COVID-19: New York City pandemic notes from the first 30 days.

Introduction

The COVID-19 pandemic has evoked dramatic global disruption as health and governmental agencies struggle to manage this historic medical event. As of April 4, 2020, over 200 countries and territories have been affected, with over 1,000,000 cases and 60,000 deaths worldwide [1]. The United States currently is the country with the highest prevalence of COVID-19 cases, with New York City (NYC) serving as the epicenter of this pandemic [2].

Emergency medical services in NYC face unprecedented challenges in patient acuity, bed management, and hospital operations, while experiencing high levels of provider stress and fatigue. While robust literature on emergency medicine responses to natural disasters and pandemics exists [3], the unique challenges of the pandemic in NYC will likely be experienced by other emergency departments (EDs) across the country, as the disease continues its anticipated trajectory. Here, we report an overview of our experiences and response, as a NYC ED at the center of this pandemic.

The volume and acuity of suspected COVID-19 cases in our ED accelerated rapidly over the course of four weeks. New York Presbyterian Hospital-Columbia encompasses an adult and pediatric academic quaternary medical center, in addition to community sites in upper Manhattan and Westchester, with a collective annual volume of approximately 250,000 visits. For the month of March, we have seen approximately 850 cases of COVID-19 with the majority arriving from March-15th-30thz. Faced with rapid acceleration of volume and acuity, broad challenges have included: optimization of physical space and staffing, the development of management strategies for high numbers of patients requiring respiratory support, minimizing transmission risk to other patients and healthcare staff, determining best strategies for redeployed non-emergency medicine physicians and staff, and finally, frontline staff fatigue and well-being.

Strategies and general approaches

Taking a “comprehensive healthcare” approach

Our strategy included integration of ED, hospital, city, state, and national leadership to coordinate the delivery of efficient care during this pandemic. With the support of institutional leadership we orchestrated a multi-departmental response to the crisis. To accommodate the anticipated ED volume and acuity, flexible approaches to staffing from within and outside our ED were implemented. Due to low pediatric volumes and cancellation of elective procedures/surgeries, we harnessed an influx of available critical care beds, physicians, and support staff. We designated an incident commander to help lead efforts and support clinical staff 24 hours per day. In collaboration with the hospitalist service, transfers of care (e.g. “sign out”) to admitting teams were done in the ED, with redeployed off-service clinicians managing admitted patients to allow emergency clinicians to treat new patients. In collaboration with ambulatory care providers, “cough and cold” clinics were established outside of the ED to rapidly evaluate low acuity patients with viral symptoms, helping to reduce ED volumes. In addition, they performed a medical screening exam, facilitating transfer to specialty clinics for isolated low acuity complaints (e.g. orthopedics, gynecology). Finally, patient bedding was adjusted to reduce transmission risk, with suspected COVID-19 patients placed into isolation rooms and positive cases cohorted together.

Coordinating care with other critical care services to optimize patient care and reduce provider risk

The volume of patients requiring high-risk aerosolizing procedures during COVID-19 has been significant. Recognizing the high volume of emergent airways, we developed protocols with the anesthesia service to assist with ED intubations that included the use of HEPA viral filters and appropriate PPE. Additionally, a COVID-19 “SWAT” team consisting of surgical chief residents and attendings was organized and available to perform procedures such as central lines and arterial lines. Given the increased need for difficult goals of care conversations, we involved palliative care, social services, and ethics consultations early and often for critically ill patients, including pre-intubation.

Consider remote/telemedicine opportunities for low acuity patients and follow-up care

Telemedicine has played a critical role in our COVID response, providing another pathway for determining need for acute care, while also decreasing ED patient volume and potential viral exposure. Telemedicine has also allowed us to extend our footprint of care into the home, through a follow-up program involving video visits with oxygen concentrators and pulse oximeters distributed to patients during their index ED visit.

Staff morale/health

Protecting healthcare workforce is paramount in fighting COVID-19. The concern for illness, fatigue, low morale, and clinical error is high [4]. It is important to allow for increased flexibility and surge staffing during this time period. We had a number of support resources available, including mental health experts, spiritual care, virtual wellness rounds, and frequent staff huddles. Concerns about exposure risk were high amongst our providers, and an emphasis on PPE and supplies has been paramount.

The COVID-19 pandemic has placed immense burdens on healthcare systems globally. We hope our early experiences in confronting the pandemic will provide valuable information for other EDs and health care systems around the country during this ongoing crisis.

Grant

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Meetings

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