Intensive Care Med (2010) 36 (Suppl 1):S32–S37

DOI 10.1007/s00134-010-1767-y

Christian Sandrock
Chapter 4. Manpower

Abstract Purpose: To provide rec- determine the hospital’s daily needs

Copyright jointly held by Springer and ommendations and standard operating including a sick and no-show list
ESICM 2010 procedures (SOPs) for intensive care together with ICU requirements;
unit (ICU) and hospital preparations (5) provide clinical care to patients
On behalf of the European Society of
Intensive Care Medicine’s Task Force for for an influenza pandemic or mass only with clinical staff and not with
Intensive Care Unit Triage during an disaster with a specific focus on non-clinical staff; (6) delegate duties
Influenza Epidemic or Mass Disaster. manpower. Methods: Based on a not within the scope of workers’
literature review and expert opinion, a practice under crisis conditions with
Delphi process was used to define the proper supervision and support from
essential topics including man- experienced clinicians to ensure
power. Results: Key patient safety; (7) intensivists should
recommendations include: (1) plan to supervise nonintensivist physicians to
access, coordinate and increase labor expand the workforce if patient surge
resources for continued and expanded exceeds the number of available
ICU care including increasing critical ICU-trained specialists.
care specialists and expanded practice Conclusions: Judicious planning and
for non-critical care personnel; adoption of protocols for providing
(2) develop an education, awareness, adequate manpower are necessary to
preparation and communication pro- optimize outcomes during a
gram to ensure a well-protected and pandemic.
prepared workforce with coordinated
rapid manpower expansion; (3) main- Keywords Manpower

tain a central inventory of all clinical Recommendations

C. Sandrock ()) and non-clinical staff with their Standard operating procedures

Intensive Care Unit, Division of Infectious Intensive care unit
Hospital
H1N1

Diseases, Division of Pulmonary current roles along with possible
and Critical Care Medicine, emergency re-training possibilities; Influenza epidemic
Pandemic

UC Davis School of Medicine, (4) coordinate all clinical and non- Disaster
Sacramento, CA 95820, USA clinical staffing requirements and

Introduction accommodate the large increase of patients with physician-

nurse collaboration [1]. Critical care delivery, in particular,
A large-scale disaster such as an earthquake, flood or out- will be essential given the specialized medical resources and
break of infectious disease has the potential to generate large staffing that are required. However, in certain disasters, such
numbers of critically ill patients sufficient to overwhelm as pandemic influenza, staffing may be limited. In fact, 25–
hospital and critical care resources. The health care system, 40% of critical staff may be absent in a pandemic because of
from clinics to the intensive care unit (ICU), will need to staff absenteeism and exposed or treated staff. Thus, an
 S33

essential plan to access and coordinate the labor resources Scope

will be required to support extensive ICU care [2, 3]. This
will include increased access to critical care specialists as This standard operating procedure (SOP) document pri-
well as expanded scope of practice for non-critical care marily focuses on labor force maintenance for critical
trained medical personnel. The need of critical care man- care delivery within hospitals and health care systems. It
power will vary over the course of the pandemic, leading to a includes the expected labor resources at each pandemic
flexible and variable need and scope of practice that must level along with recommended levels of resources
adjust to the changes of the disease process. (Table 1). The number of trained staff is the dominant
rate-limiting step to increasing surge capacity.
Key manpower resources should be identified within
Purpose the following groups to provide an ICU labor pool:

To ensure that during an immediate or extended disaster, • Medical doctors

critical care, medical, nursing and ancillary staff are readily • Registered nurses (RN), licensed vocational nurses
available across hospital, alternate care sites and regional (LVN) and respiratory care practitioners (RCP)
facilities to ensure the best possible patient care. • Pharmacists

