Coronavirus: Is New York City prepared to deal with thousands of cases?
Surge capacity, coordination are key
It’s only a matter of time before the novel coronavirus (COVID-19) breaks out in New York City, according to officials and the city Health Department. Is the city’s health care system ready?
That depends in part on hospitals’ “surge capacity” — the ability to handle 20-25 percent more patients than usual.
National policy calls for hospitals to accommodate surges of 500 new patients per million population in a disaster. That would amount to 4,300 additional patients across New York City. Based on population, Brooklyn would need to handle about 1,250 additional patients during a surge, and there could be two or three surges during an outbreak.
It also depends on the city’s ability to coordinate the responses of hospitals, agencies and the state and federal government. During biological outbreaks, the New York City Department of Health is considered the “primary agency” under the Citywide Incident Management System, and takes on coordination responsibility.
Increasing surge capacity means hospitals have to empty rooms currently being used for less seriously ill patients (in a process called Rapid Patient Discharge) and utilize unused spaces. During Superstorm Sandy, for example, some receiving hospitals turned lobbies into inpatient wards.
Hospitals must also create rooms fitted out especially for children. (A 2010 study found that few hospitals with pediatric intensive care units had detailed surge capacity plans.)
Hospitals have to muster extra staff, stockpile protective gear, equipment and medicines, and arrange myriad details — like contracting with linen companies for extra sheets and towels. The city must coordinate with state and federal authorities, and may need to acquire medicine from the Strategic National Stockpile.
In the New York area, Joint Base McGuire-Dix-Lakehurst in New Jersey and Fort Hamilton in Brooklyn have been designated as potential emergency camps to quarantine people with possible exposure.
Sen. Chuck Schumer said last week that New York City could be faced with expenses of roughly a million dollars a day to pay for the Department of Health’s prevention and surveillance activities, doctors, nurses, security and overtime, along with diagnostic and lab testing, equipment, supplies, gear, and additional security assistance from the NYPD.
Likely to stress the system
So far, all suspected cases of coronavirus in New York City have been ruled negative. But as Mayor Bill de Blasio said at a press conference in January, it’s not a question of if, it’s a question of when.
Panelists testifying before the Senate’s Homeland Security subcommittee on Friday spoke urgently about the country’s surge capacity.
“We have to look and see what’s happening in these other countries and assume the same thing is going to happen here,” Dr. Asha George, executive director of the Bipartisan Commission on Biodefense, said. “I think we have to plan for the possibility that we have thousands of cases. Or hundreds of thousands.”
Dr. Luciana Boreo, vice president at In-Q-Tel and former director for medical and biodefense preparedness at the National Security Council, told the panel, “It’s pretty clear that [coronavirus is] likely to severely stress our health care systems because of the lack of surge capacity we have today to treat a large influx of patients with acute and serious respiratory diseases.”
Dr. Scott Gottlieb, former Commissioner of the Food and Drug Administration, told the Senate panel that the odds are high that cases are already going undetected in the U.S.
“Some of the modeling out of the U.K. suggests we’re capturing about 25 percent of the cases at best,” he said. “At least some of these cases are probably propagating virus at a local level.”
‘Staffing, supplies, space and system’
NYC Health + Hospitals, the city’s public health care system, says surge capacity preparations include the four S’s: staffing, supplies, space and system.
“NYC Health + Hospitals regularly prepares and drills for all hazards, including special pathogens such as the coronavirus,” the agency’s spokesperson Christopher Miller told the Brooklyn Eagle.
“Any time there is a potential for a surge, we revisit our existing plans to ensure that we can triage and accommodate patients should we receive a high volume of potential or confirmed cases,” he said.
New York City’s private hospitals and clinics have also been preparing.
Dr. Reed Caldwell, chief of service at NYU Langone Cobble Hill Emergency Department, told the Eagle that NYU has carried out an “enterprise-wide table top drill and [has] been doing daily site-specific preparations.”
“Interdisciplinary teams have developed plans to expand capacity within each of our facilities” and are working with senior leadership and NYU’s emergency management team to assess the need for staffing, Caldwell said.
NYU Langone “works closely with city, state and federal agencies to plan for this and all kinds of emergencies,” he added.
Some of New York City’s hospitals have been participating in joint drills, such as the recent SurgeEx 2020. This state-level drill included 55 hospitals, 17 nursing homes and multiple state agencies. During the drill, seven hospitals were designated as “evacuating” facilities (including Bellevue in Manhattan) and nine were selected as “receiving” facilities (including SUNY Downstate Medical Center in Brooklyn).
Worst case: tens of thousands of bodies
In a pandemic, the office of the city’s Chief Medical Examiner has estimated it might have to handle two to three surges, with each surge lasting roughly eight weeks.
In its detailed pandemic plan for a severe influenza outbreak drawn up by the Medical Examiner’s Office, death rates were estimated to range from 1.1 percent to 3.5 percent, leading to a potential for 27,000 to 86,000 victims over an eight-week period. Numbers released by the Chinese Centers for Disease Control on February 17 calculate the overall coronavirus mortality rate in China is 2.3 percent. The rate is lower for the young and higher among older age groups.
The agency will “recover, process and hold decedents from residential and healthcare facility locations until private sector entities are able to manage final disposition,” the plan says. If the decedents’ family members are also sick, the agency may have to store the bodies in refrigerated trucks until someone can deal with them. Since supplies such as body bags are stocked using a just-in-time inventory system, the agency could run short.
Supply chain could become a problem
NYC Health + Hospitals says it is in regular contact with suppliers to ensure that their medical equipment and medicine supply chain remains uninterrupted.
NYU Langone also says it’s ready, as far as masks, gowns, equipment and medications are concerned. “We have evaluated our stock and are well prepared,” Caldwell told the Eagle.
But in the long run, obtaining supplies and medicine could be a problem.
The FDA has estimated that about 80 percent of active drug ingredients are manufactured overseas, many in China.
Dr. Gottlieb told the Senate panel on Friday that China is the sole source of many medications and medical supplies essential to Americans. Wuhan, where the virus broke out, is a global center of production for pharmaceutical ingredients.
“We’ve identified a critical choke point for critical pharmaceuticals,” Gottlieb said. “It calls into question disruptions in the supply chain.”
Dr. Julie Gerberding, chief patient officer at Merck, co-chair of the Commission on Global Health Security and former CDC director, told senators on Friday that the U.S. has a strategic national stockpile, “an enormous reservoir of medical equipment, supplies, medicines, vaccines, etc. strategically situated around our country.
“That is our first line of defense,” Gerberding said. “The stockpile is not limitless, and the supply chains for replenishing it will be very marginal at best, so I don’t think it’s a solution, but it will definitely help us buy some time.”
As of Friday, there were 47,505 laboratory-confirmed COVID-19 cases in China, according to the World Health Organization. There have been 1,381 deaths in China, including 121 reported on Friday. Outside China, there have been 505 cases in 24 countries and two deaths. 1716 Chinese health workers have been infected, and six have died.
Updated on Feb. 18 with figures from China’s CDC showing a coronavirus mortality rate of 2.3 percent.
Updated on Feb. 18 with information about coronavirus-related expenses to the city.
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