Rethinking Surge Preparedness After COVID-19: Effective Patient Load Balancing Within Health Systems and Beyond

Abstract

Within weeks of New York State's first confirmed case of COVID-19, New York City became the epicenter of the nation's COVID-19 pandemic. With more than 80,000 COVID-19 hospitalizations during the first wave alone, hospitals in downstate New York were forced to adapt existing procedures to manage the surge and care for patients facing a novel disease. Given the unprecedented surge, effective patient load balancing—moving patients from a hospital with diminishing capacity to another hospital within the same health system with relatively greater capacity—became chief among the capabilities required of New York health systems. The Greater New York Hospital Association invited members of downstate New York's 6 largest health systems to talk about how each of their systems evolved their patient load balancing procedures throughout the pandemic. Informed by their insights, experiences, lessons learned, and collaboration, we collectively present a set of consensus recommendations and best practices for patient load balancing at the facility and health system level, which may inform regional approaches to patient load balancing.

Introduction

The first confirmed case of COVID-19 in New York was identified on March 1, 2020. Six weeks later there were 18,825 COVID-19 inpatients, with nearly all cases (96%) in the downstate regions (ie, New York City, Long Island, and the Lower Hudson Valley).¹

In total, downstate hospitals cared for more than 170,000 COVID-19 inpatients during Wave 1 (spring 2020) and Wave 2 (winter 2020-2021) combined.¹ While all downstate hospitals experienced extreme patient surges, the extent of these surges varied, with some experiencing rapid influxes of extremely sick patients, threatening to overwhelm the facility. By mid-March 2020, most large downstate health systems began adapting transfer processes to move patients out of hospitals experiencing the highest surge levels to other hospitals within their health systems that had relatively greater capacity, a process known as patient load balancing, to meet patient needs and maintain facility operations.

While patient load balancing is now recognized as a critical strategy,^2-5 in the early days of the pandemic, its significance was not yet well understood. For the 6 largest downstate health systems, continuous innovation and rapid improvement of patient load balancing procedures were central to managing the surges associated with the COVID-19 pandemic. These health systems—Montefiore, Mount Sinai, New York-Presbyterian, Northwell Health, NYC Health + Hospitals, and NYU Langone Health (hereinafter the “systems”)—collectively operate 55 acute care hospitals in downstate New York (Table 1).⁶ They are members of the Greater New York Hospital Association (GNYHA), a trade association with 160 hospital and health system members across Connecticut, New Jersey, New York, and Rhode Island. GNYHA supported its members in all aspects of the COVID-19 response, including authoring lessons learned and recommendations documents on key response issues.⁷

Table 1.

Number of Acute Care Facilities in Downstate New York by Health System and Region

Health System	Number of Acute Care Facilities	Location of Facilities
Montefiore	8	NYC, Mid-Hudson Valley
Mount Sinai	7	NYC, Long Island
New York-Presbyterian	9	NYC, Mid-Hudson Valley
Northwell Health	17	NYC, Long Island, Mid-Hudson Valley
NYC Health + Hospitals	11	NYC
NYU Langone Health	3	NYC, Long Island
Total	55

Abbreviation: NYC, New York City.

Before March 2020, each of the 6 systems maintained some form of a system transfer center that was predominantly focused on patient transport. At a minimum, these centers were used to both transfer patients from a hospital outside the health system to a system hospital and move patients from community-level hospitals within the health system to system facilities that offered a higher level of care. One system relied on a vendor, while the others used internal health system staff, which often included nurses with critical care experience. Entering the pandemic, only 2 of the systems used the same electronic medical record system across all sites, and none had a centralized bed management system. While all hospitals had well-developed patient surge plans, these plans only minimally contemplated the use of transfer center capabilities to coordinate movement of patients within the systems to balance capacity.

Collectively, these systems cared for 73% of New York State's COVID-19 patients during the spring 2020 patient surge.¹ Additionally, across 2 waves, a total of 13,080 capacity transfers—5,125 during Wave 1 and 7,955 during Wave 2—were carried out by these 6 health systems (personal communications between leadership from each system and J. Mandel-Ricci, November 1, 2021, to January 31, 2022).

Identifying Issues

GNYHA sought to capture system experiences and best practices for patient load balancing within downstate New York. In the summer of 2021, the 2 team leads developed a set of questions designed to explore how each system evolved their patient load balancing procedures over the first year of the pandemic and what role load balancing played in their overall response. Specifically, the questions focused on: (1) prepandemic patient transfer capabilities and processes, (2) the systems and processes developed during the initial patient surge, (3) iterations made on those processes in the period between Wave 1 and Wave 2, and (4) how those evolved systems and processes have become institutionalized within health system operations.

