Lessons Learned From COVID-19 Resource Management at a New York Hospital

THE NOVEL coronavirus disease 2019 (COVID-19) was declared a global pandemic by the World Health Organization in early 2020. The first reported cases in the United States were at the end of January in the West Coast states of Washington and California, and the first case of COVID-19 was diagnosed in New York City a month later. However, by mid-April, the rate of infections in New York State had exceeded every other state, accounting for more than 30% of all of the US cases.¹ As the epicenter of the virus, the surge of cases stressed and threatened to overwhelm the state's healthcare systems due to the volume and acuity of COVID-19 patients.²

The Mount Sinai Hospital is the academic flagship of an eight-hospital health system affiliated with the Icahn School of Medicine at Mount Sinai located in New York. It averages 4.1 million annual patient visits, has 410 ambulatory practices, and has more than 42,000 employees. By early April, the health system had more than 2,000 patients hospitalized with laboratory-confirmed COVID-19. This required the rapid diversion of inpatient and ambulatory resources almost exclusively toward inpatient COVID-19 care. In the setting of potential overwhelming of the healthcare system, this approach was supported by public health authorities. During this initial surge, the authors encountered several challenges, including the need to safely increase inpatient and critical care capacity, manage an apprehensive workforce in the setting of many unknowns, innovate testing and therapeutics, and provide parallel care while preparing for postsurge care.

To quickly increase capacity, the authors took a number of important steps. All nonurgent visits. as well as elective and urgent surgeries, were deferred. Ambulatory practices immediately moved to telemedicine despite previous hesitancy on the part of both clinicians and patients to engage. All but three inpatient adult medical-surgical units were converted to COVID-19 units. The authors more than doubled their intensive care unit (ICU) capacity in fewer than three weeks by placing two patients into single occupancy rooms in their eight native adult ICUs and converting post-anesthesia care units to non-COVID ICUs—94 licensed beds became 240 ICU beds. They also were able to increase the number of negative-pressure rooms. Using high-efficiency particulate air filters and replacing room windows with “cutouts” for exhaust, the authors converted 260 patient rooms to airborne infection isolation rooms. Finally, the authors incorporated the use of nontraditional patient care spaces, including the rapid construction of patient units in the hospital lobby and the erection of a field hospital in Central Park. To avoid overwhelming the system, the authors asked the mildly symptomatic and asymptomatic to stay home to preserve resources, including testing capacity and personal protective equipment (PPE), and to decrease exposures.

Workforce management included stafftraining and engagement, communication, redeployment, and the use of a team-based model of care. Staff-directed crisis communications were detailed, balanced, frequent, and multimodal in a setting of dynamic public health recommendations and increasing anxiety. Messaging regarding protective planning, including how to keep oneself safe outside the workplace, was paramount, and staff wellness continues to be a priority. Staff comfort and safety were vital, leading to early liberalization of the use of surgical masks and, subsequently, N95 respirators. Despite an extensive prepandemic stockpile, tremendous supply chain pressure and instability led to frequent changes in PPE. This required repeat fit-testing, retraining, and early use of contingency standards of care (change in practice with no significant change in care delivery or healthcare worker safety) including extended use of N95 respirators. Eye protection and isolation gowns were ubiquitous and posed challenges in the supply chain. Staff redeployment both within the hospital and to other health system hospitals was essential to maintain capacity as hospitals in the outer boroughs were over capacity. Teams of individuals, including operational leaders, provided frontline care and stability. Regardless of training, physicians (both attendings and residents), nurses, and technicians were drafted to ICUs, emergency rooms, and other hospital units caring for patients with COVID-19. The anesthesiology department was at the forefront of providing education and simulation training for all providers. Examples of staff redeployment included having anesthesiologists serving as intensivists and staffing intubation and vascular access teams, cardiothoracic surgeons providing extracorporeal membrane oxygenation (ECMO) services and staffing tracheostomy teams, operating room technologists serving on the proning team, and medical students helping with ventilator assembly and distribution.³

Testing and therapeutics challenges included the ramping up of in-house viral, cytokine panel, and antibody testing, ventilator acquisition and airway management, the use of ECMO, and the development and testing of novel therapeutics.

