At the Hospital for Special Surgery (HSS) in New York City, everything changed around mid-March, when the facility closed because of the COVID-19 crisis.
“The decision for us to close down was, initially, to make sure we could help out by sending over as many personal protective equipment [PPE] as possible to other New York hospitals,” says Bryan Kelly, MD, MBA, surgeon-in-chief and medical director of HSS.
New York City was among the hardest hit cities during the pandemic’s first wave. By the third week of April, the city’s coronavirus death toll was more than 13,600 and hospitalized COVID-19 patients reached close to 35,000. “We’re an all-orthopedic surgery hospital, and we typically do 130 to 140 orthopedic surgeries per day,” Kelly says.
Ten of the more than 50 operating rooms (ORs) are at ambulatory surgery centers (ASCs) in three different locations, he adds. “We have only four critical care beds for patients who have complications,” Kelly says.
The first four weeks since HSS closed to elective surgeries were a time of dizzying change. First, Kelly and other HSS leaders realized that New York City hospitals were overwhelmed with COVID-19 patients. HSS began to accept transfers of non-COVID-19 patients. “We converted one of our ASCs into an orthopedic triage center, an urgent care center,” Kelly says.
Orthopedic emergency cases from all other hospitals in the area were diverted there to keep these non-COVID-19 patients away from emergency rooms that were filling with COVID-19 patients. At first, it seemed as though the surgery center would fill with non-COVID-19, orthopedic trauma cases. But it did not work out that way. “There was not that much trauma because everyone was quarantined, and not that many were COVID-negative,” Kelly says.
“We converted the ninth floor OR into an intensive care unit [ICU] with 30 ICU beds,” he explains. “We have about 20 COVID-positive ICU bed patients. We’re an orthopedic hospital and are not designed for this.”
HSS changed two inpatient floors to keep COVID-19 patients who are not on ventilators. “All of this requires us to reconfigure the space,” Kelly says. “All had to be converted into negative pressure rooms.”
The building created safe spaces for staff, and filled up with 140 patients, including 20 orthopedic patients. The rest were COVID-19 patients. “We have an anesthesia department with 70 anesthesiologists, and we created a tiered system where a critical care specialist oversees the entire group of ventilated patients,” Kelly reports. “Patients have an anesthesiologist, internal medicine physician, resident, fellows, physician assistants, and nurses all staffing it — overseen by critical care people.”
Everyone at HSS is handling work they are not used to. For instance, post-anesthesia care unit (PACU) nurses began working as ICU nurses. “This has been a hard transformation,” Kelly says.
Physicians, nurses, and other staff were asked to perform duties that are quite different from what they were handling the previous month. “Now, we have orthopedic surgeons acting like floor interns in the ICUs to support the internists,” Kelly says. “It’s been an amazing team effort by all of the staff.” By adapting as the pandemic evolved, HSS avoided furloughing staff.
“We’re doing everything we can to protect our staff, whether with PPE or jobs,” Kelly says. “There are 6,000 employees in our institution, and 3,000 are clinical.”
Before March 15, HSS had 200 people working virtually from home. “Now, we have 2,000 people working from home, and we’ve implemented a telemedicine program that we were planning to roll out in 2020, but hadn’t started it,” Kelly explains. “We had zero virtual consultations on March 15. Now, [in mid-April], we have 800 per day, and we’re shooting for 1,000 per day. We also have nine satellite locations that all were converted into urgent orthopedic care clinics.”
HSS converted its space for COVID-19 patients in the span of one week, Kelly says. “It was a lot of long days,” he notes. “It’s not what the hospital was designed for, but the staff and physicians here are incredible people. They dived into this problem, wanting to do everything we can to help the city get through this crisis.”
Since HSS revenue is generated through orthopedic surgery, most of these procedures were put on hold — except for emergency traumas, Kelly notes. “Our feeling is we have to try to figure out how we can help with the COVID-19 crisis and maintain our ability to take care of typical orthopedic patients,” he says. “Our patients would love for us to get back to where we were.”
HSS physicians, nurses, and other staff have been bombarded with multiple stressors, including learning new skills on the fly, avoiding illness and knowing people who have become ill, financial pressures, and family issues, Kelly observes.
More than 50 employees tested positive for COVID-19. While most exhibited minor symptoms, a few were hospitalized. As of mid-April, none of the staff became critically ill, and none had died.
“It’s stressful. We brought in a crisis management specialist, and we have a team of people working on crisis management stress reduction and anxiety,” Kelly says. “There are resources and access to emotional and psychological support.”
Everyone is concerned about when their surgical work can return to normal, but no one knows what the new normal will look like. “What impresses me is when you go up on the floors now, they’re working away as they would under normal circumstances. They seem to be managing it well,” Kelly observes. “But we worry about stress on the other side of it as well. Data from China show healthcare workers having long-lasting issues with anxiety and post-traumatic stress disorder. We want to make sure we have resources for that.”
Lessons learned, from a surgery center perspective, include the practicality of telemedicine. “Patients don’t mind telemedicine visits. It’s more convenient for them,” Kelly notes. “We’ll have more than 200 people working from home on the other side of this — maybe not 2,000. With regard to social distancing, we’ll make some modifications in how we do it.”
For instance, patients and healthcare workers will continue to wear masks for a period. The facility will implement COVID-19 testing.
Returning to a new normal will not be easy, Kelly notes. “As hard it was to create all of these changes, unraveling them will be a bit of a puzzle, as well,” he acknowledges. “We’re trying to figure out the best way to unravel them in a way that is safest for staff, patients, the institution, and the community around us as well.”