Background: Nearly 15% of Americans live in rural communities, but only 1% of intensive care unit (ICU) beds are located in those same communities. The COVID-19 pandemic highlighted the dangers of this disparity. Many rural communities were devastated by COVID-19, with rural counties having four of the five highest population-adjusted death rates in the U.S. Thus, there is an urgent need to identify successful approaches to maximize ICU care for rural communities during times of increased healthcare demand, such as COVID-19. The long-term goal of this R01 project (Rapid Understanding of Best Practices in Rural Intensive Care or RUBRIC) is to ensure that critically ill patients in rural communities receive the best possible care during times of pandemic and beyond. The overall objective is to develop a toolkit of strategies used by high-performing rural ICUs and to rapidly disseminate this toolkit to improve ICU care for rural communities. Project Methods: We will use a sequential explanatory mixed methods study to rapidly understand best practices in rural intensive care. First, we will administer a nationwide survey of rural ICUs to characterize adaptations made in response to COVID-19. Next, we will leverage national administrative claims data to estimate the effect of increased healthcare demand due to COVID-19 on survival for acute respiratory failure among rural ICU patients. Finally, we will perform interviews and detailed hospital assessments during site visits at eight rural ICUs (four high- and four low-performing) to define best practices. Unique Features and Innovation: Since limited evidence is available to broadly define and compare rural ICU performance, our study will make unique national comparisons exclusively among rural ICUs. Using a difference-in-differences analysis, we will estimate the effect of increased healthcare demand on rural ICUs, by using heterogeneity in exposure to COVID-19 across rural counties. Anticipated Impact: We will identify strategies used by rural ICUs to adapt to COVID-19, compare the effectiveness of rural ICUs in responding to COVID-19-related healthcare demand, and define best practices of high-performing rural ICUs. To support rural ICUs in anticipation of successive pandemic waves, we will disseminate a report of strategies used by rural ICUs during COVID-19 within six months of this R01 award and will disseminate additional findings every six months. At the study?s completion and as a next step, a toolkit of best practices in rural intensive care will be implemented and tested in a future proposal.
The COVID-19 pandemic risked overwhelming rural intensive care units (ICUs) that, even in the best of times, were fundamentally challenged to ensure access and quality care for their critically ill patients. Some rural ICUs had tremendous success despite their challenges, but the strategies used by these high-performing rural ICUs to succeed are unknown. Our proposed project will rapidly identify and disseminate a toolkit of best practices in rural intensive care in response to COVID-19, which will help improve quality, safety, and health system value for vulnerable rural communities.
