Creation of a medical ward from non-clinical space amidst the Covid-19 pandemic.

INTRODUCTION: Hospitals were mandated to dramatically increase capacity during the Covid-19 crisis in New York City. Conversion of non-clinical space into medical units designated for Covid-19 patients became necessary to accommodate this mandate.
METHODS: Non-clinical space was converted into medical units at multiple campuses of a large academic hospital system over 1 week. The conversion required construction to deliver basic care including oxygen supplementation. Creation of provider workspaces, handwashing areas, and colour-coded infection control zones was prioritized. Selection criteria were created with a workflow to determine appropriate patients for transfer into converted space. Staffing of converted space shifted as hospitalizations surged.
RESULTS: The unit was open for 18 days and accommodated 170 unique patients. Five patients (2.9%) required transfer to a higher level of care. There were no respiratory arrests, cardiac arrests, or deaths in the new unit.
CONCLUSION: Converting non-clinical space to a medical unit was accomplished quickly with staffing, workflow for appropriate patients, few patients who returned to a higher level of care, and no respiratory or cardiac arrests or deaths on the unit.

INTRODUCTION

Montefiore Medical Center opened its Emergency Operations Center to prepare for the Covid‐19 pandemic on February 11, 2020 and the first Covid‐19 patient was admitted on March 11, 2020. On March 23, 2020, an emergency order from New York State Governor Andrew M. Cuomo mandated all hospitals in the state increase capacity by 50% to accommodate the expected surge in Covid‐19 cases. At the time, state health officials estimated 55 000 new hospital beds would be needed. Montefiore Health System is the largest hospital system in the Bronx, NY, the borough with both the highest per capita hospitalizations and deaths from Covid‐19 in New York City. During the initial surge of patients with Covid‐19 in March and April of 2020, Montefiore converted non‐clinical hospital spaces into Covid‐19 patient care areas to accommodate the growing inpatient census. Although the conversion of existing clinical space to Covid‐19 medical wards has been described, there are limited reports available that describe the conversion of non‐clinical space. Unfortunately, as the Covid‐19 pandemic continues and with hospitalizations in the United States rising, the need for additional capacity is ongoing. As of the first week of March 2021, there are over 46 000 Covid‐19 hospitalizations in the United States. We describe here the steps taken to convert non‐clinical space into a functioning medical unit including the physical alterations of the space, methods by which we selected appropriate patients, the staffing model, and patient outcomes.

METHODS

Non‐clinical space was converted into a temporary medical unit at each of the three campuses of the Montefiore Medical Center: Montefiore Medical Center Moses Hospital, Jack D. Weiler Hospital, and Montefiore Wakefield. At Montefiore Medical Center Moses Campus, the Grand Hall is a multi‐purpose open space for large lectures and ceremonies and the Tishman Learning Center, adjacent to the Grand Hall, consists of five smaller conference rooms used for meetings and small learning sessions. In 1 week, both spaces were converted into a medical unit. Construction included walls fitted with oxygen piping, suction capability and electrical wiring. Curtains divided the spaces into 39 patient beds, each with a stretcher, bedside table, power socket, light, and sharps container (Figure 1). The converted unit, including both the Grand Hall and the Tishman Learning Center, will be referred to as the “Grand Hall.”

In addition to patient beds, equipment and workspace in the Grand Hall was identified for doctors, nurses, and other staff. Delineated workstations included computers, label printers, printers, and telephones. Sinks and hand sanitising stations were installed at all entrances. Tablets for video interpreters, electrocardiogram machines, portable oxygen tanks, a crash cart and personal protective equipment (PPE) stations were acquired. Three smaller adjacent conference rooms became a satellite pharmacy, a clean utility room, and a break room.

Colour‐coded infection control zones were outlined throughout the space, which included three zones: green (no patient contact; no PPE other than clean mask, that is, work room and break room); yellow (some patient interaction via transport or ambulation; PPE donned and doffed here, full PPE if directly in contact with patient); and red (areas of direct patient care; full PPE required, Figure 2). Patient transport to and from the Grand Hall was restricted to one entrance to minimize the use of public hallways (Figure 1).

