Navigating Pandemic Responsiveness in an Acute Care Setting: A Community Hospital’s Operational Experience with COVID-19

Background: To ensure continuity of services while mitigating patient surge and nosocomial infections during the coronavirus disease 2019 (COVID-19) pandemic, acute care hospitals have been required to make significant operational adjustments. Here, we identify and discuss key administrative priorities and strategies used by a large community hospital located in Barrie, Ontario to manage COVID-19. Methods Guided by a qualitative descriptive approach, we conducted a thematic analysis of all COVID-19-related documentation discussed by the hospital’s Emergency Operations Centre (EOC) during the first pandemic wave. We solicited operational strategies from administrative leaders to construct a narrative for each theme. Results Seven recurrent themes critical to the hospital’s pandemic response emerged: 1) Organizational Structure : a modified EOC structure was adopted to increase departmental interoperability and situational awareness;2) Capacity Planning : Design Thinking guided rapid infrastructure decisions to meet surge requirements;3) Occupational Health and Workplace Safety : a multidisciplinary team provided respirator fit-testing, critical absence adjudication, and wellness needs;4) Human Resources/Workforce Planning : new workforce planning, recruitment, and redeployment strategies addressed staffing shortages;5) Personal Protective Equipment (PPE) : PPE conservation required proactive sourcing from traditional and non-traditional suppliers;6) Community Response : local partnerships were activated to divert patients through a non-referral-based assessment and treatment centre, support long-term care and retirement homes, and establish a 70-bed field hospital;and 7) Corporate Communication : a robust communication strategy provided timely and transparent access to rapidly evolving information. Conclusions The hospital benefited from an interconnected command structure that focused on inter-operability, communication, novel administrative tools, and community partnerships.


Background
The emergence of the previously unknown severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to the rapid worldwide transmission of coronavirus disease 2019 (COVID-19) (Wiersinga et al., 2020). The relatively high infectiousness of SARS-CoV-2 and increased recognition that COVID-19 exhibits a diverse array of symptoms and complications (Wiersinga et al., 2020), has placed unprecedented strains on healthcare systems. With rates of hospitalization among COVID-19 patients ranging between 4-20% in different populations, and 25% of those cases requiring intensive care (Salzberger et al., 2021;Uddin et al., 2021), hospitals and other acute care facilities have been impelled to shift operational priorities and strategies to maintain critical services, while managing surges of acutely ill and infectious patients. Further adding to this burden, post-acute sequelae are experienced by the majority of hospitalized COVID-19 patients, which can lead to slow or incomplete recovery (Nalbandian et al., 2021;Pavli et al., 2021).
As the ongoing pandemic monopolizes human and nancial resources, operational transformation can be challenging for hospitals (Emanuel et al., 2020;Legido-Quigley et al., 2020). Early in the pandemic, hospitals contended with a lack of empirical information regarding the pathophysiology, transmission, and treatment of COVID-19; however, rapidly evolving scienti c literature, real-world data, and shared best practices helped inform on the clinical management of patients and e cient work ow strategies for various medical specialities (Brethauer et  With a hospital's capacity to respond to a pandemic often dependent on local expertise in infection prevention and control (Popescu, 2020;Rebman et al., 2009), this might place community hospitals at a particular disadvantage, as they often operate in geographic, administrative, and data silos, and are unable to access the same nancial and human resources as their academic counterparts. This is of particular concern, considering that community hospitals serve as the primary healthcare site in most communities. For example, in Ontario, Canada's most populous province, community hospitals operate as independent, not-for-pro t organizations that are responsible for the majority of acute healthcare services provided to residents (DiDiodato et al., 2017). As the experiences of community hospitals during the COVID-19 pandemic emerge, new operational tools will help these organizations better manage their resources during emergencies.
