• Kelly C Vranas, Sara E Golden, Kusum S Mathews, Amanda Schutz, Thomas S Valley, Abhijit Duggal, Kevin P Seitz, Steven Y Chang, Shannon Nugent, Christopher G Slatore, Donald R Sullivan, and Catherine L Hough.
• Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR; Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR; Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. Electronic address: vranas@ohsu.edu.
• Chest. 2021 Nov 1; 160 (5): 171417281714-1728.

BackgroundThe COVID-19 pandemic resulted in unprecedented adjustments to ICU organization and care processes globally.Research QuestionsDid 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 MethodsBetween 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.ResultsThirty-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.InterpretationWe 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.Published by Elsevier Inc.

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