Yale New Haven Hospital (YNHH), a 1541-bed, two campus medical center in New Haven, Conn., has transformed itself many times over in order to meet patient care demands due to the COVID-19 pandemic. Leaders looked at the way the hospital functioned overall, where patients were cared for and by whom, along with other operational procedures to determine what changes needed to be implemented to best care for COVID-positive patients. By the time the first COVID-19 patient was admitted to YNHH on March 13, the facility was in the midst of a remarkable transformation.
In late February, leadership within Yale School of Medicine’s (YSM) Department of Internal Medicine began discussing how to reorganize in-hospital and outpatient care and education to balance quality, efficiency, sustainability, and risks. Led by Chair Gary V. Desir, MD, the team identified key operational variables that required attention and planned for those changes. By March 14, the team was implementing dramatic and fundamental changes in their workflow under the direction of Vice Chair of Clinical Affairs Lynn Tanoue, MD, MBA.
While the staffing models were changing, physical changes were taking shape. The number of elective procedures was decreased starting the week of March 16, to help conserve personal protective equipment and free up hospital resources. Additionally, Yale Medicine ambulatory appointments were converted to telehealth and routine visits were rescheduled. Temperature checks were initiated at all building entrances and the visitation policy was revised on March 17 to prevent the virus spread. Women’s Services and Neonatology were consolidated onto YNHH’s York Street Campus.
A goal was to maximize the number of available negative pressure rooms, important in reducing contagion of infectious diseases such as COVID-19. By mid-March, patients, nurses, caregivers, and staff from the top three floors of Smilow Cancer Hospital had been relocated to YNHH’s Saint Raphael Campus. North Pavilion (NP) 15, 14, and 12 – all built in such a way that they could convert to negative pressure fairly easily. The conversion of these floors resulted in an additional 84 critical care-capable patient beds, which became designated COVID units, and began to receive patients on March 27.
The Department of Internal Medicine reconfigured its firm structure and workforce set-up to maximize resources. The hospitalists, or physicians who care for patients exclusively in the hospital, were spread across new units throughout the hospital. Infectious disease specialists started consulting on every COVID-positive or COVID-rule out patient. Responsibilities of the pulmonary, critical care, general internal medicine specialists were expanded to care for the influx of those needing care and significant changes were made to the units that treated nephrology, medical oncology, and digestive diseases patients.
Based on other institutions’ experience in Seattle and New York, it was quickly recognized that the biggest challenge for patient care in the hospital would be seen in the Internal Medicine wards and in particular, the medical intensive care units (ICUs). Providing attending coverage for the latter was anticipated to be the biggest potential barrier to continuing to provide safe patient care of highest quality. To meet this challenge, the entire YSM faculty was polled electronically to identify physician faculty from non-Medicine departments who would be willing to work on the Medicine service and capable of providing critical care independently or with supervision. A remarkable outpouring of volunteers ensued, with over 800 faculty from every department at YSM responding to the survey. Subsequent surveys identifying their own department responsibilities, restrictions to working with COVID patients, and a critical care skills analysis resulted in a cohort of nearly 100 faculty who were subsequently deployed as needed in the ICUs and on the Medicine wards. Additionally, critical care faculty from the Departments of Anesthesiology, Surgery, Neurology, and Pediatrics committed to caring for medical ICU patients who would predictably overflow into their own critical care units.
A call for volunteers to serve on general medicine floors or ICU was also well received. Over 177 residents and fellows from the Departments of Anesthesiology, Neurology, Dermatology, Pathology, Surgery, Radiology, Psychiatry, and Pediatrics stepped up to assist the Department of Internal Medicine with their patient load. Over 70 community physicians were issued emergency credentials to treat patients at YNHH.
The ingenuity of everyone involved to determine how our hospital could best function to care for the COVID patients should be commended.
Dr. Gary V. Desir
Throughout March, Yale New Haven Health (YNHHS) opened multiple drive-through specimen collection sites, where the public could gain access to testing, extending from Greenwich to New Haven.
As inpatient volume grew, additional units were transformed. As of April 20, 16 of the 27 units at the York Street Campus and 11 of 18 at the Saint Raphael Campus are dedicated COVID-positive spaces, where patients can be safely cared for without endangering others who don’t have the disease.
YNHH’s Emergency Department (ED), led by Gail D’Onofrio, MD, MS, and Andrew Ulrich, MD, is on the frontline of the pandemic. The administration team quickly developed an ED COVID-19 Task Force, managing many potential COVID-19 patients, developing triage and treatment protocols, and adapting staffing patterns, patient flow, and testing as the crisis evolved. Tents were added outside of the ED on March 23 to triage people before they can enter the facility.
In early April, collaboration between ITS and our Pulmonary/Critical Care Medicine leadership resulted in a dramatic expansion of tele-ICU services across YNHHS, with 149 tele-equipped rooms available—up from 41 before the pandemic began. In addition, large volume infusion pumps were moved outside of the ICU rooms to reduce the need to don PPE and make rapid changes to IV infusions.
“These physical moves could not have taken place without the tremendous teamwork of hospital staff, physicians, nurses, Environmental Services, ITS, and many others,” said Desir. “The ingenuity of everyone involved to determine how our hospital could best function to care for the COVID patients should be commended.”