Table 1 Expected labor resources and activities at each pandemic level

WHO pandemic phase Manpower activity

Interpandemic Review and update communications plan with staff

Period: Phases 1 and 2 Review the Disaster Plan and standard operating procedure with all staff
Pandemic alert period: Review critical elements of the Pandemic Plan with all staff including nonclinical resources
Phase 3 Complete fit testing of all current employees as needed
Initiate webpage to keep staff informed on status and provide educational updates; coordinate with
Communication and Education Workgroup
Initiate call number or other plans for staff to call in and receive current status report
Monitor employee absenteeism for increases
Pandemic alert period: Senior leadership collaborates with local and regional health care groups in attempt to coordinate response
Phase 4 with manpower support
Update webpage and call in number to provide information to staff; coordinate with Education and
Communication Workgroup
Implement staff rotation restriction; staff in cohort areas do not move to non-cohort areas
Coordinate with staff protection, vaccination and anti-viral use
Pandemic alert period: Manager or designee to implement phone alert system: first level phone calls to ascertain if staff is available to
Phase 5 come for their next scheduled shift
Manager or designee to assess current patient staffing needs and available resources; notify Staffing Office of
status
Designee to notify Non-Clinical Labor Pool Leader of potential needs and status of pandemic
Patient Care Resources Manager or designee to poll all personnel in non-direct care positions for availability to
staff, e.g., nursing recruitment, ancillary support, clinical research scientists
Implement staff rotation restriction; staff in cohort areas do not float to non-cohort areas
Pandemic period: Activate pandemic staffing plan for clinical and non-clinical resources. Pull non-clinical call list into action
Phase 6 Manager or designee to assess patient needs, communicate with staff on those needs and keep Staffing Office
informed of needs and available resources
Staffing Office to be the central hub for clinical staffing resources under leadership of designee
Designee to coordinate available resources with non-clinical labor pool leader
Update webpage and information number to keep staff informed
Staff sick calls: call into home unit charge nurse; charge nurse records sick call and notifies Manager or
designee; records to be reconciled at a later date
Designee to coordinate with Hospital Emergency Executive Control Group on need to staff alternate care sites
Continual assessment of staff s physical and emotional status and provide intervention as needed
Implement staff rotation restriction; staff in cohort areas do not float to
Non-cohort areas
Post pandemic period: Return to normal operational staffing procedures
Phase 7 Evaluate staff’s physical and emotional status and provide intervention as needed, e.g., critical incident
debriefing management program and grief management
Assess staff’s needs for days off, vacation, alternative schedules
Evaluate effectiveness of pandemic plan, revise as needed
S34

• Ancillary staff (e.g., assistants, transport, social ser- – Hospital-based specialists

vices, clergy, housekeeping, clerks) – Primary care physicians
• Intensive care unit administration (medical and man- – Surgical sub-specialists (e.g., neurosurgery)
aging director) – Respiratory care therapists
• Support therapists (occupational, physical and speech) – Medical/surgical nursing
• Clinical infectious disease and microbiology laboratory – Students of professional medical and nursing schools
support – Veterinarians, dentists and other health professionals
• Radiology technicians, surgical scrub technicians and – Retirees
equipment specialists – Volunteers
• Respiratory care specialists and therapists
• Infection control and health care epidemiologists • Providing a hospital structure and process to ensure
• Nutrition and dietary effective manpower availability. Education, awareness,
• Physical and environmental support (e.g., plant preparation and communication are required to ensure
management) the following:
Hospitals and other critical care response facilities
should implement this SOP within the broader network of – A well-protected and -prepared workforce
cooperation at a local, regional and national level. In – Coordinated and rapid manpower expansion
particular, the numbers of ICU staff are frequently limited – Adequate psychosocial and family support
and vary in experience throughout a region. Therefore, – Worker safety and health
direct coordination with the Regional Emergency Exec- – Ability for adequate rest and support
utive Control Group in conjunction with the health care – Rapid de-escalation and return to normal medical
system is required to deliver care equally and ethically. function
The ICU needs should be balanced against other hospital
service needs. • Defining the roles and responsibility of key individuals
This section addresses clinical labor pool issues only; with regard to the implementation of emergency
clinical staff should employ the precautions in the fol- response plans.
lowing sections when providing patient services:

