Coping with complexity in the COVID pandemic: An exploratory study of intensive care units

Abstract

Although the COVID pandemic has challenged the resilience of health services in general, this impact has been most visible in intensive care units (ICUs). This paper presents an exploratory study of how ICUs in Brazil have coped with the complexity stemming from the pandemic. Five guidelines for coping with complexity were adopted as analytical framework. The guidelines were concerned with slack resources, diversity of perspectives, visibility, work-as-done, and unintended consequences. There were three main sources of data: (i) a survey with respondents from 33 ICUs, which indicated their agreement with 23 statements related to the use of the complexity guidelines; (ii) semistructured interviews with seven survey respondents and two public health officials; and (iii) 20 h of observations of the meetings of a municipal bed management committee. Seventy resilience practices were identified from these data sources. Most of these practices (n = 30) were related to the guideline on slack resources, which were commonly obtained from other hospital units. As for the survey data, the statement related to the availability of extra or standby human resources obtained the lowest score, reinforcing the key role of slack resources. Five lessons learned for coping with complexity in ICUs were drawn from our data; one lesson for each guideline. Furthermore, the survey questionnaire is a potential ICU assessment tool, which can be adapted to other health services.

The rise of resilient healthcare research during COVID-19: scoping review of empirical research

“…Over half the researcher-developed questionnaires (n = 7, 64%) were based on a conceptual framework, including Hollnagel’s [ 53 ] ‘four cornerstones of resilience’ [ 54 ], Anderson et al’s [ 55 ] Integrated Resilience Attributes Framework [ 56 ], Bueno et al’s [ 57 ] guidelines for coping with complexity [ 58 ], Macrae and Wiig’s [ 59 ] resilience framework [ 35 ], the WHO’s [ 60 ] fundamental ‘building blocks’ of health systems [ 61 , 62 ] and the WHO’s hospital readiness checklist [ 63 , 64 ]. Three additional survey studies lacking a conceptual framework collected predominantly open-ended questionnaire data on how everyday clinical work is being performed during the pandemic (i.e., work-as-done), via the perceptions and experiences of healthcare workers [ 32 , 43 ], using inductive content analysis, and to confirm or corroborate any emerging themes identified from interview data [ 65 ].…”

From Threatening Chaos to Temporary Order through a Complex Process of Adaptation: A Grounded Theory Study of the Escalation of Intensive Care during the COVID-19 Pandemic

“…In line with subsequently published guidelines for surge capacity [24,25], the ICU management adjusted plans, negotiated and prioritized different stakeholders' interests, reorganized and tried to compensate for deficiencies by adapting the ICU's capacity in terms of space, stuff, staff, system and science. Although corresponding types of surge response have been described by other researchers [5,6,[36][37][38]44,45], in light of possible publication bias, the bottom-up approach seems to distinguish Sweden from other countries. Selforganization and microlevel autonomy were facilitated by trusting leadership, which has been recognized as an enabler of adaptive capacity [17,27]; subsequently, these outcomes were also supported by crisis management, as well as administrative and practical support, from actors at the mesolevel.…”

“…The process of adaptation continued until the contagion faded away and the aftermath of the escalation was discernible. As in other settings [4,35,36], pent-up care and staff with recovery needs were prominent. However, individual and organizational development (commonly referred to as learning or growth [8,27]) were also visible, thus possibly improving preparedness for future challenges.…”

“…The establishment of temporary ICUs to provide cohort care was enabled by large premises with access to oxygen, compressed air and isolation facilities, as described by other researchers [5,6,36,37]. These temporary ICUs facilitated capacity escalation but entailed suboptimal working conditions and challenges for patient safety, points which have also been emphasized by previous researchers [6,22,36].…”

“…The establishment of temporary ICUs to provide cohort care was enabled by large premises with access to oxygen, compressed air and isolation facilities, as described by other researchers [5,6,36,37]. These temporary ICUs facilitated capacity escalation but entailed suboptimal working conditions and challenges for patient safety, points which have also been emphasized by previous researchers [6,22,36]. To meet future escalation needs in a more expedient manner, the development of preprepared "silent" ICUs, which can be used for other activities during normal circumstances and easily activated in a surge response.…”