The impact and efficiency of medical screening exams in forward treatment areas at New York City public hospitals during the initial COVID-19 surge.

BACKGROUND: New York City (NYC) emergency departments (EDs) experienced a surge of patients because of coronavirus disease 2019 (COVID-19) in March 2020. NYC Health and Hospitals established rapid medical screening exams (MSE) and each hospital designated areas to perform their MSE. Five of the 11 hospitals created a forward treatment area (FTA) external to the ED to disposition patients before entering who presented with COVID-like symptoms. Three hospitals used paper-based, and 2 used an electronic medical record (EMR)-based MSE. This study evaluated the effectiveness of safely discharging patients home from the FTA while also evaluating the efficiency of using paper-based versus EMR-based MSEs. METHODS: Charts were reviewed using standardized data extraction templates. Patients discharged from the FTA were contacted by phone, and a structured interview captured additional data regarding subsequent clinical courses. Chi-square tests were used to compare proportions of patients hospitalized, as well as proportions of patients with vital signs recorded. Mortality rates were compared with Fisher exact test. A logistic regression model with fixed effects to account for clustering at hospitals was used to compare the odds of being sent to the ED for further evaluation based on vital signs and adjusted for age and sex. RESULTS: Across 5 EDs, 3335 patients were evaluated in their FTAs from March 17, 2020, to April 27, 2020. A total of 970 (29.1%) patients were referred for further evaluation into the ED, of which 203 (20.9%) were hospitalized and 19 (2.0%) died. Of 2302 patients discharged from the FTA, 182 (7.9%) returned to the ED within 7 days, resulting in 42 (1.8%) hospitalizations and 7 (0.3%) deaths. Facilities using EMR-MSE discharged more patients from their FTA (81.9% vs 65.3%, P < 0.001) and had similar 7-day return (9.3% vs 7.1%, P = 0.055) and mortality rates (0.49% vs 0.20%, P = 0.251). CONCLUSION: MSEs in an FTA are an effective process to disposition patients safely in a high-volume situation. Differences exist in paper- versus EMR-based approaches, suggesting EMR-MSEs provide better data, efficiency, and effectiveness. This suggests prioritizing an EMR-based MSE should be considered in future circumstances.

Stroke Code From EMS to Thrombectomy: An Interdisciplinary In Situ Simulation for Prompt Management of Acute Ischemic Stroke.

INTRODUCTION: Treatment of acute ischemic stroke is challenging because it requires prompt management, interdisciplinary collaboration, and adherence to specific guidelines. This resource addresses these challenges by providing in situ simulated practice with stroke codes by practicing clinicians at unannounced times. METHODS: An emergency department team was presented with a 55-year-old simulated patient with speech difficulty and right-sided weakness. The team had to assess her efficiently and appropriately, including activating the stroke team via the hospital paging system. The stroke team responded to collaboratively coordinate evaluation, obtain appropriate imaging, administer thrombolytic therapy, and recognize the need for thrombectomy. Learners moved through the actual steps in the real clinical environment, using real hospital equipment. Upon simulation completion, debriefing was utilized to review the case and team performance. Latent safety threats were recorded, if present. Participants completed an evaluation to gauge the simulation's effectiveness. RESULTS: Six simulations involving 40 total participants were conducted and debriefed across New York City Health + Hospitals. One hundred percent of teams correctly identified the presenting condition and assessed eligibility for thrombolytic and endovascular therapy. Evaluations indicated that 100% of learners found the simulation to be an effective clinical, teamwork, and communication teaching tool. Debriefing captured several latent safety threats, which were rectified by collaboration with hospital leadership. DISCUSSION: Impromptu, in situ simulation helps develop interdisciplinary teamwork and clinical knowledge and is useful for reviewing crucial times and processes required for best-practice patient care. It is particularly useful when timely management is essential, as with acute ischemic stroke.

Characteristics and outcomes of COVID-19 patients in New York City's public hospital system.

