Government Missteps Added to the Problem
June 12 | Posted by mrossol | Big Govt, CoronavirusYou wonder what agencies do with the money allocated to keep prepared.
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WSJ. 6/12/2020. By Shalini Ramachandran , Laura Kusisto and Honan
Hasty expansion of facilities by state, city and hospital leaders led to grave mistakes.
New York leaders faced an unanticipated crisis as the new coronavirus overwhelmed the nation’s largest city. Their response was marred by missed warning signs and policies that many health-care workers say put residents at greater risk and led to unnecessary deaths.
In the first few days of March, Gov. Andrew Cuomo and Mayor Bill de Blasio assured New Yorkers things were under control. On March 2, Mr. de Blasio tweeted that people should go see a movie.
Only after the disease had gripped the city’s low-income neighborhoods in early March did Gov. Cuomo and Mayor de Blasio mobilize public and private hospitals to create more beds and intensive- care units. The hasty expansion that ensued, led by New York government leaders and hospital administrators, produced mistakes that helped worsen the crisis, health-care workers say.
The virus has hit New York harder than any other state, cutting through its densely populated urban neighborhoods and devastating the economy. New York state’s death toll of 30,575 accounted for 7% of the world’s deaths and 27% of American deaths as of June 11, according to Johns Hopkins University data.
The Wall Street Journal talked to nearly 90 front-line doctors, nurses, health-care workers, hospital administrators and government officials, and reviewed emails, legal documents and memos, to analyze what went wrong. Among the missteps they identify:
• Improper patient transfers. Some patients were too sick to have been transferred between hospitals. Squabbling between the Cuomo and de Blasio administrations contributed to an uncoordinated effort.
• Insufficient isolation protocols. Hospitals often mixed infected patients with the uninfected early on, and the virus spread to non-Covid-19 units.
• Inadequate staff planning. Hospitals added hundreds of intensive- care beds but not always enough trained staff, leading to improper treatments and overlooked patients dying alone.
• Mixed messages. State, city government and hospital officials kept shifting guidelines about when exposed and ill front-line workers should return to work.
• Overreliance on government sources for key equipment. Hospitals turned to the state and federal government for hundreds of ventilators, but many were faulty or inadequate.
• Procurement-planning gaps. While leaders focused attention on procuring ventilators, hospitals didn’t always provide for adequate supplies of critical resources including oxygen, vital-signs monitors and dialysis machines.
• Incomplete staff-protection policies. Many hospitals provided staff with insufficient protective equipment and testing.
A spokeswoman for Mr. de Blasio, Freddi Goldstein, and a member of Mr. Cuomo’s virus task force, Gareth Rhodes, said the city and state did everything they could to increase hospital capacity and enhance social distancing once the risk became clear. “Ultimately our hospitals withstood the pressure,” Ms. Goldstein said. Kenneth Raske, president of the Greater New York Hospital Association, defended the state and hospitals’ response as remarkable considering the “wartime conditions,” adding: “We have a large, very sophisticated hospital system. It took us to the breaking point.”
One planning lapse showed up in improper patient transfers. More than 1,600 largely Covid-19 patients in two of the state’s largest hospital systems were moved from overloaded hospitals to ones less hit, according to spokespeople for those systems. Some patients arrived in worse condition than when they left, sometimes without names and treatment information, said doctors and nurses at several hospitals. Under normal protocol, only stable patients typically would be transferred, but these people came in with “one foot in the grave,” said Dr. David Buziashvili, who worked many shifts at Bellevue hospital, part of the city’s public system, NYC Health + Hospitals. On one shift there, he was alarmed to see 10 new transfers in beds with little medical information, he said. “That is not how it should be done.”
A Health + Hospitals spokeswoman, Stephanie Guzmán, said the city’s 11-facility hospital system provided “the highest quality care to all New Yorkers.” Only the least-sick patients were transferred between hospitals and their personal information was in a centralized system, she said.
Avery Cohen, a City Hall spokeswoman, blamed the state for denying a request from the city to establish a centralized hub, called a Healthcare Evacuation Call Center, that would have helped better coordinate transfers between hospitals, whether they were private or public. “We were grasping for every tool at our disposal to save as many lives as possible,” Ms. Cohen said. “The state was not interested.” Dani Lever, a spokeswoman for the governor, said that system wasn’t designed for individual patient transfers. She said a state transfer system was created in late March after hundreds of open beds near harder-hit New York City hospitals had gone unnoticed.