GNYHA invited health system leadership to contribute feedback, asking them to include members that were directly involved in and knowledgeable of system patient load balancing structures and processes. The members who contributed feedback became active participants in the recommendation development process. GNYHA also reviewed internal documents provided by member health systems, including written plans, reports, and published papers on related topics. The consensus recommendations shared in this case study were derived from that collaborative feedback and review process. While the day-to-day roles of each contributor were quite diverse, all were directly involved in developing and adapting the operational and clinical coordination structures used for patient load balancing during COVID-19 patient surges.

Key Findings

Each of the participating 6 health systems concluded that effective patient load balancing is essential to ensure not only patient health but also the “operational health” of individual facilities within a health system and of the system as a whole. In this context, “operational health” refers to the ability of the facility/system to maintain adequate resources, including staff, supplies, equipment, and patient care spaces, to maintain operations required to support current patients along with anticipated surge patients. Accordingly, based on its significance to the overall capacity of a health system to function, intrasystem patient load balancing is a critical component of effective surge planning.

From Reactive to Proactive: Rapid Innovation During Wave 1

The breakneck speed of the March 2020 surge and the geographic concentration of patients in certain communities necessitated rapid cycle innovation on multiple fronts, including transferring patients out of overwhelmed hospitals within a health system and moving them to other, better-resourced facilities. With an initial focus on supporting facilities inundated with patients, the systems rapidly modified transfer procedures to accommodate the surge.

For the most part, initial iterations of these procedures were time-consuming, inefficient, and placed most of the work on clinicians and administrators at sites already reaching their breaking point. Recognizing the need for more efficiency, speed, and automation, the systems independently focused on 3 areas that enabled them to rapidly evolve the transfer process: data, clinical coordination, and communication/decisionmaking (Table 2).

Table 2.

Three Areas of Focus to Strengthen Surge Management

Area	Description
Data	The systems rapidly evolved their ability to collect data on individual facility capacity, considering staffing, resource levels, and service areas to better understand and anticipate facility needs. This increased the systems' ability to identify patients for transfer, substantially reducing the burden on staff at overwhelmed facilities.
Clinical coordination	These new, modified procedures necessitated enhanced clinical coordination capabilities. The systems identified some form of clinical command center or group that was essential to their success in this area.
Communication and decisionmaking	The systems described the establishment of regular meetings, often several times a day, that convened clinical command center staff with facility-level clinical and operational leaders. The purpose of these meetings was to review current data and trends, toward mobilizing resources to move patients as needed. These meetings were often followed by additional facility-specific meetings.

The interplay of these focus areas—data, use of a coordinating body, and a strict communication cadence—enabled the systems to employ a more proactive approach to managing patient surge. They also built trust among individual facility leaders and system coordination leadership, rapidly increasing the ability of these large health systems to use their limited resources in the most effective manner.

By mid-April 2020, the systems had moved from a focus on patient transfers to patient load balancing and continued to evolve these procedures in preparation for the anticipated winter wave. In doing so, they developed capacity to identify the right patients for transfer, match patients to available beds and resources, and create a health system culture in which individual hospitals are prepared to send or receive patients based on overall circumstances. These developments established a foundation for more robust systemwide patient load balancing approaches.

Balancing More Than Just Patient Load and Integrating Lessons From Wave 1

The number of hospitalized COVID-19 patients in the New York City region sharply decreased from a crest of 12,184 on April 12, 2020, to 440 by June 30, 2020—a 96% decrease.¹ Hospital leaders began to work toward providing services beyond emergent care and COVID-19 management, especially for patients who had delayed needed care during spring 2020.

Thus, for the systems, the twin objectives for the Wave 2 response were to meet the needs of patients and communities for routine care while also caring for anticipated COVID-19 patients. For the former, health system leaders plotted out surgical procedure and service line capacity for each facility within their health system and developed contingency plans for scenarios when specific services would be curtailed, and how patients needing that service could be redirected to other locations within the health system. This work was married with intensive efforts to use telehealth and other strategies to provide care at locations outside of acute care settings.

