In the Trenches

EMTs wheel a stretcher into the emergency room at New York-Presbyterian Lower Manhattan Hospital, March 18, in New York. (AP Photo/Mary Altaffer)

A look at how hospitals are adjusting operations to manage the coronavirus outbreak

The coronavirus outbreak and extreme measures being taken to contain it have sent ever-mounting shockwaves through the lives of nearly every American over the past two weeks. With schools closed, businesses shuttered, public events canceled, and the entire country being told to stay close to home and away from all but immediate family members, the feeling of life under siege has quickly set in. Each individual and sector has its own story to tell and its own set of impacts to deal with.

At the epicenter of the storm are hospitals. The societal freeze is largely aimed at “flattening the curve” of cases so that a more gradual rise, and hopefully plateau and fall, will give health care facilities a flow of coronavirus patients they will be able to manage without compromising their treatment or the safety of staff.

Already hospitals have had to make major adjustments to handle the case load they are presently seeing, and even under the best of projected scenarios, case numbers are expected to rise significantly for several weeks ­­— at least.

The challenge has sent hospital leaders and public health experts to pursue strategies to address the crisis. One hopeful sign that the right approaches were in place is that nearly every major hospital seems to be taking the same steps.

Shifting

While the vast majority of people who contract COVID-19, the illness caused by the present stream of coronavirus, have mild symptoms, a significant number require treatment and hospitalization.

Dr. John Marshall, Chair of Maimonides Hospital’s Department of Emergency Medicine, said last week that a continued shortage of testing materials and slow turnaround of results make it impossible to track exactly what the upsurge has been, but its impact is quite clear.

“We’ve seen a pretty marked increase in patients,” he said. “In a regular flu season, we might expect 10 to 15 patients a day with flu symptoms. Now, we’re seeing eight to ten times that. The vast majority have mild symptoms, but we have seen some severe ones, mostly in older or infirm people, or those with underlying medical conditions. Of those we have admitted, fewer than 10 are confirmed COVID-19 cases, but we’ve admitted around eight times that number who we are in the process of testing and who we think [will be confirmed based on] the symptoms they are presenting. It’s been taking us up to five days to get test results back.”

Even in locations that have seen far fewer cases, given the rapid rise that has occurred in other cities, hospitals have adjusted their operations to prepare for the high likelihood of an eventual spread.

“We are seeing more patients already, but most cases here have been relatively mild, so we have not had a lot in the ICU. But from watching other places, everybody is on high alert that the numbers will climb,” said Dr. Howard Forman, professor of radiology, public health, and economics at Yale University and a diagnostic radiologist at New Haven Hospital in Connecticut.

Whether the need exists already or is anticipated, hospitals have taken steps to free up beds, staff time, and equipment.

One of the most impactful moves has been a universal policy to cancel or postpone all elective and semi-elective surgeries. While most of the population does not opt for surgery without a pressing medical need, the categories go far beyond the cosmetic procedures that the term “elective” brings to mind; they cover a wide range of operations that can be delayed without causing harm to the patient.

“Physicians and patients are in good positions to adjudicate what is elective and what has to be done now,” said Dr. Forman. “There are cancer surgeries that are absolutely elective. You could have a small nodule that could wait three months to be operated on. But there are others that should be having operations now, and will. Some people with back pain could wait, others would risk permanent damage. I’ve had seven surgeries, six of them elective. If any of them would have gotten postponed, I would have been upset, but it would not have been life-threatening.”

The move to put off as many non-essential procedures as possible goes a long way in cutting patient traffic and freeing up much-needed equipment and beds in the ICU, which has been the source of much worry since the onset of the outbreak.

“Many surgical patients end up in the ICU, especially if they have complications, and so [postponing surgery is] an effective way to free up some beds. There are also patients who need ventilators during surgery and it’s a way to free up some of those as well, as many serious COVID-19 cases have upper-respiratory issues,” said Professor Carrie Chan, an expert in health-care operations management who teaches at Columbia University and has been involved in planning efforts at Columbia Presbyterian Hospital in New York.

