Kelly C Vranas1, Sara E Golden2, Kusum S Mathews3, Amanda Schutz4, Thomas S Valley5, Abhijit Duggal6, Kevin P Seitz7, Steven Y Chang8, Shannon Nugent9, Christopher G Slatore10, Donald R Sullivan11, Catherine L Hough12. 1. Center to Improve Veteran Involvement in Care, VA Portland Health Care System; Portland, Oregon; Division of Pulmonary and Critical Care, Oregon Health & Science University; Portland, Oregon; Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: vranas@ohsu.edu. 2. Center to Improve Veteran Involvement in Care, VA Portland Health Care System; Portland, Oregon. 3. Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York. 4. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan. 5. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan. 6. Department of Critical Care, Respiratory Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio. 7. Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee. 8. Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan-UCLA Medical Center, Los Angeles, California. 9. Center to Improve Veteran Involvement in Care, VA Portland Health Care System; Portland, Oregon; Department of Psychiatry, Oregon Health & Science University, Portland, Oregon. 10. Center to Improve Veteran Involvement in Care, VA Portland Health Care System; Portland, Oregon; Division of Pulmonary and Critical Care, Oregon Health & Science University; Portland, Oregon. 11. Center to Improve Veteran Involvement in Care, VA Portland Health Care System; Portland, Oregon; Division of Pulmonary and Critical Care, Oregon Health & Science University; Portland, Oregon; Knight Cancer Institute, Oregon Health & Science University, Portland, OR. 12. Division of Pulmonary and Critical Care, Oregon Health & Science University; Portland, Oregon.
Abstract
BACKGROUND: The COVID-19 pandemic resulted in unprecedented adjustments to intensive care unit (ICU) organization and care processes globally. RESEARCH QUESTION: 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-November 2020, we performed semi-structured interviews of intensivists from tertiary and community hospitals across six regions in the United States (U.S.) that experienced early and/or large surges of COVID-19 patients. We identified themes of hospital emergency responses using the "four S framework" of acute surge planning (i.e., Space, Staff, Stuff, System). RESULTS: 33 intensivists from 7 tertiary and 6 community hospitals participated. Clinicians across both settings felt 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 re-use 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 maintain trust among staff. INTERPRETATION: We identified several strategies to potentially mitigate strain as perceived by intensivists working in both tertiary and community hospital settings. Our study also demonstrates the importance of trust and transparency between frontline staff and hospital leadership as key components of effective emergency responses during public health crises.
BACKGROUND: The COVID-19 pandemic resulted in unprecedented adjustments to intensive care unit (ICU) organization and care processes globally. RESEARCH QUESTION: 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-November 2020, we performed semi-structured interviews of intensivists from tertiary and community hospitals across six regions in the United States (U.S.) that experienced early and/or large surges of COVID-19patients. We identified themes of hospital emergency responses using the "four S framework" of acute surge planning (i.e., Space, Staff, Stuff, System). RESULTS: 33 intensivists from 7 tertiary and 6 community hospitals participated. Clinicians across both settings felt 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 re-use 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 maintain trust among staff. INTERPRETATION: We identified several strategies to potentially mitigate strain as perceived by intensivists working in both tertiary and community hospital settings. Our study also demonstrates the importance of trust and transparency between frontline staff and hospital leadership as key components of effective emergency responses during public health crises.
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