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Hospitals Move Into Next Phase as New York Passes Viral Peak

A sharp drop in coronavirus patients was “like someone turned off the hose,” one doctor said. But the city’s health system faces challenges ahead.

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From Chaos to ‘Scary Silence’: Elmhurst Hospital After the Coronavirus Surge

Elmhurst Hospital in Queens had been inundated by patients. The Times went back to see how the staff was recovering, and planning for the possibility of another wave.

Elmhurst Hospital, which is in Queens, was one of the epicenters of coronavirus in New York City. It was the place that went viral. There were fears about running out of a lot of things: protective equipment, ventilators — many, many, more patients were dying every day in the hospital than usual. It was a very scary situation. I’m Sheri Fink. I’m a correspondent at The New York Times. Earlier this month, we were able to spend a day at Elmhurst. The number of new cases had dropped, but they had to figure out a new normal. And they also had to deal with the really, really difficult emotions that the staff had after having been in a situation of crisis for many weeks. “It felt surreal when it was crazy, and it’s real surreal a little bit now I think too.” There’s almost a scary silence because normal operations haven’t started yet, but yet new coronavirus cases have gone down. When coronavirus hit, people were not coming for other emergencies. What doctors are afraid of now is that that’s still the case. People may be dying at home because they’re not going to the hospital. “And it’s got the ability to talk to the patients without going in the room. It’s got an intercom system.” They were rapidly scrambling to try to reconfigure. There is a real urgency to get these hospitals back to being able to care for patients who did not have coronavirus. But also, they have to plan for the possibility that there will be another surge. So they are doing things like constructing plexiglass barriers for the registrars. They are taking whole units that were used for treating coronavirus patients, and they’re turning them back into regular intensive care units intended for people who don’t have Covid. These ultraviolet light emitters disperse this ultraviolet light, which can inactivate viruses and other pathogens. Early in the pandemic, they were worried that they didn’t have the equipment that they needed. There was a lot of fear. Now they have an advanced system for having P.P.E., for distributing it. It was very well organized. “You would have your bleach wipes, your sani-wipes, your gloves and isolation gowns.” There’s a big global demand for it. And so they try to use as little as possible while also staying safe. They’re also still engaged in treating patients with coronavirus. “The connections between E.T.T. and ventilator are secure?” As the cases were going up, doctors didn’t know, the staff didn’t know how long that would last. It wasn’t clear what kinds of treatments might help. “All of us were like, we’ll figure this out, and it’s just very frustrating to realize that to a certain extent nobody’s figured it out.” It really has had an impact on them — just seeing so many deaths and feeling so, so helpless. All around the hospital, there are displays of cards and messages of support. Some people seemed to really appreciate all of the thanks. But I spoke with others who have been telling me they also feel in some ways, that they weren’t able to save everybody. A lot of the health workers are staying in hotels, and so they arrive for their shifts on these buses. There is round of applause for essential workers. That happens every night at 7. And one of the nice things at Elmhurst is that the staff — they arrive right around 7 o’clock. And so some of these providers walked off the bus, and there was the sound of clapping and cheering, and people honking their horns. And I was noticing that their heads were down, most of them didn’t really look up and acknowledge the applause. They have worked through the peak of this coronavirus, and some of them are exhausted, both physically and emotionally. And they’re also just filled with the sense that they don’t yet know what lies ahead.

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Elmhurst Hospital in Queens had been inundated by patients. The Times went back to see how the staff was recovering, and planning for the possibility of another wave.CreditCredit...Erin Schaff/The New York Times

Across New York City, hospitals have moved into a new phase in their battle against the coronavirus.

In the city that was hit hardest by the pandemic in the United States, the number of new patients and the daily death toll have dropped sharply. Many of the refrigerated trucks filled with bodies are gone. Doctors no longer routinely plead for help in makeshift protective gear. The emergency room at Elmhurst Hospital in Queens, once overwhelmed, treats barely a third of the people it did before the outbreak.

“It’s like someone turned off the hose,” said Dr. Eric Wei, an emergency medicine physician and senior vice president of quality for NYC Health & Hospitals, the public health care system, referring to patient numbers in recent weeks.

“There’s a huge psychological desire to be like, ‘Whew, we’re through the worst of it,’” he said, but cautioned, “It’s a challenge to fight that human nature to over-relax or say now we can just go back to how things used to be.”

