The Covid-19 Response in New York City: Crisis Management in the Epicenter of the Epicenter

The COVID-19 Response in New York City: Crisis Management in the Largest Public Health System provides an historical accounting of the response to the COVID-19 pandemic through the eyes of the largest public health system in the United States. The book offers a roadmap to guide healthcare systems and their providers in the event of future pandemics. Readers will learn about surge staffing and level loading, as well as tips from the ED and ICUs on how to respond to an unprecedented influx of inpatients.

Written by healthcare providers who were at the epicenter of the pandemic in New York City, this book provides a sound accounting of the response to the pandemic in one of the world's largest cities.

• Provides historical context of the COVID-19 response by NYC Health + Hospitals
• Covers how to respond to a mass influx of patients and sustained crisis over a year+
• Presents information on standing up genomic sequencing

• Language: English
• Publisher: Academic Press
• Release date: Apr 21, 2024
• ISBN: 9780443187568

Book preview

Section I

In the beginning

Outline

Chapter 1. Standing up the emergency response in the epicenter of the epicenter

Chapter 2. The history of NYC Health+Hospitals

Chapter 1: Standing up the emergency response in the epicenter of the epicenter

Colleen Smith, Suzanne (Suzi) Bentley, Geoff Jara-Almonte, Veronica Delgado, Phillip Fairweather, Cathy Lind, Ram Parekh, Stuart Kessler, and Laura Iavicoli     New York City Health + Hospitals, New York, NY, United States

Abstract

When the light switch turned on, the patients showed up in droves. How the NYC Health+Hospitals/Elmhurst Emergency Department stood up a response as the first and hardest-hit facility of its kind in the United States. Without knowledge of virulence, infectivity, treatment protocols, or clinical course, the staff at Elmhurst Hospital rallied to care for the neediest community.

Keywords

COVID-19 surge; Emergency department; Emergency medicine; Epicenter; Pandemic response; Surge; Surge response

This chapter is dedicated to Dr. Joseph Masci who passed during the writing of this book. Dr. Masci, an infectious disease doctor at NYC Health+Hospitals/Elmhurst, was an early pioneer in HIV treatment and developed HIV/AIDS programs in countries around the world. He also helped NYC prepare for potential terrorist threats after 9/11 and possible infectious disease outbreaks like Ebola. From the words of Joe Masci, What I want people to take away from my words is a recognition that connecting with patients is really the center of what we do. Patients first and foremost. This is our mission at NYC HealthandHospitals: to extend equally to all New Yorkers, regardless of their ability to pay, comprehensive health services of the highest quality in an atmosphere of humane care, dignity, and respect. And so our story begins….

Vignette ¹

Ventilator alarms, cardiac monitor alarms, and ambulance sirens all blared simultaneously in a cacophony of sound that would define those few harrowing weeks in March, 2020. Flashing warning signs screamed at the hospital staff from the wall mounts indicating dangerously low oxygen levels in the hospital's main tanks. The emergency department (ED) doctor scheduled for the ED critical care shift that night entered the ED and paused in his tracks. Looking all around him, he was disoriented, not knowing where to go, not knowing what to do first, trying to comprehend what was happening. A resuscitation and trauma room designed to fit seven patients comfortably now held 20. They were all side by side, within touching distance—if they were able to extend an arm in either direction, they could hold hands. But they were not able, because they were spending all their energy trying to breathe.

The patients all had that helplessly distressed look. Worse yet, the doctor knew the unfortunate possibility that the patients didn't: they were on death's door. Still, he wondered, was this the look of people who somehow knew their fate? NYC Health+Hospitals/Elmhurst (Elmhurst Hospital) ED was 2weeks into the pandemic and the number of critically ill patients was overwhelming. Patients all lay there, side by side, amid the same blaring onslaught of sounds. If they were not on a breathing machine with a breathing tube (mechanical ventilation), they had noninvasive ventilation masks strapped to their faces for hours, sometimes days, on end.

The ED physicians tried to hold off on mechanical ventilation for as long as possible. In part because the ventilator supply was strained, but also because our intesive care colleagues had yet to successfully extubate a patient. Still, over the first weeks of the pandemic we were coming to the realization that patients did not tolerate less invasive ways to deliver the high amounts of oxygen that they required, such as noninvasive ventilation or high flow supplemental oxygen. Most simply did not improve. Some held out for hours, many held out for days, but they ultimately required mechanical ventilation. The doctors quickly discovered that the intensity and severity of the native strain of COVID-19 during the first wave proved to be too much for any patient gasping for their last breath. Despite the highest level of skilled critical care provided for every patient, when the ED doctor's only lifesaving option was mechanical ventilation, he knew it was only a matter of time. For all of them.