Here, we review and discuss key non-clinical, operational strategies and tools used by the Royal Victoria Regional Health Centre (RVH), a 408-bed acute care community hospital located in Barrie, Ontario. While RVH was the site of the rst COVID-19-related death in Ontario, the hospital maximized e cient use of operational resources to mitigate nosocomial infections, create additional bed and staff capacity, accept patients transfers, and assist community partners in their own pandemic response. The objective of this work is to share this community hospital's pandemic strategies and tools, such that peer organizations may bene t from this knowledge.

Design
A qualitative descriptive methodology was used for this study (Sandelowski, 2000). This design was chosen as a result of limited information on the non-clinical, operational approaches taken by hospitals to manage their internal resources during a pandemic. This study sought to answer the question: what were the operational initiatives, strategies, and tools utilized by a large community hospital to respond to the COVID-19 pandemic?
Setting RVH is the largest acute care hospital within the Simcoe Muskoka region, an area located in the central portion of southern Ontario, Canada. The hospital provides basic birthing, medical, and surgical services, as well as a range of tertiary services, including advanced cardiac care, cancer treatment, renal care, child and youth mental health, and maternal and perinatal care, to a catchment population of 540,000 residents. In 2019-2020, RVH had an average of 1,339 daily patient visits and was comprised of a team of 457 credentialed staff, 2,959 employees, and 750 volunteers, with over 1,000 student learners cycling through the hospital.
As of June 30, 2021, near the tail end of Ontario's third COVID-19 wave (March-July, 2021), RVH had provided care for 535 COVID-19 inpatients and experienced 82 COVID-19 related deaths, including the provinces rst laboratory-con rmed death on March 11, 2020. The hospital provided support to 30 long-term care (LTC) and retirement homes, assumed temporary, onsite management of a LTC home experiencing outbreak, accepted more than 220 patient transfers from other hospitals, performed 114,300 COVID-19 tests, and provided 87,400 COVID-19 immunizations. RVH did not experience any nosocomial infections among staff and patients until December, 2020.

Analysis
We performed a thematic review of all COVID-19-related documentation discussed at RVH's Emergency Operation Centre (EOC) during the rst wave of the pandemic (March-August, 2020). A qualitative content analysis according to Thomas (2006) was utilized in the development of themes. No pre-existing codes were applied to data; rather the codes, categories, and themes were inductively developed after lengthy review. Operational issues critical to RVH's pandemic responsiveness emerged and could be binned into seven themes ( Figure 1). We further solicited moderately structured, open-ended questions on operational initiatives and strategies to leaders involved in each theme to construct a narrative of events (Supplemental Table 1).

Organizational Structure
The emergency management program at RVH is a longstanding planning priority, with emergency policies and processes reviewed and updated every three years or earlier (e.g., accreditation). In 2019, RVH undertook a review of its traditional EOC structure, aligning its emergency response and recovery processes with an Incident Management System (IMS) developed and updated by the Government of Ontario (Province of Ontario, 2009). Adoption of an IMS system permitted greater interoperability among clinical and external stakeholders by standardizing adherence to organizational structures, functions, processes, and terminology. The new IMS system was tested in an annual emergency exercise in November, 2019, which included the involvement of local public-and private-sector partners. RVH's overall emergency response structure was further strengthened by a Pandemic Response Plan and Surge Capacity Plan, both reviewed and updated in 2019, as well as Business Continuity Plan, which was undergoing revisions in early 2020.
The hospital's EOC was activated on March 13, 2020, one day after it received noti cation of its rst lab-con rmed case of COVID-19 and two days after the World Health Organization declared COVID-19 a global pandemic. The EOC adopted a standard IMS organizational structure, consisting of an Incident Commander responsible for the overall coordination of Command Staff and General Staff. Over the rst two weeks of operation, the EOC expanded its structure to address local needs, as new information about the natural history and transmissibility of COVID-19 emerged. To enable a more robust focus on clinical care, three interconnected pillars comprised the overall functional framework of the EOC structure: Clinical Care, Clinical Support, and Capacity Planning. Each pillar was divided into one or more traditional IMS functional sections, including Operations, Planning, Logistics, and Finance and Administration, which, in turn, were comprised of multiple clinical and/or administrative departments ( Figure 2).
