds by 50% to 100%, set by a state executive order.1 One of the initial challenges included the unknown number of patients, level of care, and nursing needs. As the pandemic took a significant toll on Italy and China, the assumptions were that COVID-19 would present as a severe respiratory disease, with many patients requiring critical care beds and ventilators. The conversion of OR space, postanesthesia care spaces, and cardiac catheterization labs and the upgrade of medical-surgical and step-down beds to critical care beds helped meet capacity requirements.2 In planning for the worst-case scenario, two field hospitals were also constructed. The level of critical care patient acuity added to the complexity of the situation.
This case study describes skill mix identification, staffing modeling, deployment strategies, and competency management during the COVID-19 crisis, with a focus on NYP's key successes and opportunities for future pandemic surges or mass casualty incidents.
Staffing plan: Ratios and skill mix
The departments of nursing partnered with physicians from Weill Cornell Medicine and Columbia University Vagelos College of Physicians and Surgeons to ensure a collaborative approach to critical care growth. The proliferation of critical care beds required a staffing model to handle increased patient capacity. The leadership team's initial strategy focused on how to rapidly increase the critical care bed ICU capacity from 421 beds to nearly 1,000 in 3 weeks across the enterprise, an increase of approximately 138% from baseline. The leadership team projected staffing ratios of one ICU nurse to 10 patients in worst-case scenarios.
We rapidly identified who could support ICU nursing functions, which included step-down RNs, certified registered nurse anesthetists (CRNAs), NPs, midwives, pharmacists, and respiratory therapists. Unlicensed assistive personnel roles to support the ICU clinicians were also compiled. These licensed and unlicensed personnel practiced to their level of professional competency with identified tasks, supporting the critical care nurse. For example, nurses partnered with physical therapists to assist with proning and turning patients and pharmacists to provide onsite medications. Recognizing the need for additional clinical resources and extra demands for personal protective equipment, all elective procedures were canceled. Staff members from these areas were then used to assist with the care of COVID-19 patients aligned with their skill set.
Parallel to identifying nursing resources at the local campuses, corporate nursing teams developed a pandemic nursing model that maximized available competency levels. Competencies were assessed at the local campus level, with assistance from incumbent ICU nurses to meet staffing needs. Two sets of competency levels were identified within our organization for both adult and pediatric patients, which were authored by the director of professional nursing practice and the director of nursing professional development (NPD).
The ability to match skill sets through a staffing structure allowed for a pyramid model to be established, a team-based concept incorporating several levels of nursing proficiency. (See Pyramid staffing model.) The most specialized nurses were placed at the pinnacle of this framework to complement the acuity of patient assignments. To support these nurses, colleagues from a variety of areas with diverse skill sets completed the other planes in the structure. Each role and responsibility within the pyramid model was interconnected. It was crucial for the nurses and the entire care team to understand their purpose in the execution of the new approach; every layer of the pyramid model influenced the productivity and sustainability of patient care.
Models of care fluctuated among the campuses based on staffing and patient volumes. The models also varied between the type of critical care setting, such as “pop-up” ICU, OR ICU, or traditional ICU setting. Pods were formulated based on geography and patient acuity, driving the configuration of the care teams. Each pod also incorporated a physician complement who was part of a provider pyramid model. Depending on patient acuity and the composition of additional support, the ICU-level nurse-to-patient ratio was able to increase from 1:2 to a max of 1:6 with the supporting staff. The thoughtful design and execution of the team model made provisions for moving beyond the norm to meet the exponentially growing need for ICU care.
The majority of NYP campuses adopted this team approach to provide ICU-level care during the spring 2020 surge. On larger campuses, the model served as a structure to expand staff as needed. Although not all identical, there were consistent similarities within each model. For instance, one campus had an ICU RN paired with one step-down, postanesthesia care unit (PACU), or ambulatory care unit RN, providing care for four to six patients. Another campus had one ICU RN or cardiac catheterization RN paired with one to two medical-surgical RNs, providing care for six or possibly more patients. The support staff, including other RNs, techs, and unlicensed assistive personnel (UAP), differed, bolstering the team approach. Campuses had to adjust their approach as patient volumes expanded rapidly across different parts of the healthcare system.
The standard design of the pyramid model established the opportunity to quickly revise task allocation based on the daily team's makeup to meet patient needs. Consistent across all care team models, a nurse with ICU skills was at the helm collaborating activities of care. This pivotal role orchestrated the work patterns for team members. Role delineation was vital to the success of the model. It was prudent to keep in mind that staff redeployment included incorporating nurses from non-ICU areas, so providing detailed information related to workflow and the staffing model was critical. Pertinent job functions were identified and communicated to the care team. Expectations of each role were clearly identified to mitigate redundant work and wasted efforts.
Within the perioperative ICU setting, responsibilities were thoughtfully delineated because the model required individuals to adopt workflows that weren't typical of their daily practice. The providers in the model included physicians and CRNAs who were responsible for the care and documentation of activities such as assessments, patient orders, and ventilator settings. The ICU-level nurses, also referred to as “primary nurses,” were accountable for assessments and documentation of patient care activities and administration of sedative, paralytic, and vasoactive medications. As described above, other disciplines, such as respiratory therapy, physical therapy, and perfusion, supported the primary nurse. Ultimately, the primary nurse was responsible for coordinating all aspects of patient care.
