I write while sitting in an airport following a long and delayed cross-country flight, waiting for my misdirected luggage to appear. Today has been relatively easy compared with 3 days ago, which featured 12 hours of delays culminating in cancellation of my flight.

I was not alone, as heavy storms and wildfires disrupted the national transportation system. Many trips were delayed, connections missed, and plans simply cancelled. Safety required that we stay at the airport, our planes parked at their gates. As our experienced pilots observed: better to be on the ground wishing we were in the air than to be in the air wishing we were on the ground. Our collective frustration would eventually dissipate, and my fellow inconvenience travelers and I made the best of the time until we were on our way.

The intensity and frequency of flight-limiting weather has increased. The demand for air travel has also increased. Sadly, there has not been a parallel increase in preparedness by corporations or government for responding to an absorbing the large scale disruptions that follow these increasingly common major weather events. While part of the responsibility falls on the travelling public—flexibility has to be engineered into our plans—the downstream effects of a large-scale disruption ought to be more effectively softened by ready-to-implement functional responses that minimize collective inconvenience and expedite individual resolution.

Unlike those of us waiting for the boarding call, patients who require ICU care rarely tolerate delay in the care that each of them in need. COVID-19 and other disasters have exposed our collective vulnerability and our patients suffer and die when we fail to prepare for large volume, sustained surges. Even under normal circumstances, ICUs are commonly “stressed,” typically operating at or near capacity in terms of bed availability and staffing requirements (1). We can say—and say with great confidence—that that another surge in demand is coming (2). We cannot know the particular trigger, nor can we know precisely when that trigger will be pulled.

In this issue of Critical Care Medicine, Nates et al (3), on behalf of the Academic Leaders in Critical Care Medicine (ALCCM) Task Force for of the Society of Critical Care Medicine, present a description of the variables that determine how academic critical care organizations (CCOs) deal with resource needs under both usual circumstances and during situations of excess strain and surge, along with the factors that critical care providers must consider to ensure that critical care systems deliver timely, effective, and fluid response. Key to all of this is the concept of “flow-sizing,” which as the authors describe, reflects the ability of an organization to shift staff, resources, beds, services, and perhaps even facilities to adapt to and meet the acute clinical demands that patients who need ICU care during surge-like situations. This report is not an isolated endeavor by the ALCCM but rather represents the latest effort in a series of recent related published missives commissioned by the ALCCM which have addressed similar issues, most notably regionalization of critical care services (4) and provider workforce, workload, and burnout (5). Clearly there’s a synergy among these endeavors, as they are interrelated and are especially relevant during surge conditions when the usual level of staffing, resources, and beds are unable to meet the sudden—often sustained—increased demands for care.

The Task Force cited several factors that largely determine operational critical care capacity, including: 1) the number of ICU beds immediately available and those that could be annexed; 2) the infrastructure and equipment needed to support the care of patients in those beds; and 3) the availability and efficiency of trained ICU providers (3). Yet as the authors write, what unifies and synthesizes all of this is the concept of “patient-flow efficiency,” which essentially captures the ability to safely and efficiently adapt to surges and ensure that quality of and access to care does not falter and rises to the situational need. Preparedness is more than counting the resources. Preparedness requires the ability to rapidly mobilize those resources to operational readiness. From a methodologic standpoint, the Task Force derived their recommendations from a comprehensive review of the literature, followed by regular meetings among the members to synthesize the inputs and create an overall framework for a consensus.

The ALCCM’s recommendations make both intuitive and practical sense, identifying the crucial links to efficient, high-quality, and safe critical care delivery during times of surges and strains. While this effort targeted surge conditions, the recommendations apply to critical care delivery for both stress and non-stress situations, as they address general critical care efficiency and effective patient throughput. Similarly, the recommendations may also apply beyond the ICU realm and apply more generally to acute care and other healthcare settings, including the emergency department, urgent care clinics, and other key loci of patient care. Successful organizations and systems have as part of their core values an ethos to continually strive for efficiency, excellence, and proactive planning for future challenges, changes, and surges.

