Hospitals Move Into Next Phase as New York Passes Viral Peak

Across New York City, hospitals have moved into a new phase in their battle against the coronavirus.

In the city that was hit hardest by the pandemic in the United States, the number of new patients and the daily death toll have dropped sharply. Many of the refrigerated trucks filled with bodies are gone. Doctors no longer routinely plead for help in makeshift protective gear. The emergency room at Elmhurst Hospital in Queens, once overwhelmed, treats barely a third of the people it did before the outbreak.

“It’s like someone turned off the hose,” said Dr. Eric Wei, an emergency medicine physician and senior vice president of quality for NYC Health & Hospitals, the public health care system, referring to patient numbers in recent weeks.

“There’s a huge psychological desire to be like, ‘Whew, we’re through the worst of it,’” he said, but cautioned, “It’s a challenge to fight that human nature to over-relax or say now we can just go back to how things used to be.”

Hospital executives and doctors, wary about what comes next as the city looks to ease out of its near lockdown, are asking whether this is a lull before a new wave of cases or a less chaotic slog. At hospitals, staff members are preparing for both possibilities.

Credit…Erin Schaff/The New York Times

Health workers are still tending to nearly 500 critically ill Covid-19 patients around the city, but are admitting fewer than 100 new patients a day, down from the peak of nearly 1,700 daily in late March and early April, according to the city’s health department. Doctors are culling data to identify best practices in treating them, and institutions are seeking long-term care — or planning to create it — for those expected to remain on ventilators.

At the same time, they are turning hot zones into cold zones, in hospital parlance — shutting some temporary Covid-19 intensive care units to restore them for regular use. Mount Sinai in Manhattan closed a temporary ward in its soaring atrium, while at Long Island Jewish Medical Center in Queens, empty beds have been moved into hallways.

And institutions are revamping facilities and taking additional measures to control the spread of the disease. Elmhurst is decontaminating rooms as managers try to persuade community residents to come in for emergencies now and elective surgery as soon Gov. Andrew M. Cuomo lifts a ban imposed in March.

Physicians there are increasingly worried that stroke victims, heart patients and those with other ailments may be dying at home rather than seeking help. “Patients who are sick need to come back to the emergency department,” said Dr. Stuart G. Kessler, its director.

“It’s almost this eerie silence,” said Dr. Sylvie de Souza, chair of the emergency department at the Brooklyn Hospital Center, an independent institution where the daily E.R. volume last week was less than half of the 200 to 250 patients it typically saw before the pandemic. “None of us are at peace. We’re sort of bracing for it to come back. All of us are wondering, can we go through this again?”

Credit…Victor J. Blue for The New York Times

The need to shift back to providing a broad range of care is urgent, both for public health and the future of hospitals and health systems, which have in some cases lost millions of dollars a day because of canceled surgeries and other lucrative services.

A recent analysis by the New York City health department found that from mid-March to early May, over 24,000 more deaths than normal occurred, with nearly a quarter involving people not believed to be infected by the virus. Many may have been caused by “delays in seeking or obtaining lifesaving care,” the study’s authors wrote.

Dr. Richard Schwarz, the medical director of Long Island Jewish, part of Northwell Health, the state’s largest hospital system, said it had to postpone about 12,000 surgeries since the governor’s order.

“Many of these people are quite sick and have gotten sicker,” he said, including those whose cancer may be metastasizing. Patients with chronic illnesses like diabetes are also a concern. Last week, he heard that surgeons had performed amputations on patients who might have kept their limbs if they had been able to be treated sooner.

“One of the things we’ve got to do a better job of advertising is that we right now have a Covid-free building,” he said. “Our main building is Covid-free.”

Here and across the country, health systems are working to restore staff, supplies and services while trying to protect patients and workers from contagion. But recent visits by The New York Times to a half-dozen of the worst-hit institutions showed that New York City hospitals faced additional challenges. Many workers were too fearful of another surge to feel much relief at the slowdown.

More than 20,000 people have died from Covid-19 in New York City, according to the health department, which counts confirmed and probable cases. The daily coronavirus death toll in the city peaked at nearly 600 in early April; now it is fewer than 100.

Credit…Erin Schaff/The New York Times

Dr. Colleen Smith, an E.R. physician at Elmhurst who recorded a widely shared video showing conditions in late March, said that even as the cases dramatically declined, the new normal did not feel normal.

“It felt surreal when it was crazy, and it feels surreal a bit now,” she said, sitting in protective gear in a nearly empty patient area. “The difference is so stark.”

Hospitals are eager to restart elective surgery, a needed service that is also a major revenue generator.

At Elmhurst one recent day, staff members told hospital leaders that they were reviewing surgeries that had been delayed since March. They said they had a list of patients who should be operated on this month. That included cancer and neurosurgery patients who, in a tiered system released by Medicare in April, fell into categories marked “do not postpone.”

But preparing to resume the procedures is challenging because spaces reserved for surgery patients — post-anesthesia units, surgical I.C.U.s. and even operating rooms — were repurposed around the city to treat those who were critically ill with the virus. On Tuesday, Elmhurst still had 35 critically ill Covid patients, more than the total I.C.U. capacity it maintained before the pandemic.

