Coronavirus: How New York City's Public Healthcare System Managed Epic Patient Surge

To accommodate the city's coronavirus patient surge, NYC Health + Hospitals increased critical care capacity and retooled emergency departments.

It was a nightmare scenario.

Emergency rooms were overwhelmed with coronavirus patients—sick patients walking through the door and dozens of seriously ill boarded patients awaiting inpatient beds. In some metropolis hospitals, demand for ICU beds exceeded supply.

It was March and April in New York City, and The Big Apple's 11-hospital public healthcare system—NYC Health + Hospitals (NYC H+H)—was at the U.S. epicenter of the global coronavirus pandemic. As of May 22, the city had 193,000 confirmed cases of novel coronavirus disease 2019 (COVID-19) and more than 50,000 hospitalizations, according to the New York City Department of Health and Mental Hygiene.

NYC H+H's efforts to increase critical care capacity and retool emergency departments is featured in a new article published by Health Affairs.

"As health systems nationwide prepare for potential resurgence of COVID-19 infection with relaxation of social distancing measures and the frightening prospect of a second peak, principles and actions taken by New York City Health + Hospitals provide a model for how hospitals across the United States can expand critical care capacity and manage frontline ED care to lessen the toll on human life," the article says.

Boosting critical care

Before the city's coronavirus crisis began in March, NYC H+H had about 300 ICU beds. When COVID-19 patients surged, the health system provided ICU care to more than 1,000 patients.

NYC H+H pursued three primary strategies to increase critical care capacity.

1. Increasing ICU beds

• The health system organized ICU resources in two categories: "primary" spaces that were already equipped with the full suite of ICU equipment such as adequate power supply and physiology monitors, and "flex" spaces that could be quickly converted into fully equipped ICUs. Flex spaces included post-operative areas, operating rooms, procedural areas, and critical care rooms in the EDs.
   
• For infection control in the ICU setting, the virus that causes COVID-19 was assumed to be aerosolized and airborne.
   
• In many primary ICU spaces, individual patient rooms had negative pressure, so total personal protective equipment (PPE) only had to be donned by caregivers working in a patient's room.
   
• Flex ICU spaces were more challenging because they often did not have single rooms that could serve as an individual isolation unit, requiring all staff to wear total PPE.
   
• The most seriously ill COVID-19 patients were treated in primary ICU spaces.
   
• Some hospitals experienced higher demand for ICU beds than others, so critical care beds were shared across the health system. In the six-week period starting March 20, more than 850 critical and noncritical patients were transferred between health system locations.

2. Increasing ICU staffing

• Ambulatory clinic and elective surgery staff were reassigned to serve in critical care roles. Several of these staff members had specialized skills well-suited to the ICU setting such as anesthesia clinicians who could lead intubation teams and surgery staff who were familiar with proning patients.
   
• To maximize the effectiveness of experienced critical care staff, the health system used a tiered staffing model in ICU settings, with experienced clinicians and nurses leading teams of reassigned healthcare workers. This approach freed up critical care physicians and nurses to manage more patients than pre-pandemic levels.
   
• The health system recruited staff from across the country, including volunteers and military personnel with medical training. For example, more than 100 respiratory therapists were recruited. To maintain efficiency and efficient workflows, experienced staff members led teams of recruits whenever possible.

3. Increasing critical care equipment and infrastructure

• The health system's supply of ventilators was supplemented with acquisitions from federal stockpiles and vendors. Ventilators also were sourced internally such as using operating room anesthesia machines. At the peak of the patient surge, about 1,000 patients were on ventilators, which was about five times the utilization level in pre-pandemic spring months.
   
• COVID-19 patients require volumes of oxygen that are beyond the capacity of free-standing oxygen tanks, so installing piped oxygen systems was crucial.
   
• Many seriously ill coronavirus patients require renal replacement therapy, and the health system had to redistribute dialysis machines and establish new peritoneal dialysis programs at some sites.
   
• Ventilators and renal replacement therapy machines have several disposable parts such as filters and circuits. The health system had to redistribute these parts between hospitals to help manage supply shortages.
   
• The high volume of patients put pressure on the health system's supply chain for common supplies such as IV tubing and dressings. Frontline staff and supply chain leaders monitored the "burn rate" for these supplies.

Managing emergency departments

NYC H+H established an action team featuring health system and local ED leaders to focus on three areas.

1. Protecting staff

• Initially, suspected COVID-19 patients were placed in dedicated areas, where staff donned full PPE.
   
• As the patient surge intensified, all EDs and ICUs were designated as "hot zones" requiring clinical and nonclinical staff to don full PPE.

2. Matching resources to clinical needs

• The action team initiated text message campaigns to urge city residents with mild symptoms to stay home and monitor their conditions, which helped avert ED overcrowding.
   
• As the patient surge intensified, the health system issued a citywide open letter that gave residents more detailed medical advice such as how to self-isolate from other household members and when to seek medical attention.
   
• The health system built a telehealth capability paired with the city's 911 call-center to provide clinician assessments of coronavirus symptoms. If more medical attention was warranted, the telehealth clinicians would direct patients to the appropriate care setting.
   
• Some low acuity COVID-19 patients transported by ambulance were taken to urgent care centers or tents outside EDs for triage.
   
• To increase ED throughput, protocols were created for the evaluation of potential COVID-19 patients such as streamlined clinical work-ups. Many high-risk patients were admitted, but those who did not meet admission criteria were often held in the ED for observation.
   
• A home-monitoring program was established with text messages and phone calls to enhance discharge safety.

3. Increasing capacity and improving efficiency

• ED-based ICUs were created to board seriously ill COVID-19 patients who were awaiting hospital admission. Some EDs boarded as many as 100 of these patients at a time.
   
• Staffing was increased and workflow efficiency was improved to increase time for bedside care. Staff onboarding processes were accelerated—the duration of onboarding was reduced from a few months to a few days.
   
• Staff efficiency was improved through methods such as dividing clinicians into key teams, including ventilator monitoring, transport, and proning.
   
• Documentation for COVID-19 patients was streamlined in the electronic medical record, which also was updated with coronavirus-specific ordering tools.