Discussion

The results of this survey reveal gaps and differences in SARS-COV-2 preparedness among community hospitals in the southeastern United States. A recent survey of hospitals in the Society for Healthcare Epidemiology of America Research Network highlighted similar shortages in academic hospitals and large medical centers,^{Reference Calderwood, Deloney and Anderson6} but our survey is the first report, to our knowledge, focusing on the state of smaller community hospitals during the COVID-19 pandemic.

Almost half of the community hospitals reported shortages in their supplies of PAPRs, environmental disinfectants, and gowns. In addition, 80% of hospitals reported an adequate supply of N95 respirators, face shields, and googles, likely due to use of crisis capacity strategies to extend, reuse, and reprocess these PPE. Our report is different from a recently reported survey of hospitals in Idaho that reported shortages of face shields.^{Reference Kanwar, Heppler, Kanwar and Brown7} Our survey highlights that face shields are less prone to shortages due to their simpler design, reuse potential, and durability.^{Reference Advani, Smith, Lewis, Anderson and Sexton8}

More than half of the community hospitals in our network had employed strategies to extend the use of face masks, N95 respirators, gowns, face shields, and googles. Currently, to our knowledge, no data are available on the safety of extended use PPE or time limits for safely extending the use. Similarly, most hospitals were employing strategies to reuse N95 respirators, PAPRs, face shields, goggles, and masks. Although some data exist on the safety of reprocessed N95 respirators, safety data on reuse of other single use PPE are scarce.^{Reference Berardi, Perinelli and Merchant9} Shortages of disinfectants and sanitizers may lead to the introduction of new agents with a potential decrease in cleaning efficiency, variation in equipment compatibility, an increase in staff dissatisfaction, and occupational safety hazards.^{Reference Berardi, Perinelli and Merchant9}

Our survey also demonstrates that most of our community hospitals had implemented policies related to employee screening at the point of hospital entry. Although most hospitals had developed policies related to universal masking, the content of these policies varied widely. There was significant variation in policies related to testing for active infection with SARS-CoV-2 infection, with respect to the laboratory used, testing before surgical procedures, and testing prior to discharge to skilled nursing facilities.

Our study has several limitations. It was a cross-sectional study and relied on self-reported data from infection preventionists. We did not include other healthcare facilities such as nursing homes. However, this survey provided valuable information on differences in outbreak readiness among community hospitals that may help identify factors influencing preparedness.

We found several differences in community hospital preparedness for SARS-CoV-2 with respect to type of conservation strategies used to preserve PPE, protocols related to testing, masking, and restarting elective procedures. We believe that this lack of standardization in approaches was due to differences in state guidelines, the decentralized federal approach to SARS-CoV-2 preparedness, and a lack of confidence in public health guidelines. These differences also highlight the challenges with implementing guidelines related to SARS-CoV-2 in community hospitals because of PPE and personnel shortages, financial constraints, and uncertainty regarding how and when to implement policies such as universal masking, preoperative testing, and predischarge testing. This study also offers a starting point for future assessments of pandemic preparedness among community hospitals in the United States.