Fewer surgeries taking place also allows hospitals to repurpose some spaces used to perform and support those procedures as additional ICU space or other facilities to deal with the outbreak.

Maimonides Hospital converted some of its clinic facility, which will not be used as non-essential procedures are pushed off, and converted it into space to treat lower-risk COVID-19 patients in a contained area where they are less likely to infect others. The early stages of a renovation of the hospital’s ICU has allowed them to prepare to repurpose more space for seriously ill patients as needed.

Government action to address the potential shortage in beds began to kick in as well, as the Navy deployed the USNS Comfort, a 1,000-bed hospital ship, to New York to serve as a facility for non-COVID-19 patients. Several voices in Congress called on the administration to order the military to build temporary hospital space, as was done in China.

Another effort to allow for staff to focus on the rising COVID-19 patient load has been to shift some consultations to telephone and video communication between doctors and patients, a move that was already in place in some hospitals such as New York’s Cornell Medical Center since before the outbreak. This step also limits the ability of potentially infected individuals to spread the virus to others at the hospital.

“They’re trying to limit interaction when possible without sacrificing quality of care,” said Prof. Chan. “Patients [who need] follow-up visits to check on their meds or to make sure they understand their care plan … can be [taken care of] by video. There are people who come in for well visits and there is really no reason for them to be in the hospital.”

Some hospitals and officials have also sounded high alarm that as the outbreak grows, the nation’s supplies of ventilators will not be enough to meet the need. As no central body tracks how many ventilators each hospital has, estimates on what is available in the country vary greatly, with the high mark being somewhere around 200,000. The federal government began to release some of the more than 12,000 of the devices held in stockpiles, and several voices in Washington are calling for the administration to take a more active role in ramping up production.

Still, Prof. Chan said media reports that paint an uncoordinated effort on the part of the government to procure ventilators from available sources was “concerning.”

“There needs to be help from state and federal government to push these things along. It’s something that’s too hard for individual hospitals to do,” she said.

Some experts have said that several creative solutions exist, should the problem arise, including using older models no longer in use for those with less severe conditions.

A statement by New Jersey’s Robert Wood Johnson-Barnabas Healthcare Network which operates among its branches at Monmouth Medical Center, its Southern Campus in Lakewood (formerly Kimball Hospital), and its central New Brunswick campus, said neither beds nor respirators were an immediate concern.

“Supply management and personnel are being reviewed daily. RWJBarnabas Health does not anticipate a shortage of beds. We have a total of 5,099 beds. Current utilization of beds and nursing units are being assessed and can be repurposed, as needed. We also do not anticipate a shortage of respiratory equipment. RWJBarnabas Health has 674 ventilators. This does not include alternate devices that can also be used as ventilators, including anesthesia machines, if necessary.”

Protecting the Troops

(Claudio Furlan/LaPresse via AP)

One issue, however, over which RWJBarnabas did sound a note of concern was “the possibility of a potential shortage of personal protective equipment including masks, eye shields and gowns.” The healthcare network said that it had placed orders for all of these items, but was afraid of taking steps to deal with the potential spread of COVID-19 among staff.

“We are also concerned about the potential for a staffing shortage moving forward and, as such, are developing a staff reassignment strategy to be used as necessary,” said the statement.

It was a concern that had been on the minds of hospital planners around the country.

“Isolating patients and protective equipment is something that is at the forefront of leadership’s minds,” said Prof. Chan. “They’re concerned, and rightfully so, about the limited supply of masks and gowns. Without these, our frontline employees who interact with patients and get exposed will start getting sick and seriously hamper our ability to handle this. Even with beds and ventilators, you can’t treat a patient without staff.”

She added that an additional challenge to the procurement of N95 masks, which offer additional air filtration, was that their production largely takes place in China and the outbreak there has significantly affected output.

Cancellation of elective surgeries has, however, helped the effort to conserve protective gear.

Dr. Marshall said that Maimonides had been masking its emergency staff for the past two weeks, and last week extended the protocol to all staff and patients.

