Months before COVID-19 landed in New York, NYC Health + Hospitals mapped out a detailed strategy on how to handle an airborne virus of unknown origin.
The 77-page document, titled “Frontline Hospital Planning Guide” and filed in June 2019, warned that an adequate supply of personal protective equipment (PPE) for staff in the 11 city-run hospitals is crucial during a pandemic involving a respiratory ailment.
The city’s pandemic playbook also sounded another note of caution: The PPE supply would have to be bigger than usual if the virus was of unknown origin.
“Maintaining readiness is a challenge,” the report warned. “However ‘ready or not, patients will present.’ Lack of readiness creates significant safety problems.”
Nine months later, a lack of readiness did exactly that.
When the virus struck in March, staffers at some public hospitals were forced to reuse the same N95 masks for days at a time as H+H struggled to maintain an adequate supply. Nurses complained of having to preserve used N95s in paper bags out of desperation.
That directly contradicted H+H’s 2019 guidelines, which called for giving staff enough N95 masks to cover each visit with an infected patient.
The report also advised making sure there are always enough staff on call to guarantee full coverage. At the height of the crisis last spring, so many workers called in sick H+H began requiring doctor’s notes to qualify for a day off.
And the documents noted that city-run hospitals needed enough space to separate infected patients from non-infected patients. Last spring, that also fell apart, with the infected and non-infected at times sharing rooms.
Asked by THE CITY about the disconnect between the document’s warnings and what unfolded months later, H+H officials insisted they were prepared for the coronavirus crisis.
And they said they are prepared as the number of patients hospitalized with COVID-19 once again is on the rise.
The figures are nowhere near where they were in early April when all city hospitals — public and private — peaked with more than 12,000 COVID hospitalizations. The numbers dropped dramatically through the summer, then began to grow steadily again in October and hit 2,005 as of Wednesday.
Lessons From Ebola
The June 2019 “Frontline Hospital Planning Guide: Special Pathogens” report is not readily accessible on H+H’s public-facing website. The agency only revealed its existence after THE CITY obtained an earlier 2002 report on pandemic preparation and asked if there were any more up-to-date protocols.
The 2002 report is an internal document obtained by THE CITY via a Freedom of Information Law request. It was last officially revised in 2013 and has been reviewed several times since during prior medical crisis events.
The last review came in August 2016, the same month the federal Centers for Disease Control & Prevention declared a breakout of Ebola in the U.S. had come to an end.
The 2002 document, with the sprawling title “general protocol for suspected and/or confirmed infectious/disease (Surge) outbreak,” specifies that it’s a plan for Queens’ Elmhurst Hospital — the facility hardest hit last spring.
It offers a remarkably prescient warning that a pathogen of unknown origin could create unique challenges requiring a deep supply of PPE and extra space within hospitals to curb the spread of a virus.
“Novel pathogens” that are “unknown or incompletely understood would require a higher level of isolation precautions,” the 2002 protocol says, “resulting in a higher consumption of supplies, fewer alternative options for patient housing and a higher potential for adverse psychological effect on staff, e.g. fear of contagion.”
‘Failed to Make Judgment Calls’
Stanley Brezenoff, who was interim chair of H+H from December 2016 through January 2018, noted that disaster preparedness plans can, at times, be drafted as a kind of bureaucratic cover-your-back exercise.
“It’s a question we all have to ask ourselves about this, which is how serious these various emergency planning exercises are across a whole range of things — the risk that these things become boxes to tick off,” he said.
Still, Brezenoff emphasized, the sheer scope and brutality of COVID-19 could likely have never been fully imagined before the virus emerged
The city hospital system, he said, “has a responsibility to itself to be adequately prepared.”
“But even assuming a lot more attention was being paid and taking into account whatever budgetary constraints there were, I don’t believe anybody would have been able to initially anyway cope with this,” he added. “God knows we all collectively — especially nationally — failed to make judgment calls.”
Referring to the 1918 Spanish influenza pandemic that killed 50 million people worldwide and 675,000 in the U.S., he added, “Unless you think of 1918 as a benchmark year, this is completely out-of-the-range of thinking.”
Mask Guidelines Violated
Both the 2002 protocol and the June 2019 “special pathogens” update stress the importance of possessing ample PPE for nurses, doctors and medical technicians to stem the transmission of the virus — and to keep hospital workers healthy so they can serve patients.
The 2019 document states that the hospitals “must have ready access to the correct sizes and types of PPE” and are advised to “tak(e) inventory of items used or currently in stock” and “purchas(e) additional equipment and supplies used to replenish stock and any reserves.”
