The world is currently battling the SARS-CoV-2 (COVID-19) pandemic, the first pandemic of this magnitude in more than a century. With possible cases occurring as early as November 2019, the World Health Organization first received reports on December 31, 2019, of a cluster of mysterious pneumonia-like illnesses in the Wuhan Province of China.1 This outbreak has since expanded to more than 3 million cases worldwide, with more than 1 million cases in the United States. New York has become the epicenter of the crisis in the United States, with more than 300,000 cases to date. Confronting this crisis and an unprecedented surge in patient need has posed a unique challenge to New York City health systems.
A “wartime effort” has been initiated, with diversion of resources to treat patients with COVID-19 while allowing departments to meet their community care and educational responsibilities. With a systemwide approach and early action through the establishment of emergency management teams, the Northwell Health Department of Orthopaedics rose to meet the challenges of the COVID-19 pandemic while continuing to provide orthopedic care for patients within the community. The department has had to contend with redeployment of clinical staff and physicians, diversion of research efforts, maintenance of educational and research programs, and initiation of a system-wide telehealth program. This article provides an overview of these initiatives, including lessons learned, with an emphasis on future health care issues.
Northwell Health by the Numbers
Northwell Health is the largest health care system in the State of New York, with 23 hospitals (5692 beds) and 14 ambulatory surgical center (ASC) sites and more than 33,000 inpatient and ambulatory orthopedic surgical cases annually. Positioned in the middle of the COVID-19 crisis in New York, the system spans the New York City region and surrounding counties, including Westchester and Long Island. In early March 2020, the North-well Health Department of Orthopaedics initiated a large-scale contraction of all orthopedic operations, including canceling 13,900 ambulatory patient visits and postponing 2800 surgical cases. Efforts to expand the workforce in the face of admission surges prompted the department to redeploy 14% of orthopedic attending faculty members, 40% of residents and fellows, and 82% of physician assistants and nurse practitioners. To date, the system has admitted more than 13,555 COVID-19–positive patients. The mean COVID-19 census across the system is approximately 3000 patients, with a peak of approximately 3400 patients reached during the week of April 9, 2020. Approximately 28% of admitted patients were admitted to the intensive care unit (ICU), and approximately 24% required a ventilator. As of April 27, 2020, the system has safely discharged nearly 12,270 patients with COVID-19.
Lenox Hill Hospital, a tertiary hospital within Northwell Health, is located in Manhattan. From the onset of the COVID-19 pandemic, this hospital has been admitting patients through its emergency department and accepting transfers from hospitals within and outside of the system. As of April 29, 2020, Lenox Hill Hospital had 1121 admissions and 966 discharges of COVID-19 patients.
Clinical Response and Transition to the Pandemic
As the virus spread rapidly from the Eastern Hemisphere to the Western Hemisphere and evolved into pandemic status, the situation transitioned from a possibility to an inevitability. An organizational effort was initiated, with diversion of resources to accommodate patients with COVID-19 while allowing the department to continue to provide urgent and emergent orthopedic care.
In early March 2020, a system-wide scale-down of orthopedic operations was initiated, including cancellation of approximately 13,900 ambulatory patient visits and postponement of 2800 surgical cases. Given the impending surge of admissions and the threat that existing resources would be overwhelmed, efforts were initiated to expand the focus on COVID-19.
Redeployment included initiating ICU prone positioning teams, staffing urgent care centers and emergency department sites, and managing COVID-19 inpatient wards. Within days, rapid surge planning initiatives were instituted to meet these system-wide challenges. These included daily emergency management team efforts, with regular daily remote access communications and the adoption of modified staffing and patient care workflows, including a telehealth program and “work at home” administrative shifts.
Communication within the system has been continuous, given the fluidity of the growing crisis. The first departmental and system-wide communication on COVID-19, which occurred on March 4, 2020, established a comprehensive emergency response team to convey the Centers for Disease Control and Prevention recommendations and travel guidance. Initially, all nonessential domestic and international travel was restricted, but this restriction escalated quickly to include all business and personal travel. The health system also provided daily system-wide text updates and e-mails, initially suspending all gatherings with greater than 20 attendees and shortly thereafter prohibiting all conferences, regardless of size.