Hospital executives and doctors, wary about what comes next as the city looks to ease out of its near lockdown, are asking whether this is a lull before a new wave of cases or a less chaotic slog. At hospitals, staff members are preparing for both possibilities.

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At Elmhurst, workers’ protective gear hung on hooks to be reused.Credit...Erin Schaff/The New York Times

Health workers are still tending to nearly 500 critically ill Covid-19 patients around the city, but are admitting fewer than 100 new patients a day, down from the peak of nearly 1,700 daily in late March and early April, according to the city’s health department. Doctors are culling data to identify best practices in treating them, and institutions are seeking long-term care — or planning to create it — for those expected to remain on ventilators.

At the same time, they are turning hot zones into cold zones, in hospital parlance — shutting some temporary Covid-19 intensive care units to restore them for regular use. Mount Sinai in Manhattan closed a temporary ward in its soaring atrium, while at Long Island Jewish Medical Center in Queens, empty beds have been moved into hallways.

And institutions are revamping facilities and taking additional measures to control the spread of the disease. Elmhurst is decontaminating rooms as managers try to persuade community residents to come in for emergencies now and elective surgery as soon as Gov. Andrew M. Cuomo lifts a ban imposed in March.

Physicians there are increasingly worried that stroke victims, heart patients and those with other ailments may be dying at home rather than seeking help. “Patients who are sick need to come back to the emergency department,” said Dr. Stuart G. Kessler, its director.

“It’s almost this eerie silence,” said Dr. Sylvie de Souza, chair of the emergency department at the Brooklyn Hospital Center, an independent institution where the daily E.R. volume last week was less than half of the 200 to 250 patients it typically saw before the pandemic. “None of us are at peace. We’re sort of bracing for it to come back. All of us are wondering, can we go through this again?”

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At Long Island Jewish in Queens, beds used to treat virus patients are now being moved elsewhere.Credit...Victor J. Blue for The New York Times

The need to shift back to providing a broad range of care is urgent, both for public health and the future of hospitals and health systems, which have in some cases lost millions of dollars a day because of canceled surgeries and other lucrative services.

A recent analysis by the New York City health department found that from mid-March to early May, over 24,000 more deaths than normal occurred, with nearly a quarter involving people not believed to be infected by the virus. Many may have been caused by “delays in seeking or obtaining lifesaving care,” the study’s authors wrote.

Dr. Richard Schwarz, the medical director of Long Island Jewish, part of Northwell Health, the state’s largest hospital system, said it had to postpone about 12,000 surgeries since the governor’s order.

“Many of these people are quite sick and have gotten sicker,” he said, including those whose cancer may be metastasizing. Patients with chronic illnesses like diabetes are also a concern. Last week, he heard that surgeons had performed amputations on patients who might have kept their limbs if they had been able to be treated sooner.

“One of the things we’ve got to do a better job of advertising is that we right now have a Covid-free building,” he said. “Our main building is Covid-free.”

Here and across the country, health systems are working to restore staff, supplies and services while trying to protect patients and workers from contagion. But recent visits by The New York Times to a half-dozen of the worst-hit institutions showed that New York City hospitals faced additional challenges. Many workers were too fearful of another surge to feel much relief at the slowdown.

More than 20,000 people have died from Covid-19 in New York City, according to the health department, which counts confirmed and probable cases. The daily coronavirus death toll in the city peaked at nearly 600 in early April; now it is fewer than 100.

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Dr. Colleen Smith and Dr. Ryan O’Halloran in the Elmhurst emergency room, which has seen a steep drop in coronavirus cases.Credit...Erin Schaff/The New York Times

Dr. Colleen Smith, an E.R. physician at Elmhurst who recorded a widely shared video showing conditions in late March, said that even as the cases dramatically declined, the new normal did not feel normal.

“It felt surreal when it was crazy, and it feels surreal a bit now,” she said, sitting in protective gear in a nearly empty patient area. “The difference is so stark.”

Hospitals are eager to restart elective surgery, a needed service that is also a major revenue generator.

At Elmhurst one recent day, staff members told hospital leaders that they were reviewing surgeries that had been delayed since March. They said they had a list of patients who should be operated on this month. That included cancer and neurosurgery patients who, in a tiered system released by Medicare in April, fell into categories marked “do not postpone.”

