By mid-December of last year, more than six weeks after Hurricane Sandy devastated the mid-Atlantic coast, New York City's vast health care system was still staggering: four hospitals forced to close had only partially reopened, leaving lower Manhattan without a level-one trauma center and the five boroughs with 2,000 fewer hospital beds. As EDs became overcrowded, many uninsured and elderly residents in the hardest-hit areas still lacked services and medications needed to manage chronic conditions.
Figure. Medical work...Image Tools
In response, on December 15 a group of health care providers (including the New York State Nurses Association [NYSNA]) calling themselves the Build Back Better campaign picketed at the Manhattan home of Mayor Michael Bloomberg. They demanded that he focus urgent attention on four areas:
Figure. Mary Fitzger...Image Tools
* “Fill the gap in care” created by the closures of the four hospitals after the storm.
* Restore all services at the four hospitals—Coney Island Hospital in Brooklyn, and Bellevue Hospital, the Veterans Affairs (VA) Medical Center, and New York University's Langone Medical Center on Manhattan's east side—on “a clear, safe, and expedited timeline,” while taking care to renovate damaged infrastructures.
* Oversee medical relief work in the city, including the transfer of needed supplies and medications and the collaboration between city and community organizations.
* “Build back better”—that is, correct the faults in the system that the storm laid bare, such as problems in care access for the poorest New Yorkers and inadequate emergency preparedness in hospitals.
“It is still considered a crisis,” said NYSNA member Mary Fitzgerald in late December. “With the cold and the risk of mold and respiratory illnesses and the flu, it could get worse.”
The Build Back Better campaign arose as a collaborative effort of the NYSNA, Physicians for a National Health Program, and Occupy Sandy, a volunteer outgrowth of the Occupy Wall Street movement, said Fitzgerald, the clinical transitions of care coordinator at Montefiore Medical Center in the Bronx, where she's also on the executive council of the NYSNA. As she began to volunteer in the Rockaways section of Queens in the weeks after the storm, she found many opportunities for collaboration with other professionals, such as the Visiting Nurse Service of New York and many unaffiliated volunteers. (For more on the campaign see the NYSNA's related news release at http://bit.ly/WrcP1h.)
Fitzgerald and other clinicians found themselves frustrated by what they saw as an inadequate response from the city—for example, mobile care units that were supposed to have been sent to the Rockaways didn't show up—and from Mayor Bloomberg. Many news outlets reported on the miserable living conditions for many low-income elderly people in the Rockaways—people who live in the evacuation zone, Fitzgerald said, but who didn't leave as ordered because they couldn't.
“In our great city, unfortunately, there was an inadequate disaster plan, and the entire hospital infrastructure was stressed,” Fitzgerald said. “If people don't evacuate, then what? If a storm can knock out all of this, what do we do? The city has got to be more transparent. We're looking for stronger alliances.”
A ‘HAPHAZARD’ TIME FOR DISPLACED NURSES
Such hospital evacuations and closures are exceedingly rare. Bellevue Hospital, for instance, closed for the first time since 1736 on October 31, after millions of gallons of seawater flooded its basement.
Marion Machado, the head nurse in the emergency ward at Bellevue, was in London when the East River breached its banks, inundating her facility and disabling the backup generators. When she returned on November 15, she encountered an eerie scene: a darkened hospital emptied of its patients, with most of its nurses deployed elsewhere in the New York City Health and Hospitals Corporation (HHC), which owns Bellevue and 10 other acute care hospitals, as well as nursing homes and community clinics.
“It was very haphazard,” Machado said of the deployment of Bellevue's nurses. At one hospital, the staff were welcoming, but it took a long time for them to give the Bellevue nurses the codes to its glucometers—“the kind of thing that makes you useful,” Machado said—and the orientations for Bellevue nurses varied at other hospitals they were sent to. Many of her nurses also suffered personal losses, such as flooded basements, damaged roofs, and weeks without electricity in their homes, on top of having to adjust to the loss of their “work home.” (Nurses who weren't sent elsewhere to work had the option of attending courses in professional development.)
Terry Mancher, chief nurse executive at Coney Island Hospital in Brooklyn, also in the HHC system, said that her staff had been forced to evacuate a year before, when Hurricane Irene battered the region. That experience made for better preparations for Sandy, she said. They discharged or transferred as many patients as possible before Sandy made landfall, confining their most critically ill patients to the newer of two buildings at the facility. They endured more than four hours without power or phone (a nurse and a respiratory therapist stood by each mechanically ventilated patient during those harrowing hours), and the staff stayed in touch with a sister hospital via radio. They decided to evacuate when it became clear there would be no power for support services like the dietary and radiology departments.
Mancher said that severe gasoline shortages after the storm posed the most serious challenge for the Coney Island nurses deployed to other facilities, and the hospital had to provide transportation assistance for several weeks. Otherwise, she said, the placement of most of the Coney Island nurses went smoothly.
AT HOSPITALS, A STEADY RECOVERY
Mancher said that although the return to full inpatient capacity may appear slow moving, the recovery at Coney Island Hospital was advancing as it should. The hospital opened a 24-hour-a-day urgent care center, outpatient clinics provided such services as pediatric vaccines and obstetric and gynecologic care, and by late December an inpatient behavioral health unit opened.
“We're taking care of the community as best as possible,” she said of the long interim period. “A lot of people are working day and night to make sure things are perfectly clean and safe. Every decision we make is for the safety of the patients.”
Machado said that Bellevue's plan was to reopen the ED for walk-in and ambulance service by December 10, and although they were still awaiting clearance to receive ambulances at the time of this writing, Bellevue did open its freestanding emergency clinic. She said that wait times in the ED at a nearby hospital were five hours or more, and she was gratified to be able to begin providing emergency services. “We had no hospital. We had X-ray, a full lab system, and pharmacy. We screened patients as they came in the door,” she said. Anyone requiring immediate computed tomographic scanning for chest or abdominal pain was sent to another hospital.
She praised the HHC for opening the walk-in clinic: “You make your money from inpatients. This is an altruistic move on their part.”
Slow progress has been evident at the other two hospitals, as well. New York governor Andrew Cuomo delivered $114 million, the first in federal recovery aid to the region, to NYU's Langone facility. But that was just a beginning; according to a December 16 Associated Press article, it will take an estimated $1.1 billion in payments from insurance and the Federal Emergency Management Agency for that 1,000-bed facility to fully resume its operations. The Manhattan VA is looking to provide care to outpatients by March, and although at the time of this writing it had no plan to reopen inpatient units, it is helping veterans to find needed care at other VA facilities in the city.
When the U.S. Congress ended its session at the start of the year without approving President Obama's requested $60 billion in federal disaster aid to the region, many complained, as New Jersey governor Chris Christie put it, that the delay resulted from “the toxic internal politics” of the House Republicans. (A two-part vote was set for when the new Congress convened in January.)
The larger questions of why the city's health care system had taken such a blow and how such a catastrophe could be prevented in the future were also being discussed. Bloomberg didn't respond formally to the Build Back Better campaign's protest, but he announced one idea under serious consideration: the cogeneration of power, which would allow large hospitals to independently produce their own heat and electricity (read his entire speech at http://on.nyc.gov/ULk32S).
It's just one of many possible long-range solutions that clinicians, politicians, and the public will be debating for months, and perhaps years, to come.—Joy Jacobson
© 2013 Lippincott Williams & Wilkins, Inc.