Non-traditional IMS sections were also created, including a Corporate Communications section to synthesize and disseminate information, a Capacity Planning section to develop solutions for COVID-19 patient surge, and a Resource Leads section to provide evidence-based guidance on infection prevention and control, epidemiology, and bioethics ( Figure 2). Resource Leads personnel included a Technical Specialist role, which was assigned to the hospital's Infectious Disease Specialist, thus creating a direct link to the Infection Prevention and Control (IPAC) team, an Analytics Specialist role, comprised of research and decision support staff with knowledge of statistics, and a third-party bioethics consultant. The Safety O cer role, typically identi ed as Command Staff, was moved to the Planning section to better support the Occupational Health and Wellness and Human Resources departments.
A key element in the effectiveness of the EOC was the regularized operational cycle, which followed a traditional emergency planning approach: assess, plan, act, and report. The assess and plan phases were undertaken by the EOC as a whole, predicated on shared and collaborative situational awareness. The act phase was undertaken by each section, under the leadership of the sections' chiefs (i.e., Operations Chief, Planning Chief, Logistics Chief, Finance and Administration Chief, and Capacity Planning Chief) or command o cer (i.e., Emergency Information O cer, Liaison O cer). In the report phase, section chiefs and command o cers held situational awareness meetings with their branch leads to develop section reports that formed the basis of the next assess phase.
During the most acute phase of rst wave, which occurred from March-May, 2020, the EOC met once or twice daily. As the impact of COVID-19 began to lessen on hospital operations, the EOC met less frequently, from every other day to twice per week. By mid-May, 2020, the hospital's Executive Leadership Team, comprised of the President and CEO, the Chief of Staff, Executive Vice Presidents, and Vice Presidents, continued to meet regularly to discuss pandemic matters of critical importance.

Capacity Planning
Given the highly transmissible nature of SARS-CoV-2, patient surge was identi ed as a critical operational priority. Early modelling predicted between 842 to 93,826 cumulative hospitalizations in the region over the rst three months, depending on the extent to which nonpharmaceutical public health measures would be implemented (e.g., social distancing, contact tracing, quarantine, lockdown). To prepare for this wide range of hospitalization possibilities, detailed capacity plans were developed for the Intensive Care Unit (ICU), Medicine Program, and Emergency Department. A phased approach permitting the rapid conversion of existing clinical infrastructure to level III critical care units, standard beds, and cots, on an "as needed" basis. This permitted safe reallocation of existing inpatients, while maintaining other critical services (e.g., decompensating ward-based patients, urgent non-elective surgeries) during surge conditions. In general, the rst COVID-19 inpatient admission to each unit triggered implementation of the next phase.
Adapting re-purposed facilities to meet the technical requirements of critical care units was required for surge expansion. A design methodology termed Design Thinking (Brown, 2008) was used by the RVH Capacity Planning team to address surge demand for increased air exchange, negative air capacity, anterooms, ltration, and exhausting. Using non-linear, iterative concepts, Design Thinking is typically utilized for developing solutions for complex systems within the private sector, but is increasingly used by healthcare systems to address problems or practices that are ill-de ned or unknown (Roberts et al., 2016). The Design Thinking framework adopted by RVH encompassed methodological aspects of empathizing, de ning, ideating, prototyping, and testing (Seidel and Fixson, 2013). This provided a practical framework for rapid problem solving, often with some failure that was learned from. The Design Thinking approach ultimately led to various mechanisms being tested to permit different departments to safely receive COVID-19 patients, including the use of air balancers, temporary hoarding, HEPA ltration units, leveraging headwall space and medical air availability, installing drivers on fan units, and leveraging vacant shelled space to expand internal capacity. The Design Thinking approach was further used to ideate and develop the 70-bed eld hospital (see 'Community Response' section below).