Surgical Services: Elective Surgical Case Postponement and Emergent Surgical Care
Before the COVID-19 pandemic, approximately 150 orthopedic procedures were performed across the system daily. Once elective cases were ceased, this number decreased to approximately 15 procedures per day. At Lenox Hill Hospital and its affiliated ASCs, this number decreased from approximately 40 procedures to 1 or 2 per day.
Despite the postponement of elective cases, care must be provided for patients with urgent and emergent needs. Guidance on what constituted urgent or emergent surgery was disseminated, with strict adherence maintained throughout the system. A chain of command was implemented to review approved cases, starting with the local chairman and escalating to system leadership as needed to ensure adherence to guidelines and safety standards. Before surgery, all patients were tested for COVID-19 with polymerase chain reaction testing.
Repurposing of Space
In anticipation of a surge of admissions of patients with COVID-19, several measures were taken to maximize and reorganize hospital beds and resources. Steps taken included discharging inpatients without COVID-19 as judiciously and safely as possible and ceasing all non-urgent elective surgical cases, allowing for reallocation of services. The system accessed 1600 additional beds rapidly by repurposing skilled nursing facilities, procedural areas, ASCs, conference rooms, and auditoriums. In partnership with the State of New York and the US Armed Forces, the system also provided administrative and logistical support to convert the Jacob Javits Convention Center into a patient care facility.
The cessation of elective surgical cases freed up hospital beds and allowed for conversion of postanesthesia care units and reallocation of ventilators.
At Lenox Hill Hospital, the emergency department was converted to a COVID-19 unit, with additional isolation units built ad hoc. The outpatient postanesthesia care unit was transitioned to a non–COVID-19 emergency unit. The ICU capacity was increased from 4 units with 48 beds to 10 units with 116 beds, and regional capacity was increased from 3 units with 78 beds to 8 units with 213 beds. Within the health system, more than 1200 ICU beds were added. In addition, ASCs, such as Lenox Hill Greenwich Village, were repurposed into additional COVID-19 facilities.
Workforce Redeployment: Prone Positioning Team
In line with other hospitals, the Lenox Hill Hospital orthopedics team developed a prone positioning protocol, staffed with trainees and clinical volunteers. This protocol was initiated in response to research suggesting a decreased 30-day mortality rate for intubated patients with acute respiratory distress syndrome who were routinely placed in the prone position.2 The skills of the orthopedic residents were redirected to help to meet the needs of patients and colleagues
Turning ventilated patients to the prone position safely and effectively involves an investment of time and labor. Orthopedic surgeons are experienced in repositioning intubated patients. In partnership with intensivists, a group of physicians and volunteers developed a protocol to reposition intubated patients twice a day.3 This practice has shown decreased duration of intubation and will be further investigated.
Safety and Personal Protective Equipment
Since the start of the crisis, the demand for personal protective equipment has been tremendous because of societal anxiety and a lack of well-defined guidelines. Consumers purchased so many N95 respirators and face masks that a shortage occurred within the nation's medical system. On March 13, 2020, Northwell Health determined that all patient-facing encounters required a face mask and emphasized the importance of effective hand washing, social distancing, and the use of contact precautions. To facilitate such requirements and needs, a system-wide program for N95 fit testing and distribution was initiated at each hospital. Because of the national shortage, N95 respirators were used for a longer time than the standard prepandemic limits. Standard face masks were recommended to be used on top of N95 respirators to minimize contact contamination and allow for extended use. To further increase the life span of equipment, efforts have been made nationally to develop methods to decontaminate used masks.4,5 Considered single-use items before the pandemic, face shields are now cleaned with germicidal wipes and reused to conserve supplies.
