by Andrew Cuomo
Elmhurst revealed what was needed. The question was how to build and operationalize a real public health system overnight that could act quickly and have the logistical capability to ensure that no single hospital was overwhelmed or in need of additional staff or supplies while hospitals in the vicinity, or anywhere else in New York State, had vacant beds and available supplies, staff, or equipment. Unless such a system was in place, building new hospital capacity at the Javits Center and other temporary sites would be essentially meaningless and New York State would be unable to effectively care for even close to the number of patients that might require hospitalization at what experts believed would be our peak in late April.
A few days after the Elmhurst situation, New York State launched what we called “Surge & Flex,” an effort that effectively built one statewide, coordinated public hospital system. Surge & Flex included four key elements that are each detailed below: (1) building hospital capacity; (2) mobilizing additional staff; (3) balancing equipment and supply needs; and (4) establishing an operational command center to coordinate the entire system.
There is no question that Surge & Flex saved lives. Nearly 1,500 patient transfers between hospitals and hospital systems occurred as a result in just weeks. Millions of pieces of PPE were delivered to hospitals in need. A twenty-four-hour hotline in the command center helped address hundreds of logistical requests, managing ambulance transfers, staff travel and accommodations, and much more vital support. As a result, no other hospital was inundated to the extent that Elmhurst was during those days in late March, and New Yorkers in need of care had access to hospital beds, helping New York avoid the tragic collapse of the health-care system that we witnessed in Italy.
New York State has, via regulation and Department of Health guidance, institutionalized the Surge & Flex system that now gives the state the ability to quickly activate each component of the operation during a future wave of COVID cases or another public health emergency, and ensure hospitals know what is expected of them so they can properly prepare.
Four Elements of Surge & Flex
1. Increasing Hospital Capacity
In early March, epidemiological projections showed that New York needed between 110,000 and 140,000 hospital beds to meet the expected influx of COVID cases. This required New York State to effectively double the number of hospital beds available in the state’s 213 hospitals. To increase this capacity, three steps were quickly taken. First, an executive order was issued for hospitals to postpone or cancel most elective procedures, freeing thousands of beds that would otherwise have been filled by patients seeking treatment for non-COVID and non-life-threatening conditions. Second, an additional executive order was issued that required all hospitals to increase their own capacity by at least 50 percent. This could be accomplished by adding a bed to single rooms, converting cafeterias and meeting rooms into patient care centers, and other measures. Third, the state deployed inspection teams to underutilized or vacant health-care and other facilities statewide in order to build temporary hospitals. These inspection teams also created detailed reports and plans to convert specific college dorms and hotels that were located near existing hospitals into temporary health-care facilities, if needed.
Remarkably, these three actions expanded New York’s hospital capacity from 53,000 beds to approximately 90,000 in just a matter of weeks.
2. Mobilizing Additional Staff
Additional hospital beds were of no use without additional staff—a particular challenge given that thousands of health-care workers were being infected by COVID. In early March, New York State issued a public call for retired health-care professionals from around the state and country to sign up to be relicensed. Further, the state asked medical and nursing school students, and related health professionals such as podiatrists, to also serve. The response was overwhelming—nearly 100,000 health-care professionals agreed to serve, including 30,000 from outside of New York State, willing to travel to what at the time was a global hot spot of COVID cases. To match these additional staff with hospitals in need, New York State built a world-class online portal that allowed hospitals and nursing homes, prioritized by those with the highest need, to connect with these health-care workers and employ them at their facilities. New York State provided additional support, including human resources management, access to temporary housing, and transportation logistics to facilitate health-care facilities employing these volunteers. In addition, the state transferred health-care workers from underutilized hospitals upstate to hospitals in hard-hit communities downstate, and directed federal medical personnel to facilities most in need of additional staff.
3. Balancing Supplies and Equipment
Every state in the nation was faced with the challenge of quickly purchasing and deploying enormous amounts of health-care supplies and equipment, such as PPE, medications, and ventilators. This became particularly challenging given the nation’s dependence on an international supply chain and the lack of federal coordination and leadership. While New York State secured tens of millions of pieces of PPE and thousands of additional ventilators, it was clear that even these efforts would not be sufficient to meet what might be required at the projected peak in late April. The Surge & Flex system took on this challenge. First, the Department of Health expanded the daily reporting requirements for hospitals to include not just bed occupancy and vacancies, but also detailed reports on each facility’s individual stockpile of supplies and equipment. In essence, this data enabled the creation of a real statewide inventory of ventilators, medical drugs, PPE, and other supplies and equipment. An executive order was signed to ensure that New York State had the ability to properly distribute these items to hospitals in need—an exercise that was informed closely by data that demonstrated which hospitals were experiencing the most hardship and shortages of critical supplies and equipment. Further, a transportation logistics system was mobilized to help move this equipment around the state. It would be a tragedy for a patient in need of a ventilator to not receive one, while a hospital nearby had dozens of available ventilators. By the end of May, New York State had successfully allocated in excess of thirteen million pieces of PPE and other critical equipment and supplies.