Through this planning, RVH provided an ICU Surge Capacity Plan that was capable of expanding its level 3 critical care capacity from 16 beds to 105 beds in 5-12 weeks, along with an additional 334 standard beds and 300 cots, as required ( Figure 3).

Occupational Health and Workplace Safety
In 2019, RVH separated the services traditionally delivered by a single Occupational Health and Safety department into two distinct departments: Occupational Health and Wellness, and Workplace Safety. This separation resulted in an effective division of various roles and responsibilities addressing workplace safety during the COVID-19 pandemic. Notably, two major issues arose: respirator t testing and COVID-19-related employee absences.
In January, 2020, anticipating that the novel coronavirus may be airborne, the Workplace Safety department, supported by staff from Occupational Health and Wellness, Emergency Management, and Security departments undertook a major campaign to conduct 700 qualitative respirator t tests for staff, a liated professional staff, and partnered community health agencies. Fit-testing clinics were held every day between 08:00-23:30 hr for a three-week period. The organization's IPAC team further contributed by adapting their annual PPE training to a 'justin-time' training delivery model for frontline staff, including a newly established seven-day, 24-hour telephone support line.
In early March, 2020, the Workplace Safety team responded to ongoing concerns related to routes of SARS-CoV-2 exposure and transmission. A key concern was the diminishing supply of N95 respirators across the province, which was subsequently addressed by provincial guidance related to acceptable levels of respiratory protection and increases in organizational supply chains (see 'Personal Protective Equipment' section below). The acquisition of several hundred half-face, ltered elastomeric respirators, which can be worn for many hours and then processed for reuse, was an important factor in RVH's PPE conservation strategy. A dedicated location was established for the donning, do ng, and reprocessing of this new PPE and a decision made by the PPE Conservation Committee to deploy these respirators to clinical staff who were most likely to be involved in aerosol-generating medical procedures (AGMP). In order to facilitate the ongoing need for mask t-testing and to operationalize the deployment of elastomeric respirators, the Workplace Safety team received assistance from redeployed staff, with dedicated stations established in multiple areas of the hospital. As elastomeric respirators require a 45-minute quantitative assessment of faceseal leakage per person, a partnership was developed with local re and emergency services, who generously loaned their quantitative t testing machines and participated in testing.
Distinct from the efforts of the Workplace Safety department, the Occupational Health and Wellness department engaged in early exposure assessments and contact tracing initiatives. In partnership with the local health unit's Communicable Disease team, these efforts were based on existing protocols for the management of infectious disease outbreaks long established at the hospital. However, an unexpected corollary of the rapidly changing public health measures used to mitigate COVID-19 spread, was the development of a wide range of complex employee absence scenarios that impacted sta ng availability and compensation. To provide safe, consistent, and standard guidance to staff and leaders, Occupational Health and Wellness proactively developed an Absence Scenarios document. The document began as a tool for leaders to address travel-related exposures and/or symptomatology in order to foster equitable pay treatment and to establish rigorous and consistent infection prevention and control practices for returning staff to work. Initially addressing six potential COVID-19-related absence scenarios, the document has grown to address up to 19 potential scenarios, including absences related to the unavailability of childcare (Supplemental Table 2).

Human Resources/Workforce Planning
Additional clinical personnel, cleaning staff, environmental services aides, and other staff essential to upholding safety and prevention protocols were required in preparation for and management of an acutely ill, infectious patient population. In addition, student and volunteer placements were inde nitely suspended to protect the broader community, thus requiring additional redeployment to help ful l traditionally held volunteer roles. As such, a Professional Staff Human Resources COVID-19 Response Plan and Regional Health Human Resources Redeployment Plan were developed to address key issues related to human resources management, including: 1) internal departmental plans to address surge, speci cally in ICU and Medicine programs; 2) inter-departmental co-operation to support capacity management (e.g., utilizing 'extender' and 'buddy' systems); 3) Emergency department surge; and 4) eld hospital sta ng.