But preparing to resume the procedures is challenging because spaces reserved for surgery patients — post-anesthesia units, surgical I.C.U.s. and even operating rooms — were repurposed around the city to treat those who were critically ill with the virus. On Tuesday, Elmhurst still had 35 critically ill Covid patients, more than the total I.C.U. capacity it maintained before the pandemic.

Even if those areas can be freed up, medical institutions have to create a safe pathway for patients to avoid infection as they enter hospitals, move to operating rooms, undergo monitoring afterward and then recover or receive intensive care.

While Mr. Cuomo recently allowed some hospitals around the state to perform elective surgeries, he has not permitted those in the city to do so. According to rules he set, they and each county as a whole must keep at least 30 percent of hospital and I.C.U. beds available to maintain stability in case of another surge.

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A unit for remaining Covid-19 patients at Elmhurst this month.Credit...Erin Schaff/The New York Times
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Reception staff worked behind new Plexiglass protective barriers.Credit...Erin Schaff/The New York Times

“It’s killing us,” Gary G. Terrinoni, chief executive and president of the Brooklyn Hospital Center, said of the ban. “We have to be able to open up safely relatively soon or I think things will be tragic.”

Capacity is also limited because some Covid patients are left needing lengthy treatment on ventilators. Only one hospital offering long-term acute care — part of the city’s health system — accepts such patients in the state. But it cannot accommodate those who require continuous sedation.

North Central Bronx, one of the 11 public hospitals in the city, has raced to build a new I.C.U. Workers are laboring day and night on a unit with 120 beds, which doctors hope may be used for such patients instead. Northwell, a private nonprofit system that includes 23 hospitals in the metropolitan area, is planning to open two units for long-term ventilator patients.

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Work to expand I.C.U. capacity at North Central Bronx has been going on 24 hours a day.Credit...Erin Schaff/The New York Times

As hospitals clear out unneeded Covid units, they are taking extraordinary steps to clean them, to build confidence with the community and their own staffs. At Elmhurst, in one of the worst-affected neighborhoods in the city, the virus killed five employees and sickened over 470 others.

Usually, once a patient room is empty, workers wipe it down, swab for biological matter and visually inspect it. Now, they also sanitize all surfaces, vacuum the vents, apply electrostatic spray and strip and wax the floors. At Elmhurst, even the dials on the walls that regulate suction are replaced.

Employees there and elsewhere are taking an additional step: hauling ultraviolet lights into rooms, stepping outside and closing the doors as the machines inactivate any remaining viruses.

But once an area is clean and safe for non-Covid patients, how to keep it that way?

“Who goes there?” asked Dr. Maurice Policar, an infectious disease specialist at Elmhurst. “How do we vet these people?”

When new patients are admitted, he said, doctors must decide whether to put them in a ward for Covid-positive patients, where they may be exposed, or an intermediate area with negative pressure, designed to keep infectious particles inside each room.

For now, everyone is presumed infected until proven otherwise. Before transferring to a non-Covid unit, patients are tested twice for the virus. They also get a chest X-ray. And masks are worn even in areas reserved for uninfected patients.

“We feel that that’s a level of protection, even if we miss it and some people are there,” Dr. Policar said.

The E.R. staff at Lincoln Medical Center in the Bronx was still dressed in masks, goggles, face shields, gowns, bootees and hair coverings on a recent afternoon, but it was no longer in constant motion. Nearby, rows of beds stood empty.

At the peak, the hospital had about 425 patients coming in a day, a quarter of them requiring hospitalization and many critically ill, its chief of emergency medicine, Dr. Adrienne Birnbaum, told a group of engineers and hospital officials walking through the E.R.

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Christine Flaherty, a senior vice president for the city’s hospitals, checked in on North Central Bronx.Credit...Erin Schaff/The New York Times
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A floor plan for the new ward, in which doctors hope to treat long-term ventilator patients.Credit...Erin Schaff/The New York Times

Workers unrolled measuring tape and stepped on construction ladders as Christine Flaherty, senior vice president of facilities management for the health system, reviewed airflow and infection control measures.

