Lincoln Hospital staff (photo: Michael Appleton/Mayoral Photography Office)
As public health officials eye a second major swell of COVID-19 infections and an increase in hospitalizations, New York's hospital systems have begun to brace for another flood of patients. The state has even opened a field hospital on Staten Island in response to rising numbers, a dismal reminder of the devastation of the spring.
In the months since the height of the pandemic in the spring, New York's health care institutions have been making preparations to try to avoid the same chaos and loss of life, which has been partially attributed to a lack of coordination. But in many areas, like before, hospital administrators and staff are just trying to stay one step ahead of the virus, keep staff safe, and maximize patient survival.
The city's hospital systems "faced an unprecedented situation for which no one was fully prepared," wrote City Comptroller Scott Stringer in a review, issued in July, of the city's public hospital system, which saw many of the most severe problems. "The lack of preparedness forced all players to improvise responses, sometimes successfully, sometimes not – but inevitably at a cost in human lives."
Hospital administrators have signaled to their staff, lawmakers, and the public that they don't believe a second covid wave in New York will be as bad as the first -- with lessons learned and months to upgrade facilities, stockpile supplies and ventilators, and develop so-called "surge plans" to be used in the event another round of mass admissions strains hospitals. But experts are questioning whether hospitals will have enough staff and personal protective equipment (PPE) if hospitals see the crisis levels of March, April, and May again, and even ICU nurses onboarding others are expressing doubt about the adequacy of a heavily-truncated training regimen. New York City and State are hoping to better balance patient loads across hospitals to avoid overwhelming any one facility, but no new system has been finalized and much remains unsettled about how a patient diversion program would operate.
In the spring, hospitals were overflowing with covid patients and, along with governments, struggling to procure enough PPE, particularly within Health + Hospitals, the city's network of public hospitals. Government and hospitals worked together to nearly double the state’s bed count from 53,000 to roughly 90,000, and though they were never all filled, there were concerns about the state’s ability to meet the upper projection of 140,000 hospital admissions.
To comply with an executive order from Governor Andrew Cuomo to increase capacity by 50%, hospitals rapidly converted offices and auditoriums into intensive care units; field hospitals were set up in convention centers like Javits, and the USNS Comfort, the Navy hospital ship, docked temporarily in the Hudson. Some facilities, like the now-infamous example of Elmhurst hospital in Queens, one of the city's 11 public hospitals, were overflowing while others had space. At the apex in April, the state had 90,000 additional health care workers, including 25,000 from other states.
More than 26,000 people are confirmed to have died from COVID-19 statewide. According to city data, over 24,000 New Yorkers have died of covid in the five boroughs, which includes unconfirmed but suspected covid deaths, or about 1 in 350 city dwellers.
The spring surge in patients meant hospitals needed more space for beds and more personnel to staff them, more supplies to protect or save both patients and staff, and the systems to manage the new, exhausting demands. Many of those systems remain in place or serve as the basis for current emergency plans, like the "NYC Strategic Reserve” PPE and ventilator 90-day stockpile ordered by Mayor Bill de Blasio that the city says is near completion. These issues were especially acute within the 11 public hospitals run by Health + Hospitals, according to Comptroller Stringer’s report, which had been requested by the governor and also pointed to underfunding by the state.
"All of our hospitals have learned from the devastating first wave of the pandemic and really poured their hearts and energies into preparing for the second surge, which we hope won't happen, but unfortunately we are at risk of given the numbers we are seeing," said New York City Health Commissioner Dave Chokshi, last week.
The next morning Mayor Bill de Blasio said "our hospital system is strong right now," but warned that it remained essential to work to keep covid numbers low and avoid strain on ICUs. At a recent City Council oversight hearing, city public health officials testified about lessons learned from the spring and preparations in place for a second wave, including by noting they now often use less invasive ventilation techniques and new protocols for stabilizing patients before transferring them.
The citywide seven-day average number of hospitalizations per day topped 80 admissions last week, three times what it was in August but still far below the thousands of daily admissions at the peak. As of Monday, 931 people were hospitalized due to COVID-19 citywide, of whom 196 were in intensive care. Test positivity has been ticking steadily upward since the summer and the city and state have begun shutting down key sectors of public life, like in-person schooling, a reprise of the conditions on the eve of the apex. Governor Cuomo, Mayor de Blasio, and others have been sounding the alarm that a second wave is staring New York in the face, and imploring New Yorkers to follow all guidelines.