4. Establishing an Operational Command Center
Standing up the Surge & Flex system in a matter of days was an operational challenge, and to ensure that the system worked seamlessly required a operational command center, staffed twenty-four hours a day, seven days a week, that could make each part work together in a coordinated manner.
The state created a Hospital Capacity Coordination Committee (HCCC) that served as a command center, comprising staff from the New York State Department of Health, senior officials from major hospital systems, and logistical experts from the New York National Guard. The HCCC operated 24/7 and was available to every hospital and health-care facility in New York State, accessible via a hotline that was answered at any time of day. With real-time data being displayed on large television monitors, members of the HCCC could see at a facility-by-facility level which hospitals were seeing influxes of new COVID patients and which facilities needed additional staff, equipment, or other support. Throughout the most challenging days of the COVID crisis, the HCCC was operational and helped facilitate thousands of patient transfers, deliver millions of pieces of PPE, and deploy hundreds of ventilators.
Without Surge & Flex, the impact of COVID on New York State would have been much worse. New York State has now institutionalized each of these four elements so Surge & Flex can be quickly operationalized should a new wave of COVID hit the state or we face another major health emergency.
NEW YORK STATE TESTING PROGRAM
New York State recognized early in the COVID-19 crisis that testing would be the single most important tool to combat and contain COVID-19. New York was the first state in the nation to develop its own diagnostic test and worked quickly to build a network of hundreds of local priva
te labs to test, and set up access to more than 850 collection sites where New Yorkers can go get a test. As a result, as of this writing New York leads the United States and large nations in total tests performed per capita. New York’s testing program is a national model that helped New York not only flatten the curve but actually reduce the infection rate since reopening the economy. The testing program established by New York State was instituted in part by executive order and Department of Health directives that are summarized below.
Creating New York State’s Own Test
Early in the COVID crisis, America’s testing capabilities were severely limited. Specimen samples had to be mailed from all fifty states to the CDC laboratory in Atlanta, where testing was conducted. By the end of January, New York had sent just eleven samples to the CDC. On February 4, the FDA issued an emergency use authorization that allowed a small number of CDC-designated clinical laboratories across the nation to test for coronavirus, using the same test that was being run in the CDC lab in Atlanta. That week, the CDC began to ship approximately two hundred CDC-developed coronavirus laboratory test kits to select U.S. labs, each kit capable of testing approximately seven hundred to eight hundred specimens.
New York’s Wadsworth Center, the state’s public health research lab, received the CDC test kits on Saturday, February 8. Upon examining the kits, the Wadsworth lab technicians realized they would not be able to rely on the CDC test kits. First, as the press later reported nationwide, the kits produced false positives—inaccurately reporting that someone was infected when in fact they were not. Second, the reagent chemicals needed to run the CDC test were in limited supply, available only from the CDC.
New York immediately mobilized to create our own COVID test, using different chemical reagents that were both more reliable to accurately find positive COVID cases and more commercially available than the reagents provided by the CDC—a potential “win-win-win” where New York State would have its own test with results reported within a day, a more reliable test than the CDC’s, and the ability to scale up quickly by purchasing the chemical reagents from commercial suppliers. By the third week of February, Wadsworth had developed a test that passed the validation process—where known positive specimens are run and successfully detected on the new test. On February 29 the FDA sent over the official documents approving Wadsworth’s test—the first non-CDC test to be approved by the FDA.
It is critical during a viral outbreak on the scale of COVID-19 that public health laboratories have the expertise, supplies, and equipment necessary to quickly develop in-state testing capabilities, helping ensure states are able to perform widespread testing in case the federal government fails to establish a national testing program.
Mobilizing a Network of Local Labs
The moment the FDA approved New York’s test, the state mobilized to activate a network of hundreds of labs licensed by New York State to test. Within the first two weeks of March, New York State had helped eight top-quality labs in the state get the equipment, supplies, and necessary FDA approval to test for COVID. Finally, on March 13, the FDA gave New York’s Department of Health the authority to approve all labs within New York State.
