Table 2.

Identified themes from interviews with example quotations to demonstrate underlying codes

Theme	Code	Example quotation
Communication
	Patients	“… So I think it’s hard on the kids to have us walk in with these. Even if it’s just a gown and gloves and face mask. We look pretty ridiculous…I think we’ve lost some of that kind of humanity side of being pediatricians where you now just look like a little space monster walking in.”
		“I feel now that there is a barrier between myself and my patients that hadn’t existed before. And there’s just something about the masks and the goggles, and the gown, and all of that, that that sets up a barrier…a small example is having to walk in the room and ask the parents to put on a mask, you know, so you become the mask police and it’s set us up for negative interaction.”
	Departments	“I think everyone got the same information, but I think where we ran into some difficulties was that our physicians are employed by the university. The nurses and everybody else are also employed by our health care facility.”
		“The COVID leader from the ED team would communicate with ED staff, and kind of filter out or filter through all the different messages that were coming out and making sure everything was synced, because in the beginning, there was just an overload of information coming from multiple different resources…So one of our jobs we identified within the first month was to filter through that information and summarize it for everybody.”
	Frontline providers	“…because we try to keep the door closed, there is minimal communication in and out of the rooms. This was much harder. So we actually set up iPads and were able to create Zoom conference for each of our resuscitation rooms so that the outside teams could listen in.”
		“Also, with our resuscitation rooms now being completely empty we have the role called the gatekeeper, and they stand by the door, and they help with communication, but they also help with getting the right people in, but they’re also making sure that not everybody goes in. So they’re exactly the kind of a gatekeeper role.”
	Methods of dissemination	“…we have these huddles first, we’re having them daily, like every morning, there’d be a little huddle in the command center. And all information was supposed to come through there and, you know, be checked by the team and then disseminated out once we thought we had the right information, especially when it was changing so frequently, like with what’s aerosolized and what PPE do you use, and what is our visitor policy…We would then incorporate whatever new things had changed in the last five hours since information was changing so fast into the twice daily ER board huddles with physicians, nurses, techs, etc.”
		“I think our communication could always tune it up a little bit. You know, finding new ways to reach people, global emails are fascinating, but nobody reads the global emails. I would definitely do the town halls again. I think it’s important to be transparent.”
Leadership and planning
	ED representation	“…we really needed to have representation, because it was clear that the infection prevention people didn’t necessarily have the perspective or the appreciation for the frontline worker. And a lot of it was kind of almost like a clinics approach or inpatient approach to COVID, which is much different.”
		“I was the incident commander for the ED. And so I had two associates, a nurse and a physician who would virtually communicate with me while I was in the actual incident command for the hospital. So I was the liaison officer to the ED in a way. And so that was really helpful.”
	Pandemic plans	“I was hoping that H1N1 and all that stuff we learned from that would help. And it doesn’t because it’s a different disease. Totally different.”
		“There’s a Bio-Response Team hospital wide that was set up to prepare for Ebola. We were one of the few centers in the US that would accept Ebola patients. So that infrastructure was there, and we’ve kind of pivoted to COVID and COVID prep.”
	Initial and surge preparation	“I think after any type of event, you always think, Oh, I wish we just spent a little more time with X, Y, or Z. Like we spent so much time trying to figure out how we set up stupid surge tents, which we never used, maybe we’ll use someday. But we should have already had that as a plan. Like, we should have had a type of surge tent plan for any type of aerosolized disease anyway. And we didn’t.”
		“I usually did one pediatric and one OB, tabletop, and we would just, we would just run it for, you know, half hour with our incident command staff, just to sort of run the whole thing. And it was interesting, because, you know, a lot of it was done virtually…this was done to test new protocols.”
	Leadership structure	“We had too big a group at the beginning, we narrowed it way down to about maybe eight people after a while, and that helped get decisions made.”
		“We’re changing up how we do training for incident command going forward because we found that sometimes roles would start muddling together and planning an operation would kind of start squishing together in that way.”
	Finances and taking adult patients	“We definitely cut shifts back and you know, I’m sure like everywhere like there’s zero raises this year. There’s no bonuses, there’s no travel money, there’s no CME money, there’s none of that. There’s no extra money anywhere when there’s no hiring. So they did cuts like that, but we didn’t have to take a salary cut.”
		“So we have a plan in place that we would take people up to the age of I think 30. Our surgeons are on board to do things like appendectomies and cholecystectomies, and I think ortho might be on board to do simple ortho stuff, you know, we’re obviously not going to take sick COVID people, though we did take a 42 year old on ECMO in the ICU, which was insane”
	Supply chain	“Supply chain had already planned for a lot of this in the sense that once they knew this was coming, they started looking to see who are my other suppliers besides all the suppliers from China…How can we get here? How can we go collaborate with the distillers to get our hand sanitizer?”
		“We had one of those calculators and a dashboard in the command center where you see the number of ventilators, PPE, number of N95s a week, it was constant inventory control and constant management.”
Clinical practice
	Personal protective equipment	“I mean, very early on, there were recommendations that said, maybe masks weren’t even helpful, like this was coming from I think it was the CDC, which is really interesting to think about the history of all this. So are masks really helpful? Or should they just be used by people who have preexisting condition conditions or immunocompromised and this kind of thing? You know, and then you have, what sort of masks should we be using? You know, and then it felt like a switch kind of flipped.”