Although personal protective equipment can help to limit transmission, another critical factor in the fight against viral transfer is the mitigation of surface exposure risks. With literature suggesting long periods of viral viability on surfaces, environmental services across the system escalated efforts to address the risk.6 A study found that the most frequently contaminated surfaces included hand sanitizer dispensers, glove boxes, and face shields.7 The health system has prioritized safety and the use of personal protective equipment.
Quarantine Policy and Testing
Policies for testing have been revised continuously because of the availability of tests and the unclear nature of the virus. Initially, health care providers and workers who were confirmed positive for COVID-19 infection were told not to return to work until their symptoms resolved and they had at least two negative test results. Those with confirmed contact exposure were recommended to self-quarantine for 14 days, which was believed to be the latent incubation period. This policy was gradually revised to allow individuals to return to work if they were afebrile for greater than 72 hours and if they showed overall improvement or resolution of symptoms. This change of policy was a result of inexperience in treating COVID-19 and concern for crippling the workforce. Unknown variables included the viral serologic markers, the duration of viral shed, the incubation period, the possibility of reinfection, and the limited availability of tests. At an early stage of the pandemic, because of limited availability, only 100 tests were allocated to Northwell Health per day. Currently, in line with New York State criteria, testing is available for all employees.8
The Orthopedic Research Department at Northwell Health is actively involved in more than 15 clinical studies. As with other departments within the overall health system, the research division has been redeployed with the director of clinical research to assist in spearheading COVID research efforts across the North-well Health System. This group is known as the COVID-19 Research Consortium.9 The consortium is actively engaged in three clinical trials for COVID-19: (1) anti-interleukin-6 infusion, currently in phase II/III trials; (2) an investigational nucleotide analogue with broad anti-viral activity; and (3) hydroxychloroquine combined with famotidine.
Practice Challenges: Adapting to Telehealth
In mid-March, state and local governments made “stay at home” recommendations for all nonessential workers, keeping most New Yorkers at home and unable to seek nonurgent medical care. As a result, patients of all socioeconomic means had no clear pathway to receive medical care unrelated to COVID-19. To meet the identified need, telehealth services were deployed and implemented rapidly throughout the region and system. The telehealth initiative was of paramount importance to allow patients, particularly those at highest risk for COVID-19 exposure and transmission, to avoid nonessential office visits but still receive care. It has been suggested that a combination of telehealth and live visits can allow providers to achieve up to 50% of their typical clinical volume within 2 weeks.10
Webinars and tutorials were prepared and distributed for a rapid and clean roll-out. Although telehealth has long been available to medical providers, its adoption has been slow. A randomized controlled study from Norway compared orthopedic video consultation with standard office-based consultation and showed that video consultation was not inferior; no adverse events occurred, and no difference was found in patient satisfaction or reported outcomes.11 Before the COVID-19 pandemic, no national standard was in place, and regulatory hurdles were eased to allow for the rapid rollout of the technology.
To address concerns about Health Insurance Portability and Accountability Act compliance and violations, on March 17, 2020, the Office of Civil Rights in the US Department of Health and Human Services announced that it “will not impose penalties for noncompliance with the regulatory requirements under the [Health Insurance Portability and Accountability Act] Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.”12
The pandemic altered clinical duties for fellows, residents, and students and changed didactic and conference education.13 As it became apparent that the time to return to normalcy was uncertain, videoconferencing was initiated to preserve residency and fellowship daily didactic lectures. Northwell has a total of 60 residents and 9 fellows in orthopedic surgery across the system in three distinct programs, based at different locations: Lenox Hill Hospital, North Shore-Long Island Jewish Hospital, and Plainview Hospital.
With the use of a shared screen and virtual meeting space, all programs within the system continued to conduct fracture rounds and focused specialty lectures from a safe distance. The severity of the situation and the need to adapt education allowed the program to employ technology more quickly than has been traditionally possible.