Part of the pyramid model was rapidly educating nurses to perform duties that supported the primary nurse, which allowed for an increase in nurse-patient ratios as necessary. Most of these nurses didn't have critical care experience but had the training to perform in this capacity. If the census allowed, critical care RNs, referred to as “resource nurses,” were strategically assigned to provide hands-on assistance to each primary team in the perioperative areas. This role brought a high level of expertise to the unit, and the development of checklists supported newly defined work structures, tasks, and responsibilities.
Use of a central nursing deployment team
With a heightening urgency and dramatic influx of high acuity patients, all available nursing resources were needed to meet staffing demands. As admission volumes began to fluctuate at each campus, it became imperative to create a central nursing deployment team. This team worked to obtain nursing resources from facilities throughout the New York City area. The additional support came from a specialty nursing hospital; academic medical center partners; and nurses whose current roles were nonpatient facing, such as those working in information technology, quality, patient service administration, and finance.
The new staffing pool consisted of approximately 250 nurses managed by a virtual, remote corporate nurse staffing command center, which was manned by 16 individuals for 12 hours a day, 7 days a week to assist with local campus staffing needs. Each team member was responsible for a particular nursing complement and was in contact with these staff members regularly for questions regarding schedules, parking, and housing requirements. Daily communication occurred between the central corporate command center and local campus-based command centers to understand nursing deployment needs.
Routinely, each campus held daily staffing and bed huddles to review the number of patients and the nursing staff members who were going to be needed for each shift. Most of the redeployed nurses started in the clinical support role and then advanced to more complex roles through a self-identified ability to provide more complex care. An e-learning curriculum was provided for the nurses in the clinical support role. For those who moved to a more complex role, additional training was provided. Communication, clinical system access, and clear expectations of the command center and the deployed nurse volunteers are some of the lessons learned from the use of the virtual command center deploying nurses to roles outside of their usual practice.
Competency and training
The training necessary for a new critical care nurse is historically from 12 weeks to 6 months, depending on experience, combining a deliberate progression of knowledge through simulation, critical care didactics, case studies, and a preceptor structured experience to achieve competency.3 This structure is aligned with the American Association of Critical-Care Nurses' Synergy Model, a framework that links nursing competencies to patient needs.4 A new pool of critical care nurses needed to be developed quickly to meet the rapidly expanding “pop-up” ICUs. Each campus used a distinct approach to meet these training needs to ensure that nurses could be developed and deployed as needed.
The training teams at each campus were comprised of NPD personnel, clinical nurse specialists (CNSs), CRNAs, and NPs, as well as assistance from experienced critical care nurses. Although step-down nurses were cross-trained to ICU-level care, the majority of those who participated in the training were nurses from the perioperative and procedural areas. A combination of skills fairs and shadow experiences were employed in a “crash course” to bring the nurses up to speed as quickly as possible. An abbreviated competency tool was generated to train nursing staff to become critical care nurses. With limited time, meeting the nine major elements of the tool proved to be a challenge. The education focus was reframed to include the following priority areas: mechanical ventilation, medication management, documentation, and physical care. Again, this was accomplished with various learning methodologies across the campuses. Overall, approximately 1,400 nurses were trained to work in some critical care capacity.
In planning for the future, it's imperative to look at lessons learned from this training plan. Focused competencies need to be refined and vetted by NPD colleagues. As the baseline knowledge of COVID-19 evolves, it's important to ensure that nursing staff members acquire this knowledge. Equally, nurses new to critical care need to learn the overall critical care workflow and patient population nuances. The integration of case studies with clinical training can ensure content applicability. Content items such as resilience, liability, ethics, and self-care should also be included in the curriculum to ensure the nurses' ability to function to their highest potential as they navigate this “new normal” in their practice.
Planning must start early for a rapid escalation of nursing resources. Each NYP campus faced various challenges throughout the spring 2020 surge as the number of cases varied by geographic location. However, one consistent theme identified was the need for more critical-care level nurses early in the pandemic. Staffing wasn't only impacted by the need for more nurses; the care environment also created anxiety and fear that led to further daily staffing fluctuations. Internal resources weren't enough and the NYP system was able to obtain travel nurses and volunteer staff from other hospitals across the country.
- Communication of the pyramid staffing model: Discussions centered on expectations and execution allowed for widespread communication of the model.
- Real-time education: Rapid partnering with the NPD staff and CNSs occurred to facilitate educational offerings consisting of didactic and clinical training.
- Resource nurses: These critical-care level RNs provided support and guidance in the management of complex patients to complement the team model.
- Interdisciplinary partnerships: Collaboration with other disciplines allowed for the use of their expertise to support patient care.
- People: Staff members came together to ensure that patients received the best possible care, reaching beyond their comfort zone and working tirelessly to serve our patients.
- Redefine the model of care for future pandemics or large-scale disasters.
- Plan ongoing training efforts to ensure that nurses are “trained up” to assist critical care nurses during potential future surges.
- Evaluate the training of providers who can assist with clinical tasks during a surge.
- Design deconstruction of silos with a strong chain of command.
Resilience and teamwork
Standing at the US's epicenter of the COVID-19 pandemic in the spring of 2020, NYP's workforce remained proactive and agile. Despite several obstacles to rapidly expand and train labor resources, nursing and its leadership broke through barriers and helped redefine care and care teams. Although daunting, the experience strengthened the notion of teamwork throughout the enterprise, built new relationships, and cultivated a new notion of excellence and respect. Jessica Romero, RN, patient care director, central sterile processing department, remarked, “The impact that this will leave on all of our lives may be immeasurable, but I'm so incredibly proud to have been a part of this team that overcame vulnerability and leaned on their resilient nature to care for our patients in need.”