"Rates go up, you overburden the hospital system, you overburden doctors, nurses...Numbers go up and people die. People die. Period. It is a mathematical equation," Cuomo said at a news conference on Sunday, warning rates could "easily" skyrocket for months "if we are irresponsible."
On Monday, Cuomo announced a field hospital would be opened on the site of South Beach Psychiatric Center in Staten Island in response to a dramatic rise in hospitalizations in New York's most isolated borough. "The hospitals have contacted us, and they say they need emergency beds on Staten Island," the governor said at a press briefing. "Remember when we had to set up field hospitals, emergency hospitals for additional capacity? Well, that's what we have to do on Staten Island.”
Throughout the pandemic, the state has functioned as a regulatory body, coordinating resources among public and private hospitals, suspending some requirements and setting new guidelines. As of August 6, emergency regulations from Cuomo's Department of Health establish the framework to reinstate many of the "surge and flex" provisions imposed at the end of March. Hospitals must have plans to expand capacity by 50%, manage mass casualties, and enlist workers in the event of another state of emergency. Each facility is required to stockpile 90 days worth of PPE.
To manage it all, the plan calls for the state health department to maintain a statewide data system and coordinate patient loads across New York's various hospital systems. In another serious outbreak, the state Department of Health may designate healthcare facilities as covid-priority "trauma centers."
In response, a loose organization of government agencies and private healthcare providers has taken shape across the city and state, mobilizing a massive operation that eight months in is still a bit of a leaky ship.
A big focus in recent months has been upgrading spaces and preparing surge plans for the rapid conversion of hospital units and non-clinical space, the offices and auditoriums, into covid ICU wards.
While much of the space has reverted to its traditional use, officials have retained the knowledge to transform facilities and are building up the infrastructure to do it faster. New York City Health + Hospitals tripled ICU capacity by adding 760 ICU beds, some of which were made permanent, as was much of the digital roadmap for tracking them.
“NYC Health + Hospitals has been on the frontline of the COVID-19 crisis, providing the highest quality care to all New Yorkers in the face of an unprecedented global pandemic – and we stand at the ready to provide that care as we brace for a potential second surge," wrote Stephanie Guzman, a spokesperson for Health + Hospitals, in a statement to Gotham Gazette. "Since the spring surge, the public hospital system has made strategic enhancements in space, equipment and staffing to ensure each of its hospitals is even more prepared now to treat critically ill COVID-19 patients."
The city Department of Health and Mental Hygiene has been working with public and private hospitals using federal grant money to support covid response and improvements at hospitals and long-term-care facilities. Facilities are incorporating design changes to support rapid unit conversion, like negative pressure rooms, which are used to help prevent the spread of the coronavirus through the air.
Health + Hospitals has increased piped oxygen and dialysis capacity to more easily turn beds into covid ICU beds. Hundreds of rooms have been modified to allow for physically distant patient monitoring with more to come soon, according to Guzman.
The city has some sites on stand-by, like the Roosevelt Island Medical Center, which was opened up this spring on the campus of NYC Health + Hospitals/Coler, where Mayor de Blasio announced plans to open 350 additional non-covid beds in March, which by April were also serving covid patients.
"[An]other thing we learned is that temporary field hospitals like the USS Comfort aren't going to be as effective as expanding the current sites or reopening sites like they did on Roosevelt Island," said New York City Council Member Carlina Rivera, chair of the Council hospitals committee, in an interview. The Comfort treated just 182 patients in its one-month stay docked off of midtown Manhattan.
One of the failures of the first wave was a lack of coordination within and among the public and private hospital systems to balance patient loads.
At Elmhurst Hospital, a Health + Hospitals facility in Queens, health-care professionals were overrun with patients -- one day at the end of March seeing 13 deaths in 24 hours -- despite close to 900 beds open across the public system and 3,500 total beds in New York City, counting private hospitals. The surrounding neighborhoods of Elmhurst, Jackson Heights, and Corona had some of the highest covid mortality rates in the city.
"[T]he problem the Elmhurst situation exposed was not one of hospital capacity, but one of patient load management across all hospitals and hospital systems," reads an excerpt from state Department of Health regulations issued in August and November.