The inability to test for severe acute respiratory  syndrome coronavirus 2 hampered early containment efforts. To preserve initial testing capacity, PPE, and potential healthcare worker exposures, diagnostic testing was prioritized to hospitalized patients. Once high-throughput testing was available, the need for rapid, sensitive, and higher volumes of testing became more apparent and continues to be a challenge as influenza season approaches.

One of the most daunting challenges was the need to increase ventilator capacity to multiples of normal capacity. The authors accomplished this by incorporating the use of nontraditional ventilators and through innovation. Nontraditional ventilators used included anesthesia machines and transport ventilators. Additionally, they leveraged their simulation laboratory to facilitate several ventilator innovations, including the development of a split breathing circuit for shared ventilation that used three-dimensional printed flow control valves to deliver differential ventilation to two patients connected to a single ventilator⁴ and the development of a protocol for the use of bi-level positive airway pressure (BiPAP) machines as an invasive bi-level ventilator.⁵ Split ventilation and adapted BiPAP devices were not used clinically, as traditional and transport ventilators were in adequate supply at the peak of the April surge. A fleet of anesthesia machines was used for ventilation for approximately two weeks as a proof of concept and to optimize the redeployment of the anesthesia care team into a patient unit that was converted into an “anesthesia” ICU.

The role of ECMO in COVID-19 remains undetermined.⁶ At Mount Sinai, the authors developed ECMO protocols that remain in place. Although the authors prepared for significant need, this did not materialize and ECMO has not measurably improved outcome.

Concurrent with all clinical efforts, a dynamic and flexible research enterprise evaluated the use of antivirals,⁷ immunomodulators,⁸ convalescent plasma,⁹ and anticoagulation.¹⁰ Collaborations with world-renowned virology and immunology medical school laboratories enabled the transition of research assays into the hospital clinical laboratory, including a cytokine panel and quantitative antibody testing.

Nonpharmaceutical interventions (eg, masking and social distancing) and aggressive regional mitigation efforts allowed New York to flatten the curve, and now the authors are addressing the physical and fiscal consequences of deferred care and the need to provide parallel non–COVID-19 care while preparing for potential future surges. Shortly after the onset of the pandemic, the hospital experienced a sharp decline in non–COVID-19 related visits. From March to April in New York City, emergency medical services noted an increase in out-of-hospital cardiac arrests. Evaluation of national syndromic data noted a decrease in emergency room visits by 42% early in the pandemic, including a 23% decrease for acute myocardial infarctions, 20% for strokes, and 10% for hyperglycemic crises compared with the previous 10 weeks.¹¹ In New York City, there was a significant and precipitous decrease in the monthly surgical case volume of acute type A aortic dissection from 13 ± 5 cases per month in the 26 months before the COVID-19 pandemic to 3 ±1 in the first two months of the New York City surge, raising important health concerns about the collateral effects of the pandemic.¹² Even after the surge was over and despite New York continuing to have a low incidence of new cases, patients remain hesitant to use in-person healthcare. In the outpatient setting, a profound decrease in preventive care, including vaccinations, has been noted in the setting of deferred care and hesitancy on the part of patients to come back to in-person care. Crisis communications have transitioned from being primarily staff-directed toward engaging the public so that the return to healthcare is vital and safe. External communication from both public health authorities and healthcare professionals to reinforce the importance of timely care for medical emergencies, vaccinations, and preventive care are critical to address deferred care and the stigma surrounding healthcare institutions. Providers need to actively assure the public that inpatient and ambulatory areas have implemented appropriate infection prevention practices to ensure the safety of both patients and healthcare workers.

Lessons learned from the initial surge are informing the next steps. The authors know that PPE works when used appropriately and that staff satisfaction and continued reassessment are important, so continued strategies are needed for staff fatigue and crisis communication. The increased incidence of hospital-acquired conditions requires reassessment of practices that were aimed to minimize interactions. The prolonged effects of COVID-19 on the health of New Yorkers, whether it be from the disease itself or interrupted medical care, will continue to affect health systems. Parallel and postsurge care require strong staff engagement and flexible, dynamic, and forward-thinking leadership. Furthermore, it is essential to remember that everyone is someone's person—visitors are part of the healing process.