• Protection of staff and patients (see Chap. 6, Protection Definitions

of patients and staff)
• Surveillance 1. Hospital Emergency Executive Control Group: The
• Clinical management coordinating hub of the hospital. There should also be
Local and Regional Emergency Executive Control
Groups for the local and regional levels. There should
Goals and objectives be an incident manager at the hospital, local and
regional levels.
To establish a system of enhancing and coordinating labor 2. Incident manager: the coordinating and commanding
pool resources between the ICU and the health systems lead within the hospital or health care facility (usually
across a region by: the hospital director or designee).
3. Personal protective equipment (PPE): Protective mea-
• Identifying key manpower resources within the health sures, such as masks, gloves and gowns, used by the
care system to provide an adequate critical care labor workforce for reducing transmission of disease.
pool. These include: 4. Ancillary support: All staff that do not have direct
patient care contact and provide support to infrastruc-
– Medical staff ture maintenance and expansion.
– Non-essential academic staff
– Hospital administration
– Volunteer resources
– Ancillary support departments Basic assumptions
– Retirees 1. Only clinical staff should provide care to patients.
Non-clinical staff should not provide clinical care.
• Creating an expanded scope of practice for non-critical 2. The credentialing and training should be provided for
care medical personnel to provide critical care. These staff and coordinated by the hospital in coordination
may include: with the regional regulatory authorities [4].
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3. Medical care provided outside of the scope of standard conditions with proper supervision and support from
practice should be coordinated and controlled within experienced clinicians to ensure patient safety [6].
the hospital and regional Emergency Executive Con- 4. Systematic efforts to reduce care variability, procedure
trol Groups. complications and errors of omission should be used
4. All liability and legal issues surrounding an expanded when possible [6].
scope of practice should be addressed by the provincial 5. Work conditions may have to be modified (e.g.,
or national government [5]. lengthening shift hours, changes in type of work,
5. Communication with staff should be coordinated by call-backs and holding staff, provision of housing).
the hospital and regional coordinators. Staffing ratios may have to be altered to compensate
6. Manpower of non-clinical support, such as nutrition, for working in an unfamiliar environment, use of less
housing and facilities management should be main- skilled staff and time to don personal protection
tained and adequate for labor force support. equipment.
7. Ancillary support, such as housing and nutrition, 6. Staffing needs (housing, food, family support and
should be provided to staff during the disaster. childcare) and appropriate protective measures (vac-
8. A proactive workforce education and health and safety cinations, protective equipment and antivirals) along
protection program will reduce the strain and help better with the appropriate training should be provided.
prepare employees for the realities they will face when 7. Once hospital manpower needs are exceeded, the local
an influenza pandemic occurs (see Chap. 6, Protection of authority followed by regional or national authorities
patients and staff; Chap. 9, Educational process). may provide support for health care facilities.
9. There may be limited availability of PPE, but the
assumption is the workforce should be provided with In some cases, the labor force will be stretched and
adequate protection in clinical care circumstances. clinical care may be given by individuals beyond their
standard scope of practice. In these cases, the following
guidelines should be followed:

Lines of authority 1. Individuals with clinical experience and the necessary

skills are preferred to work outside their scope of
The coordination of the labor force, including expansion practice.
of the scope of practice, will be required at the hospital, 2. If patient surge and critical care needs exceed the
local, regional and national levels. Initial authority should number of critical care trained specialists, then indi-
be managed internally by the health care facility with the viduals with critical care experience may directly
direction of the incident manager. The needs of man- supervise a series of health care personnel in an effort
power should be assessed and integrated by the to expand the workforce [6].
operations, logistics and planning sections of the Hospital 3. Staffing ratios should be increased based on local
Emergency Executive Control Group. needs and laws. Ideally, the ratio should remain
Once manpower needs exceed that of the local health constant and equal throughout ICUs in the hospital
care facility, the local jurisdiction should provide support and region in order to provide equitable care.
to the health care facility. In turn, the regional or national 4. Specialists in critical care can assist other non-
government should provide further support as the need for specialist health professionals through video confer-
manpower continue to grow. encing or telehealth when necessary. This is preferred
over phone, Internet or e-mail support.