As most acute care providers sought to expand their skilled workforce during the pandemic, an external labour market analysis was performed and talent acquisition strategy developed to help overcome barriers and shortages. A Workforce Planning Process was developed to provide information on existing workforce skills, desired workforce needs, and strategies and actions to address workforce gaps (Figure 4). Strategies for internal and external recruitment included: 1) promoting internal opportunities; 2) establishing new leadership structures; 3) creating an internal 'Reserve Unit'; 4) exploring opportunities to utilize non-practicing retired, graduate, or student healthcare professionals; 5) creating evergreen postings for clinical, allied health, environmental, and clerical roles; 6) conducting virtual job fairs; 7) establishing recruiting campaigns outside the region; and 8) creating a formal tactical acquisition plan.
Supporting staff employed at multiple sites or organizations presented additional human resources challenges, due to the prospect of suspected or declared COVID-19 outbreaks at other locations. Adopting the recommendations of Ontario Health, the government agency that oversees the administrative activities of the provincial health system, RVH chose not to restrict part-time staff from working at multiple organizations, but rather limit staff to a single location when working on a suspected or declared COVID-19 outbreak unit, a COVID-19 area within an organization, or an intensive care unit caring for probable or con rmed COVID cases until the outbreak had cleared. With professional staff increasingly redeployed to assist with COVID-19 efforts within the broader community (see 'Community Response' section below), the Human Resources department developed a Mobility Between Work Locations/Sites Scenarios tool to assist leaders in balancing clinical resources to local conditions (Supplemental Table 3) Personal Protective Equipment Prior to COVID-19, RVH maintained a 3-4-week stockpile of essential PPE for emergency use, including gloves, masks, and gowns. Due to onsite space limitations, RVH typically stored stockpiles at an offsite location, in partnership with a third party who managed product expiration and refreshed supplies accordingly.
In January, 2020, in response to reports of an emerging novel coronavirus, RVH's Procurement and Logistics team began increasing regular orders of essential PPE and cleaning supplies (e.g., hard-surface disinfectants, hand sanitizer). During this time, the maximum permitted allotment from manufacturers and distributors to the organization were ordered, with the goal of increasing RVH's onsite stockpile and with the intention of reintegrating excess PPE back into regular circulation if not required for pandemic use. As few hospitals are able to maintain a large onsite warehouse of supplies, identifying additional storage space was a challenge, so non-traditional spaces were secured and dedicated to storing PPE, such as converted administrative areas and vacant shelled space.
In March, 2020, a PPE subcommittee was formed to make decisions on PPE usage and preservation in response to constraints in global supply.
A key aspect of the PPE subcommittee was that it was comprised of medical, nancial, and legal professionals with delegated authority to make rapid decisions on behalf of the organization. With a greater emphasis on PPE conservation, the committee began tracking and forecasting daily PPE inventory. One early limitation of the tracking system was the relative lack of historical and published data on e cient PPE utilization and distribution during supply chain shortages. To combat shortages, non-traditional suppliers that met the required safety standards were engaged. The PPE subcommittee established a process of veri cation and evaluation to ensure that these supplies met all regulatory standards, including an American Society of Testing and Materials (ASTM) rating for all masks, Association for the Advancement of Medical Instrumentation (AAMI) rating for gowns, and ASTM or Acceptable Quality Level (AQL) requirements for gloves. An independent third party was contracted to test all PPE purchased from non-traditional sources. Finally, RVH supported local manufacturers and automation companies who retooled their operations to produce medical supplies, including providing assistance with navigating regulatory and licensing requirements.

Community Response
RVH provided critical support for three COVID-19 community initiatives: 1) establishing a local community assessment centre; 2) redeploying staff to long term care and retirement homes experiencing COVID-19 outbreaks; and 3) creating of a 70-bed eld hospital, known locally as the Pandemic Response Unit (PRU).