The systems began integrating what they learned during Wave 1, and developing and implementing just-in-time solutions to inform more proactive procedures and processes. For example, health system leaders created detailed surge plans based on their Wave 1 experience for each facility within their system, which mapped out:

Spaces and equipment that would be preserved to meet non-COVID-19 care needs

Locations where COVID-19 surge beds and units could be added and in what order, based on available data

Locations of existing beds and units that could be converted for COVID-19 care

Supportive services and resources that would be required to care for COVID-19 patients (ie, medical gases, pharmaceuticals, respiratory therapists) and the quantities required for varying levels of surge activity

Staff that would be available to be redeployed as necessary

Armed with this information, health systems developed triggers and complementary actions and processes to curtail services in a “dimmer switch” fashion as necessitated by increases in COVID-19 patient volume. Facility-level planning also included the development of triggers for load balancing out of each facility to ensure the facility's operational health. In addition to these intensive planning activities, several of the systems also worked swiftly to improve and standardize data systems, standardize clinical equipment and procedures, cross-train staff, and carry out other activities designed to increase the ability of individual facilities within their systems to support one another.

GNYHA Assumes Regional Coordination Function During Wave 2

With these foundational pieces in place, when Wave 2 began in early December 2020, the systems were well positioned to manage the COVID-19 surge while continuing to meet the needs of their communities. The systems' actions during this period were complemented by GNYHA's activities in downstate New York. While GNYHA provided substantial support and assistance to its members during Wave 1, its role became more formalized during Wave 2.

With the support of the Governor's Office and the New York State Department of Health, GNYHA assumed a regional coordination function composed of 4 key components: (1) enhanced situational awareness coupled with proactive outreach, (2) creation of formal partnerships between independent hospitals and health systems for hospital capacity management, (3) frequent coordination meetings with hospitals and health systems, and (4) routine coordination meetings with the Governor's Office and the New York State Department of Health. This function, described in detail elsewhere,⁸ enabled the entire healthcare system to proactively stay ahead of emerging operational and regulatory issues and collectively manage regional capacity.

GNYHA also played a central role in facilitating formal partnerships between independent hospital and health systems. These partnerships served as a critical safety valve for independent hospitals and small systems in downstate New York. Clinical and operational leaders from the large health systems provided technical assistance on a day-to-day basis to their partnered facilities, and also helped place patients as needed.

Discussion

A Different Way of Thinking

The health system leaders were asked what processes will be permanently altered by the COVID-19 response. All mentioned a greater emphasis on “system-ness”—considering how all of a system's assets can be best utilized to support individual facilities and patients. This includes continued investments in coordination functions to support facility operational health and patient movement, greater reliance on specialization, cross-training of staff, standardization of policies and protocols, and sharing of resources across facilities. It also means communicating with patients differently to help them understand that the care they need may entail moving to a different facility. One leader stated, “We are now thinking of the health of the patient and the health of the system collectively.”

Consensus Recommendations and Best Practices Supporting Health System Patient Load Balancing

With events necessitating patient movement becoming more frequent, patient load balancing must be a central part of health systems' preparedness and response planning. Additionally, to support widespread events, processes to support cross-system patient movement are needed regionally and in conjunction with neighboring states. Our recommendations and best practices can serve as a road map for such efforts in the Northeast and throughout the United States (see Table 3).

Table 3.

Consensus Recommendations and Best Practices

Phase	Recommendation	Associated Best Practices
Preparedness	Every hospital within a system should regularly review and update their comprehensive hospital surge plan that contemplates both repurposing of existing beds and creation of surge beds	Each hospital's surge plan should detail trigger points for signs of facility distress and thresholds that define a tiered surge strategy.A comprehensive plan should consider and incorporate staffing levels, emergency department volume, availability of critical care resources, capacity of infrastructure needed for patient support, inpatient census, and tactics for decompressing the facility if nearing distress.Emergency processes and protocols should be built upon day-to-day ones, flexing up in phases or levels, based on preestablished triggers. The plan should also include deescalation triggers, enabling resumption of curtailed services and return of redeployed staff, equipment, and other resources.This plan should also contemplate transport needs associated with surge and potential solutions to deliver timely, reliable transport support.
	Health systems should build upon facility-level plans to create overarching systemwide plans and processes including surge, decompression, service line shifts, and deployment/redeployment of staff, equipment, and other critical resources	Central access to facility EMRs and bed boards should be established, along with ways to monitor critical resources.Effective system-level plans will support facility-level surge management and decompression needs and should maximize use of system assets.A comprehensive system plan will contemplate facility-level thresholds in the context of systemwide thresholds, which might trigger service line shifts, rescheduling/relocation of services, staffing changes, and resource movement across facilities. The system-level plan should also include phased deescalation based on utilization trends.This plan will also integrate patient communication and information to address systemwide service shifts/location changes.
Response	Key clinical and resource data, tied to the above planning documents, must be accessible and available to system leadership to inform decisionmaking	Centralized access to facility EMR and bed board data is ideal, allowing real-time data pulls.Alternatively, a method for collecting and pushing facility-level data to a centralized location at regular intervals, including information about emergency department volume and throughput, discharge activity, and fatality management operations, may be considered.Methods for monitoring resource availability including staff, critical equipment, PPE, and medical gases and medications would better inform critical decisions.
	Health systems should establish a clinical command center to oversee hospital and health system capacity management and facilitate operations that support efficient patient throughput	This center should be composed of clinical and operational leaders with the authority to manage systemwide assets.This team will continuously balance patient care, growth of hospital and health system capacity, and preservation of facility and system operational health using established communications and incident command mechanisms.
	Set a communication and decisionmaking cadence with key system and facility leaders	Clinical command staff should have regular and structured meetings with facility-level clinical and operational leadership to review data, share critical contextual information, and address issues.Real-time data summaries should also be shared to ensure a common operating picture to support decisionmaking.Complementary communication pathways should ensure continuous, consistent communication into facilities and to other parts of the system's incident command.