Concepts of operations
During the initial scope of operations, health care facili- Functional roles and responsibilities of the internal
ties should plan on the following guidelines when personnel and labor workforce
increasing their labor pool: 1. Staffing office This is the central hub for coordinating
all staffing needs, including both the clinical and non-
1. Patient care assignments for caregivers should be man- clinical labor workforce. This unit should determine
aged by the most experienced clinician available [6]. the daily needs of the hospital and coordinate the input
2. Assignments should be based on staff abilities and from staffing designees regarding the clinical and non-
experience [6]. clinical labor workforce. The estimated 24-h need
3. Delegation of duties that usually lie within the scope of should run through this office. The Staffing Office
some workers’ practice to different health care work- should report to the Hospital Emergency Executive
ers may be necessary and appropriate under crisis Control Group.
S36

2. Clinical labor designee This person should determine the 9. Staffing needs, including housing, food, family support
clinical needs and staffing issues. This should include a and childcare, should be provided as needed for the staff
sick and no-show list along with subspecialist and critical during the pandemic. This will be especially important
care requirements. This person should relay information given quarantine or isolation issues.
back to the staffing office, and should also alert clinical 10. A plan for appropriate equipment training should be
personnel to any staff or practice changes. available for the health care staff as needed.
3. Non-clinical labor pool designee This individual 11. All staff should be given the appropriate PPE training
should determine the non-clinical personnel needs, as needed throughout the outbreak as clinical need
which include support staff (e.g., housekeeping) along and situations vary.
with non-clinical labor that should move toward a
clinical support role (e.g., housekeeping to unit clerk).
Maintenance of standard operating procedures
Logistics support and requirements necessary
for the effective implementation of the SOPs Hospitals should participate and evaluate one full-scale
exercise annually plus one review exercise annually. This
1. Training of staff should be provided as they move exercise should evaluate the labor work force plan as out-
into an expanded scope of practice along with dif- lined in this SOP. The exercise should be designed to help
fering staff roles [5]. Education should include identify and assess gaps in preparedness and response
medical management, personal protection, environ- competencies in key individuals and units. The SOPs should
mental contamination, training of recruited staff, be modified and updated following each review to ensure
handling laboratory specimens, alert lists, ethical and that communication technology, processes, protocols and
psychosocial issues, dealing with the deceased and the information contained within them are current.
visitor restrictions (see Chap. 9, Educational process).
2. This training should be provided in adequate rooms
and facilities. If necessary, distance or web-based
programs should be provided with regular updates. Recommended training and exercises activities
3. A central inventory of all staff with their current role
at each health care facility should be maintained. All hospitals that provide intensive care services should
This should include labeling that should provide provide training in communication and labor force acti-
clinical and non-clinical staff with possible emer- vation for senior staff in crisis situations. Training should
gency re-training as needed. be uniform across the region and often done in conjunc-
4. A central database for health care professional tion with other local, regional/state or national exercises.
volunteers should be available at the local, regional Staff training modules should be developed and tested
or state level in order to provide manpower support to ahead of time and should focus on varying labor force
health care facilities. roles and support in a disaster.
5. An allocation plan for vaccine and antivirals, based on In conjunction with national authorities, additional
clinical risk and workforce role, should be available. testing of specialist activation, credentialing and compe-
6. An employee health plan, including managing exposed tency testing and larger national volunteer team activation
and infected staff members, should be available. should be performed to demonstrate and strengthen the
7. Family support and a childcare plan should be enacted labor force movement within the health care system,
for the labor force at each health care facility. across the health care field and within national and private
8. Appropriate protective measures, including a vaccine health care facilities.
allocation plan along with protective equipment,
should be available for staff members. Conflict of interest None.

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