The New York state outbreak was extraordinary, and much of the disarray in its hospitals from mid-March on traced to impacts few had anticipated, including the federal government.
The impact was made worse because the city went into the pandemic less prepared than it could have been. The city hospital system has long been considered underfunded. Private hospitals in the outer boroughs, particularly Queens, had closed over the years. New York hospitals had long ignored alarms by the nurses’ union and respiratory therapists about insufficient staffing levels, according to nurses and respiratory therapists at several city hospitals.
A contributing factor was New York leaders’ delayed reaction. Early signs of the virus’s arrival—including a rise in patients with flulike symptoms visiting hospitals—went largely un-investigated by hospital, state and city officials. Throughout February in calls with hospitals, the city health department played down the possibility the virus could spread through the air or by asymptomatic people.
In early March at Health + Hospitals’ Elmhurst, Dr. Chad Meyers and his colleagues in the emergency room worried they were missing community spread of Covid-19. But when they called the city’s health department to get patients tested, it rejected for testing even many patients who satisfied the criteria, Dr. Meyers said, leading to “often protracted and unproductive calls” with the department.
Hospital, city and state officials said they were relying on the federal government for testing capability and were limited by criteria set by the Centers for Disease Control and Prevention on whom they could test. Jason McDonald, a CDC spokesman, said: “CDC testing guidance has always allowed for clinical discretion. So, while we set guidelines, states and health-care providers have had the flexibility to determine who to test.”
In an April interview, Health + Hospitals Chief Executive Mitchell Katz said the system prepared as best it could, given the difficulties of building additional space in already-full hospitals. In a May 15 city council meeting, he said he should have acted quicker.
While leaders in states like California and Ohio acted quickly to contain the spread, Messrs. Cuomo and de Blasio delayed taking measures to close the state and city even as the number of cases swelled, despite warnings from doctors, nurses and schoolteachers. California issued a statewide lockdown with 1,005 cases as of March 19, while New York remained open with 5,704 cases, according to updated Johns Hopkins data.
Even after New York announced its first coronavirus case on March 1, the city health department was advising New Yorkers they were more likely to get the flu. “I speak for the mayor also on this one—we think we have the best healthcare system on the planet,” Mr. Cuomo said at a March 2 news conference.
Five days later, Mr. Cuomo declared a state of emergency, but medical and emergency-response experts worried the city and state administrations still weren’t taking matters seriously enough. Richard Serino, an adviser to the city, told a senior aide to Mr. de Blasio early on March 13 that he was “concerned about the cavalier attitude of the hospital community” in the city, especially compared with other cities like Boston, according to an email. Officials with the city’s emergency-management agency agreed, according to people familiar with the matter. Mr. Serino in April said he didn’t recall the email and praised the city’s response.
March 13 became a turning point after it became clear there was community spread from one man in a New York City suburb. Two days later, when Mr. de Blasio said known New York City cases had already ballooned past 300, he reluctantly closed schools. Los Angeles closed schools around the same time with about 50 cases, according to Johns Hopkins data.
By March 20, the ICU of the Northwell Health system’s Long Island Jewish Medical Center in Queens was overflowing, and Health + Hospitals’ Elmhurst had to borrow ventilators from a sister hospital to keep up. The governor ordered most of New York be put under quarantine two days later.
On March 23, Mr. Cuomo ordered hospitals to increase capacity to treat Covid-19 by 50%, anticipating the need for 140,000 new beds. When hospital executives asked where they would get staffing, beds and protective gear, state officials told them to “do your best,” said a hospital executive familiar with the conversation.
Ms. Lever, the governor’s spokeswoman, said the state offered every hospital access to 90,000 volunteer health-care workers and to a central inventory system for the resources and equipment they needed to fight the virus.
Once they realized how widespread the virus had become, Messrs. Cuomo and de Blasio were frank about the gravity of the illness in daily public briefings, and Mr. Cuomo’s job-performance rating soared. Mr. de Blasio focused on inequities within the city, establishing a food program and using out-of-work drivers to make deliveries to homebound residents.