Preface

A single case in the first week of March 2020 turned into a tidal wave of COVID-19 at Elmhurst Hospital that would last far longer and be far more severe than anyone anticipated. This brutal onslaught would challenge every aspect of emergency care, pushing staff on the front line to the limit, but ultimately many innovations and lessons learned were harnessed through the heroic ingenuity of a hospital system under siege. That first patient was seen in the ED with only mild vomiting and diarrhea (no cough or fever) and discharged the same day. There was no suspicion for the disease caused by the SARS-CoV-2 virus (COVID-19) until he came back 2days later. One case turned into 30. Thirty cases quickly turned into hundreds. Elmhurst Hospital became the epicenter of the epicenter of COVID-19 in the United States (US), and the world watched on television screens as patient lines grew longer and longer outside the ED. The fight was relentless: intubate, cardiac arrest resuscitation, move on the next patient, intubate, cardiac arrest resuscitation. Stepping outside for even a minute to catch a breath and collect thoughts before continuing on with patient care was a luxury staff couldn't afford. Time was not on Elmhurst Hospital's side. It was a nightmare, with some likening it to the end of the world or a war scene in a movie. The worst part was the unpredictability. Would this onslaught go on for days, weeks, or months? No one knew.

The beginning of a virus taking a foothold in New York City

During the holiday season of 2019, the media began to report the first official accounts of a novel coronavirus emerging in Wuhan (Worobey, 2021). At that time, the virus and the disease it caused did not have a name. A cluster of cases was reported on December 30, 2019, leading to the closure of the Hunan Wholesale Seafood Market on January 1, 2020. The SARS-CoV-2 virus was isolated January 7, 2020, and sequenced 3days later. Rapid diagnostic tests were developed and distributed in China, and a Cordon Sanitaire was established on January 23, 2020, in Wuhan and surrounding cities—50 million people quarantined (Yu et al., 2020).

The Elmhurst Hospital ED reported an anecdotal increase in influenza-like illnesses (ILI) in the last weeks of February but did not have access to COVID-19 testing. The team relied on information from the Centers for Disease Control and Prevention (CDC) and state and local health departments and trusted them to investigate potential COVID-19 cases and make the appropriate notifications. As the CDC was not reporting COVID-19 cases in the US or advising testing, it was presumed that these ILI cases were not related to the known outbreaks in China, Iran, and Italy.

And so it began …

In reality, Elmhurst Hospital was flying blind despite the best efforts to be prepared. The staff was well trained. The attending physicians completed a Frontline Special Pathogen Course in February of 2019, and kept up competencies with personal protective equipment (PPE) donning and doffing skills. The ED symptom and travel screening was created based on the latest CDC guidance and implemented by mid-January 2020. Watching the scene unfold in other countries, Elmhurst Hospital staff were nervous but reassured by their vigilance and preparations.

March 2020 began with the first diagnosed case of COVID-19 in the State of New York in NYC's adjacent county, Westchester. When it became a cluster of cases in the course of that week, the team at Elmhurst Hospital resigned themselves to the fact that COVID-19 would be on their doorstep soon. As ILI cases increased in the ED, the medical team ramped up quickly, implementing supply, registration, admission, transportation, and elevator use guidance for possible COVID-19 patients.

In the first weeks of March, the NY State Department of Health (NYSDOH) began accepting COVID-19 swabs for testing with extremely limited criteria. These criteria had not been updated to reflect known outbreaks in Italy, South Korea, Iran, the cases in Washington state, or Westchester County, NY. A very narrow and limited number of patients met the testing criteria, which specified that a travel history from Wuhan, China, or exposure to a known case must accompany symptoms. Multiple updates to CDC and NYSDOH testing criteria would be rolled out over the next few weeks as testing capacity slowly ramped up (Han Archive, 2020).

Quarantine and isolation criteria were disseminated by the NYSDOH (Hans, 2020). Elmhurst Hospital quickly adopted the guidelines and created customized discharge instructions to give to patients on how to isolate at home. Many appeared to have the same viral illness, but due to limited testing capabilities, confirmation of COVID-19 infection was impossible. The team was left with the significant challenge of trying to convey the urgency to limit the spread of this virus that was inundating the ED but without hard evidence of infection. A febrile patient from Northern Italy and a critically ill hypoxic patient with no fever and a close contact from Wuhan, China did not meet testing criteria. There was a sinking concern that COVID-19 was here and a sense of helplessness to respond because it couldn't be proven by laboratory testing.

