At the end of a recent week attending critically ill COVID-19 patients at New York University-Langone, I witnessed our expansion from three major intensive care units for adults and another for children to 12 ICUs — all filled with critically ill, mechanically ventilated adults with the coronavirus.
The hospital library and conference center, where in earlier times 200 white-coated physicians assembled for major meetings or graduation of fellows and residents, became an ICU with freshly laid linoleum, reengineered ventilation, newly piped-in oxygen and suction outlets.
Both underscore the ability to rapidly surge the capacity of delivering critical care in real time. While attention is focused often on initial ventilator and PPE shortages, the focus on vulnerabilities in infrastructure, personnel and critical-care capacities has been less examined.
So far, the lessons learned can be mapped onto the future.
America’s health systems must be planned and operated with public health security in mind. This would be a significant departure from the focus of the last 25 years of downsizing hospitals to cut costs, driving care into the community and continually abbreviating the hospital stay not only for better outcomes but also for maximum profit.
ICU beds have been a frequent casualty. A recent survey has identified New York among the lowest in terms of ICU beds per capita.
COVID-19 patients have extraordinary demands on high levels of oxygen — both the percentages of oxygen and the need for ventilators. At NYU-Langone, an additional liquid oxygen and vaporizing system was acquired as the existing built-in oxygen supply system simply couldn’t meet the escalating demand of critically ill patients. Oxygen is a critical consumable resource at a time of pandemic.
Though most hospitals — including mine — build oxygen systems with preexisting redundancy and maintain large amounts of liquid oxygen on site, the pandemic is driving a soaring demand on commercial gas suppliers for liquid oxygen.
From March, when the first patient with COVID-19 was diagnosed in New York, to today, the city has been in a dress rehearsal for disaster response. This time it was a pandemic, next time it could possibly be biological warfare.
Certainly some new hospitals have been designed with bioterrorism and pandemic preparedness in mind, most notably Rush University Medical Center in Chicago, which was constructed with specific architectural and engineering capabilities. Its architectural preparedness has been critically acclaimed for hospital design since its 2012 inauguration.
But this needs to become a feature of every hospital — whether a new building or an established facility. Hospitals with these features are be able to cope with conventional and unconventional threats.
Advanced ventilation systems are critical to caring for COVID-19 patients and to managing the impact of the pandemic on health care workers, who have been among the most at risk of serious and sometimes fatal infection.
These patients must be nursed in “negative pressure” rooms, which are at lower atmospheric pressure than surrounding areas. The HVAC system creates a negative pressure gradient sucking out contaminated air into a single-way exhaust system and avoids contamination of other areas. None of the exhaust air is recirculated. At NYU-Langone, entire wings have been reengineered to be ventilated this way to keep both patients and health care professionals safe.
Similarly, at Rush University Medical Center, its tower has 40 negative-pressure rooms. Normally only 2% to 4% of a hospital’s beds are fitted to be negative pressure because the cost is prohibitive. The emergency room ambulance bay at Rush can be rapidly converted into an expanded and isolated receiving area for patients potentially contagious.
These are remarkable innovations but must now become standard across the board.
America needs to build facilities similar to the Sammy Ofer Fortified Underground Emergency Hospital in Haifa, Israel, a 2,000-bed underground facility built after the 2006 Lebanon-Israel war. It is the largest in the world, built with combat in mind, and able to accommodate thousands of patients, staff and even their pets if needed. It could remain sealed, and its fully sufficient and secure against conventional and unconventional warfare.
But a pandemic-ready new building is powerless in the face of a pandemic without a similar surge capacity in personnel. Even as disaster management plans have been deployed across the country, including disaster privileges that reinstate physician credentials to practice critical care within 48 hours (mine included), the scarcity of critical care practitioners continues.
That critical care gap is caused by an aging American medical workforce, critical shortages of intensive care specialized nurses and doctors at a time when the American population is aging. These trends are likely to continue in the next 20 years.
Fifty-seven percent of American hospitals report difficulty filling critical care vacancies, according to a 2019 study. Hospital systems have been bridging the gap with virtual critical care networks where dozens of critically ill patients are managed through single intensive care specialist physicians using Telemedicine portals. For instance, New York physicians have been managing the critically ill in many intensive care units in the Hudson Valley by telemedicine since 2015 .
The Department of Homeland security has envisioned disaster scenarios and planned responses pivoting on virtual critical care, including nuclear detonation, anthrax attacks, biological and chemical warfare (weaponized contagion and natural disasters).
COVID-19 reinforces that responding to such events on massive national scale are not the stuff of science fiction and movies but very much part of our new reality.
Hospitals have long operated with the same premise as hotels — 100% occupancy with waiting lists. COVID-19 has relegated these models to the past. While it is necessary to maintain efficiencies and good outcomes, it is critical to be able to surge rapidly if societies are to survive devastating threats.
The COVID-19 pandemic is the biggest impetus to reimagining health care capacities since the aftermath of World War II. In 1946, President Harry Truman signed the “Hospital Survey and Construction Act” into law. It enabled the construction of more than a third of America’s hospitals by 1975.
In 1975, the Hill-Burton Act, as the law is also known, was embedded within the larger Public Health Service Act, a much bigger piece of legislation that allowed for the financing of 6,800 facilities in 4,000 American communities by the beginning of this century. The legacy of the Hill-Burton Act was extraordinary: As America recovered from World War II, it ignited the launch of one of the most extensive and advanced health care systems in the world.
In the time of COVID-19 pandemic, health professionals must demand that public policy makers show similar vision. It must be one that is sufficient to carry subsequent generations with renewed public health capacities into the next century and beyond with confidence.