Using Interfacility Transfers To ‘Level-Load’ Demand From Surging COVID-19 Patients: Lessons From NYC Health + Hospitals

On January 20, 2020, the United States recorded its first confirmed case of SARS-CoV-2 (COVID-19) in Washington State—a young man with recent travel to Wuhan, China. Since then, the disease has spread rapidly across all states, placing strain on hospitals in urban centers, where widespread community transmission is common and disease burden greatest. Overstretched capacity worsens patient outcomes and further endangers overburdened staff, concentrating mortality in those hospitals most taxed. In response to the pandemic, hospitals in the nation’s most afflicted regions have sought to expand inpatient and intensive care capacity. While many hospitals have successfully expanded or repurposed internal capacity in various ways, COVID-19 surges have exposed the need for innovative ways to reduce the demand placed on hospitals most impacted. 

Leveraging Hospital Systems To Redistribute Overwhelming Demand

Coordinated interfacility transfers are one potentially vital method for helping balance the surge of COVID-19 patients across hospitals within regions. In the United States, two-thirds of hospitals are part of larger multihospital systems, with as many as seven hospitals on average per system. Within such systems, individual hospitals with distinct catchment areas may be differentially impacted by the pandemic. Redistributing patients from greater- to lesser-impacted hospitals—so-called “level-loading” demand for inpatient capacity—may help systems reduce strain where it is most jeopardizing. Traditional interfacility transfer processes, however, may not be designed for transfers of large numbers of patients per day as may be necessary for effective level-loading during a disaster.

We confronted these challenges at New York City Health + Hospitals, the largest public health care system in the country. New York City had rapidly become the world’s epicenter of COVID-19, eclipsing other cities in number of cases, hospitalizations, and deaths. When the pandemic initially spread across the city in early March 2020, it disproportionately affected vulnerable populations in Queens, South Bronx, and North Brooklyn, with relatively fewer cases in Manhattan. NYC Health + Hospitals prepared for a potential surge by increasing its critical care capacity and workforce across 11 hospitals. Nevertheless, because of the virus’ uneven geographic distribution, several NYC Health + Hospitals facilities experienced sudden and overwhelming surges of patients with suspected COVID-19. These surges, akin to repeated mass-casualty incidents occurring daily at the same hospitals, quickly exhausted physical infrastructure and resources. Ambulance diversion, although helpful, did not stem the surge, as scores of patients with COVID-19 awaiting an inpatient bed were boarded in emergency departments (EDs).

In response, NYC Health + Hospitals re-engineered its COVID-19 response strategy to include a more aggressive bulk redistribution of patients from its hardest-hit hospitals to those with more capacity. To do this, we used a novel integrated dashboard to identify various daily measures of capacity utilization, hospitals that needed relief, and hospitals that had capacity for receiving patients. This dashboard included data from our 11 hospitals including the number of ED boarding admissions, inpatient medical-surgical bed occupancy, intensive care unit (ICU) surge level (defined based on critical care staff, ventilator availability, and alternate ICU space use), and ventilators in use. Next, to expedite large-volume transfers across system hospitals, dedicated, physician-led teams at individual hospitals worked daily to identify batches of potential non-ICU and ICU-level patients for transfer. Priority was given to admitted patients boarding in the ED thus minimizing repeated cleaning of inpatient rooms. We also abstracted transfer and clinical data for identified patients from the electronic medical record using combined automated bulk extraction and focused manual review to ensure safety and stability of patients prior to transfer. A centralized transfer team then delivered clinician handoff of non-ICU patients to a designated accepting clinician in batches of 5 to 20 patients, whereas sending and receiving physicians conducted verbal handoff for ICU patients. Nursing handoff was streamlined using a written “Situation-Background-Assessment-Recommendation” form. The transfer team would then manage large numbers of transfers directly with the system’s dedicated ambulance vendor.

Over 21 days, from March 20, 2020, to April 9, 2020, we moved 545 patients—116 ICU and 429 non-ICU patients—from the four most impacted facilities to those with capacity to care for patients. These transfers represented nearly three times the system’s typical transfer volume over the same period. As a result, capacity utilization at sending and receiving hospitals remained comparable instead of diverging (exhibit 1). By preventing critical overcrowding of ED, inpatient, and intensive care settings, systemwide level-loading invariably saved lives and boosted morale at hospitals that were overwhelmed.

Exhibit 1: Impact of systemwide level-loading on inpatient capacity utilization

Source: NYC Health + Hospitals. Note: 1. Average daily census calculated from January 1, 2020 to February 9, 2020.

Lessons Learned For Regional Level-Loading

Strategic interfacility transfer of patients across NYC Health + Hospitals reduced critical overcrowding of ED, inpatient, and intensive care settings. While NYC Health + Hospitals distributed patients across 11 acute care hospitals throughout New York City, the benefits realized might be even greater if leveraged across a larger geographical area, where variation in disease burden and capacity utilization is even wider. Several regional and state leaders have signaled openness to such level-loading; however, to our knowledge, no centrally coordinated campaigns are yet active to affect regional patient redistribution in bulk. For example, even as New York City hospitals filled, patient transfers to upstate hospitals, where COVID-19’s impact has generally been lighter, occur on an individual ad hoc basis, missing opportunities gained through central demand analysis, strategy, and facilitation.

Data Harmonization And Decision Making

For the strategic interfacility transfer of patients across a region to be maximally effective, several challenges must be overcome. First, hospitals must agree on key measures of hospital strain and capacity. The experience at NYC Health + Hospitals leveraged integrated data systems and dashboards that reflected staffing-to-patient ratios, number of critical patients, and other clinical data, as well as on-the-ground reported measures to determine which patients would benefit most for transfer. Leadership at both sending and receiving hospitals must work together, setting aside individual organizational aims while acknowledging shared responsibility for public well-being. A central body, independent of any given hospital, should help guide transfer and capacity allocation decisions to prioritize hospitals in gravest need, with a focus on saving lives.

Technology And Task Shifting

Second, bulk transfer processes allow frontline clinicians to focus on critical patient care. At NYC Health + Hospitals, dedicated transfer teams made up of clinicians at each hospital liaised with frontline clinicians to identify patients safest for transfer then supplanted frontline staff in subsequent batch handoff processes. Our central coordinating body then ensured safe and timely transfers with real-time monitoring in collaboration with regional interfacility transport providers, while overseeing process transparency and quality assurance. 

Staff Morale

Finally, special attention should focus on staff morale. Some receiving hospitals may be asked to stretch well above their average census to relieve harder-hit hospitals. Their staff should be encouraged with regular appraisals of their life-saving impact given by departmental and hospital leadership, as well as through inter-hospital communication. At NYC Health + Hospitals, ICU directors held daily conference calls that allowed real-time communication, appreciation, and thoughtful discourse amongst clinicians and nurses. Care must be taken not to overwhelm receiving hospitals. Indeed, as disease burden evolves across time and region, some facilities that initially helped others by receiving patients may ultimately themselves need similar assistance.

Saving Lives By Sharing Demand

As the surge of COVID-19 hospitalizations grows nationwide but continues to impact areas differently, it is likely that hospitals in regions hardest hit will continue to face overwhelming demand for inpatient care. Efficient, high-volume, centrally coordinated transfers from these overstretched hospitals to those with available capacity—both within multihospital health systems and across them—will become necessary. Lessons learned from New York City’s public health care system can inform the rapid scaling of level-loading processes elsewhere and mitigate preventable mortality.

Authors’ Note

Authors are currently employed by NYC Health + Hospitals. The contents of this work are solely the responsibility of the authors and do not necessarily reflect the official views of NYC Health + Hospitals.