New York City’s hospitals and health workers were overwhelmed in March last year when their city became the epicentre of the COVID pandemic in the United States.
Hard lessons were learnt and these are now being shared to help inform planning and preparation for future pandemic surges. Some of the lessons also have wider application than COVID.
Writing recently in JAMA Internal Medicine, three doctors involved in the NYC response shared lessons from their experiences that may be helpful as Australian health services and workforces come under increasing pressure from COVID outbreaks.
“We can honour the people we lost to COVID-19 by learning from the experience in ways that could benefit all patients,” wrote Dr Eric K Wei, Dr Theodore Long and Dr Mitchell H Katz.
“We believe that the nine lessons we have learned from the pandemic would improve hospital care and health care delivery in both day-to-day circumstances and future emergencies.”
Their key points are summarised below.
• It was better to outfit additional areas of the hospital for inpatient care (such as using “mothballed units”) than building field hospitals to deal with the influx of patients. Field hospitals were problematic because of the need to replicate all the equipment and staffing needs of a hospital (such as pharmacy, blood bank, radiology).
• Finding sufficient ICU nurses, respiratory therapists, intensivist physicians and dialysis nurses was a huge challenge. While cancelling elective surgeries and discharging stable patients provided a staffing pool, many of these diverted staff were not familiar with the areas where they were needed. “Just in time” training videos helped familiarise clinicians with using ventilators, while nursing competency modules helped prepare nurses to assist in ICUs.
• Hospitals should have clear policies for providing emergency credentials to physicians not on their medical staff.
• Going forward, all hospitals should have a detailed disaster plan that addresses: what areas of the hospital to expand to and in what order, how to increase ability to care for incoming patients, and how to gain immediate access to additional staff.
• To help maintain line of sight so nurses could evaluate patients while not entering their rooms, windows were put in walls, wood doors were replaced with glass doors, and communication and video devices were put in patients’ rooms.
The doctors noted the wider application of this lesson: “Indeed, video monitoring may prevent falls, a chronic problem in hospitals, by alerting nurses that patients are getting out of bed.”
• When hospitals ran out of isolation rooms during the surge of the pandemic, they improvised to reduce the risk of transmission; for example by using high-efficiency particulate air filters and UV lights.
The authors noted: “Given the potential for transmission of airborne agents, it makes sense for hospitals to put more efforts into the quality of the air in the hospital, including in common areas, such as waiting rooms.”
• To support health workers facing burnout and distress, the hospitals provided stress management and resilience training, recharge rooms, peer support, and easy-to-access mental health resources.
The authors said: “We believe that these resources should remain permanently in place.”
• Masks also should be an ongoing feature. “Going forward, we intend to continue to wear masks in the hospital even if SARS-CoV-2 disappears (an unlikely possibility),” they wrote, noting that the combination of mask wearing and social distancing dramatically decreased the proportion of outpatient visits for influenza-like illness.
The authors said: “Beyond this, the COVID-19 pandemic has challenged the hospital disease control dichotomy that respiratory spread occurs either through respiratory droplets (as with influenza) or aerosolized spread (as with measles).
It is likely that SARS-CoV-2 is spread primarily through droplets but can also be airborne, requiring rethinking of respiratory infection control procedures and raising the question of whether it is appropriate to still have multioccupancy rooms in the hospital.”
• Electronic tablets were provided to patients to enable communications with families when they were unable to have visitors. This service also should remain, the doctors said.
An unexpected benefit was that patients used the tablets to communicate with friends and family who were not in the local area. Family conferences included faraway relatives in ways that would not have occurred prior to the pandemic.
Tablets enabled us to increase participation because even people in the local area did not have to travel all at the same time to meet with the care team. A video option for including relatives in hospital care should remain post pandemic.”
• The typical approach of hospitals maintaining minimal excess supplies and sourcing supplies from a limited number of vendors, in order to save costs, were “a disaster” during COVID. The NYC hospital systems ran out of supplies and equipment and had to substitute medications and develop alternative strategies.
Although individual hospitals cannot afford to maintain large excesses in supplies, regional caches with rotation of expiring medication should be established.
Many countries have learned of the harms from no longer manufacturing certain medical equipment themselves. Ultimately, the federal government could subsidise sufficient manufacturing within the country to protect against severe shortages in crises.”
• The surge of COVID patients arriving in emergency departments and ICUs forced many improvements to electronic health record processes, and these should continue after the pandemic “to allow physicians and nurses to spend more time with patients and to reduce burnout”.
• The authors noted the inequitable toll of the pandemic and highlighted the importance of primary care in helping to address persistent racial, ethnic and socioeconomic disparities in health.
To be fully accessible, primary care must be geographically near, be culturally competent, provide translation services for persons with limited English proficiency, and support persons with low literacy levels.”
The authors said hospital systems in the US increasingly are successfully partnering with community-based agencies and other resources to address the social determinants of health, and these efforts should be expanded.
“In addition,” they said, “hospital systems should ensure that their organisation promotes antiracism, equity, and inclusion in their patient-care and employment policies and practices.”
The authors did not discuss the lessons about telehealth as they said that has been covered elsewhere.
Dr Clare Skinner, an emergency medicine physician from NSW and President Elect of the Australasian College for Emergency Medicine, said she agreed with the paper’s conclusions.
She told Croakey:
We don’t even allow/plan for expected surges in demand at the moment, let alone unexpected ones. This is true when it comes to staffing (for example, not enough FTE on the roster to cover sick leave), beds (especially in specialist areas such as ICU/paediatrics) and operating theatre time (constant tension between emergency and ‘elective’ cases).
It is important to prioritise staff wellbeing but this has to be multi-faceted, including genuine attention to structural factors that contribute to staff burn-out, moral injury and low morale.
Healthcare workers need stable employment with good conditions and reasonable flexibility. They need reasonable rosters with access to leave, breaks and training in work hours.
They need parking or accessible and safe public transport, food, and staff-only spaces for rest and debriefing. They need well-trained, empathetic leaders and well-designed clinical guidelines, digital technology and governance processes.”
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