**Background:** The COVID-19 pandemic has caused unprecedented mental health disturbances, burnout, and moral distress among health-care workers (HCWs), threatening their ability to care for themselves and their patients. As of February 10, 2023, over 677 million COVID-19 cases and 6.8 million deaths were reported globally, with an estimated 115,500 HCWs dying from COVID-19 between January 2020 and May 2021. HCWs have reported increased anxiety (12%-89%), depression (16%-82%), stress reactions (5%-80%), sleep disturbances (8%-96%), and posttraumatic stress disorder (7%-73%). Burnout rates during the pandemic ranged from 3% to 69%, with emotional exhaustion in 3%-50% of HCWs. The US Surgeon General in May 2022 described HCW burnout and moral distress as threats to public health requiring systems-oriented solutions. The Task Force for Mass Critical Care (TFMCC) convened a Workforce Sustainment subcommittee of 22 experts (17 physicians, 2 nurses, 2 advanced practice nurses, 1 pharmacist) to address these issues.
**Methods:** The subcommittee used a consensus development process merging frameworks from the WHO and the Guidelines International Network-McMaster Guideline Development Checklist. A three-round modified Delphi approach was employed: round 1 synthesized published evidence, round 2 gathered anecdotal evidence from panelists' direct clinical experience, and round 3 developed suggestions. A five-point Likert scale derived from the GRADE grid was used, with retention criteria requiring a mean score of ≥3.5/5 and at least 80% of members voting. The GRADE Evidence to Decision framework guided voting, factoring in priority of problems, quality of evidence, balance of values, resource requirements, cost-effectiveness, and feasibility. An initial literature search in December 2020 yielded 44 articles, updated in December 2021 with 153 additional articles, plus 6 more from references and panelist input. From these, 152 evidence-based statements and 45 anecdotal statements were extracted.
**Key Results:** After consolidation and voting, 14 major suggestions meeting retention criteria were approved by consensus. These were organized into three categories: (1) Mental health and well-being for staff in medical settings (Suggestions 1-5); (2) System-level support and leadership, with subcategories on staffing/training and policy (Suggestions 6-12); and (3) Research priorities and gaps (Suggestions 13-14). Key recommendations include: balancing heavy workloads through flexible hours and rotating between high- and low-stress environments (Suggestion 1); ensuring adequate nutrition, hydration, rest breaks, and compliance with mandated rest periods and 12-hour shift limits (Suggestion 2); providing voluntary, stigma-free mental health resources with drop-in sessions and embedded mental health professionals (Suggestion 3); targeting high-risk groups including less-experienced staff, ED/ICU bedside nurses, and those involuntarily deployed (Suggestion 4); decreasing workload by eliminating nonessential tasks and not mandating overtime (Suggestion 6); establishing positive work atmospheres and destigmatizing mental health support (Suggestion 7); limiting overtime to no more than 25% above full-time (1.25 FTE) except for short periods during acute events (Suggestion 10); and establishing dedicated triage teams removed from bedside care to mitigate moral distress during crisis standards of care (Suggestion 12). The overall quality of evidence was low because included articles were primarily observational, and anecdotal statements were based on expert opinion.
**Clinical Implications:** The pandemic has worsened pre-existing burnout, which affected 25%-33% of nurses and 45% of physicians before COVID-19, with rates rising by approximately 10% from pre-pandemic levels. Burnout leads to increased medical errors, staff departures from ICUs, and threatens the viability of critical care delivery. The authors emphasize that burnout must be treated as an individual outcome with systems-based root causes rather than solely an individual issue. They note that 75% of US HCWs are women, and that addressing burnout must include addressing inequities. Implementation requires financial support from government and private sources, including loan repayment programs, educational support, onsite childcare, and pay equity between temporary/traveling and permanent staff. The authors stress that without preventative measures, health systems risk continued loss of critical personnel to address future disasters.