Lessons learned in one of the nation’s first hot spots

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In part one of a two-part series, AMA Chief Experience Officer Todd Unger talks with three New York health care experts about lessons learned during their hotspot phase and advice for physicians in states experiencing a surge in COVID-19 cases now.

Learn more at the AMA COVID-19 resource center.

Speakers

• Eric Wei, MD, senior vice president and chief quality officer, NYC Health + Hospitals
• Ramon Rodriguez, president and CEO, Wyckoff Heights Medical Center 
• Mark Jarrett, MD, senior vice president, chief quality officer, deputy CMO, Northwell

Unger: Hello, this is the American Medical Association's COVID-19 update. This is part one of a two-part series where we're talking to three healthcare leaders in New York about lessons they learned in one of the nation's first hotspots. I'm joined today by Dr. Mark Jarrett, senior vice president and chief quality officer as well as deputy chief medical officer at Northwell in New York, Ramon Rodriguez, president and CEO of Wyckoff Heights Medical Center in Brooklyn, New York, and Dr. Eric Wei, senior vice president and chief quality officer for New York + Health Hospitals in New York. I'm Todd Unger, AMA's chief experience officer in Chicago. Let's look back six months and talk about how you prepared as it became clear there would be a surge of COVID-19 cases in New York, that is if you had time to prepare. When you think about that, Dr. Jarrett, what in that preparation worked and what didn't?

Dr. Jarrett: The thing that worked in that preparation time was immediately standing up our emergency operation center and going to a full incident command system to bring in all the resources we have in the system, which thankfully were quite extensive and also due to our experience being in New York, to bring it together so we can both tackle the problems going on at the time but also plan for what you expected would happen over the next several weeks to a month. What I thought that we didn't expect was how rapidly this was going to go zero to 60 in terms of an event, whereas our first patient was admitted in the first week of March and by the middle of April we had over 3,500 patients admitted to our hospitals with 800 plus on ventilators.

Unger: Now Dr. Jarrett I was just interviewing the team that made the documentary "They Get Brave" and illustrated that very point and one of the hospitals they did feature was a Northwell one. Dr. Wei, what do you think about in terms of preparation or what worked and didn't work?

Dr. Wei: So I think what worked similarly standing up our incident command structure, our Tiger Team calls and our president and CEO Dr. Mitch Katz challenged each of our facilities' CEOs and their leadership, "What would happen if 75 ILI patients showed up at your front door of your emergency department today?" And so, doing some of those tabletop exercises certainly helped us, but similar to as Dr. Jarrett mentioned, we had our first case on March 6th and then it was no longer a tabletop exercise, it just blew up. And so I think one of the things that stands out that didn't work was figuring out this was something like Ebola that you could ask certain questions for and screen and isolate patients and put them in isolation rooms.

And I just remember early on shift trying to ask questions to screen for chances of COVID and then realizing that it was such a futile effort. And being surprised by traumas coming in and you put them in a CT Scanner and they have bronchiectasis in their lungs. Ankle sprains coming in and they had fevers and they were coughing. And so, I think a hard lesson learned is just every patient was a potential COVID patient.

Unger: Mr. Rodriguez?

Rodriguez: Well, six months ago I don't think we were thinking much about what might be happening. I think the timing six months before the actual incidents things started really getting hot in December. And we are not a system we are one hospital, a number of primary care and specialty care organizational entities around us, but we have a very close working relationship and affiliation with Northwell. And they are good teachers and they're very good at supporting, but we needed a safety net hospital. So we started in December with a part of their organization called True North and started doing very much the same kinds of things that were being talked about by the physicians.

One thing I would say that is critical and I wish that we had as early as possible started thinking about this, is the single most important problem we had was staffing. And I think that's true about a lot of places and because of our extent position on the border of Brooklyn and Queens, initially the torrential downpour came with us. You've heard about Elmhurst Hospital, which is part of the health and hospital system. They were hugely overrun. Well, we're only three miles from there and most of our patients like the patients Elmhurst, where I grew up. Are Latino, have migrated to this country, are living in situations where I may have grown up in a one or two family home and I had four or five people living with me, the same apartment I have near 20 people living there. And as one example, we had one family, nine people got the virus and they all die, of one family.

Unger: So staffing, obviously one of the key challenges. Dr. Wei, what are some of the other unexpected challenges that you encountered?

Dr. Wei: I think something that has gotten a lot of attention is obviously the PPE supply and also just the nervousness of ventilators and running low. I think on top a lot of this, it's just American doctors and the American health care, you never have to make these types of decisions, just the threat of potentially getting to a point where you have to make choices and then rationing. Thankfully, we never got there and New York City was able to flatten its curve, but we certainly learned a lot about the vulnerabilities of our supply chain for personal protective equipment. And we certainly had to rely on FEMA, the states, the federal government for ventilators. And so I think that was a big wake up call, not just for New York city, but we're seeing it across the country and across the globe.

