← Becker’s Healthcare Podcast
Becker’s Healthcare Podcast
Andrew B. Wallach, Ambulatory Care Chief at NYC Health + Hospitals/Bellevue and Ambulatory Care Chief Medical Officer for NYC Health + Hospitals
00:16:19
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- [00:01]
A
Hi, this is Paige Twiner, assistant editor with Beckers Healthcare. I'm so, so excited to be joined by Andrew Wallach, an ambulatory care leader at NYC Health and Hospitals. I don't want to take your thunder. So Dr. Wallach, if you can just briefly introduce yourself, tell us a bit about your organization and then we'll dive right in.
- [00:23]
B
Wonderful. Well, thank you Paige for having me today. Indeed. My name is Andrew Wallach and I am a board certified internist. I like to describe a recovering hospitalist who's now working clinically solely in the outpatient arena and at my institution, which is New York City Health and Hospitals. I currently serve as the system's ambulatory chief medical officer. You may or may not know, but New York City Health and Hospitals, often known as H and H, is the largest municipal healthcare system here in the US we operate as a public benefit corporation and essentially serve as a safety net for New York City and provide care for over 1 million New Yorkers regardless of their ability to pay or their immigration status. Interestingly, we provide over 60% of all behavioral health care here in New York City. Really are at the forefront of that. We have 11 acute care hospitals, we have five post acute or long term care centers, we have a federally qualified health center, we run a correctional health service operation and we also have our own high quality, low to no cost health insurance plan called Metroplus. So all that to say we are big and we reach all parts of.
- [01:40]
A
New York, big and mighty. And I'm excited to hear about Urals strategy through this particularly severe flu season. Currently we were talking before the. For listeners, we're Dr. Wallach and I were talking before the podcast and it sounds like New York's data latest kind of shows that the state has just passed its peak in flu hospitalizations. That's correct. I would love to hear, and I'm sure listeners would love to hear what you all saw on the grounds. Like what did you see in your in HNH in terms of capacity and flu. Flu acuity.
- [02:22]
B
Yeah, no, that's exactly right, Paige. Thankfully, at least here in New York State, not only are total number of flu cases that are reported weekly down, but so are hospitalizations, which as we know oftentimes lags the number of cases. But as you alluded to, New York City was hit really hard and early this year by the flu outbreak, perhaps earlier than other jurisdictions across the country. And in fact, on December 2nd of last year, our health commissioner declared influenza prevalent throughout the state, which is really kind of the activation if you will, of our flu season. If you look at the data, the number of reported cases here in New York peaked at over 70,000 affected individuals in a week. And again, just to give you some comparison, last year's flu season in New York State at its peak, only had 55,000 cases reported per week. So pretty significant increase compared to previous years. And in fact, not only these case counts, but the hospitalizations are the highest ever recorded in our region, dating back to 2004, when we started tracking this information. So it hit early and it hit hard. Now, interestingly, as of the week of January 3rd, as I mentioned a moment ago, a little bit of a lag in hospitalizations, but those started to come down. And then today's data actually showed continuing decrease in hospitalizations related to flu. So what did we see here at New York City health and Hospitals? Well, our experience really mimicked very closely what we were seeing in the reported numbers. Our emergency departments really started seeing large numbers of folks presenting with respiratory symptoms. Our virtual express care, which is something that we have really grown out since the pandemic, was also very busy in taking calls and patients who weren't feeling well, many from the flu. And then lastly, our outpatient practices also saw large influx of individuals presenting with these symptoms. Now, interestingly, the piece that we don't always talk about is not just the patients, but certainly wearing my healthcare system cap, if you will, is we want to make sure that our staff also are protected because they're people, too. They get sick. We're not immune to all things. And so we really wanted to protect our workforce to make sure they were able to show up to work, to be able to take care of folks who weren't doing well.
- [04:54]
A
Were you all expecting the early, like, season of flu or expecting, you know, that weekly caseload to exceed last year's record?