In March, 2020, healthcare providers across Ontario were tasked with establishing local COVID-19 assessment centres dedicated to screening, clinical assessment, and testing. The objective of these centres was to divert patients with mild COVID-19 symptoms from emergency departments. Although the core function of each assessment centre was shared across Ontario, operationalization was left to the local providers, including infrastructure, workforce and sta ng, hours of operation, and service modality (e.g., in-home, virtual, in-centre, drive-through). This rapid response would have been a formidable task for local providers had it not been for the revitalization of the Barrie and Area Surge Planning Committee in 2019, which focused on preparedness activities in anticipation of an annual in uenza-related surge across the full spectrum of regional healthcare services. Adopting a modi ed regional plan for an alternate treatment and assessment centre that had been implemented in 2009 during the H1N1 in uenza pandemic, the committee was able to rapidly pivot from its focus on in uenza to COVID-19. The plan was further edi ed by the commitment of local partners, including family health teams and paramedic services, to provide a clinically-sound location and clinical staff for the centre. RVH provided nurse practitioners and nursing support staff, PPE for all clinic staff, coordinated laundry services, and served as the paymaster for environmental services. While the assessment centre was highly effective, conducting an average of 80 assessments per day during the rst three months of operation, one drawback was that it was designed for relatively short-term surge resulting from seasonal in uenza. Work demands on clinical staff were high and it was determined that long-term operations would bene t from a location that did not negatively impact the operations of other clinics, with funding for dedicated clinical and administrative staff. By June, 2020, it was apparent that the assessment centre no longer required the support of RVH, becoming a stand-alone, community-run clinic.
LTC and retirement homes became the epicentre of Canada's rst COVID-19 wave. With a 34% resident case fatality rate that accounted for more than 80% of all reported COVID-19 deaths in Canada during this time (Canadian Institute for Health Information, 2021), residents experienced sustained and devastating outcomes that have been linked not only to the medical complexities and multi-morbidities of residents, but to longstanding systemic issues, such as underfunding and business models (Canadian Institute for Health Information, 2021; Clarke, 2021; Liu et al., 2020; Stall et al., 2020). Moreover, infections among staff at residential care facilities represented more than 10% of the country's total cases. On April 24, 2020, the Ontario Minister of Long-Term Care responded to the challenges faced by residential care facilities by issuing a Minister's Directive requiring all long-term care homes in outbreak to provide entry to hospital staff to provide assistance with resident care, including IPAC assessments, clinical supervision, and nursing and personal support services. In response to the emergency order, RVH developed a Long-Term Care Management Plan in conjunction with the County of Simcoe, an 'upper tier' municipal government composed of mayors and deputy mayors from towns and townships located within the region. A 90-day action plan was established that focused on three goals: 1) control the outbreak; 2) stabilize operations; and 3) transition operations. To meet these goals, twelve priority areas were identi ed through audits and risk assessments: 1) resident care; 2) environmental services; 3) general supplies and equipment; 4) IPAC; 5) PPE conservation and deployment; 6) quality, risk, and privacy; 7) nancial management; 8) occupational health and workplace safety; 9) staff stabilization; 10) communication with licensee; 11) family engagement; and 12) joint corporate communications. Actions were performed by hospital staff to address gaps for each priority area to ensure residential care and infection prevention met or exceeded legislative standards of operation and best practices. For example, RVH's Environmental Services department performed decluttering and terminal cleaning of the facility, including removing unnecessary furniture and equipment, as well as auditing existing environmental services practices and products, and implementing new policies and procedures that aligned with recommendations made by the Provincial Infectious Diseases Advisory Committee. RVH's clinical experts, IPAC, Corporate Communications, Occupational Health, and Workplace Safety departments further developed and delivered education and training plans that helped establish more consistent infection prevention practices (e.g., creating a PPE donning and do ng station) and resource management issues (e.g., creating and tracking PPE inventory; ensuring daily sta ng needs were met). RVH was also able to assist 30 LTC and retirement homes improve their IPAC processes to help overcome and prevent outbreaks.