Rodriguez: If I can add to that just a quick thing. For us it was distribution that was a problem. For us it was, at one point we had people who had PPE envy. They were looking to get more and more and more things. We had enough, but we had a hard time making sure that it was fairly distributed throughout our little hospital. And I'm hoping that this time around we'll be more ready in the first instance, if we do get a surge.

Unger: Well, let's talk about one of the questions I asked before we started taping was how does it feel to be looking somewhat on the outside as your colleagues across the country are now in a similar hotspot situation throughout the South and the West? What are the key lessons that you want to impart to those physicians to help them battle this pandemic? Mr. Rodriguez, why don't you go first?

Rodriguez: Well, I would say that communication between and within the organization and between the families of people who are affected. It is beyond my comprehension that what's happening in Texas, Arizona, Florida, other locations that you can really prepare, but the most important thing is the staffing, making sure that you have the backup and support of whatever state entities will be helping you and have that communication going on a regular basis. And I think it feels daunting when you think about the locations, but with respect to the locations, you figure it out. You're able to now learn from our experience and figure it out and go forward. The PPE is a matter of making sure that you're getting into the right place at the right time, but it's all about staffing. And we were lucky, we had people coming from Arkansas that worked with us. We had a pulmonologist that came from Arkansas and worked three straight weeks and she saved us, as one example.

Dr. Jarrett: I would add something else in addition to what Mr. Rodriguez said, and that's about the importance of using data.

Rodriguez: Absolutely.

Dr. Jarrett: In terms of what your staffing is, in terms of what your bed capacity is, in terms of even your testing abilities. Really need the data to see both where you are, where you need to be, and we were doing this every day in terms of ventilators. As I know Dr. Wei was doing as well, looking at ventilators every day, but looking at all this and developing almost predictive models to tell you where you are on that slope up, or much more the slower slope going down. It's not as rapid as the uprise, but you need that because you may think you're okay, but any way you are on the curve, you may not realize that you're going to need a heck of a lot more, whether it's staff, beds, supplies and supplies are an issue. It's not just PPE.

I mean, we had so many people who needed intensive care, we were running out of triple-lumen catheters. I mean, we were running out of Foley catheters. Things that you wouldn't even think about, all of a sudden they come in short supply, but that's where predictive analysis and using your own data to see where you are every day and figure out where you're going to be in another three days, five days, in a week is critical in maintaining yourself in an event like this. And it takes a while to start building up that expertise to really get that data. There's now models out there that we've developed and other people have developed, people need to learn from that. So they can really predict what they still need for the next several weeks or a month.

Rodriguez: Dr. Jarrett's right, and we were recipients of that information. We really got a lot of help from Northwell in that process. We had to deal with it ourselves, but they assisted us. One thing that I didn't add that I want to add. The next time around, we had one PRO team. We were getting 10, 12 codes a day and we couldn't keep up. So we're now dealing with setting up an A and an B and an C backup PRO team, and everybody who is not a critical care nurse is being in service and prepared as part of a process.

And the teaching element came actually from Northwell, two half day sessions that we're working on and we learned from them. So that's been very helpful. And I can't say enough about how helpful the state was, the city too was very helpful, but I can't say enough about how helpful the state was. We never ran out of the most important aspects of our organization, the ventilators, et cetera. We had some problems with the tubing, but the ventilators cetera, really helpful. And it caused us to be able to be responsive to, I think, one of the hottest spots in the whole city of New York.

Unger: Dr. Wei, how about you in terms of lessons learned that you would like to impart to today's hotspots?

Dr. Wei: Yeah, so I agree a hundred percent about data analytics and intelligence and having insight into where every ventilator and where every staff member is, and being able to move equipment and staff around to meet the need. And so sometimes we were sending in reinforcements and ventilators two, three times a day to hospitals like Elmhurst. And I absolutely agreed that staffing is the hardest and often the last component. You can create a new surge ICU space and have the oxygen piped in and have the ventilators and all the equipment there, but without the staff, you can't bring patients in there. And so that's why we're forever grateful for the Department of Defense, bringing military health care personnel in to support our staff, the volunteers who came. And so, it is heartbreaking seeing what's happening across the South and West in the United States, and it feels so far away. We definitely empathize with what they're going through and our heart breaks for them.

And then another thing to add as a lesson learned, I know Northwell is a large system similar to New York City Health and Hospitals and we felt fortunate that we were able to level load the surge across our facilities. And so, not only sending staff and equipment to where the most patients are coming in the front door, but actually moving patients around, so not allowing one facility to drown. And so, if we could do this all over again in the next wave, if there is one, it would be for us to work together as a city, as a state, as a region, to be able to level load across and not just the Northwells and the Health and Hospitals get the advantage of doing that, but others do not.

Unger: Well, that concludes part one of our series. I want to thank Dr. Jarrett, Mr. Rodriguez, and Dr. Wei for being here today and sharing their perspectives with us. We hope you'll join us tomorrow for part two of our update. In the meantime, for updated resources on COVID-19 go to ama-assn.org/covid-19. Thanks for joining us and please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.