- [05:05]
B
Yeah, it's a really great question. So the short answer is yes. You know, based on experience that we saw in the Southern hemisphere earlier this year and then certainly reports coming out of Japan and the United Kingdom, we knew about, you know, kind of the variant that was, you know, circulating, the subclay, subclade K variant, which we knew was causing, you know, havoc, if you will, overseas and down under. So we had the anticipation that it would be a rough flu season this year, but I don't think we appreciated just how quickly it would fall upon us here in New York.
- [05:42]
A
You mentioned both the virtual express care and investment in protecting staff to be able to care for this influx of patients. Can you kind of dive further into those kind of care coordination strategies.
- [05:58]
B
Yeah, no, sure. You know, I think one of the, you know, I'm definitely a glass half full kind of guy. And if you look back over the COVID pandemic, which was so traumatic on so many levels for all of us in health care, one of the good things, or one of the several good things that we learned and were able to develop was the role of virtual care. We really weren't doing very much of it before the pandemic. And quite honestly, we turned it on essentially overnight. And in the years since, we've been able to fine tune and grow it. And it has really become such an important aspect of our care delivery model to allow patients to seek health care without having to physically come in to a facility. So it's something that we've continued to grow over time and in a situation like this really lends itself very nicely, especially in conjunction with the fact that there is so readily available in 2025 and 2026 the ability for one to go to a retail pharmacy and purchase an over the counter flu test, if you will, so somebody can test themselves if they have symptoms in the comfort of their home and then can pick up the phone, you know, and speak to a clinician to get treatment, if appropriate, and if nothing else, to get guidance. Now, with regard to our staff, again, to your point that we knew that it was going to be a rough flu season, we really, this year, earlier than ever, really pushed with our staff the importance of getting vaccinated. We really, you know, did full court press to let people know how important it was to get the vaccine. And although we know that the vaccine is not a perfect match this year to the circulating strains, we do know that it still offers protection, certainly in decreasing severity of disease and certainly hospitalization and death. So those are some of the strategies that we kind of use this year in anticipation.
- [08:03]
A
Speaking on a broader lens outside of New York, the day we're recording this podcast, you know, we were talking of New York's kind of dip. But other regions in the US are expecting or have not yet hit their peak, likely in flu cases and hospitalizations. For hospital leaders out there that, you know, are reading the research like, you know, we're watching the southern hemisphere data, we're, you know, watching what's happening and New York and a few other states, what top recommendations would you give them?
- [08:38]
B
Yeah, it's a really great question. And so, you know, from my perspective, again, I can't overemphasize and I know I'M speaking, you know, to the, to the converted. But making sure that staff and patients are vaccinated is just so critical. So I just want to say that again and again and again because I think, you know, getting the word out is just so critical. So can't under or overestimate rather the importance of that. Now that said, you know, when hospitals face a sudden surge in things like flu, for example, you really need to shift your strategy from what I call routine care to surge capacity management. And oftentimes when we talk about surge capacity, I think of it in the 4S framework and that's really staffing, space, supplies and systems. And so I'll go into a little bit more of what I mean by that. So space, again, lessons learned from the COVID pandemic is the ability to repurpose nonclinical areas, right, in order to maintain patient flow and safety. So there are areas and parts of our facilities where we can readily flex back to active clinical care to be able to take care of patients as needed. Some facilities, depending on how severe things may be, you might want to put up temporary structures like tents, heated tents outside your emergency departments. But really think creatively of how you can add clinical space to be able to adjust and flex for the incoming. The other thing that we did, and again, I would highly recommend to other health systems out there, is the idea of cohorting patients. Historically we always think of one patient to one room, especially when you're talking about isolation, but that's not always possible. We don't have enough isolation rooms for each individual person. So you can move towards cohorting together flu patients in a multi bedded room to help get with space and flow. Oftentimes they're called respiratory pods or dedicated wards. It also helps streamline your nursing care because your nurses can really be dedicated to these folks. They know what they're doing and can be very attentive