Still staff continued to prepare and respond as the number of ILI patients increased. Donning and doffing videos and photo guides for personal protective equipment (PPE) were created by the simulation center leads. These were distributed and displayed throughout the hospital. Staff were using a new set of PPE for each new encounter with an ILI patient. PPE supplies were flying off the shelves—being used faster than could be restocked. With the shortage of masks in the community, patients and visitors were stopped as they tried to take boxes of masks and gloves from the hospital. Due to the rising burn rate of N95 respirators and the need to conserve and safeguard supplies, N95 respirators were secured in a locked critical care area cabinets—accessible to all who truly needed one.

More and more patients showed up every day with the same constellation of ILI symptoms (cough, fever, sore throat, runny nose). Gradually criteria for who could be tested was expanded. As patient volumes increased, having enough isolation areas became a challenge. Hospital leaders including the Chief of Facilities, Chief of Infectious Disease, and Director of Infection Prevention convened to plan modifications to existing physical space for better cohorting of patients. Installation of new ductwork and air scrubbers and the creation of large negative pressure spaces was discussed. The goal was to contain those with the same presumed viral illness and thereby decrease the risk of spreading to staff and other patients.

By the second week of March, the Elmhurst Hospital ED had settled on the name COVID Care Unit. As ILI patient numbers soared, the ED's fast track space, newly outfitted with HEPA filters, served as the first COVID-19 unit in the system. Elmhurst Hospital then implemented a full PPE protocol for the ED COVID Care Unit—staff could not enter without N95 respirator, gown, gloves, and eye protection.

On March 11, 2020, the WHO declared a worldwide COVID-19 pandemic (Cucinotta & Vanelli, 2020). Most New Yorkers were oblivious to how quickly Elmhurst Hospital was getting overwhelmed. Staff coming out of grueling ED shifts saw people overflowing into the street patronizing nearby bars and restaurants, blissfully unaware of the looming disaster. Public health messaging continued to warn against mask use for the general population until early April 2020 when literature emerged that public use of cloth masks had benefits (Howard et al., 2020).

In less than a week from its creation, the ED COVID Care Unit was overwhelmed with patients and was relocated to a larger space. But it wouldn't be enough. Patients kept coming. Nonclinical staff, who had been instructed by hospital administration not to wear masks for fear of scaring the public, were being exposed and began falling ill. Even patients coming in for unrelated reasons such as trauma, without any symptoms of COVID-19, were found to have evidence of the infection in their lungs on X-rays and CT scans. These patients had not been placed in the isolation unit. It seemed like every patient had COVID-19.

Despite a concern by many in hospital leadership that the optics of wearing a mask could scare patients, the entire ED (beyond the COVID Care Unit) was declared a COVID-19 hot zone. No one could get in without donning full PPE and they were required to doff before leaving, keeping only their N95 mask on.

On one day in mid-March, there were 120 patients with ILI symptoms waiting for ED triage. The sit-down waiting room was standing room only with patients spilling out of the doors. The next day, there were 225 patients in the ED and another 120 patients still to be registered and triaged, with ambulances lined up and down the street to drop off more. Of those in the ED, 140 were admitted patients on life-sustaining oxygen awaiting inpatient beds, with 40 of those requiring noninvasive ventilation, high flow oxygen, or mechanical ventilation (Fig. 1.1).

Figure 1.1  Ambulances lining up to deliver patients to Elmhurst Emergency Department in late March 2020. Image credit: Laura Iavicoli, MD.

The spaces were beyond overcrowded. One area with 12 beds now held 60 patients, literally standing room only even for patients. Another space with 14 beds held 80 patients without a glimpse of the floor to be seen. Many were seated in folding chairs surrounding portable oxygen tanks. The resuscitation and critical care (RACC) space with seven beds for critical medical and trauma patients was overflowing with 14 intubated patients. Eventually, the ED staff would run an overflow ICU with more than 40 patients in a 12-bedded space and another 22 in the RACC. In the face of this onslaught, the team performed evaluations of patients at the ED entrance, and treated and released stable patients with the option to get tested in a newly erected testing tent positioned just outside.

As the month progressed Elmhurst Hospital was declared an All COVID-19, All Critical Care hospital. Any non-COVID-19 patients were to be transferred to other sister facilities, which did little to ease the overburdened hospital as it had zero COVID-19 negative patients by that time. Even patients admitted for reasons unrelated to COVID, also had COVID-19.

