ICU Telehealth Use and Concern for Workforce Shortages Among Rural Hospitals in Michigan at the Onset of the COVID-19 Pandemic

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.