A Phenomenological Study on the Challenges Faced by Nebraska Hospitals During the COVID-19 Outbreak
Colleen C. McLaughlin
Round 1
Reviewer 1 Report
This qualitative research study has some strengths to highlight, and the project could lead to insightful findings. The results are well organized and presented. The writing is clear. The information that has been collected and distilled seems comprehensive of the point-in-time experiences of hospitals. The inclusion of both CAH hospitals and larger general is unique.
My primary concern is with the discussion, which I feel needs critical editing that is grounded in the functioning of the healthcare system as a whole. For example, the suggestions for augmented reality and simulation methods do not seem connected to the results presented. I am not sure in what context AR would be used by existing hospitals to address the challenges identified, particularly by resource limited hospitals and CAHs. While simulation might be useful in crisis planning, it is probably out of the reach of individual facilities to conduct and learn from simulation without (possibly expensive) outside help. It is also not clear how AR and simulation would address many of the issues identified, such as the unique problems of staffing shortages and supply chain issues that arose during the pandemic. Reading further, simulation seems to link to the author's conference proceedings in press, so perhaps it should be discussed in that context. At a bigger picture level, how would these suggestions scale to the US hospital sector?
Another improvement would be to recognize the challenges that were unforeseen, underestimated, or exacerbated by the pandemic. The loss of revenue due to cancelling elective surgeries can be viewed as an exacerbation of the move to ambulatory surgery and consequent lower hospital census, which has been a factor in the fiscal instability of inpatient hospitals for much longer. Nursing shortages are also an example of an ongoing challenge due to the aging demographics of the US. Other challenges have been identified in the past but were inadequately addressed. Lack of doning and doffing space and ED isolation capacity was also a theme during the 2014-2016 Ebola outbreak.
Many of the themes presented have been discussed elsewhere. I agree the local picture can be helpful, but this statement would be stronger if the findings were presented against the background of Nebraska healthcare landscape.
I am concerned with the conclusion. My inclination would be to conclude with summary thoughts on healthcare policies that could lead to better responses in the future for all hospitals and patients, but the conclusions as written run counter to this. First, while I understand the sentiment in the last sentence that the interviewed administrators felt policies were a hindrance and hospitals should be more autonomous ("However, the frequent policy changes remained highly disruptive, and many participants preferred hospitals to have greater autonomy in establishing their operational guidelines."), this doesn't seem supported by the results which spoke little to the federal or state policies that were problematic. Second, the authors should distinguish between hospital level policy changes and regulatory (CMS, state) level policies. Line 308, bracketed test added by me: "As for adaptation of [hospital?] policies and protocol, hospitals faced multiple challenges, including addressing the [society, elected officials?] political complexities (H2), addressing and adapting to daily [CMS, CDC, Nebraska?] policy changes, making frequent adjustments to protocols (H2, H4, H7), and continuously modifying [hospital] procedures to adjust to new situations (H7)." Third, many people in the healthcare field in the US were frustrated by the politics of the pandemic, but changes in policy related to science (e.g. new information about diagnosis and treatment of the disease, Table 2 1.i), the supply chain, and myriad uncertainties should not be grouped into blanket "policy changes" with an implication that the changes were "political." Lastly, the assumption that hospitals can figure out and cope if left alone is not grounded in science, as demonstrated by the experiences of healthcare workers and patients across the US and world during the first wave of the pandemic. Leaving hospitals to "adapt" during the next pandemic would be setting us up for another crisis. What can the authors draw from their findings that inform healthcare policy analysis? How can hospitals proactively change their internal policies and procedures to be flexible in terms of surge capacity, different modes of transmission of future epidemics (respiratory versus hemorrhagic), addressing staff absences due to the epidemic disease, etc? What role do hospital/professional associations & organizations (ACHE, state hospital associations) and accreditors & regulatory authorities (TJC, CMS, state) play in mitigating the challenges identified?
There seems missing text at line 99 where citation 21 is used.
Must be addressed: The exact number of beds of the included hospitals is given in table 1. At least a few hospitals can be re-identified based on bed size with a good degree of confidence.