“At this point in time, it’s hard to predict who has it and who does not. Travel history was useful in the beginning, but not anymore, and some cases do not have fever or respiratory issues,” he said. “I think every organization in the country is spending a lot of time thinking about if they have enough supplies…We’re making sure we are careful stewards of these supplies and only using them where needed, and making sure the use of the high-level masks is controlled.”

Despite concerns and the rapidly changing situation, Dr. Marshall said he was “comfortable” with the level of protection being used by staff.

Many sources covering the issue of hospital preparedness have discussed the need for more negative-pressure rooms, a technique used in isolating patients and preventing the contracting of highly contagious illnesses such as tuberculosis. Dr. Marshall said that the rooms are mostly needed in containing airborne sicknesses, and that given that COVID-19 is believed to be spread through the transmission of respiratory droplets, the technique has not been heavily used except in extreme cases.

“In general, a disease droplet doesn’t travel more than five or six feet, so you don’t need [a negative-pressure room]. We are using them for some with the most severe breathing problems, since the treatment we use for them increases the amount of virus in the atmosphere. Just in the last week, we took nine or ten beds into negative-pressure rooms, and some of the other suites we have can be used in the same way to help us increase the use of isolation rooms.”

Dr. Forman said that while a sluggish response by the federal government to the crisis played a role in the fears of supplies shortages, he was hopeful about it, saying: “In the U.S., when there is massive demand, business finds a way to keep up. If I’m a vendor and I know the demand will grow, I’m going to find a way to meet it, so I’m cautiously optimistic that the private sector will step in where the public sector has failed.”

Driving in Fog

A pedestrian wearing a mask walks by New York Presbyterian Lower Manhattan Hospital, March 16, in New York. (AP Photo/John Minchillo)

More than three weeks into the U.S. outbreak, doctors and public health experts still say that a lack of materials to test for COVID-19 and slow turnaround of results is hampering the ability of hospitals to properly manage the crisis.

“I’m a little annoyed that too many people are announcing widespread testing capacity; we are still not up to doing that,” said Dr. Forman. “We are not able to turn around tests in 24 hours. We need to be able to do massive-scale testing. Here, too, I think the private sector is rising to it, but the capacity healthcare providers need in place is not there now.”

The problem goes beyond a lack of accurate statistics of how many COVID-19 cases there currently are. Without adequate testing, many people who are carrying the virus continue to interact with others, and hospitals are forced to use their limited supplies of protective gear around patients who might test negative. Yet another challenge posed is that, without mass testing in place, healthcare professionals who have the virus continue to work with patients and colleagues until they develop advanced symptoms.

“We do not have enough access to testing; nobody does…we are sending out our tests to three different sites, but they’re busy and it takes time to get them back,” said Dr. Marshall.

A difficult step that hospitals across the country are taking is to place strict restrictions on visitors to sick patients. In most cases those who have tested positive for COVID-19 are not allowed to have visitors at all.

Nearly all hospitals are allowing one parent to visit children, and husbands to visit wives in the maternity ward, as well as several other narrow exceptions. All must be free of any possible COVID-19 symptoms, and hospitals screen potential visitors for any trace of fever.

“It’s very hard for the patient’s morale and for families, but out of an abundance of caution we have prohibited visiting to do what we can to prevent [the virus] from being passed on to others,” said Dr. Marshall. Despite nearly unanimous prognostications that the number of COVID-19 cases, including serious ones, will rise for some time, Dr. Forman was “optimistic” that the drastic measures of social distancing in place would produce a situation hospitals could manage, but said it would take time to see positive change.

“It takes two weeks from implementing policy to see an impact on cases arriving at the hospitals which means we shouldn’t expect to see it until March 31. It will get worse for a while…don’t be scared by the numbers.”

Dr. Marshall felt that the measures put in place by government should stave off the feared health care crisis, but stressed that its success is dependent on the public’s actions.

“It’s very difficult on folks, but the reality is that if you look at the numbers, if we don’t reduce social contacts by 50% or more, we will be entirely overwhelmed by a tsunami of sick people,” he said. “If measures are followed properly, I think we’ll slow down the rate of transmission and give us more time to conquer this thing once and for all.”