‘Absolute crisis’
Among the missteps that would make matters worse after mid-March, health-care workers said, was that government officials and hospital administrators failed to create adequate plans to provide the needed staff as they expanded beds into operating theaters, old auditoriums and lobbies.
“Creating beds isn’t the most difficult thing,” said Northwell CEO Michael Dowling. “The issues that get complicated with the creation of beds is the staffing.”
As Covid-19 patients flooded into NewYork-Presbyterian/Columbia, the private hospital created new pop-up ICUs. The inadequacy of staffing levels quickly became clear in one operating- room-turned-ICU, according to medical staff there and emails residents sent attending physicians. Garbage in the makeshift 80-bed unit overflowed with contaminated needles, masks and gowns.
“The scope of patient needs compared with the training and resources available presented an absolute crisis,” said Julia Symborski, a nurse who worked in the new ICU. “You can magically make an ICU appear, but you can’t make staff appear immediately.”
A NewYork-Presbyterian spokeswoman, Kate Spaziani, defended the hospital system’s response to the “unprecedented challenges.”
It isn’t that there weren’t staff available nationwide: Brian Cleary, CEO of Krucial Staffing, an agency Health + Hospitals tapped to send 4,000 medical staff during the crisis, said it could have sent in 6,000 more “without blinking.”
A Health + Hospitals spokeswoman said the hospital began securing additional staffing in early January and Krucial “does not encompass the full scope of the assistance we sought from outside groups.”
While travel nurses arrived at Bellevue and other locations, “a lot of them had no experience whatsoever,” said Laura Jaramillo, a Bellevue ER nurse.
The Health + Hospitals spokeswoman said new staffers were “formally trained to cover the areas they were posted in.”
In the new operating-room ICU at NewYork-Presbyterian/ Columbia, one respiratory therapist at times cared for over 80 patients a shift, according to workers and emails; seeing about 10 a shift is typical in normal times, respiratory therapists said. Overworked staffers there weren’t able to suction mucus out of patients’ lungs often enough, resulting in patient complications, according to the workers and emails.
NewYork-Presbyterian’s Ms. Spaziani said the hospital system began recruiting additional staff in February and ended up with more than 2,850 volunteers and temporary front-line staff, including 150 additional respiratory therapists. Joji Thadathil, a Health + Hospitals Elmhurst respiratory therapist, estimated that more staffing and better equipment could have saved 30% to 40% of Covid-19 patients who died there. The Health + Hospitals spokeswoman said the system “mobilized quickly to shift staff…and equipment to the hardest hit hospitals.”
Air supply
During the surge’s early days, Mr. Cuomo, Mr. de Blasio and hospital officials often talked publicly about the urgent need for ventilators. That procurement emphasis, some medical workers said, overshadowed staffing and other vital needs like oxygen and oxygen monitors. Supplemental oxygen became especially important to keep Covid-19 patients breathing and off the dwindling supply of ventilators. At least eight New York City hospitals experienced problems with their oxygen supplies, said some health-care workers and state officials.
At Health + Hospitals’ Lincoln in the Bronx, a severe oxygen shortage hit mid-surge, said doctors there, including Dr. Dasol Kang. The Health + Hospitals spokeswoman said the hospital didn’t have a shortage and never rationed oxygen.
With scores of patients needing ICU-level care, hospitals ran short of the vital-signs machines needed to effectively monitor such patients and of the staff needed to keep track of them. Covid-19 patients gasping for breath sometimes weren’t being properly monitored as they lay hooked up to oxygen, and sometimes died without anyone’s knowing, said doctors and nurses from at least eight New York City hospitals.
A big surprise to doctors and nurses was the number of shoddy ventilators, called LTVs, distributed by the state from its own stockpile and by both the state and city from the federal government’s reserve. Several health-care workers, including Mr. Thadathil, the Elmhurst respiratory therapist, and Dr. Meyers, the ER physician, said the government ventilators were old and many patients worsened on them, leading to collapsed lungs and other complications.
The Health + Hospitals spokeswoman said many state ventilators “were not ‘ready to go’ when they came.” She said the system did additional maintenance before they could be used on patients. Ms. Lever, the governor’s spokeswoman, said the state tested every ventilator before sending them to hospitals and received no complaints.
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