The PRU was constructed in response to local surge forecasting and in alignment with similar structures constructed by two peer hospitals and with Ontario's Emergency Order for Alternative Healthcare Facilities. The PRU is an 8,250 square-foot, four-season, fully-functioning 70-bed eld hospital located in RVH's parking lot and connected to the health centre by an enclosed walkway ( Figure 5). Mock codes with debrie ngs were frequently conducted to prepare for internal and external emergencies; this provided an appropriate level of response readiness, which was unexpectedly tested when an EF-2 tornado with 210 km/h winds touched down in south Barrie on July 15, 2021. The PRU opened in November, 2020, and was used for the transition of non-COVID-19 inpatients out of hospital, allowing RVH to continue providing core services and acting as a regional asset for other hospitals facing capacity challenges. Among the challenges of operating the PRU, the identi cation of an appropriate patient population was critical. Because of its structure (e.g., stand-alone facility, exposed ductwork) and limited sta ng, only independently mobile patients awaiting discharge were permitted. Additional patient inclusion criteria were required, as the PRU lacked geriatric and visitor chairs, overhead lifts, handrails and therapy poles, doors and ceilings on patient bays, and was limited in telemetry, space for assistive devices, and the ability to physically/visually redirect patients (Supplementary Table 4). As of June 30, 2021, the PRU has acted as an invaluable regional asset having treated over 795 patients, thereby enabling RVH to accept more patient transfers from local and distant partner hospitals than any other hospital in the province. gratitude for those working at the health centre. Through this hashtag, words of encouragement and appreciation, signs and artwork from the community were received and posted to the internal website. Conclusion RVH bene ted from an early, aggressive, and robust response to the pandemic by leveraging its regular strong adherence to reviewing and testing existing emergency management plans. A modi ed IMS-based EOC structure permitted productive interoperability between clinical and administrative teams, as well as clear, timely, and accurate communication with all stakeholders. Utilizing local expertise to inform on infectious disease management and epidemiology helped forecast surge capacity priorities, along with an associated increase in technical and sta ng requirements, particularly for the ICU and PRU. Novel administrative tools were developed to assist leaders and staff navigate pandemic-related absences. Importantly, local partnerships were helpful in managing an array of new challenges, such as community response initiatives and PPE sourcing. To overcome limited resources in pandemic preparation and management, community hospitals are encouraged to leverage multiple local and external partnerships, engage in regular and proactive policy review and revision, frequently conduct mock simulations, and participate in standard assessment programs (e.g., accreditation).

Declarations
Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Competing interests: The authors declare that they have no competing interests A review of all COVID-19-related documentation discussed at RVH's EOC committee between March-June, 2020, as well as COVID-19 documentation provided by external partners between February-June, 2020, identi ed recurrent themes critical to RVH's pandemic response.  A robust capacity plan guided by the principles of Design Thinking permitted RVH to expand its level 3 critical care capacity from 16 beds to 105 beds in 5-12 weeks, along with an additional 334 standard beds and 300 cots (not shown), as required.

Figure 4
A structured, ve-step Workforce Planning Cycle was established to identify and ful l clinical sta ng requirements, as well as cleaning staff, environmental services aides, and other staff essential to meeting workforce demands and upholding patient safety. This framework was further supported by strategies and actions to source, recruit, onboard, train, and develop staff. The Pandemic Response Unit (PRU) is a 70-bed, 8,250 square-foot, four season, fully-functioning modular eld hospital located in RVH's parking lot and connected to the health centre by an enclosed walkway. The PRU is professionally staffed and fully-equipped regional asset to assist RVH and partner hospitals facing capacity challenges during the COVID-19 pandemic. Of note, the PRU is not a unit for COVID patients, but for medically stable inpatients with an estimated stay of 3-5 days.

Supplementary Files
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