On the Front Lines at NYC’s Elmhurst Hospital

On the Front Lines at NYC’s Elmhurst Hospital

by Rishi Khakhkhar - April 07, 2020

Elmhurst Hospital, in Queens, New York, is a 545-bed city hospital that serves as a safety-net institution for a largely working-class immigrant population. The novel coronavirus has quickly spread through this vulnerable community, and the hospital is currently operating at more than 100% capacity. In an effort to free up precious beds, dozens of non-Covid-related cases are being transferred to other facilities. Inpatient wards are overwhelmed with those who, under different circumstances, would belong in intensive care units. This is the “epicenter within the epicenter” of the Covid-19 crisis in New York City. It is also where, as a resident emergency physician, I spend most of my days.

While the pandemic is a public health crisis, it is also a crisis of management, procurement, and operations in our health system. A month ago, Elmhurst had no confirmed Covid-19 cases. Now, possible Covid-19 patients make up more than 80% of the emergency department. As the wave has crashed over Elmhurst Hospital, its leadership and team have responded with creative solutions while working in a bureaucracy not otherwise known to be lean, interactive, or nimble.

Despite the bleak outlook, Elmhurst Hospital took early, decisive action to rapidly transform itself into a Covid-19 treatment center. These crucial lessons - implemented on-the-fly at Elmhurst - include stemming the tide of relatively healthy Covid patients, tackling sticky bottlenecks, and empowering the right leadership team. Here’s how we are managing.

Stemming the Tide

In Italy, doctors observed that the emergency department is not the right place for most low-risk patients who appear well yet have flu-like symptoms. The majority of them were treated with over-the-counter medicine and frequent hydration at home. Health officials recognized that patients who didn’t have the virus were much more likely to contract it in the emergency department than in the relative isolation of their own homes.

Following this observation, doctors at Elmhurst Hospital set up a tent - one of the first in New York - outside of the emergency department. This stemmed the tide in three ways: First, it kept non-critically ill patients out of the emergency room and away from risk. Second, it allowed us to assign physicians who typically work in ambulatory clinics to the tent, freeing up ER doctors for the more critical cases. Finally, in the face of unprecedented demand, New York City hospitals have constrained supplies that need to be judiciously managed for high-risk patients. Keeping the critically ill apart from the non-critically ill helps us allocate resources appropriately.

No matter how your community handles it, reducing the pressure on your emergency department will allow staff to focus on the coming wave of critically ill patients. Other hospitals have been able to offload ER volume by quickly standing up telemedicine offerings. Your hospital may have other creative solutions.

Tackling Bottlenecks

At Elmhurst, we’ve experienced three major bottlenecks to providing ideal care:

1. Clinical Staff 

The last thing we want is for a mostly healthy person to be sitting next to someone critically ill with Covid-19 in the emergency department. In the early days of the crisis, this was exactly the case. The bottleneck in this case was staffing: Triage nurses who typically segment patients by acuity were in short order. Without this crucial staff, patients languished in the waiting room, sharing space with other seriously ill patients.

Erecting the tent and separating patients was part of the solution. The other side of it was rapidly updating policies that brought as many staff to the hospital as possible. We brought back needlessly quarantined nurses and also utilized advanced practice providers, such as physician assistants (PAs) and nurse practitioners (NPs), as “super-triagers”: staff that could quickly evaluate and discharge otherwise healthy patients.

2. Personal Protective Equipment (PPE)

The national shortage of gowns, masks, gloves, and other materials that keep medical staff safe has created a bottleneck and forced us to find creative ways to conserve. For example, Elmhurst has contained suspected Covid patients in a specific, separate area of the hospital under negative pressure, which helps prevent cross-contamination between rooms. Providers working in a Covid section of the hospital can feasibly wear one N95 mask and face shield throughout a shift, while still protecting themselves from infection. While not an ideal long-term solution, it’s allowed Elmhurst to continue seeing and admitting new patients at a reasonable pace while slowing the burn rate of precious PPE.

3. Ventilators

Already, on multiple occasions, doctors at Elmhurst have scrambled to find a ventilator for a critically ill Covid-19 patient. We nervously anticipate the day when we will not have one. “Make more ventilators” is an obvious solution, but ventilators are complex machines, difficult to produce quickly, and they have been subject to an enormous surge in global demand. We need them immediately — not next month or next week.

In response, we have freed up existing ventilators in operating rooms and obtained others from less impacted hospitals in our health system. This has only been possible as elective surgical cases are put on hold, but it also offers a national model for finding urgent supplies in forgotten places. Many ambulatory surgical centers, for instance, are equipped with ventilators and should be transformed into makeshift ICUs.

Empower the Right Leadership Team

The most important aspect of Elmhurst Hospital’s response to the coronavirus pandemic has been a willingness to constantly adapt - as the tide strengthens and the bottlenecks narrow - to impossible pressures. By their nature, hospitals are bureaucratic structures with many layers of management. The key has been to empower a leadership team closest to the clinical reality. While working around the clock, Elmhurst emergency department leadership has had the freedom and insight to rethink workflows on-the-fly, create entire negative pressure areas that did not exist before, and coordinate flexible admission protocols that can be adjusted as the patient load mounts.

Will It Be Enough?

My peers on the front lines are constantly going above and beyond to take care of critical patients with innovative strategies. So far, Elmhurst has been able to scramble one step ahead, but more difficult decisions - unproven treatments, rationing ventilators, and more - are likely coming.

While the ingenuity of our clinicians and leaders has steered us this far, I fear that Elmhurst is reaching the limit of what one hospital can do. So my final lesson from the front lines of Covid-19 is this: It is time for a swiftly coordinated effort between our local, state, and national institutions to free the movement of ventilators, ramp up the production and distribution of PPE, and create desperately needed ICUs from existing resources. We’re doing our best at Elmhurst, but unless we all work together, it won’t be enough.

Rishi Khakhkhar is a resident emergency physician at Elmhurst Hospital and Mount Sinai Health System in New York City. He holds an M.D. and an M.B.A. from Northwestern University. He currently lives in Astoria, Queens.