Table 2

On-the-day adaptations used in ICUs with illustrative examples

Theme	On-the-day adaptation	Example
Flex resources
	Manage patients who need intensive care outside unit	Outreach team used to manage patients on the ward until bed becomes available in ICU. Provide care to patients in the emergency department to prevent further deterioration before delayed admission to ICU.
	Flexing staff to address numbers or skill mix	Adaptively flex staffing throughout the day based on acuity of patients, nursing ratios and available skill mix of staff. For example, replace junior team members with more experienced staff when patient’s acuity exceeds experience and skill set.
	Managerial staff take on clinical roles and responsibilities	Education team help on busy days or provide intermittent break relief. Senior nurses postpone or share administrative tasks in order to provide direct patient care or collectively manage crisis for a short period of time.
	Adjusting staff–patient ratios	Adapt and flex rules for nurse–patient ratios in intensive care. For example, senior staff may sometimes care for two level 3 patients. Use of students and healthcare assistants (supervised by a more senior staff member) to make sure all patients have a dedicated member of staff.
	‘Cohorting’ patients in the unit by acuity	Patients are moved around the unit so that the most critically ill patients are concentrated in an area with the most experienced staff, making care for patients more efficient and manageable for the whole team.
Prioritise demand
	Prioritising patients within the unit by urgency and by who would benefit most	Prioritise patients and tasks by urgency. For example, physiotherapists had their own loosely held criteria of who to prioritise based on body area (eg, chest patients) and procedure (eg, tracheostomy).
	Transferring or relocating patients with less need	Discharge patients early to the ward when ordinarily they would be kept an extra day for reassurance. Outreach teams asked to follow-up on the ward.
	Temporarily stopping or delaying some activities/types of care	Delay or suspend some tasks and activities such as tasks relating to patient comfort such as washing and activities such as staff education and training. Tasks that were occasionally delayed temporarily included ward rounds, taking patients outside or talking to families.
Adapt ways of working
Adapt communication	Increasing communication with other teams to coordinate faster admissions and discharges	Increase communication with outreach, operations and duty manager teams at times of pressure, to coordinate patient admissions and discharges with multiple areas of the hospital, including surgery, the emergency department and the wards.
	Use of instant communication to troubleshoot problems	Regular use of WhatsApp, emergency Microsoft Teams meetings and other means of instant communication to request urgent support or updates.
	Boards for monitoring and communication	An interface to monitor beds and demand during COVID-19, which was carried forward into routine practice to identify units under pressure for beds.
Adapt leadership	Greater presence ‘on the shop floor’	Be more visible, which often involved patrolling the unit to monitor, check-in and support where needed. Doctors use mobile computers on wheels to maximise efficiency of administrative work on the ward and to be immediately available in the ICU to support nurses.
	Using networks to advise and help	Knowing who to call in a crisis, with individuals relying extensively on personal contacts across the hospital.
	Providing additional support to staff and opportunistic teaching	Ensure staff take breaks, eat and monitor fatigue and well-being (eg, hot debriefs, welfare checks). Create learning opportunities where possible on the day, such as impromptu bedside teaching.
	Stepping back to have better awareness of the situation	Step away and find a quiet undisturbed place for a moment to gain a better overview of the situation and understand how best to prioritise and delegate tasks.
	Adjusting and communicating goals for the system	Call for a brief huddle to clarify aims or refer to contingency plans, including reallocation of roles, when an uncommon event occurs (eg, paediatric admission).
Adapt teamwork	Increasing collaboration and asking for help	Junior members of the team encouraged to ask for help and support, for example, transfer task to senior staff or delegate to healthcare assistants as appropriate.
	Task shifting between professions	Doctors assist with turning patients or cover breaks and nurses are asked to be involved in ward rounds. Physiotherapists monitor patients when nurses are unavailable or during emergencies (eg, cardiac arrest).
	Adjusting or making clear allocation of roles	Clear allocation of tasks, emphasising their priority and providing a timeframe when pressures are high.
	More use of confirmation and closed-loop communication	Increased use of closed-loop communication as a checking mechanism (read-back) to confirm instructions have been listened to and understood.

ICUs, intensive care units.