to the needs of those folks all with the same diagnosis. From a staffing perspective, that's always the crux of all of our facilities. And we rely so heavily on our amazing nursing staff. They really are the ones that keep us moving forward and making sure patients are well cared for. And so developing things like internal float pools have been very effective in being able to again, flex and manage when you have these surges and be able to focus on those areas of the hospital that need it. Other things from a systems perspective, I like to really tend to think about performance from a system perspective is what can we do to kind of implement kind of triage to treatment orders, if you will, like non patient specific orders. That includes things like having nurses when patients come in with respiratory symptoms, go ahead and do swabs and test folks, start hydration protocols even before the provider starts to see the physician. You don't want to lose any time. So whatever you can do up front to kind of work as a team, I think really goes a long way. And then similarly, again, what's really important is the use of our antivirals. Right. So we wanna get the message out to staff and to patients that if you're not feeling well, get tested early so that we know what we're dealing with. And if you're eligible, they're antivirals that we can give you to shorten your course and certainly decrease the severity. So again, getting that message out and working with our clinicians to make sure folks are getting treatment as appropriate. And then of course, lastly, you know, everything, you know boils down to supplies and infection control. So maintaining a system and monitoring your PPE supplies so you don't get to the point where, oh, my goodness, we only have a day's worth of, you know, N95 masks available. But really to make sure that you've got hard triggers that let you know in advance so that you can order and make sure that you always have a good supply of these needed items. The last thing that I will mention from an infection prevention and control process and something we actually did at my hospital is when we saw this large surge, we actually moved to universal masking policies, meaning that during the surge, when we saw so many cases, we moved to the fact that you needed to wear a mask regardless of whether you've had a flu vaccine during every direct patient encounter. Again, the goal is to mitigate further transmission, keep our patients and our staff healthy, and not have others get infected.
- [13:22]
A
Yeah. And also on that note of supply, I would imagine, like the antiviral, just supply of, you know, Tamiflu and other common flu medications. Shortages are popping up in different regions of different areas of the US So I know also just something to keep track of. I'm not sure if that's a big attempt at the.
- [13:44]
B
Yeah, it's a really great point. Right. And again, you know, looking back, not to beat a dead horse, but to look back to the pandemic, you know, again, another lesson learned from us is don't put all of your eggs in one basket. So historically, like, we would have one supplier. Right. For antivirals. Right. And so our supply chain now has gotten very adept at making sure that if our main supplier is out of a particular medication, do they have a backup? Do they have a second and a third tier to make sure that we're always well stocked with the needed medications.
- [14:18]
A
We have about one minute left for our podcast recording. Is there anything we haven't talked about yet that you'd love to share with other hospital execs?
- [14:27]
B
Yeah, I mean, I think from my perspective here at New York City health and hospitals, my recommendation to my colleagues out there, and again, I hope that you guys quickly follow us in coming down from your peak. But there are four main essentials that I think of kind of wearing my healthcare executive cap, and that is to make sure that there's tight communications. And so one of the things we did is we conducted bed huddles on a regular basis just to understand our census and our discharges, to be able to plan how to run our house again from a safety perspective, making sure that you get the message out to folks that if you don't feel well, if you're sick, stay at home. We don't want you coming to work infecting other individuals. Again, we talked about efficiencies using standing orders where appropriate and allowed, you know, by your state legislatures. But that really goes a long way in helping with those efficienc. And then lastly, I would just remind all of us that it's hard to being a healthcare provider in 2025 and 2026. And so, you know, be aware of what the toll that has taken upon our staff and, you know, make sure that you recognize them, that you rotate people out. You don't want the same people working, you know, in the flu wards, if you will, day after day, give folks a break and consider, you know, consider that to be able to, to have sustainable positions and keep your. Keep your workforce healthy.
- [15:50]
A
They keep patients healthy in the end of the day.
- [15:53]
B
Yes, exactly.
- [15:55]
A
Well, thank you so much, Dr. Wallach, for joining us on the Becker's podcast.
- [16:00]
B
It was my pleasure. Thank you for having me.