Author Response
Please see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
1. Introduction:
The introduction effectively established a foundational understanding of the topic. To further enhance its clarity and direction, a concise statement of the research objectives should be explicitly included at the end of this section, immediately preceding the literature review.
2. Literature Review:
Within the literature review, the statement "irrelevant entries were excluded" lacks crucial detail. To ensure transparency and rigor, clearly articulate the specific inclusion and exclusion criteria used during the literature selection process.
Furthermore, the justification for using a "combination of keywords" for the literature search requires clarification. Explain why a "theme search" approach was not prioritized. Theme-based searches offer a more comprehensive approach, potentially capturing relevant articles that utilize synonyms or related terminology, thus mitigating the risk of overlooking pertinent research. Employing a thematic structure could also facilitate the organization of the literature review into the distinct themes evident in your results section (Hospital Operational Issues, Physical Layout Challenges, Capacity Concerns, Supply Chain Issues, Staff Management Problems, Communication Challenges, Infrastructure Defects, Financial Constraints, Organizational Management Matters), rather than presenting a consolidated overview.
3. Methodology:
The methodological approach appears sound; however, the description of the sample selection process presents a discrepancy. While the text mentions a compiled list of 35 hospitals across Nebraska, including sixteen (16) general acute hospitals, seventeen (17) critical access hospitals, and two (2) children’s hospitals, Table 1 only provides data from 8 hospitals. Please clarify the rationale for this significant reduction in the sample size presented in the results.
4. Results:
Building upon the aforementioned concern regarding the sample size, the exclusive reference to hospitals H1-H8 throughout the results presentation necessitates explanation. Given the initial sample of 35 hospitals, clarity is needed regarding the exclusion of the remaining 27 hospitals from the analysis and discussion.
Further Suggestion:
Considering the research focus on the challenges faced by Nebraska hospitals during the COVID-19 outbreak, the inclusion of a dedicated subsection offering actionable recommendations for hospital managers on how to mitigate similar challenges in future events would significantly enhance the practical value and impact of this research.
1. Introduction:
The introduction effectively established a foundational understanding of the topic. To further enhance its clarity and direction, a concise statement of the research objectives should be explicitly included at the end of this section, immediately preceding the literature review.
2. Literature Review:
Within the literature review, the statement "irrelevant entries were excluded" lacks crucial detail. To ensure transparency and rigor, clearly articulate the specific inclusion and exclusion criteria used during the literature selection process.
Furthermore, the justification for using a "combination of keywords" for the literature search requires clarification. Explain why a "theme search" approach was not prioritized. Theme-based searches offer a more comprehensive approach, potentially capturing relevant articles that utilize synonyms or related terminology, thus mitigating the risk of overlooking pertinent research. Employing a thematic structure could also facilitate the organization of the literature review into the distinct themes evident in your results section (Hospital Operational Issues, Physical Layout Challenges, Capacity Concerns, Supply Chain Issues, Staff Management Problems, Communication Challenges, Infrastructure Defects, Financial Constraints, Organizational Management Matters), rather than presenting a consolidated overview.
3. Methodology:
The methodological approach appears sound; however, the description of the sample selection process presents a discrepancy. While the text mentions a compiled list of 35 hospitals across Nebraska, including sixteen (16) general acute hospitals, seventeen (17) critical access hospitals, and two (2) children’s hospitals, Table 1 only provides data from 8 hospitals. Please clarify the rationale for this significant reduction in the sample size presented in the results.
4. Results:
Building upon the aforementioned concern regarding the sample size, the exclusive reference to hospitals H1-H8 throughout the results presentation necessitates explanation. Given the initial sample of 35 hospitals, clarity is needed regarding the exclusion of the remaining 27 hospitals from the analysis and discussion.
Further Suggestion:
Considering the research focuses on the challenges faced by Nebraska hospitals during the COVID-19 outbreak, the inclusion of a dedicated subsection offering actionable recommendations for hospital managers on how to mitigate similar challenges in future events would significantly enhance the practical value and impact of this research.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
My concerns were addressed
none.