The 2002 protocol advises the hospital system’s “materials management” unit “may need to concentrate on purchase of personal protective equipment” — including N95s — and contact suppliers “to determine the realistic resupply (delivery) based on expected usage.
Last week, in an emailed response to THE CITY’s questions, Stephanie Guzman, an H+H spokesperson, said the hospitals were ready when the first confirmed coronavirus case hit in March.
“The public hospital system began preparing for the coronavirus to reach NYC as it moved through Wuhan and Italy, increasing equipment supply orders in January 2020 and activating its central command center on January 21, 2020,” she wrote.
Guzman added that the system “ensured resupply by expanding its portfolio of suppliers before the surge was experienced in March,” and she insisted city hospitals “had sufficient PPE during the first COVID-19 surge.”
She contended that the hospital system followed the recommendations of the CDC and the state and city health departments on “conservation practices ahead of potential shortages that could’ve been caused by global supply chain challenges.”
These “conservation practices,” however, directly contradict the H+H’s own guidelines outlined in the two pre-pandemic planning documents examined by THE CITY.
Both the 2002 protocol and the June 2019 playbook state that N95 masks are supposed to be discarded after the examination of each infected patient.
The 2002 document recommends that such patients be kept in “negative pressure” rooms that seal in air circulation, and that while in these rooms, “all personnel should wear an N95 respirator and use non-sterile gown and gloves when caring for the patient.”
The protocol instructs “all PPE should be disposed upon exiting negative pressure rooms after each visit with an infected patient.”
‘How is This Acceptable?’
In April, as hospitals across the city filled with desperately ill COVID-19 patients, nurses at several H+H hospitals — including Bellevue in Manhattan, Elmhurst in Queens and Jacobi in The Bronx — chafed against what they called a serious lack of PPE that they say left them vulnerable to infection.
At one point in April, Bellevue ran out of N95s.
At all three hospitals, nurses were forced to-reuse the same N95 mask repeatedly. At one point in April, nurses at Jacobi described the humiliation of this during a rally outside the hospital where he worked.
“I was told once I got this mask, I could not get another mask for another week,” nurse Michelle Shaw, who wound up infected with COVID-19, said during the rally. “I’m seeing patients and I’m still coughing. How is this acceptable in America? We’re not getting the masks necessary.”
Jacobi nurse Sean Petty, who also attended the April rally, recalled this week how staffers had to store their one-a-week N95 “in paper bags so they could dry out and reuse them.”
“We knew this virus was likely airborne transmission and that you are never to reuse N95 masks because of cross contamination,” he added. “The minute you take them off they are designed to go into the garbage.”
Petty blamed the system’s failure to accumulate an adequate supply of N95s on the state and particularly the federal government, which hadn’t maintained a proper national stockpile.
As for H+H’s pre-pandemic plan, he noted, “If it was in place there would be nurses alive today.”
He said Jacobi lost one nurse to the pathogen. Two more who were put on ventilators survived.
The PPE shortage occurred despite a frantic effort by the city to obtain adequate masks and medical equipment. As THE CITY reported last month, at some points during the crisis’ peak the city lost track of some of its $1.4 billion in medical supplies and wound up paying for surgical masks that turned out to be non-surgical masks useless in medical settings.
Another complaint at the time involved staff shortages.
The 2002 protocol warns that the system must have adequate staff in place
“that might be needed to care for initial and prolonged influx of patients,” but H+H found itself confronting a staff shortage during the spring surge after a raft of employees called out sick. Public hospital officials began demanding a doctor’s note to justify a sick day — infuriating nurses.
The 2002 protocol dictates that hospitals be ready with enough space to keep infected patients separate from non-infected patients: “Patients with confirmed or probable infection should be used in one area of the unit adjacent to patients with possible risk of the same infection. Patients without the outbreak infection should NOT be housed in that unit.”
In April at Bellevue, as THE CITY reported at the time, the surge became so intense that proved impossible.
COVID-19 patients were placed with non-COVID-19 patients. In some cases, there weren’t enough beds and COVID-19 patients wound up on gurneys in hallways.
Guzman stated that during the initial wave of COVID-19 hospitalizations last spring, H+H “isolated patients by confirmed-COVID, symptomatic but not confirmed-COVID, and non-symptomatic/non-COVID, following appropriate guidance from CDC, NYS DOH, and NYC DOHMH.
“If a non-symptomatic patient was found to be suspected of having COVID through unrelated scans (i.e. lung x-rays), they were immediately appropriately isolated,” she added.