"When it came to patient transfers, I thought, we really wanted the whole system to operate as one," Council Member Rivera said. "And we heard as much in some of the press conferences. But in practice it didn't truly become a reality."
To avoid the Elmhurst syndrome, the city is working with Emergency Medical Services, a division of the state Health Department, and the Greater New York Hospital Association, a consortium of hospital networks, to develop a "unified approach" to balancing patients, according to Victoria Merlino, a spokesperson for DOHMH. The protocol would mean "moving patients from one facility to others that have more capacity available and deferring EMS to overcrowded hospitals when possible," Merlino wrote.
But it is not ready, and there are few details about how it would work in practice. EMT staffing and shortages were ongoing concerns during the siren-heavy months of the first wave, and now will be an even more central component of the city's emergency response if the system is to better balance admissions.
While the state Health Department's emergency regulations say the department "shall coordinate with health care facilities to balance individual facility patient load," the approach appears to be largely decentralized.
"While the determination of when to transfer a patient or divert EMS resources is a local one, the Department monitors facility capacity and is available to assist with the logistics of making a transfer if necessary," wrote Jonah Bruno, a department spokesperson, in an email.
A city DOHMH spokesperson directed Gotham Gazette inquiries to Greater New York Hospital Association who "developed the system for assessing strain and triggers for EMS diversion, which just recently launched."
A spokesperson for GNYHA provided a planning document Monday detailing patient balance strategies, including an outline for redirecting admissions from surging hospitals, but it does not include concrete protocols or thresholds.
Criteria for designations within the three-tiered framework (normal level, elevated surge, and significant surge) are yet to be established, according to the outline, which was circulated to GNYHA member hospitals in late July.
"We're not quite there yet," said Jenna Mandel-Ricci, GNYHA's Vice President of Regulatory and Professional Affairs, and the network's lead on emergency preparedness, in a phone interview Tuesday. "We're making good progress."
GNYHA views itself more as a "thought leader" in surge management, providing insights and a new layer of data, which it hopes the New York City Fire Department will incorporate into its EMT algorithms.
"We're in very close contact with the fire department and we are kind of watching these next couple of weeks," Mandel-Ricci told Gotham Gazette.
"It's unclear if a real system for patient load has been implemented, or if it has, whether hospitals are actually keen to use it," said Rivera.
Rivera and others have pointed to two decades of hospital closures as contributing the imbalance of the spring apex. Since 2000, the state has lost roughly 20,000 hospital beds due to budget cuts.
"These hospital closures mostly occurred in poor neighborhoods where there were fewer patients who could pay -- not fewer patients, fewer patients who could pay -- so the inequities are clear when there are more beds per person in Manhattan than there are in Queens," Rivera said, adding, "these are also the neighborhoods where more patients are falling ill and dying from COVID-19."
According to Rivera, New York City's public hospitals received $106 million per hospital in federal CARES Act funding, while some private hospitals received four times that amount. The city's safety-net hospitals, where patients are treated regardless of insurance, are struggling to stay afloat as emergency visits have been down significantly since the spring.
FEMA continues to monitor the outbreak and healthcare systems and DOHMH is using federal aid "to improve information sharing and situational awareness of hospital capacity and throughput," according to Merlino.
If covid levels reach heights from the spring, officials are worried there may not be enough health-care workers, including temporary personnel, to adequately staff surging facilities.
City health officials say they are working with the state to create a medical reserve corps of volunteers and have devised a procurement plan for emergency surge staffing. But the pool of additional workers eight months into the pandemic is limited, especially as so much of the rest of the country is dealing with spiking covid cases.
"The staffing concern is very real and I think everyone across the board will tell you that it's probably their biggest concern," said Mandel-Ricci of Greater New York Hospital Association.
A Memorandum of Agreement is available to contract personnel from the Department of Defense for private hospitals, according to DOHMH officials, but it is unclear if the federal government will make those resources available.
With covid outbreaks in many of the states where traveling nurses once hailed from, DOHMH and hospital administrators are looking to "cross-train" local non-ICU staff in intensive care, but nurses say the training is woefully lacking.
At Montefiore Medical Center in the Bronx, outpatient clinic nurses are getting online training modules and day of in-person orientation to the intensive care unit.
