ICUs advised how to improve staffing ratios as covid pressure eases

In expectation that the pandemic would put intense pressures on ICUs, staff ratios were relaxed. NHS England told trusts to base their staffing models on one critical care nurse for every six ICU patients, supported by two non-specialist nurses, and one senior ICU clinician for every 30 patients, supported by two middle-grade doctors.

Before the pandemic, guidance from the Faculty of Intensive Care Medicine recommended a ratio of one non-specialist nurse per patient. For senior clinicians the ratio was 1:10

New guidance, expected as early as next week, will encourage trusts to reduce the number of patients per ICU specialist nurses and senior clinicians on a localised basis as part of “transitional arrangements” aimed at moving staffing models back towards normal standards of care, HSJ has been told.

The new guidance, drawn up by NHS England, the Faculty of Intensive Care Medicine and the British Association of Critical Care Nurses, will give trusts recommended staffing ratios based on the occupancy rates of their ICUs. It will tell trusts the existing ratios should be applied if their ICUs are running at four times their normal capacity. For ICUs running at double capacity, this ratio would be reduced to 1:2 for ICU nurses, and 1:15 for senior clinicians.

Decisions on staffing ratios would be made at local trust level as ICUs across the country are facing differing pressures.

Alison Pittard, dean of the Faculty of Intensive Care Medicine, told HSJ the NHS “cannot sustain” the current staffing arrangements in ICUs and units need to work towards getting back to normal staffing ratios in a “phased way”.

She said: “The way it happens and the speed it will happen at will be very different and dependent on individual hospitals.

“There have been places that have had much more demand than others. Those that have had the highest demand will take longer. They have still got more patients than they would normally have. Across the country it is going to be very different.

“[The guidance will] ensure that as hospitals and the NHS start to resume some normal activity, it’s done in a safe way.”

Nicki Credland, chair of the BACCN, told HSJ the association “fully expect[s] nurse staffing to return to pre-covid ratios” in the next phase of the pandemic, but added this would not happen imminently as ICUs still have many covid-19 patients.

Ganesh Suntharalingam, president of the Intensive Care Society, said not all clinical staff on surgical pathways will be able to resume normal practice while the pandemic is still in progress, meaning transitional arrangements are needed.

He told HSJ: “We need to recognise that what has been done under surge conditions is a response to a crisis, and is not sustainable in its impact on staff or in the ability to deliver care to pre-existing standards.

“But there are non-COVID patients who need urgent care too, and it is right to be looking at a transitional stage to get a degree of normal activity back as soon as possible.

“We need to find a middle ground suitable for the next few months, which is deliverable in a time-limited way. Looking beyond that, there is likely to be a ‘new normal’ for the long term, but we need to develop a consensus on what that looks like.”

NHSE has been contacted for comment.

Updated wording on 8 May from ‘told to’ to ‘advised how’.