Even if those areas can be freed up, medical institutions have to create a safe pathway for patients to avoid infection as they enter hospitals, move to operating rooms, undergo monitoring afterward and then recover or receive intensive care.

While Mr. Cuomo recently allowed some hospitals around the state to perform elective surgeries, he has not permitted those in the city to do so. According to rules he set, they and each county as a whole must keep at least 30 percent of hospital and I.C.U. beds available to maintain stability in case of another surge.

Credit…Erin Schaff/The New York Times
Credit…Erin Schaff/The New York Times

“It’s killing us,” Gary G. Terrinoni, chief executive and president of the Brooklyn Hospital Center, said of the ban. “We have to be able to open up safely relatively soon or I think things will be tragic.”

Capacity is also limited because some Covid patients are left needing lengthy treatment on ventilators. Only one hospital offering long-term acute care — part of the city’s health system — accepts such patients in the state. But it cannot accommodate those who require continuous sedation.

North Central Bronx, one of the 11 public hospitals in the city, has raced to build a new I.C.U. Workers are laboring day and night on a unit with 120 beds, which doctors hope may be used for such patients instead. Northwell, a private nonprofit system that includes 23 hospitals in the metropolitan area, is planning to open two units for long-term ventilator patients.

Credit…Erin Schaff/The New York Times

As hospitals clear out unneeded Covid units, they are taking extraordinary steps to clean them, to build confidence with the community and their own staffs. At Elmhurst, in one of the worst-affected neighborhoods in the city, the virus killed five employees and sickened over 470 others.

Usually, once a patient room is empty, workers wipe it down, swab for biological matter and visually inspect it. Now, they also sanitize all surfaces, vacuum the vents, apply electrostatic spray and strip and wax the floors. At Elmhurst, even the dials on the walls that regulate suction are replaced.

Employees there and elsewhere are taking an additional step: hauling ultraviolet lights into rooms, stepping outside and closing the doors as the machines inactivate any remaining viruses.

But once an area is clean and safe for non-Covid patients, how to keep it that way?

“Who goes there?” asked Dr. Maurice Policar, an infectious disease specialist at Elmhurst. “How do we vet these people?”

When new patients are admitted, he said, doctors must decide whether to put them in a ward for Covid-positive patients, where they may be exposed, or an intermediate area with negative pressure, designed to keep infectious particles inside each room.

For now, everyone is presumed infected until proven otherwise. Before transferring to a non-Covid unit, patients are tested twice for the virus. They also get a chest X-ray. And masks are worn even in areas reserved for uninfected patients.

“We feel that that’s a level of protection, even if we miss it and some people are there,” Dr. Policar said.

The E.R. staff at Lincoln Medical Center in the Bronx was still dressed in masks, goggles, face shields, gowns, bootees and hair coverings on a recent afternoon, but it was no longer in constant motion. Nearby, rows of beds stood empty.

At the peak, the hospital had about 425 patients coming in a day, a quarter of them requiring hospitalization and many critically ill, its chief of emergency medicine, Dr. Adrienne Birnbaum, told a group of engineers and hospital officials walking through the E.R.

Credit…Erin Schaff/The New York Times
Credit…Erin Schaff/The New York Times

Workers unrolled measuring tape and stepped on construction ladders as Christine Flaherty, senior vice president of facilities management for the health system, reviewed airflow and infection control measures.

  • Frequently Asked Questions and Advice

    Updated May 12, 2020

    • Is ‘Covid toe’ a symptom of the disease?

      There is an uptick in people reporting symptoms of chilblains, which are painful red or purple lesions that typically appear in the winter on fingers or toes. The lesions are emerging as yet another symptom of infection with the new coronavirus. Chilblains are caused by inflammation in small blood vessels in reaction to cold or damp conditions, but they are usually common in the coldest winter months. Federal health officials do not include toe lesions in the list of coronavirus symptoms, but some dermatologists are pushing for a change, saying so-called Covid toe should be sufficient grounds for testing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

    • When will this end?

      This is a difficult question, because a lot depends on how well the virus is contained. A better question might be: “How will we know when to reopen the country?” In an American Enterprise Institute report, Scott Gottlieb, Caitlin Rivers, Mark B. McClellan, Lauren Silvis and Crystal Watson staked out four goal posts for recovery: Hospitals in the state must be able to safely treat all patients requiring hospitalization, without resorting to crisis standards of care; the state needs to be able to at least test everyone who has symptoms; the state is able to conduct monitoring of confirmed cases and contacts; and there must be a sustained reduction in cases for at least 14 days.

    • How can I help?

      Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • How does coronavirus spread?

      It seems to spread very easily from person to person, especially in homes, hospitals and other confined spaces. The pathogen can be carried on tiny respiratory droplets that fall as they are coughed or sneezed out. It may also be transmitted when we touch a contaminated surface and then touch our face.

    • Is there a vaccine yet?