Videoconferencing has offered convenience and an enhanced overall experience on multiple levels.14 Videoconferencing allows residents to connect from multiple hospital sites or from home and minimizes the inconvenience of travel. For an urban teaching program with multiple clinical sites, this technology frees up a substantial amount of time. For attending physicians, teleconferencing has facilitated the inclusion of more educators, further improving the collective knowledge base per session. The experiences and changes that have occurred will be incorporated after the crisis to enhance future educational efforts.
With the cessation of all elective cases, residents across the country are receiving their surgical education primarily from emergencies, such as fractures and infections. Lenox Hill Hospital has maintained its resident clinic in a limited capacity for those most in need. The clinic allows residents to practice continuity of care and allows senior residents to provide surgical interventions to patients under supervision. The resident clinic experience at Lenox Hill Hospital is in line with literature that shows enhanced operative competency and autonomy for senior residents.15
Because of the high ratio of surgical volume to resident trainees, at Lenox Hill Hospital, typically, it is not feasible to facilitate resident-to-resident teaching. To maximize surgical education, instruction has focused on the few available cases while minimizing exposure risks. In the era of COVID-19, fractures are managed by a supervising attending physician, a senior resident, and a junior resident. A recent study showed that increased supervised autonomy in the operating room for a senior resident provides an opportunity for both the instructor and the learner to excel in surgical proficiency.16 Although larger programs may follow this practice on a standard basis, smaller programs may take advantage of the opportunity for senior orthopedic residents to lead junior residents in a vertical teaching pathway.
As the health system recovers from the COVID-19 pandemic, it is critical to remain vigilant and to remember the lessons learned. In the post–COVID-19 era, analysis and reflection on this experience should be prioritized. Although health care professionals may hope that they will not experience a similar event again, it is likely that another global event will occur at some point in the future.
To address the current crisis, new care teams and physical units were created to enhance patient care. Careful reflection and analysis of events will lead to the creation of contingency plans and replication of the best processes developed, allowing for future rapid mobilization. This planning will provide a blueprint for future management across the system. Protocols will be needed to scale resources and facility capacity; reallocate and distribute critical assets, including ventilators and personal protective equipment; and continue to provide essential care.
Widespread adoption of videoconferencing has spread from virtual happy hours to didactic learning to patient office visits. A cultural shift occurred from discouraging the use of masks in public to embracing this practice. Just months ago, virtual office visits may have seemed impersonal; now, they are welcomed. It remains to be seen what form telehealth services will take in the future, but this technology has allowed for continuation of the physician–patient relationship during this crisis. Whether continued growth in this area will be maintained after COVID-19 remains to be seen.
Similarly, videoconferencing for resident education has allowed for the continuation of resident didactic and conference learning. Once used sparingly, it now dominates most programs in the country.17 One potential improvement seen with the use of this technology is the opportunity for interinstitutional conferencing, breaking traditional barriers and limitations and allowing departments to partner with orthopedic training programs all over the nation. At Lenox Hill Hospital, partnerships have included orthopedic training programs in Boston and Philadelphia.
Although the COVID-19 pandemic has thrown the world into a state of disarray, physicians and the entire health care community must adapt and thrive under adversity. From adjusting educational methods to reconfiguring the provision of patient care, adaptability remains key to success during this time. The experience at Northwell Health, which is at the epicenter of the pandemic, can provide a blueprint for other centers on how to manage a large-scale medical crisis. The lessons learned in this challenging time are shared by many departments around the world, and through this period, orthopedic surgeons and physicians will ultimately emerge more capable of maintaining their mission during a crisis. Amidst the chaos of the early days of COVID-19, Northwell Health leadership sought to find hope by instituting a policy known as “Here Comes the Sun,” with the well-known Beatles song being played overhead to recognize successful extubations and discharges. The message of hope communicated by this gesture speaks volumes to the thousands of health care personnel throughout Northwell Health, encouraging them to take one step and one breath at a time in the large-scale battle that the COVID-19 crisis presents and also to maintain their humanity, compassion, and strength in the face of what lies ahead.
- World Health Organization. Coronavirus disease 2019. https://www.who.int/Emergencies/Diseases/Novel-coronavirus-2019. Accessed April 29, 2020.
