Coronavirus: Northwell's 10-step recipe for addressing patient surges

One of New York's largest health systems marshaled a range of resources and expertise to cope with the spring coronavirus surge.

By ​Christopher Cheney

With coronavirus hospitalizations surging nationwide this fall, healthcare leaders can benefit from the lessons learned in the country's first COVID-19 epicenter in New York.

The resiliency of Manhattan, New York-based Northwell Health was tested in dire circumstances during the spring coronavirus surge. The health system, which features 23 hospitals and 800 ambulatory sites, treated about 20,000 hospitalized COVID-19 patients during the spring surge, says Mark Jarrett, MD, MBA, senior vice president, chief quality officer, and deputy chief medical officer at Northwell.

"On the peak day, Northwell had 3,500 inpatients and more than 800 patients on ventilators," he says.

Ten strategies and initiatives helped Northwell cope with the epic influx of seriously ill coronavirus patients, Jarrett says.

1. Focus on the basics

Northwell approached the spring surge with a focus on "basic" strategies, he says.

"Number One is the fact that Northwell has a long history of robust emergency management processes. We have gone through everything from 9/11 to H1N1 to hurricanes. So, we have a very robust emergency management system, and a corollary to that was we immediately went into our incident command structure. We started our incident command in the end of January. That gave us great flexibility because of all the different roles such as logistics and planning were able to work together very quickly."

Another basic strategy involved capitalizing on Northwell's integrated delivery network, Jarrett says. "Throughout the spring surge, we acted as if we were a single hospital even though we have multiple sites. We acted as one. There was one single command structure at the top—emergency operations centers at each hospital reported up to the incident command leadership."

2. Centralized decision-making

Decisions were made centrally—not to exercise control but to be able to shift resources from place to place quickly, he says.

"For example, when ventilators were in short supply in late March and early April, we had meetings twice a day at the system level with the critical care team leadership, procurement, logistics, and the clinical team that looked at where the patients were and how many ventilators we needed at each site. Especially at the 4 o'clock meeting, if we saw a hospital that was down to two ventilators and had a need for about six, we would move eight or nine ventilators to that hospital. We would give them a cushion."

3. Load balance

Jarrett says load balancing, which involved shifting patients from crowded hospitals to hospitals that had more empty beds, played a crucial role in managing the spring surge.

"Long Island Jewish Forest Hills Hospital was in the epicenter of the epicenter. Queens was the worst in the New York area. They were overwhelmed. Some nights, they would have 40 patients who needed to be hospitalized. What we would do is proactively move those patients rather than try to wait for a bed. We would empty the emergency room and get patients where they could get the best care, which is not in an emergency room, it is up on a floor in an ICU. We moved patients all around."

4. Building surge capacity

Northwell created nearly 2,000 additional hospital beds by converting conference rooms, rehabilitation gyms, and other spaces into clinical care sites, he says. Staffing the new clinical care sites—particularly new ICUs—was a daunting challenge.

"As outpatient care went down dramatically and elective surgeries got cancelled, we took that staff and we put them in the hospitals so they could increase the staffing in new areas that were surging. We had to build ICU-level care on regular floors. So, we took staff such as anesthesiologists from ambulatory surgery who have some critical care training to staff the new ICUs. We would mix the new ICU staff with regular ICU staff who would supervise the new staff and serve as a resource," Jarrett says.

5. Virtual ICU

Northwell enhanced the health system's existing virtual ICU program, he says. "We have an eICU that monitors our regular ICUs, and we expanded that with telemedicine carts in the new ICUs so that the doctors there could get almost instantaneous consults if the unit was busy."

6. Clinical advisory board

Northwell created a clinical advisory board that included infectious disease specialists, nursing leaders, hospitalists, and other staff members to standardize treatment protocols, Jarrett says. The board met once a day. Pivotal initiatives launched by the board included standardizing medications and proning seriously ill patients rather than quickly placing them on ventilators, he says.

7. Personal protective equipment management

In the early days of the spring surge, Jarrett says Northwell decided to have all staff members in emergency rooms and COVID-19 units wear N95 respirator masks. Staff members in other patient care areas were required to wear surgical masks. "We believe we reduced the infection rate in our employees significantly. To keep staffing levels adequate, that was important," he says.

8. Asking for staffing help

Northwell drew on existing relationships with other health systems such as Salt Lake City, Utah-based Intermountain Healthcare to import temporary nursing staff, Jarrett says. "At that point we were lucky. Coronavirus was not surging in many places across the country."

9. Communication initiatives

Several communication initiatives were launched to keep the clinical care staff informed during the crisis, including a weekly clinician update video that focused on the latest scientific information, he says. "We tried to keep everybody up-to-date with what was going on because the greatest stress is the fear of the unknown."

10. Staff well-being

Northwell also launched initiatives to bolster the hard-pressed clinical staff's well-being, Jarrett says. For example, the health system used its employee assistance program and behavioral health resources to support staff members, established respite rooms, and provided day care so staff members could leave their children at home.

For staff members who were afraid of bringing the virus home to at-risk family members, Northwell provided hotel rooms, he says. "In the beginning when there was a lot of fear, people didn't have to worry about infecting loved ones."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.