FIGURE 1

The Grand Hall and Tishman Learning Center converted into a Covid‐19 medical unit. The conversion included adding walls, oxygen piping, suction capability, electrical writing, and curtains. Each newly created bed is labelled here with a number. Zones of patient contact and required personal protective equipment outlined

FIGURE 2

Grand Hall: Photo of development of converted space in progress showing bed number, sharps container, oxygen piping, lighting, curtains, and bed

The selection of appropriate patients for the Grand Hall was dictated by several significant structural differences when compared to standard inpatient medical units. First, the limited space around each stretcher could have hindered resuscitation efforts if a patient decompensated. Secondly, no doors separated patients to limit movement of aerosols. Additionally, the only patient bathroom was approximately 100 ft away from the main care area. For these reasons, it was determined that the unit could only safely serve lower acuity patients without aerosolising procedures who could ambulate to the bathroom. The Grand Hall's main function became accepting patients who were admitted with Covid‐19, who had been cared for on other inpatient units, and who were thought to be improving and nearing discharge. Accepting transfers from general medical floors created capacity and facilitated patient flow from the Emergency Department and intensive care units. The following patient criteria for acceptance into the unit were developed in collaboration between physician and nursing staff:

Ultimately, the Grand Hall accepted clinically improving and stable hospitalized adult patients approaching discharge. Patients meeting the above criteria were identified by primary teams throughout the hospital and added to a transfer list for review. A hospitalist attending screened each patient prior to transfer via chart review and, if necessary, discussion with the primary medical team, and facilitated the transfer. Hospitalists excluded from the clinical care of Covid‐19 patients for medical reasons were chosen to perform the screenings. The hospitalist screener worked 7 days a week for 12‐hour shifts for a week at a time. In addition to screening patients for admission to the Grand Hall, they also screened for admission to several other alternative care areas including the converted rehabilitation gymnasium at the Montefire Jack D. Weiler campus and the converted ambulatory surgery centre at the Montefiore Hutchinson campus.

Covid‐19 positive (no patient under investigation, no negative patients)

Adults only

No bedside haemodialysis (HD) (routine HD performed in the HD unit)

No ventilator nor high flow nasal cannula nor non‐rebreather

No telemetry

No gastrointestinal bleed

No acute neurologic event, that is, acute stroke, seizures

No vasoactive medications, that is, pressors

No need for surgical consultation

No diarrhoea

No active psychiatric disorder that requires 1:1 (constant observation)

No need for enhanced observation with sitter

No bedbound patients

Expected additional length of stay <72 hours or medically ready for discharge

Multidisciplinary cooperation was required to staff the expanded clinical space, including attending‐led housestaff teams from the Departments of Medicine and Pediatrics, registered nurses, certified nursing assistants, pharmacy technicians, social workers, phlebotomists, physical therapists, environmental services, information technologists, and unit secretaries. For provider staffing, the unit was initially staffed by two medicine‐led teams including medicine hospitalists, medicine residents and non‐medicine residents. As the number of surge teams increased facility‐wide, one of the medicine services was transitioned to coverage by a paediatrics team. Like many other institutions, the medicine teams for Covid‐19 patients on general medicine units were staffed with a limited census of 10‐12 patients due to the acuity and complexity of patients. Because of the lower acuity in the Grand Hall unit, however, patient census was increased to 16 patients for the paediatrics‐led team, and 23 patients for the medicine‐led team. Typical clinical activities included weaning supplemental oxygen and finalising discharge plans.

Data were extracted from the electronic medical record (Epic, Verona, Wisconsin).

RESULTS

The Grand Hall was open for clinical care from April 2nd to April 20th, 2020. The unit discharged 170 patients with 82% discharged as self‐care. The median time from transfer to the Grand Hall to discharge was 32 hours, and the mean time was 52 hours. Five patients (2.9%) required transfer back to a traditional unit due to clinical deterioration such as worsening hypoxia. There were no respiratory arrests, cardiac arrests, or deaths in the Grand Hall.

DISCUSSION

The converted unit expanded hospital capacity, freeing beds on traditional units to facilitate patient flow out of the emergency department and intensive care units. As overall hospital census decreased, the unit closed to patient care but is prepared for reactivation if necessary. As Covid‐19 cases remain significant across the United States and the world, many medical centres continue to face the possibility of demand far exceeding hospital capacity. Rapid conversion of non‐clinical spaces into patient care areas is feasible and can be accomplished safely with careful planning and interdisciplinary cooperation.

CONFLICT OF INTEREST

The authors declare no conflict of interest.