Operational Challenges During Public Health Emergencies in Safety-Net Hospitals

Importance: Safety-net hospitals (SNHs) serve as essential public health hubs, providing direct clinical care and critical social services to vulnerable populations, yet gaps persist in their ability to reliably deliver these essential services during disasters. Objective: To identify common challenges faced by SNHs and actionable approaches described by participants to strengthen future emergency response capacity at these critical institutions. Design, Setting, and Participants: For this qualitative study, from April through November 2025, key informant interviews were conducted with individuals across SNHs selected to represent a spectrum of SNH types. Thematic analysis of site-level case studies was used to identify cross-cutting and context-specific patterns across 5 domains: load balancing, staffing needs, supply chain, crisis standards of care (CSC), and health care coalitions (HCCs). Main Outcomes and Measures: Stakeholder perspectives of pandemic preparedness, response, and recovery were evaluated to understand strategies to mitigate future health care disasters. Results: Analysis of interviews with 69 individuals from 10 SNH sites identified systemic vulnerabilities across all 5 domains in SNHs. SNHs rarely succeeded in transferring critically ill patients without extensive staff time spent setting up the transfer. SNHs often experienced severe workforce disruptions from limited staff pools and nurse attrition, leaving them dependent on temporary staff at higher costs. Just-in-time personal protective equipment procurement and constricted manufacturing supply chains created supply crises. Few SNHs implemented full CSC, but many worked to find creative solutions to prevent more extensive changes in care standards. Opinions on written CSC were mixed, with some preferring structured frameworks and others preferring flexibility. Experiences with HCCs varied widely, with SNHs embedded in well-resourced HCCs reporting better coordination and support. Conclusions and Relevance: In this qualitative study of SNH preparedness and response, findings indicated that SNHs faced challenges with load balancing, supply chain, staffing, CSC, and HCCs. To address such challenges in the future, SNHs, regional coalitions, and the federal government should implement sustainable changes that can be rapidly brought to bear in an emergency. Potential solutions may have outsized benefit for SNHs; however, such solutions must be designed to be accessible to SNHs and feasible in these settings.