      No. Clinical trials are underway in the United States, China and Europe. But American officials and pharmaceutical executives have said that a vaccine remains at least 12 to 18 months away.

    • What makes this outbreak so different?

      Unlike the flu, there is no known treatment or vaccine, and little is known about this particular virus so far. It seems to be more lethal than the flu, but the numbers are still uncertain. And it hits the elderly and those with underlying conditions — not just those with respiratory diseases — particularly hard.

    • What if somebody in my family gets sick?

      If the family member doesn’t need hospitalization and can be cared for at home, you should help him or her with basic needs and monitor the symptoms, while also keeping as much distance as possible, according to guidelines issued by the C.D.C. If there’s space, the sick family member should stay in a separate room and use a separate bathroom. If masks are available, both the sick person and the caregiver should wear them when the caregiver enters the room. Make sure not to share any dishes or other household items and to regularly clean surfaces like counters, doorknobs, toilets and tables. Don’t forget to wash your hands frequently.

    • Should I stock up on groceries?

      Plan two weeks of meals if possible. But people should not hoard food or supplies. Despite the empty shelves, the supply chain remains strong. And remember to wipe the handle of the grocery cart with a disinfecting wipe and wash your hands as soon as you get home.

    • Should I pull my money from the markets?

      That’s not a good idea. Even if you’re retired, having a balanced portfolio of stocks and bonds so that your money keeps up with inflation, or even grows, makes sense. But retirees may want to think about having enough cash set aside for a year’s worth of living expenses and big payments needed over the next five years.

The group plans to add movable, washable partitions as privacy barriers, install filters to capture airborne viruses, place computer screens in isolation rooms to communicate with patients from outside, install hooks for staff to hang their protective gear when they go on breaks, and pipe oxygen to new areas and monitor the patients receiving it.

The staff would also raise Plexiglass barriers to protect greeters, mark the floor with six-foot separations and space patients apart in waiting areas by blocking off seats.

As Ms. Flaherty walked through the I.C.U. construction site at North Central Bronx that same week, a colleague told her that the additional oxygen she had ordered was expected in 10 weeks. “I need it in two,” she replied.

Many other items needed to restore medical services are subject to delays or are unavailable. At Lincoln, a white board in the command center had a handwritten list of nearly a dozen supplies currently or recently out of stock, including dialysis catheters, blood transfusion tubes and tourniquets.

Amid global shortages, the city’s public hospital system has centralized ordering of once common items, including disposable protective gear. The projected “burn rates” of gloves, masks and gowns — and the need for scarce medications like some sedatives and the antiviral drug remdesivir — remained high.

Last Friday, employees discussed a list of long-delayed orders for N95 masks. Danielle DiBari, senior vice president of supply chain, interrupted the meeting to call a vendor who had failed to deliver millions of them. He told her that the handful of Chinese factories making U.S.-approved masks were prioritizing the highest-paid orders, with costs about 500 percent higher than usual.

“I don’t mind if they come in slowly, but they have to come in,” Ms. DiBari told him. “I’m burning at a crazy rate.”

Credit…Victor J. Blue for The New York Times
Credit…Erin Schaff/The New York Times

That rate may only increase, even with fewer coronavirus patients, as services are restored and visitors are allowed again. Before the pandemic, the public hospital system treated about 16,000 people a day in its outpatient clinics, according to officials. Once it struck, only about a quarter of those patients conferred with clinicians, the great majority by phone or video.

Some doctors said they hoped some telemedicine services would be permanent. “It turns out that we can prevent a large number of visits to the emergency room simply by getting good advice,” said Dr. Mitch Katz, the public hospital system’s president and chief executive.

As clinics reopen, visits will be staggered over extended hours to lower risk. Patients will be asked to preregister and undergo temperature checks at the door. The system is working to build negative-pressure rooms for those more likely to have the virus.

At the Brooklyn Hospital Center’s outpatient clinic sites — serving primarily low-income Medicaid patients — the staff was focusing on bringing in children who needed vaccines, pregnant women who required prenatal care and patients with chronic diseases like diabetes and hypertension. But consultations were down by about 70 percent.

“You wonder, truthfully, where are all these people?” said Judy McLaughlin, a senior vice president and chief nurse executive. “And what’s happening to them?”

At the same time, the enormous pressure on health workers is presenting its own challenges. Hospital leaders realize they must attend to the emotional needs of employees across every line of service.

Credit…Erin Schaff/The New York Times

At Elmhurst, therapists are available in a Covid support room where notes of encouragement and gratitude paper the walls: “This too shall pass.” “Not all superheroes wear capes.” “We love you.” A nearby room recently opened as a memorial to fallen colleagues.

Mount Sinai this month announced an initiative to study stress in medical workers and offer them access to support groups and mental health treatment.

But there are sources of stress that hospital officials cannot control.

Credit…Erin Schaff/The New York Times

“Seeing the pictures of people flaunting social distancing,” Dr. Wei said, “does feel a little bit like an insult to what we went through as a health care system and health care workers. We risked our lives to save as many lives as possible, and people can’t wear a mask — they can’t stay six feet apart.”

View original article here Source

Related Posts