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Background The COVID-19 pandemic resulted in unprecedented adjustments to ICU organization and care processes globally. Research Questions Did hospital emergency responses to the COVID-19 pandemic differ depending on hospital setting? Which strategies worked well to mitigate strain as perceived by intensivists? Study Design and Methods Between August and November 2020, we carried out semistructured interviews of intensivists from tertiary and community hospitals across six regions in the United States that experienced early or large surges of COVID-19 patients, or both. We identified themes of hospital emergency responses using the four S framework of acute surge planning: space, staff, stuff, system. Results Thirty-three intensivists from seven tertiary and six community hospitals participated. Clinicians across both settings believed that canceling elective surgeries was helpful to increase ICU capabilities and that hospitals should establish clearly defined thresholds at which surgeries are limited during future surge events. ICU staff was the most limited resource; staff shortages were improved by the use of tiered staffing models, just-in-time training for non-ICU clinicians, designated treatment teams, and deployment of trainees. Personal protective equipment (PPE) shortages and reuse were widespread, causing substantial distress among clinicians; hands-on PPE training was helpful to reduce clinicians’ anxiety. Transparency and involvement of frontline clinicians as stakeholders were important components of effective emergency responses and helped to maintain trust among staff. Interpretation We identified several strategies potentially to mitigate strain as perceived by intensivists working in both tertiary and community hospital settings. Our study also demonstrated the importance of trust and transparency between frontline staff and hospital leadership as key components of effective emergency responses during public health crises.

Rationale: Though the United States has the highest number of ICU beds per capita in the world, the regional distribution of these beds is variable. Rural areas have 1% of American ICU beds despite having 16% of the country's population. Telehealth is frequently promoted as a tool that can augment care for the critically ill in rural communities. Yet, ICU telehealth still requires clinicians at the bedside who are able to provide critical care. We sought to examine telemedicine within rural ICUs in the context of potential workforce shortages related to the COVID-19 pandemic. Methods: We identified all hospitals with ICUs in Michigan using the 2018 American Hospital Association annual survey database and internet searches. Within each hospital, an ICU physician or nurse leader was surveyed between April 6, 2020 and May 8, 2020. At that time, the state of Michigan had the fifth highest total of COVID-19 hospitalizations within the country. Participants were asked about current telehealth utilization in the ICU. Participants were also asked to rate their concern on a 4-point Likert scale regarding exceeding existing ICU capacity and ICU staffing capabilities due to the pandemic. Results: Of the 28 rural hospitals in Michigan, 14 were surveyed (response rate 50%). Among responding hospitals, 12 (86%) had fewer than 11 ICU beds and an average pre-COVID-19 census of fewer than 4 patients. At the time of the survey, ten hospitals (71%) reported using ICU telehealth support, of which two used telehealth providers exclusively overnight. Of the four hospitals without telehealth, two planned to add telehealth in response to the pandemic. In the context of the COVID-19 pandemic, 11 hospitals (79%) reported concern about exceeding their ICU capacity, and 12 hospitals (86%) planned to create more ICU beds. The majority of rural hospitals worried about impending ICU workforce shortages, with 78% of hospitals concerned about having enough nurses, 64% about having enough respiratory therapists, and 50% about having enough physicians as a result of the pandemic. Conclusions: At the onset of the COVID-19 pandemic, most rural hospitals in Michigan utilized ICU telehealth support in some capacity. Despite broad use of telemedicine, rural hospitals remained concerned about exceeding ICU capacity and a lack of ICU nurses, respiratory therapists, and physicians. Expansion of existing telehealth infrastructures within rural hospitals may improve access to critical care clinicians virtually but would not ease concerns related to capacity and workforce shortages, particularly among ICU-trained nurses.