BACKGROUND: New York City (NYC) bore the greatest burden of COVID-19 in the United States early in the pandemic. In this case series, we describe characteristics and outcomes of racially and ethnically diverse patients tested for and hospitalized with COVID-19 in New York City's public hospital system. METHODS: We reviewed the electronic health records of all patients who received a SARS-CoV-2 test between March 5 and April 9, 2020, with follow up through April 16, 2020. The primary outcomes were a positive test, hospitalization, and death. Demographics and comorbidities were also assessed. RESULTS: 22254 patients were tested for SARS-CoV-2. 13442 (61%) were positive; among those, the median age was 52.7 years (interquartile range [IQR] 39.5-64.5), 7481 (56%) were male, 3518 (26%) were Black, and 4593 (34%) were Hispanic. Nearly half (4669, 46%) had at least one chronic disease (27% diabetes, 30% hypertension, and 21% cardiovascular disease). Of those testing positive, 6248 (46%) were hospitalized. The median age was 61.6 years (IQR 49.7-72.9); 3851 (62%) were male, 1950 (31%) were Black, and 2102 (34%) were Hispanic. More than half (3269, 53%) had at least one chronic disease (33% diabetes, 37% hypertension, 24% cardiovascular disease, 11% chronic kidney disease). 1724 (28%) hospitalized patients died. The median age was 71.0 years (IQR 60.0, 80.9); 1087 (63%) were male, 506 (29%) were Black, and 528 (31%) were Hispanic. Chronic diseases were common (35% diabetes, 37% hypertension, 28% cardiovascular disease, 15% chronic kidney disease). Male sex, older age, diabetes, cardiac history, and chronic kidney disease were significantly associated with testing positive, hospitalization, and death. Racial/ethnic disparities were observed across all outcomes. CONCLUSIONS AND RELEVANCE: This is the largest and most racially/ethnically diverse case series of patients tested and hospitalized for COVID-19 in New York City to date. Our findings highlight disparities in outcomes that can inform prevention and testing recommendations.

Critical Care And Emergency Department Response At The Epicenter Of The COVID-19 Pandemic.

New York City has emerged as the global epicenter for the coronavirus disease 2019 (COVID-19) pandemic. The city's public health system, New York City Health + Hospitals, has been key to the city's response because its vulnerable patient population is disproportionately affected by the disease. As the number of cases rose in the city, NYC Health + Hospitals carried out plans to greatly expand critical care capacity. Primary intensive care unit (ICU) spaces were identified and upgraded as needed, and new ICU spaces were created in emergency departments, procedural areas, and other inpatient units. Patients were transferred between hospitals to reduce strain. Critical care staffing was supplemented by temporary recruits, volunteers, and Department of Defense medical personnel. Supplies needed to deliver critical care were monitored closely and replenished to prevent interruptions. An emergency department action team was formed to ensure that the experience of front-line providers was informing network-level decisions. The steps taken by NYC Health + Hospitals greatly expanded its capacity to provide critical care during an unprecedented surge of COVID-19 cases in NYC. These steps, along with lessons learned, could inform preparations for other health systems during a primary or secondary surge of cases.

Characteristics and Outcomes of COVID-19 Patients in New York City's Public Hospital System.

Background New York City (NYC) has borne the greatest burden of COVID-19 in the United States, but information about characteristics and outcomes of racially/ethnically diverse individuals tested and hospitalized for COVID-19 remains limited. In this case series, we describe characteristics and outcomes of patients tested for and hospitalized with COVID-19 in New York City's public hospital system. Methods We reviewed the electronic health records of all patients who received a SARS-CoV-2 test between March 5 and April 9, 2020, with follow up through April 16, 2020. The primary outcomes were a positive test, hospitalization, and death. Demographics and comorbidities were also assessed. Results 22254 patients were tested for SARS-CoV-2. 13442 (61%) were positive; among those, the median age was 52.7 years (interquartile range [IQR] 39.5-64.5), 7481 (56%) were male, 3518 (26%) were Black, and 4593 (34%) were Hispanic. Nearly half (4669, 46%) had at least one chronic disease (27% diabetes, 30% hypertension, and 21% cardiovascular disease). Of those testing positive, 6248 (46%) were hospitalized. The median age was 61.6 years (IQR 49.7-72.9); 3851 (62%) were male, 1950 (31%) were Black, and 2102 (34%) were Hispanic. More than half (3269, 53%) had at least one chronic disease (33% diabetes, 37% hypertension, 24% cardiovascular disease, 11% chronic kidney disease). 1724 (28%) hospitalized patients died. The median age was 71.0 years (IQR 60.0, 80.9); 1087 (63%) were male, 506 (29%) were Black, and 528 (31%) were Hispanic. Chronic diseases were common (35% diabetes, 37% hypertension, 28% cardiovascular disease, 15% chronic kidney disease). Male sex, older age, diabetes, cardiac history, and chronic kidney disease were significantly associated with testing positive, hospitalization, and death. Racial/ethnic disparities were observed across all outcomes. Conclusions and Relevance This is the largest and most racially/ethnically diverse case series of patients tested and hospitalized for COVID-19 in the United States to date. Our findings highlight disparities in outcomes that can inform prevention and testing recommendations.