NEW YORK — Most of the country looked on in horror this spring as Covid-19 flooded New York City hospitals and morgues, and a disease many had never heard of threw America’s biggest city into paralysis.
Now New York is watching the same scenario play out in states throughout the U.S., while presiding over three months of sustained success in keeping infections low. But with cold weather approaching, schools tentatively reopening and many forced back indoors, the threat of a new outbreak is never far from the minds of public health officials — and this time they know outside help will be harder to come by.
“The second wave is a misconception: It’s the omnipresent risk of explosive spread,” said Dr. Tom Frieden, former CDC director and current president and CEO of Resolve to Save Lives, an initiative of Vital Strategies. “That’s what we’re facing.”
With a total of 237,525 confirmed and probable cases and more than 23,500 dead, New York City has already experienced the worst the coronavirus has to offer. But as hospitals and health officials gird for a second city outbreak, the spread of the virus throughout the rest of the country is bringing some challenges the city did not face the first time around — and some that continue to linger from the darkest days of March and April.
In many cases, the city is better prepared: it knows the warning signs, hospitals are communicating weekly to share best practices and other information, and New Yorkers are largely complying with social distancing and mask guidance to cut down on transmission.
But in some areas, the wisdom of experience won’t be enough. The hospitals need to create space for surge capacity while maintaining operations that were halted when the virus first struck, nearly bankrupting even the wealthiest systems; they’ll have to build up testing capacity despite equipment shortages; and they’ll have to secure the necessary supplies for treating and diagnosing patients amid global demand.
The biggest challenge, though, is staff. The army of medical worker reinforcements who came to New York’s aid are now dispatched to hot spots around the country, and many of those based in the city are still enduring the trauma of witnessing horrors they never could have imagined in February.
“We were the first and the worst in New York, and we had to come up with a lot of solutions that weren't national solutions on the fly,” said Don Boyce, vice president of emergency management at Mount Sinai.
Protocols on staff, space, PPE and testing are now part of hospitals’ playbooks to manage a potential resurgence, influenced by new safeguards mandated by the Cuomo administration.
Hospitals across the state are required to continually maintain at least a 90-day supply of personal protective equipment starting Sept. 30 based on the peak of the first outbreak, according to guidance issued by the state health department in July.
Health systems like Northwell, Mount Sinai and NYU Langone Health said they are bolstering their PPE stockpiles and will enact conservation methods used by frontline workers during the first wave, such as reusing equipment until it’s soiled, when their burn rates increase.
“Conservation for us is key and crucial. We’re watching numbers and trends so carefully,” Boyce said. “If a site’s numbers start going up, we’ll know that in a day or two.”
The health systems are also monitoring data from the communities they serve, including through telehealth visits, to see if there’s a spike in symptoms consistent with Covid-19. In early March, the city health department reported a sharp uptick in flu-like symptoms at emergency rooms — early warning signs that New Yorkers had Covid-19 — though the de Blasio administration said it didn’t know for certain due to a lack of tests.
This time around, hospitals are keeping an eye on flu and respiratory symptoms at their facilities and urgent care centers. The emergency management team at Northwell Health, the state’s largest health care system, receives daily reports “almost by zip code,” said president and CEO Michael Dowling.
“If there’s a spike that continues for a couple of days, we might have a problem,” he said. “If it continues, we have a hot spot.”
Unlike the initial onslaught, when government officials and public health experts begged patients to avoid emergency rooms unless they couldn’t breathe, hospitals anticipate that proactively monitoring for warning signs will allow them to treat more mild cases.
“Because of the level of preparation, there’s going to be less push to keep people at home longer,” said Maimonides president and CEO Kenneth Gibbs. “People need to be comfortable getting the care. The system is ready.”
Nonetheless, hospitals are continuing to tweak their surge plans in accordance with new state directives.
The protocols must include the ability to increase the number of beds by 50 percent within 7 days and by 100 percent within 30 days, according to the guidance issued by the state health department on Aug. 6.
Many of the hospitals left up makeshift measures to prevent hospital-related Covid-19 transmissions, along with physical accommodations like HEPA filters, even as they flipped temporary intensive care units back into their original condition, according to accounts from workers and executives.
