New York City’s hospitals were woefully unprepared for last year’s nightmare surge in COVID-19 patients due to a lack of planning from the city, the state and the facilities themselves — especially when it came to deciding who lived and who died, according to a new report.
When precious resources like ventilators and oxygen cylinders had to be rationed, medical staff sometimes decided on the spot who they could save and who they could not — and there was no uniform plan from the government or administrators on how to proceed, says the report prepared by the Johns Hopkins Center for Health Security.
“Hospitals were overwhelmed” at the height of the COVID-19 surge from April through June of 2020, and their normal standard of care could not be maintained, notes the report, which was based on discussions with 15 city ICU directors and their emergency doctors.
Too often, EMS crews would rush to an emergency room with a patient they’d been struggling to resuscitate, only to have the ER staff immediately pronounce that patient dead.
“Demoralizing,” the report said of such instances, “and a source of distress for paramedics and EMS personnel.”
But the situation was made worse by a lack of “crisis standards of care” plans from hospitals, the city or the state dictating how the normal standard of care must be lowered to help the most patients under the worst imaginable circumstances.
“Participants believed that leaders of hospitals, hospital systems, the city, and the state
were afraid to admit to being in a crisis standards situation; therefore, CSC plans and
other related documents were not widely disseminated to frontline staff,” the report says.
At hospitals, officials’ conversations around that touchy subject — the necessary rationing of care and equipment — were shrouded in secrecy and fear, the report said.
“A ‘culture of secrecy’ regarding the severity of the crises” pervaded the state, extending from Albany to City Hall to the hospital boardrooms, the report says.
“Specifically, there were disagreements over interpretations of what the criteria were for determining when a patient should be deemed ‘do-not-resuscitate,’” said the report.
“In part, secrecy reflected a fear of investigations by regulators,” said the report.
“There was widespread concern that complaints by patients or their families would prompt ‘surveys,’ (compliance investigations) by city or state authorities that would find deviations from normal accepted practice and standards.
“The financial penalties for such violations can be very harsh.”
Some hospitals found themselves swamped with patients when the surge hit last spring, while others had empty beds, the report noted.
With PPE gear in short supply, “illness among healthcare workers was a huge challenge” at the worst-hit hospitals, the report said.
“One participant noted that a third of the faculty and residents became infected and were out sick during the surge.”
Sometimes temporary personnel with insufficient training were hired to “backfill” overrun COVID-19 wards, and resources such as ventilators and protective gear had to be rationed.
With oxygen tanks, ventilators, basic protective equipment and staff in short supply, healthcare workers were forced “to adjust the way that care was provided in order to do the most good for the greatest number of patients.”
The impact of these stressors on staff wellbeing was “profound and enduring,” the report noted.
“Hospital staff are still suffering deep emotional ill effects of the initial surge and are having a ‘tough time’ with subsequent surges,” the report concluded.
One participant wrote: “I see my colleagues; they are not the same people that they were before.”
Still, the doctors and administrators who spoke to Johns Hopkins from across the city agreed that the crisis brought out the best in staff, despite the harrowing conditions.
“There was a sense of duty, a heightened sense of camaraderie, and a wealth of innovative thinking,” the report said.
Attending and resident physicians would work seven days a week, and eventually had to be told to take time off, the report said.
Many participants praised the so-called “MacGyvering” used to solve technical problems on the fly — such as when pediatric ventilators needed to be rigged to accommodate adult patients.
The report — titled “Crisis Standards of Care: Lessons from New York City Hospitals’ COVID-19 Experience, The Emergency Medicine Perspective” — ultimately calls for thoughtful and transparent crisis planning with built-in mental health support.