- Guérin C, Reignier J, Richard J-C, et al. PROSEVA Study Group. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–2168. doi:10.1056/NEJMoa1214103 [CrossRef] PMID:23688302
- Rahman OF, Murray DP, Zbeda RM, et al. Repurposing orthopaedic residents amid COVID-19: critical care prone positioning team. J Bone Joint Surg. doi:10.2106/JBJS.OA.20.00058 [CrossRef]
- Viscusi DJ, Bergman MS, Eimer BC, Shaffer RE. Evaluation of five decontamination methods for filtering facepiece respirators. Ann Occup Hyg. 2009;53(8):815–827. doi:10.1093/annhyg/mep070 [CrossRef] PMID:19805391
- Mills D, Harnish DA, Lawrence C, Sandoval-Powers M, Heimbuch BK. Ultraviolet germicidal irradiation of influenza-contaminated N95 filtering facepiece respirators. Am J Infect Control. 2018;46(7):e49–e55. doi:10.1016/j.ajic.2018.02.018 [CrossRef] PMID:29678452
- van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARSCoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020;382(16):1564–1567. doi:10.1056/NEJMc2004973 [CrossRef] PMID:32182409
- Ye G, Lin H, Chen L, et al. Environmental contamination of the SARS-CoV-2 in healthcare premises: an urgent call for protection for healthcare workers. medRxiv. 2020:2020.03.11.20034546. doi:10.1101/2020.03.11.20034546 [CrossRef]
- New York State Department of Health. Novel coronavirus (COVID-19). https://coronavirus.health.ny.gov/home. Accessed April 29, 2020.
- Richardson S, Hirsch JS, Narasimhan M, et al. the Northwell COVID-19 Research Consortium. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020. doi:10.1001/jama.2020.6775 [CrossRef] PMID:32320003
- Loeb AE, Rao SS, Ficke JR, Morris CD, Riley LH III, Levin AS. Departmental experience and lessons learned with accelerated introduction of telemedicine during the COVID-19 crisis. J Am Acad Orthop Surg. 2020. doi:10.5435/jaaos-d-20-00380 [CrossRef] PMID:32301818
- Buvik A, Bugge E, Knutsen G, Småbrekke A, Wilsgaard T. Patient reported outcomes with remote orthopaedic consultations by telemedicine: a randomised controlled trial. J Telemed Telecare. 2019;25(8):451–459. doi:10.1177/1357633X18783921 [CrossRef] PMID:29973130
- US Department of Health and Human Services. Notification of enforcement discretion for telehealth. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html. Accessed April 29, 2020.
- Kogan M, Klein SE, Hannon CP, Nolte MT. Orthopaedic education during the COVID-19 pandemic. J Am Acad Orthop Surg. 2020. doi:10.5435/JAAOS-D-20-00292 [CrossRef] PMID:32282439
- Lamba P. Teleconferencing in medical education: a useful tool. Australas Med J. 2011;4(8):442–447. doi:10.4066/AMJ.2011.823 [CrossRef] PMID:23393532
- Day KM, Zoog ES, Kluemper CT, et al. Progressive surgical autonomy observed in a hand surgery resident clinic model. J Surg Educ. 2018;75(2):450–457. doi:10.1016/j.jsurg.2017.07.022 [CrossRef] PMID:28967577
- Do WS, Sheldon RR, Phillips CJ, Eckert MJ, Sohn VY, Martin MJ. Senior surgical resident autonomy and teaching assistant cases: a prospective observational study. Am J Surg. 2020;219(5):S0002–9610(20)30117-3. doi:10.1016/j.amjsurg.2020.02.039 [CrossRef] PMID:32139104
- Schwartz AM, Wilson J, Boden SD, Moore TJ, Bradbury TL, Fletcher ND. Managing resident workforce and education during the COVID-19 pandemic: evolving strategies and lessons learned. J Bone Joint Surg. 2020. doi:10.2106/JBJS.OA.20.00045 [CrossRef]