From the standpoint of surge preparedness, one could make the case for CCOs to use these Task Force’s recommendations as a stimulus to spur the wider critical care community toward a broad initiative for pandemic and disaster planning. CCOs should also commit to a rigorous quality initiative that goes beyond the ALCCM’s recommendations for surge preparedness and flow-sizing toward a process of data collection and analysis that explores past surge events and incorporates the lessons learned into clinical practice and organizational preparedness.

The ALCCM recommendations as currently tendered are relatively general and largely descriptive and do not detail a formal process (e.g., the Delphi methodology) to minimize bias and generate more objective consensus (6). Methodologic rigor may be important in persuading individuals and institutions to engage deeply with preparedness and response. Furthermore, the recommendations seem most applicable to academic medical centers and teaching hospitals in the United States and thus, revision might be required for smaller community hospitals, for institutions outside North America, and for critical care delivery and healthcare systems in less developed countries.

The key message that flows from guidance provided by the ALCCM is that we need to understand how to best respond to pandemics, disasters, and other yet-unimagined surges that will inevitably arise. It is incumbent upon the critical care community (and the larger systems of healthcare) to rigorously prepare and plan for such events.

When the severe acute respiratory syndrome coronavirus 2 pandemic struck, the critical care community realized—and at the expense of too many patients lost—that we were seriously unprepared to treat the influx of critically ill COVID-19 patients. There were significant shortfalls, gaps, and variability in how patients were managed, how units were staffed, and how hospitals and healthcare systems responded (1,7,8). While that pandemic has waned, in concert with the public’s overall precautionary diligence, the imperatives for pandemic planning remain as acute as ever.

What must not wane is the imperative for surge preparedness during pandemics, disasters, and related events. Failure to anticipate the next surge event and plan for the necessary response would constitute willful, almost blatant negligence. Herein lies the opportunity, for as Arabi et al (9) write, “the best way to handle a surge of ICU patients is to avoid one.”

We cannot prevent the storms that ground airplanes. We cannot insulate ourselves from the pathogens, tornados, floods, or fires that bring patients to our doors. We can and must, however, anticipate their occurrence, prepare for the need, and exercise the responses.

1. Bagshaw SM, Zuege DJ, Stelfox HT, et al.: Association between pandemic coronavirus disease 2019 public health measures and reduction in critical care utilization across ICUS in Albert, Canada 2021. Crit Care Med. 2022; 50:353–362 2. Kaji Am Koenig KL, Bey T: Surge capacity for healthcare systems: A conceptual framework. Acad Emerg Med. 2006; 13:1157–1159 3. Nates JL, Oropello JM, Badjatia N, et al.; Academic Leaders in Critical Care Task Force (ALCCM) of the Society of Critical Care Medicine: Flow-Sizing Critical Care Resources. Crit Care Med. 2023; 51:1552–1565 4. Leung S, Pastores SM, Oropello JM, et al.: Regionalization of critical care in the United States: Current state and proposed framework from the academic leaders in Critical Care Medicine Task Force of the Society of Critical Care Medicine. Crit Care Med. 2021; 50:37–49 5. Lilly CM, Oropello JM, Pastores SM, et al.: Workforce, workload, and burnout in critical are organizations: Survey results and research agenda. Crit Care Med. 2020; 48:1565–1571 6. Nasa P, Jain R, Juneja D: Delphi methodology in healthcare research: How to decide its appropriateness. World J Methodol. 2021; 11:116–129 7. Fleisher LA, Schreiber M, Cardo D, et al.: Health care safety during the pandemic and beyond – building a system that ensures resilience. N Engl J Med. 2022; 386:609–611 8. Fauci AS: It ain’t over till it’s over … but it’s never over – emerging and remerging infectious diseases. N Engl J Med. 2022; 387:2009–2011 9. Arabi YM, Azoulay E, Al-Dorzi HM, et al.: How the COVID-19 pandemic will change the future of critical care. Intensive Care Med. 2021; 27:282–291