Interactive Critical Care Surge Response Tool

The COVID-19 pandemic is placing extraordinary strains on the U.S. medical system, most especially hospitals. Hospitals are searching for ways to create surge capacity to provide critical care for the sickest COVID-19 patients. This tool allows decisionmakers at all levels — hospitals, health care systems, states, regions — to estimate current critical care capacity and rapidly explore strategies for increasing it. For more information about the tool or detailed descriptions of the strategies for increasing critical care surge capacity, see the related report.

How to Use the RAND COVID-19 Critical Care Surge Tool

Inputs to this tool for managing critical care surge include (1) baseline number of beds, (2) critical care doctors and nurses, (3) respiratory therapists, and (4) ventilators. The tool also allows you to set baseline numbers of intensive care unit (ICU) doctors, ICU nurses, and respiratory therapists per shift and ratios of these providers to patients (shift lengths are defined by the user and require no additional inputs). Further, it allows you to input information related to how critical care physicians, critical care nurses, and respiratory therapists might act as supervisors for “extender” care providers. These supervisory relationships may include ICU doctors supervising hospitalists, ICU nurses supervising floor nurses, and respiratory therapists supervising nurse anesthetists. You can set the ratios of supervisors to extenders and extenders to patients. You can also specify additional spaces that can be created and used as ICU space (e.g., through doubling patients in ICU rooms, or using post-anesthesia care unit—PACU—space) and additional ventilators (e.g., through purchasing or sharing with other facilities) that can be added to create critical care surge capacity. The tool then estimates the number of patients who can be cared for with the given set of inputs. It also identifies which among the three resources —staff (critical care doctors, critical care nurses, and respiratory therapists), space (beds), and stuff (ventilators)—is the limiting factor in increasing capacity.

Note that the default numbers are merely examples—you should adjust them per the instructions below.

The columns in the tool represent the five resources considered: critical care doctors, critical care nurses, respiratory therapists, ventilators, and beds. Moving down through the rows takes you step by step through the calculations.

Starting Numbers

Current Staff Levels

This set of inputs represents baseline quantities before additional resources are brought in.

• Enter the number of staff and/or resources that are available. For staff, the number entered should be the number available per shift.
• Enter the percentage of staff in each category that are absent (if you have not already accounted for absences when entering the number of staff).

Augmentation by Fully Capable Personnel or Equipment

The next set of inputs allows you to enter the number of additional fully capable (i.e., non-extender) personnel or equipment that may be brought in. By fully capable personnel, we mean individuals who have the necessary training and licenses so that they can provide critical care independently and do not require supervision.

• Enter the number of newly hired staff per shift and/or the number of ventilators or beds that are newly purchased or set up.
• Enter the number of staff or resources borrowed from other departments (e.g., from outside the ICU) to care for critical care patients. For staff, this should be on a per-shift basis. The staff should be fully capable personnel. For nurses, for example, this may mean borrowing emergency department (ED) nurses or PACU nurses to function as ICU nurses. For beds, this may mean doubling up patients in ICU rooms, using PACU beds and available operating rooms.
• Enter the number of resources, per shift. For staff, this could mean personnel from other hospitals, including federal facilities such as those belonging to the military and other agencies. For ventilators, this could be items from the Strategic National Stockpile or other stockpiles.

Augmentation by Extenders Needing Supervision

There may not be enough fully capable personnel who can be brought in to meet the needs of the hospital. In that case, the hospital may want to consider personnel who are not fully capable but who would serve as extenders under the supervision of someone who is. For critical care physicians, this might mean using hospitalists as extenders. For critical care nurses, this might mean using floor nurses as extenders. For respiratory therapists, this might mean using nurse anesthetists. The use of such resources implies altered standards of care.

• Each fully capable staff member can only supervise a certain number of extenders. Enter the extender-to-supervisor ratio (i.e., the maximum number of extenders that each supervisor could supervise). For example, a “3” in the “Critical care nurses” column would mean that each critical care nurse could supervise three floor nurses.
• Enter the number of extenders who could potentially be brought in, per shift, assuming there were enough fully capable staff to supervise them. (The spreadsheet will compute whether there are enough supervisors and determine whether all of those extenders can be brought in.)

Patient Capacity

• Enter the patient-to-staff or patient-to-resource ratio. For staff, this is the staffing ratio. For example, a “2” entered in the “Critical care nurses” column would mean that each critical care nurse could care for two patients. The patient-to-staff ratio is a value that the user will want to adjust and experiment with when examining different scenarios.
  • For ventilators and beds, the ratio is most likely to be “1.” For example, each bed can only support one patient. However, you can change that number as well.
• Each extender can only care for a certain number of patients. This is likely a smaller number of patients than a fully capable staff member could handle. Enter the patient-to-extender ratio. For example, a “3” in the “Respiratory therapists” column would mean that each respiratory therapist extender could, with proper supervision, handle three patients.

Number of Patients Who Can Be Cared For

The remaining rows of the tool report the output of calculations and do not require your input. The overall number of patients who can be cared for is determined by whichever resource— staff, space, or stuff—that is most limited. The last row of the tool flags the resource that is the limiting factor by highlighting the cell in dark blue. The overall number of patients who can be cared for is thus the minimum of the numbers in the last row. That answer is also reported at the top of the bar chart.

Examining Different Scenarios

After entering an initial set of inputs and seeing how many patients can be cared for, you should use the tool to examine different scenarios. In particular, you may want to adjust the various ratios to better understand their effect on outcomes: the patient-to-staff ratio, the patient- to-extender ratio, and the extender-to-supervisor ratio.

As you change the number of resources and the patient ratios, the flag in the last row indicating which resource is the limiting factor may move from one resource to another. For example, increasing the number of physicians or the patient-to-physician ratio may change the limiting factor from physicians to respiratory therapists. The bar chart showing the number of patients that can be cared for by each resource will also change as resources and ratios change. Keep in mind that the total number of patients who can be cared for will be limited to the smallest of these numbers.

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