"These nurses have been out of the hospital for years, you can't expect them to know, to be competent, to adequately care for the patients when they haven't been in that setting," said Shamelee Morrison, who has been a medical/surgical nurse at Montefiore for 11 years. It can take two months to orient a nurse to a new unit, she told Gotham Gazette, "so you can't take these nurses and give them one day and say, 'OK, now go out and take care of these patients in a safe manner.' It's impossible. And that's what they're expecting the nurses to do."
One ICU nurse at NYU Langone Medical Center of Manhattan said it's like the city is already set up for an encore of thousands of nurses scrambling frantically in overwhelmed ICUs.
"I don't feel like I'm an experienced enough ICU nurse to be training anybody to be in the ICU," the Langone nurse told Gotham Gazette, speaking on the condition of anonymity. "And there's nurses who were only trained as ICU nurses during COVID, who are new grads, training new grads now for the second wave, which is absurd."
"The problem with the covid patients is that they're really, really sick and unstable," the nurse said. "They're not like light ICU patients, so to just go in that after a few weeks or like a month or two of being trained by an inexperienced nurse is really dangerous."
Morrison, from Montefiore, believes the hospital had more time to prepare staff for a potential second wave and dropped the ball. "I don't think they're doing much different. They're doing the bare minimum, if anything," she said by phone during a break in her shift. The New York State Nurses Association has delivered notice of a two-day strike at Montefiore's New Rochelle campus in an attempt to secure better staffing levels, wages and benefits.
With numbers rising throughout the city, hospitals are beginning to heighten protocols as staffing levels become an increasing concern. At NYU Langone, nurses are now being told to wear face shields over their masks, an additional precaution, even with patients who don't have covid. More nurses are getting sick, the Langone nurse said, with one floor having ten out.
The nurses Gotham Gazette spoke with said they don't get many details from their hospitals' administration about preparations for a second covid surge, outside of assurances that they have sufficient PPE supplies and indications that a second wave will not be as bad as a first -- both of which there is little proof of.
Emergency regulations from the state Department of Health require all hospitals to have had a "90-day supply" of PPE by September 30. In April, Mayor de Blasio said the city would have its own 90-day stockpile, the NYC Strategic Reserve, in addition to the supplies held by individual hospitals. Representatives of the Mayor's Office and DOHMH have both said in separate statements that the Strategic Reserve will be completed "in the next few weeks," though neither office has said whether hospitals are on track to fulfill the state mandate or even whether the city is monitoring hospital supply levels. Guzman, the spokesperson for Health + Hospitals, said that the public hospital system had reached its 90-day goal.
"There are some hospitals that have not been able to achieve 90-days in all of the categories that are required," said Mandel-Ricci, of Greater New York Hospital Assocation. "But even in the categories where they haven't they're at like 70-days or 65-days, so they still have very large inventories," she added, noting, "some of these things are harder to get than others."
Mandel-Ricci pointed out that most hospitals in New York City are part of networks that can mobilize resources among their facilities.
Ventilators are more widely available than they were in March, when manufacturers couldn't make them fast enough to keep up with New York's most dire modeling.
Merlino, the DOHMH spokesperson, said hospitals were given the option to keep ventilators from national stockpiles and that the city now has "a large cache" for rapid deployment. When he announced the strategic reserve, de Blasio said the city would have a back-up supply of 4,000 ventilators but the administration has refused to say how many it now has.
Council Member Rivera said she has sought documentation on supplies and surge planning from city agencies and hospitals for months using her oversight powers as chair of the Council hospitals committee, without success.
"We have tried to get this information, not just from the Health + Hospital system, but also from the hospitals that are under that larger Greater New York Hospital Association umbrella," Rivera said.
"It's been incredibly frustrating," she added, "they just haven't provided those documents."
It remains unclear what the 90-day supply goal is based on. As Gotham Gazette recently reported, that number appears to be calibrated to PPE burn rates at the peak of the pandemic, when frontline healthcare workers were instructed to reuse equipment like facemasks far longer than what is traditionally advised. DOHMH and the federal Centers for Disease Control (CDC) have both issued conservation guidance to be put in place to reduce severe shortages.
"We were told that Monte had a 90-day stockpile," Morrison said. "But then some of our nurses recently received an email stating that we were going to have to start recycling PPE."