Table 1

Anticipatory strategies used in ICUs with illustrative examples

Theme	Anticipatory strategy	Example
Increase resources
	Initiatives to increase staff in longer-term recruitment	Substantial numbers of international nursing graduates recruited to fill vacancies. A hospital employed a dedicated recruitment and retention nurse to support them. Non-clinical staff team recruited to manage stores (eg, restocking supplies), previously managed by nurses on shift.
	Strategies to create temporary capacity in the short-term	Relocate clinical skills practitioners from educational roles to work clinical shifts in order to bridge staff shortage gaps. Advertise for bank staff, often through social groups (eg, Facebook/WhatsApp). Some hospitals used agency staff on a regular basis and others only in emergencies.
	Improving skill mix of existing staff through additional training	Create specialist job roles to improve skill mix. For example, specialist nurses who are trained to treat deteriorating patients. Education and professional development of new international nursing graduates in clinical skills and non-technical skills, such as speaking up about concerns. Train healthcare assistants to notice deterioration in blood pressure to alert nurses, allowing nurses to do other work.
	Managers required to take on more clinical hours	Managers take on more clinical work themselves to address skill-mix concerns and cut back their managerial time.
Control demand
	Flexing admission and discharge criteria depending on pressure in the unit	Use outreach teams to identify ward patients at risk of deterioration or by ‘weather-forecasting’ potential ICU admissions based on patient demand coming through the emergency department and acute medical unit. Discharge patients to ward care who would usually remain on the ICU for further days or transfer to another ICU/hospital in the network if needed. This was reciprocal based on fluctuating pressures in each hospital within the network. Pre-emptively admit patients to ICU to relieve pressure elsewhere (eg, emergency department).
	Discharging patients directly home from the ICU instead of to ward with follow-up support at home	Discharge patients straight home from intensive care rather than to a ward (if home support is available) and use outreach teams to follow-up. These patients would be carefully selected prior to discharge with the safety net of the outreach team there to be a point of contact for carers at home.
	Cancelling elective surgeries	Cancel elective surgery for patients likely to need an ICU bed following their surgery. This was generally a last resort.
Plans for managing the workload
Efficiency strategies	Using technological aids to make communication more efficient	New communication device (eg, Vocera), “like a little Alexa”, for communicating with colleagues, helpful for feeling supported and saving time (eg, contacting lab directly for emergency blood). Use of an app for storing reports and sharing news, making it easier to access information and communicate updates.
Forward planning	Contingency planning and anticipating potential scenarios	Use morning safety huddles to have “what are we going to do if…” conversations and having a back-up plan for when an unusual event occurs (eg, paediatric admission). Double-up regular and agency staff on the rota to allow for on-the-day absences of either.
Forward planning	Creating or adapting protocols to reinforce the basics	Create or simplify existing protocols to make them more accessible for junior staff and increase eligibility for tasks. Provide simulation training of protocols to remind staff of the essentials of care, and test out new/adapted protocols.
Monitoring and coordination strategies	Having planned meetings for monitoring the situation and communicating plans	Fixed checkpoint meetings (eg, safety huddles, sit reps) throughout the day to communicate emerging concerns and identify priorities with the team. These meetings always went ahead even when the units were under intense pressure.
	Having up-to-date knowledge of resources and demand in ICU and wider hospital	Keep track of available beds on the wards to discharge patients to and elective surgery patients who may need intensive care beds. Outreach teams were described as ‘the external sensors of ICU’ and helped to identify deteriorating patients on the ward who might need admitting to ICU.
	Centralised structures for co-ordination	One of the larger hospitals with multiple ICUs had introduced a new coordinator role (‘operational nurse in charge’) who communicated staff number and skill mix needs across each of the ICUs.
	Staff rotas organised to share difficult shifts evenly	Identify shifts with heavy/high acuity patient load and use of personal protective equipment so that such work could be evenly distributed between staff.
Staff support initiatives	Initiatives to provide support to staff	Dedicated wellness teams and allocated psychologists to provide emotional and practical support to staff. Professional nurse advocates with allocated time for the well-being of colleagues, including providing break relief, help with competencies or restorative supervision sessions. Additional support for international nursing graduates to help them transition including specialised induction programmes and buddy systems.

ICU, intensive care unit.