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A recent article in NEJM Catalyst: Innovations in Care Delivery discusses the challenges faced and lessons learned by New York City hospital systems in the spring of 2020, when New York City became the epicenter of the COVID-19 pandemic in the United States. The authors of the article were directly or indirectly involved in caring for over 5,000 COVID-19 patients hospitalized during a two-month time frame.

The coordinated response and challenges faced by each facility were reviewed to determine the challenges faced, strategies implemented, and future steps to decrease the likelihood of future recurrence. The response was compiled into 6 main themes:

  1. Communication
  2. Surge capacity/expansion of beds
  3. Staffing
  4. Triage
  5. Clinical care
  6. Staff wellness


Challenge: One of the main communication challenges was the large volume of rapidly changing information regarding COVID-19. This contributed to difficulties with coordinating plans and disseminating relevant information between facilities.

Strategy: The group employed a variety of communication mediums (operational calls, town halls, videoconferences, emails) at regular intervals to communicate with staff and address concerns. Residents were updated nightly on patient volume, system changes, and ongoing challenges.

Future: The authors recommend developing communication strategies using a variety of communication mediums, tailored to internal staff needs as well as between facilities.

Surge Capacity and Expansion of Beds

Challenge: Ensuring an adequate supply of intensive care unit (ICU) beds, negative-pressure rooms, and continuous oxygen saturation monitoring to handle patient volume.

Strategy: Standard rooms and previously closed units were transformed to accommodate negative-pressure and continuous oxygen monitoring requirements. Flex-ICU spaces were identified to increase the number of ICU beds available.

Future: Create sufficient flex-ICU spaces in anticipation of future COVID-19 hospitalizations.


Challenge: Maintain adequate staffing, especially ICU nurses, to handle rapid patient surges, as well as ensure timely onboarding of staff who are unfamiliar with systems or clinical areas.

Strategy: Staffing pools were created for various areas. Sufficient expertise was represented when determining staffing teams. Weekly orientations were conducted regarding clinical service focusing on COVID-19 treatment.

Future: Because the same sources of staffing pools may not be available in future pandemic waves, facilities will need to utilize internal staff rather than volunteers. Early training of physicians and nurses for ICU care was recommended.


Challenge: Separating respiratory and nonrespiratory patients at admission and developing a process to accommodate internal and external referrals

Strategy: Emergency departments were divided into separate respiratory and nonrespiratory areas with systems in place for identification and handoff of transfers.

Future: Continued planning for separate emergency department zones is recommended for future waves of COVID-19.

Clinical Care

Challenge: Because of the limited knowledge of treatment for COVID-19, there were many areas of uncertainty regarding care.

Strategy: Hospitals worked collaboratively to develop protocols in areas such as respiratory or renal failure, code teams, end-of-life care, and therapeutic management of COVID-19 patients.

Future: This work continues across all sites. Evolving clinical guidelines and protocols should be shared.

Staff Wellness

Challenge: The strain was unprecedented for all healthcare staff, both physically and emotionally.

Strategy: Sufficient time off was provided. Staff was given access to mental health professionals and resources.

Future: Make ongoing staff wellness programs available, as the pandemic is a long-term challenge.

Read the full article at NEJM Catalyst.