The group plans to add movable, washable partitions as privacy barriers, install filters to capture airborne viruses, place computer screens in isolation rooms to communicate with patients from outside, install hooks for staff to hang their protective gear when they go on breaks, and pipe oxygen to new areas and monitor the patients receiving it.

The staff would also raise plexiglass barriers to protect greeters, mark the floor with six-foot separations and space patients apart in waiting areas by blocking off seats.

As Ms. Flaherty walked through the I.C.U. construction site at North Central Bronx that same week, a colleague told her that the additional oxygen she had ordered was expected in 10 weeks. “I need it in two,” she replied.

Many other items needed to restore medical services are subject to delays or are unavailable. At Lincoln, a white board in the command center had a handwritten list of nearly a dozen supplies currently or recently out of stock, including dialysis catheters, blood transfusion tubes and tourniquets.

Amid global shortages, the city’s public hospital system has centralized ordering of once common items, including disposable protective gear. The projected “burn rates” of gloves, masks and gowns — and the need for scarce medications like some sedatives and the antiviral drug remdesivir — remained high.

Last Friday, employees discussed a list of long-delayed orders for N95 masks. Danielle DiBari, senior vice president of supply chain, interrupted the meeting to call a vendor who had failed to deliver millions of them. He told her that the handful of Chinese factories making U.S.-approved masks were prioritizing the highest-paid orders, with costs about 500 percent higher than usual.

“I don’t mind if they come in slowly, but they have to come in,” Ms. DiBari told him. “I’m burning at a crazy rate.”

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Danielle DiBari, a senior vice president for the city’s hospitals, at a meeting on delayed supplies.Credit...Victor J. Blue for The New York Times
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Workers attend to a patient at the emergency room of Lincoln Medical Center in the Bronx.Credit...Erin Schaff/The New York Times

That rate may only increase, even with fewer coronavirus patients, as services are restored and visitors are allowed again. Before the pandemic, the public hospital system treated about 16,000 people a day in its outpatient clinics, according to officials. Once it struck, only about a quarter of those patients conferred with clinicians, the great majority by phone or video.

Some doctors said they hoped some telemedicine services would be permanent. “It turns out that we can prevent a large number of visits to the emergency room simply by getting good advice,” said Dr. Mitch Katz, the public hospital system’s president and chief executive.

As clinics reopen, visits will be staggered over extended hours to lower risk. Patients will be asked to preregister and undergo temperature checks at the door. The system is working to build negative-pressure rooms for those more likely to have the virus.

At the Brooklyn Hospital Center’s outpatient clinic sites — serving primarily low-income Medicaid patients — the staff was focusing on bringing in children who needed vaccines, pregnant women who required prenatal care and patients with chronic diseases like diabetes and hypertension. But consultations were down by about 70 percent.

“You wonder, truthfully, where are all these people?” said Judy McLaughlin, a senior vice president and chief nurse executive. “And what’s happening to them?”

At the same time, the enormous pressure on health workers is presenting its own challenges. Hospital leaders realize they must attend to the emotional needs of employees across every line of service.

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An emotional support room at Elmhurst that is covered in thank-you notes for medical workers.Credit...Erin Schaff/The New York Times

At Elmhurst, therapists are available in a Covid support room where notes of encouragement and gratitude paper the walls: “This too shall pass.” “Not all superheroes wear capes.” “We love you.” A nearby room recently opened as a memorial to fallen colleagues.

Mount Sinai this month announced an initiative to study stress in medical workers and offer them access to support groups and mental health treatment.

But there are sources of stress that hospital officials cannot control.

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Hospital leaders at Elmhurst clapped as health workers left their shift on an evening this month.Credit...Erin Schaff/The New York Times

Seeing photos of people flouting social distancing, Dr. Wei said, “does feel a little bit like an insult to what we went through as a health care system and health care workers. We risked our lives to save as many lives as possible, and people can’t wear a mask — they can’t stay six feet apart.”

Sheri Fink is a correspondent in the investigative unit. She won the 2010 Pulitzer Prize for Investigative Reporting and shared the 2015 Pulitzer Prize for International Reporting. She received her M.D. and Ph.D. from Stanford University. More about Sheri Fink

A version of this article appears in print on  , Section A, Page 1 of the New York edition with the headline: Hospitals Retool For Next Battles as Nation Reopens. Order Reprints | Today’s Paper | Subscribe

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