Abbreviations: EMR, electronic medical record; PPE, personal protective equipment.

Considerations for Applying These Lessons Learned to Regional Load Balancing

One of the core takeaways for leaders of each of the 6 systems was that a better understanding of the individual needs/capabilities of each of their facilities was essential to ensuring continued operations at a system level. When considering how these lessons might inform a regional approach to load balancing, a similar premise applies. A successful regional load balancing approach must build upon the components and capabilities of the entire acute care health delivery system. A regional approach should preserve existing within-system patient load balancing processes and leverage existing business and clinical relationships between healthcare entities.

The complex nature of a regional load balancing approach will require comprehensive participation and collaboration, but it will also require developments around the critical focus areas that drove the systems' evolving response: data, central coordination, communication, and decisionmaking.

Limitations

This case study focuses on the experiences of 6 large health systems in downstate New York, which is somewhat unique in its concentration of healthcare delivery assets. The regional planning recommendations envision a model that builds on these existing health systems structures. Although we believe the recommendations shared may be valuable to health system leaders elsewhere, we recognize that our recommendations may not be applicable to some parts of the country, and that in some jurisdictions state-run transfer lines fulfilled this function with great success, while also addressing access and equity considerations. Readers should contemplate the specific healthcare delivery makeup and existing jurisdictional response capabilities of their area when considering the recommendations shared in this article.

Conclusion

The COVID-19 experience of New York hospitals and health systems has underscored the importance of patient load balancing capacity at the facility, system, and regional level. GNYHA supports state entities and our hospital and health system members in working toward this goal. Our collaborative process underscored the interdependence of facility health and system health, and the ways in which management of facility capacity and resources impact patient health. At the regional level, we believe these consensus recommendations can improve the overall “health” of the healthcare system. Furthermore, complementary principles should be employed to support a regional approach to patient load balancing. Such a framework would reduce the burden on individual health systems to manage patient surge and expand the capacity of those same systems to work collaboratively to support patient health across the region. In endeavoring to establish a regional approach to load balancing, however, there must be an appreciation that government's best role is to set expectations for facility and system behavior and provide processes and structures that connect existing resources and information.

Given the size and significance of this endeavor, we recognize that additional support, collaboration, and connection will be required. For example, based on what we learned from the 6 systems alone, for a regional patient load balancing approach to work, all regional partners would ideally have access to a single data platform providing a common regional operating picture. Standardized data collection, access, and visibility would enable hospitals and health systems to anticipate issues and better support one another while also enabling response partners and other stakeholders to better understand and address facility needs. In that context, GNYHA, in collaboration with the New York City Department of Health and Mental Hygiene, is interviewing key health and medical stakeholders to understand situational awareness and information systems currently in use, document gaps, and highlight growth and alignment opportunities, which will inform the development of a 5-year road map for the region.

Footnotes

Acknowledgments

First and foremost, the authors acknowledge the tireless and heroic efforts of the caregivers and staff at each of the contributing institutions, throughout the COVID-19 pandemic. Their selflessness, ingenuity, and perseverance inspired this paper and laid the groundwork for a more resilient healthcare system in New York. We would like to also thank each of the authors who took the time to share their experiences, the lessons they learned, and their hopes for the future of healthcare. Finally, a special thanks to Jared Bosk, vice president, Survey and Outcomes Research, for his contributions to this paper.

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