		“It’s been clear that a lot of the recommendations I’m talking about now even at the national level, has been based more on less science and more on issues like supply chain and availability”
		“So just the very concept of wearing an N95 for multiple patients, you know, that’s hard to justify from a medical perspective, and for both the provider and also for all those patients. And yet, you know, the thought of every provider switching out their mask in between every patient that wasn’t tenable, either.”
		“We had a robust and highly safe repurposing process. You doffed your N95, you packed it, you put it in a room, it was taken and went through a chemical cleaning, and brought back to you was labeled with your name.”
		“We developed a guide, you know, we follow the guidelines from the university and then basically posted them on every door, going into each exam room on how to put on your PPE and take it off, where to store it, and then the reuse guidelines. And then we would have like PPE champions who would kind of go around just watching people as they don and doff and help them.”
	Testing	“We never developed our own in-house test. We’ve been using Abbott. That limited us. And initially we had to work through the State and County Department of Public Health to get our testing like everyone did.”
		“We’ve had some rapid tests that we’ve had to dole out very carefully, rapid antigen and rapid PCR that we use for behavioral health and emergency surgery, but we’ve only got like an average of like, 4 per day.”
		“April is when we started having in-house testing, but again, it was very limited, really the main limitation was the reagent. And so we you could do in-house testing, but it was only for those that were high risk or PUI.”
		“Our biggest success honestly, was that drive thru site that we established within five days…”
		“Once we had more testing availability, we actually started being a little bit more liberal. So, we test for kind of softer symptoms just to get a better idea of the actual prevalence rate in the community. So even if you had just kind of vague symptoms sometimes, we were testing or if you had a symptomatic contact.”
	Physical space in the ED	“And so instead we’re going to split the ED into two different areas and the symptomatic over here asymptomatic kids over here. And so that was sort of the approach that we took.”
		“So, we bifurcated folks from the beginning at our visitor desk and asked them questions. Then we put a divider in our waiting room. So, there was one side that was the PUI side and one side that was not; so orthopedic injuries, that sort of stuff. But eventually, we came to the realization that almost everyone who lives in this community could be a PUI even if you didn’t have symptoms. So, the curtain, the divider, eventually went away.”
	Aerosol-generating procedures	“… early on there was no consistent document that described the way aerosol-generating procedures affected spread. Well, whose information do we use? Do we just use our own expert opinion on that? Because then what if one person of those 20 experts says the air contrast enema is an aerosolized procedure. Well, then we have to have everybody in radiology wearing N95s and hazmat suits to do an air contrast enema.”
		“We actually were able to change air flow over for a lot of our other rooms. So, facilities, I call them down had them change over the flow of the air. So, it’s not negative pressure, but there is at least a negative flow in like, thankfully, our EDs filter out so it doesn’t go anywhere else.”
Personal adaptations
	Fear and anxiety	“I think from a leadership perspective, it was difficult trying to figure out how do you help address those fears, in that minor number of people, but if you didn’t address it, their fear and anxiety spread to everyone else that we’re working with. And so, trying to figure out how you contain that, I think was a struggle.”
		“So, people have just sort of settled in. And I think, you know, once people started seeing the experience elsewhere, I think that people started feeling a little bit better about the protection they had.”
		“…there was also the reverse, where there were people who were like, you know what, we got this, and they were willing to step in and be on the front lines. And I think more than the panic, we had more people who wanted to step up and figure out how to solve and engage in solutions rather than problems.”
		“…the initial response when the anxiety was so high was to have that reassurance. I remember there’s a couple people that came up to me. I led a huddle and I said, look, you know, I don’t know what’s going to happen, but everybody’s going to be okay. You know, like, we just need to put out that message, we don’t know, but we’re going to support each other, and we’re going to be okay, and that actually, people came up to me later and said, that was really helpful for them to hear just because, you know, everything was changing so much.”
	Keeping personnel safe	“And then there are definitely some who took it a little less seriously, who would, you know, sit with their goggles off or mask partly down on the chin, or you know, the shared computer space. And so there have been multiple discussions about no eating and drinking around the computers and keeping your mask and goggles on the whole time.”
		“I feel a great deal of confidence that if we had to deal with another Ebola event, that we’re not going to have to do a lot of training for people because everyone’s just so used to putting stuff on nowadays.”
		“We have not had a single positive faculty member or fellow…we’ve had maybe only three hospital transmissions, but they’ve all been from employee to employee, not patient. Yeah. So, we’ve done well…”
	Personal habit changes	“I don’t think that I have ever taken the time to look at my infection control practices as much as I have to the point of how often do I clean my stethoscope? When do I click the keyboards at the beginning of my shift? How often do I wear gloves? I mean, yeah, no, I don’t like wearing gloves. I kind of like the touch of people. And so even that has been different. So, it’s, I think it’s my infection control practices. And I probably should be doing it all the time in an ER, but I just haven’t done it.”
		“And so maybe I’m making judgments from the doorway, you know, looking through the glass door, and looking at the patient that way, or relying on my residents and fellows who have been in the room, you know, to give me updates.”