To mobilize the labs, the state issued an executive order directing all public and private labs in New York to coordinate with the Department of Health to prioritize coronavirus diagnostic testing. In addition, the state issued executive orders waiving regulatory burdens that constrained labs from reaching greater capacity. Together with a team of logistics and laboratory experts who coordinated with each lab in the state to help on issues including securing equipment, supplies, regulatory guidance, and staff, these measures helped activate more than 250 laboratories that now do COVID testing for New York State.
In addition, New York invested in manufacturers to help develop lab equipment and supplies, including $750,000 for Rheonix, an Ithaca-based manufacturer of lab instruments and reagent kits, that have been deployed throughout New York State and now are relied upon for thousands of daily tests.
It is critical during a pandemic that states’ public and private clinical laboratories are ready to direct their resources and priorities toward testing for whatever contagious disease is part of a global viral outbreak. Further, to avoid the problems with relying on national supply chains, U.S. manufacturers should be prepared, with assistance from the government, to retool operations to build lab equipment and supplies to help meet demand.
Building a Massive Sample Collection Network
As of this writing, the most popular way to test for COVID-19 is a nasal swab, where a health-care professional inserts a cotton swab into a patient’s nose and then puts the swab in a glass vial that holds a liquid transport medium, similar to saline solution. This sample is then put on ice and transported to a laboratory to test.
New York State built a network of more than 850 collection sites located across the entire state and launched a website where New Yorkers could put in their address and find a site near them to get tested. This network of testing sites included walk-in locations in dense, urban communities and drive-through locations in rural and suburban communities. Further, New York State set up testing sites at dozens of churches in minority communities primarily in New York City. To support all these testing sites, the state provided PPE, test kits, and other resources to ensure all New Yorkers had access to testing.
In a public health crisis like COVID, states need the capacity to quickly mobilize hundreds of locations to give residents convenient locations to get tested, as well as be able to build and launch the IT systems needed for finding sites, scheduling appointments, and reporting results.
Setting Testing Criteria Based on Lab Capacity
As testing capacity expands or restricts, likewise the criteria of who is eligible for a test must be adjusted. On Friday, March 6, while New York still had very limited capacity, New York’s eligibility included New Yorkers with symptoms who had traveled from hot-spot parts of the globe, contacts of known positives, individuals in quarantine, and individuals who had symptoms and tested negative for other influenzas. In June, when New York was doing more than sixty-five thousand tests a day, the state expanded testing criteria to all New Yorkers.
Since reopening on May 15, New York successfully capitalized on our expanded testing capacity to conduct widespread community surveillance testing—random testing of asymptomatic individuals without known exposure. Because 40 percent of infected people do not develop symptoms but may still be contagious, this approach helps identify where the virus may be spreading undetected. Community surveillance testing has been critical in identifying the virus early and controlling the spread through contact tracing before it reaches those who may become sick and require hospitalization—and is a testing approach that must be supported by the government in a widespread viral outbreak such as COVID.
Requiring Prompt Reporting of Results
New York State requires every laboratory in the nation that tests a New York resident for a communicable disease to report the results four times daily to the Department of Health. Known as the Electronic Clinical Laboratory Reporting System, this provides real-time insight into new cases throughout the entire pandemic. These reporting requirements will need to be activated immediately in future major outbreaks of communicable diseases. States should use their licensure authority to ensure accurate, timely reporting of testing data during a public health crisis.
10 WAYS TO AVOID COVID
People ask me all the time how they can keep themselves and their families safe from COVID. I am not a medical doctor, but here is what I do to stay safe—and what I ask my mother to do.
Stay indoors with a select group or go outside socially distanced. Do not have people coming to the home who have not been tested and have been circulating socially. Contact with health aides, a repairman, a deliveryman, a friend of a friend, all require caution. Contact with a young person also
requires caution. No matter how many times I’ve said it, young people still put themselves in harm’s way.
You do not have to have a fever to have COVID. If you feel any symptoms, especially respiratory, get tested. The older you are, the sooner you should be tested.
Before you go for a test, find out how long the testing site will take to turn around the results. Three days is the ideal turnaround time. More and more testing sites use national laboratories to process the results. A nine-day turnaround to get results is problematic. In New York, in-state labs can turn around a test in three days.
Temperature checks are only somewhat helpful. People stress temperature checks because they’re the only prophylactic we have right now, but asymptomatic spread is very real. And people who show no symptoms are very capable of spreading the virus. Don’t take false comfort.
