June 16, 2020

New York has been the epicenter of America's new coronavirus epidemic since March, with the state so far reporting about 390,000 cases of, and more than 30,600 deaths linked to, the virus. So what can the rest of the nation learn from New York's experience?

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For an analysis published Thursday, the Wall Street Journal spoke with almost 90 health care workers and government officials in the state and reviewed emails, legal documents, and memos related to the state's response to the coronavirus outbreak.

Here's what the Journal found—including emerging lessons that could prevent future deaths in other states.

Lesson #1: High demand led to breakdowns in patient transfer and isolation protocols

According to spokespeople for two of New York's largest hospital systems, more than 1,600 patients—most of whom had Covid-19, the disease caused by the new coronavirus—were transferred from overloaded hospitals in those systems to hospitals where Covid-19 caseloads were lower.

The goal was to ease resource crunches at hard-hit hospitals, but some patients saw their conditions deteriorate seriously while being transferred, the Journal reports.

David Buziashvili, who worked at NYC Health + Hospitals' Bellevue hospital, said that typically hospitals will transfer patients only if they're stable. But some of the patients who were transferred to Bellevue during the Covid-19 surge had "one foot in the grave," he said.

A further problem, according to Buziashvili, was that some patients were transferred without adequate medical records—in some cases, without even a name. On one shift, Buziashvili said he saw 10 new transfers with very little medical information.

The Journal reports that Gov. Andrew Cuomo (D) on March 30 set up a state-run program to coordinate patient transfers between medical facilities. However, according to Jim Malatras, president of SUNY Empire State College and an advisor to Cuomo's coronavirus response, the new program didn't include supervision of medical record transfers, nor did it follow up on patients' conditions once they were transferred.

Ultimately, the program was "trying to manage volume," Malatras said, "not necessarily the individual patient need."

Some hospitals were overrun with transferred Covid-19 patients in critical condition, the Journal reports. At Bellevue's ED, for instance, ambulances brought in about 30 transfers almost every day for a few weeks, with patients often arriving in critical condition—which is atypical under normal circumstances, nurses and doctors at the hospital said.

The state and New York City officials also didn't coordinate on patient transfers, which contributed to the issue, the Journal reports.

Meanwhile, some hospitals reportedly had poor isolation protocols. According to the Journal, some hospitals housed patients with suspected cases of Covid-19 side-by-side with patients who were confirmed to have the disease. According to health care workers at those hospitals, some sick patients likely infected others who were near them and weren't previously infected.

Lesson #2: Health systems struggled to get the staff—and PPE—they needed for the 'surge'

The Journal reports that some hospitals also lacked the staff needed to treat influxes of Covid-19 patients, particularly as hospitals had to expand their capacities by setting up care units in theaters, old auditoriums, and hospital lobbies.

Michael Dowling, CEO of Northwell Health, said, "Creating beds isn't the most difficult thing. The issues that get complicated with the creation of beds is the staffing. This isn't like you can put any staff on any bed at any place."

A number of frontline health care workers also said that some New York hospitals were slow to add more staff when needed, the Journal reports.

Brian Cleary—CEO of Krucial Staffing, an agency used by Health + Hospitals to gain 4,000 medical workers during the outbreak—said his agency could have sent the health system 6,000 additional staff members "without blinking." (A spokesperson for Health + Hospitals noted, however, that Krucial "does not encompass the full scope of the assistance we sought from outside groups.")

Some providers suggested that red tape kept staff from being added as quickly as possible. Chelsea Walsh, a traveling nurse, said she decided against working for NewYork-Presbyterian because of the required processes. Instead, Walsh worked with other providers in the city.

And some newly onboarded staff members lacked training, the Journal reports. Laura Jaramillo, a nurse at the Bellevue ED, said she had a lot of travel nurses come in with "no experience whatsoever," so she had to conduct training while also caring for patients.

A spokesperson for Health + Hospitals said new staff were "formally trained to cover the areas they were posted in."

The staffing shortages led some providers to be overwhelmed with patients, the Journal reports. One respiratory therapist at a new ICU at NewYork-Presbyterian/Columbia said they cared for more than 80 patients a shift. In normal times, 10 patients a shift are typical, respiratory therapists told the Journal.

Staff members also faced frequently shifting guidelines on when sick staff should return to work and mask-wearing from CDC and state government officials, as well as shortages of personal protective equipment (PPE), the Journal reports.

Lesson #3: State and federal governments were slow to respond to the crisis

Further complicating New York's response to the new coronavirus was that leaders in both the state and federal governments were slow to react to the virus' threat, the Journal reports.

Early signs of an outbreak of the virus in New York, including an increase in rates of patients seeking care for flulike symptoms, "went largely uninvestigated by hospital, state, and city officials," the Journal reports.

In early March, Chad Meyers, a doctor at Health + Hospitals' Elmhurst hospital, and his colleagues were concerned the new coronavirus was spreading in the city unnoticed, the Journal reports. They called New York City's Health Department to have some of their patients tested for the virus, but their request was rejected despite many of their patients meeting testing criteria, Meyers said.

City, state, and hospital officials also had relied on the federal government for tests for the virus, but CDC initially set limited criteria on which patients qualified for testing.

Further, the Journal reports that Cuomo and New York Mayor Bill de Blasio (D) "delayed taking measures to close the state and city even as the number of cases swelled, despite warnings from doctors, nurses, and schoolteachers."

In addition, state officials had limited guidance for how hospitals should boost their capacity to treat Covid-19 patients, according to the Journal. On March 23, Cuomo told hospitals to increase their capacities to treat Covid-19 patients by 50%, but when hospital executives asked how they would acquire the necessary staff, beds, and PPE, they were told by state officials to "do your best," a hospital executive familiar with the conversation told the Journal.

Along with shortages of PPE, shortages of supplemental oxygen occurred at many hospitals in New York, even though oxygen was available, gas experts told the Journal. State, city, and hospital officials didn't quickly acquire and distribute extra stocks of oxygen and related supplies, the Journal reports.

Dowling said Northwell was using about 50 times more oxygen than it ever previously had, but it did not run out. "Did we at a few locations have to address an oxygen issue? Yes," he said. "Did we run out of oxygen? No."

While both Cuomo and de Blasio publicly emphasized the need for ventilators, health care workers said they were surprised by the number of poor-quality ventilators they received from both the state and federal government's stockpiles, the Journal reports.

A spokesperson for Health + Hospitals said a number of ventilators the health system received from the state "were not 'ready to go' when they came," and the health system had to perform maintenance on the equipment before providers were able to use them to treat patients.

Hospitals also lacked a sufficient number of IV pumps to control medicine flow, dialysis machines, and vital-signs machines used to monitor patients, the Journal reports (Ramachandran et. al., Wall Street Journal, 6/11).

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