NYC Health + Hospitals is adding “infection control separations between Covid and non-Covid areas and providing improvements based on lessons learned from our prior surge,” like bedside dialysis and telemetry, according to the city’s public hospital system.
“We have to plan as if it was going to be as bad as it was,” Dowling said. “The danger would be to plan for a minimal uptick and get hit.”
Hospital leaders said staffing remains the biggest challenge.
Although the hospitals will have access to a state-run portal for volunteer, retiree and out-of-state workers, Covid-19 has spread throughout the U.S. nearly eliminating the availability of reinforcements.
Instead, hospitals are planning to shift workers from different units to manage a potential new influx.
“Given what’s happening nationally, I don’t think we’d have access to the same resources,” said Dr. Fritz Francois, chief medical officer and patient safety officer at NYU Langone Health.
Medical staff on the front-lines told POLITICO the trauma they experienced then has exacerbated mental health issues like depression and anxiety, and they feel disillusioned with their institutions.
Maimonides, Mount Sinai, Northwell and NYU Langone Health said they did not report significant attrition following the height of the pandemic — Medical Society of the State of New York confirmed clinicians have not left their institutions en masse — but anecdotally, medical workers who spoke to POLITICO said the trauma has caused coworkers to leave.
“We had a lot of nurses who left or changed jobs. Some nursing staff felt like they were left on their own,” said one ICU nurse at Mount Sinai who asked for anonymity over fear of retaliation. “It’s bad. They won’t talk about it,”
NewYork-Presbyterian, which declined an interview request for this story and previously threatened employees about speaking to reporters during the pandemic, made “distressing decisions” leading up to the first wave of Covid-19 patients, workers told POLITICO.
“We had ample time to at least initiate some normal practices of quarantining and disease sequestration,” said one medical worker who asked to remain anonymous for fear of retribution. “When a hurricane comes, you put up plywood, you get ready for it.”
The continued lack of understanding or definitive treatment around Covid-19 is contributing to the anxiety of doctors and nurses.
“No matter what we did, no matter how much we did, we couldn't save them,” the ICU nurse at Mount Sinai said. “There truly isn't a treatment. We’re managing symptoms. We don't have anything preventive. We don't have anything proven just yet.”
At least one of NewYork-Presbyterian’s 13 facilities within the health system had garbage piling up due to efforts at keeping ancillary staff out of the hospitals to avoid exposure, and executives tasked doctors to get rid of it.
“I remember walking by there and helping two of my junior residents take down four-foot high worth of biological waste,” one medical professional said. “From a mental standpoint, you're exhausted anyway. To basically take away garbage … I was so distraught over that. It wasn’t mentioned in leadership meetings.”
Meanwhile, some hospital executives were monitoring the facilities via videoconferencing, the same medical professional said.
“This is their method for leadership to see what is done,” they said. “To me that’s disgraceful.”
In a statement, NewYork-Presbyterian did not specifically address the allegation.
“Our mission is to save lives, while also protecting the privacy, security and dignity of our patients,” the system said in a statement. “Our heroic health care workers have been on the front lines of this battle, and they have navigated unprecedented challenges under enormous pressure. We are constantly working to give them the support and resources they need to fight for every patient’s life.”
With the hospitals on standby, public health experts are looking at the next challenges: whether people can be reinfected, how school reopenings could throw a wrench in transmission rates and if the new normal translates to the colder months, when flu season ramps up in January.
Adequate testing will be required to separate patients based on Covid-19 status or flu status, viruses that present similarly and may not be distinguishable without a test. It also leads clinicians to wonder if patients can have both the flu and Covid-19 simultaneously, answers that scientists have yet to find.
“I’m hoping this is more like a forest fire. When the fire burns through, it burns through. There’s some embers, but that’s it,” said Art Fougner, an OB-GYN at Northwell Health and former president of the Medical Society of the State of New York. “New York got hit so hard. You would think with people out there sunbathing and all the protests, you would think there would be a flood on the hospitals. I’ve got my fingers crossed that we may be pleasantly surprised.”
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