Soon after this declaration, NYC H+H began level loading COVID positive patients, transferring them directly from the Elmhurst Hospital ED to other facilities that had more capacity. Ultimately, the system transferred 250 COVID-19 patients out of Elmhurst Hospital through the end of April 2020.

By the first week of April 2020, in only one month, the state of New York State (NYS) reported a record 12,274 new cases. In the month of April 2020, NYS reported approximately 29,000 more deaths than were reported in April 2019. By April 10, 2020, NYS had more confirmed cases than any country outside the US (COVID-19 Data, n.d).

Although the first week of April 2020 was overwhelming for the medical team, in mid-April ED volumes rapidly dropped. This was likely a downstream effect of the March 20 executive pause order issued by the NYS governor's office to close all nonessential businesses. But the patients who were still coming to the ED were extremely ill and the crisis remained unchanged for the inpatient teams due to the extended hospitalizations for COVID-19 patients. The hospital's small team of inpatient critical care doctors were overwhelmed and stretched thin, managing over 200 intubated patients. ED teams of attendings, residents, and advanced practice providers (APP) including both physician assistants and nurse practitioners were deployed to the inpatient ICU floors (Fig. 1.2).

Hospital staff were reeling with physical, mental, and psychological exhaustion after 2months of battling COVID-19. With a hospital full of critically ill patients, ongoing supply shortages, and an unprecedented death toll, they needed support. Elmhurst Hospital's Helping Healers Heal (H3) emotional and psychological support program significantly increased staffing to meet this mounting need for the healthcare teams. They rolled out hospital-wide interventions at the end of April 2020.

Figure1.2  Timeline of major COVID related events shown concurrently. The scale on the left shows Elmhurst ED patient volume for March and April 2019 (blue dotted line) and 2020 (orange line). The scale on the right shows the number of patients intubated in the Elmhurst ED (gray line) during March and April 2020. Data adapted from internal electronic medical record audit.

During the most challenging time in the history of the Elmhurst Hospital ED, staff came together as a dedicated team of professionals working tirelessly to provide care. Despite fear for their own safety and observing both patients and colleagues succumb to the COVID-19 virus, ED staff continued to show up for their patients and one another.

How was this different from the usual state of affairs in Elmhurst Hospital's large, busy, urban, safety-net ED? Three ways: volume, acuity, duration. Patient volume doubled. The acuity of these patients was shockingly high. Patients with COVID-19 required inpatient stays averaging weeks longer than usual patients. There was no clear end in sight.

Problem areas and the unwavering effort to solve them

This chapter will discuss the challenges faced by one of the first EDs in the US to be hit by the tsunami wave of COVID-19 patients, with an emphasis on solutions that were quickly formulated and implemented plus lessons learned from managing the shockingly high volumes, acuity, and long ED and inpatient stays.

Based on this experience, Elmhurst Hospital can pinpoint five areas upon which to focus:

• Communication

• Supplies

• Space

• Staffing

• Clinical guidelines

Communication

Much like the communication issues faced on the global and national levels, communication—between patients, patients' families, staff, hospital and governmental leadership, and the public—represented a significant source of challenges within the hospital. Elmhurst Hospital grappled with issues of communication on several levels: clinically, organizationally, and publicly.

Clinical challenges

Frequent changes to the ED environment had a significant and unanticipated impact on clinical communication. The use of masks and face shields significantly muffled voices, making it hard to hear. The uniform appearance of PPE-clad providers made it difficult to distinguish individual members of the care team. The overall noise level in the ED went up dramatically due to fans and filters designed to improve ventilation, as well as the ever-present cacophony of ventilators, telemetry alarms, oxygen alarms from the rapid draw of oxygen from source tanks, and infusion pump alarms. All these issues compounded with one another, making it difficult to determine who was talking or what was said. Initially, the long-term familiarity between the core group of physicians, nurses, and techs helped mitigate some of these effects; however, these structural and physical factors presented challenges when it came to incorporating supplemental staffing into existing teams and workflows.

The inability to hear and be heard, to understand and be understood eroded the provider–patient communication central to a therapeutic relationship. In addition, the sheer patient volume limited the time that providers could spend with any one patient. Restrictions on visiting hours and the eventual curtailing of visitation all together deprived patients of family and advocates who might have helped bridge the communication gaps with providers and staff and added to the communication challenges. The visitor restrictions also significantly impacted on the staff's ability to communicate with family members of the most critically ill patients about goals and progress of