A total of 394 patients were admitted over 7 weeks from April 10 to June 2, 2020. Admissions peaked on April 17 with 25 admissions, and the last admission was on May 26. Most patients (69%) were referred from local AMCs, with 42% from safety-net hospitals with large immigrant and underinsured populations. Admissions were later opened to emergency departments (EDs) and outpatient settings. The average length of stay was 8.3 days; 71% of patients were male, the average age was 57 years, and 31% were 65 and older. Patients on average were taking 6 daily medications and had 5 active medical problems on admission. The mental health team consulted on 25% of patients.
There were no intubations, cardiopulmonary arrests, or patient deaths. There were 26 unplanned patient transfers to EDs, resulting in a readmission rate of 6.6%. Most transfers were for non-COVID issues such as chest pain, hypertension or altered mental status. Seven of these transfers returned to the field hospital from the ED or after additional hospitalization.
Nearly all (91%) patients were discharged home or to a shelter, and 15% of patients required home services such as nursing or physical/occupational therapy. Eleven patients were discharged to another PAC facility for additional rehabilitation or long-term care. Seven patients were discharged Against Medical Advice.
Race demographics were available for 69% of patients: 25% Other, 18% Black, 19% White, 4% Hispanic/Latino, and 3% Asian. Nearly half (48%) of patients reported non-English languages as their primary language, including Spanish, Haitian Creole, and Portuguese Creole.
There is limited literature to guide organizations and governments who need to scale emergent PAC facilities for patients with COVID-19.
Medical Shelter Staff
Supples, and Equipment for the states of New York and New Jersey. Department of Homeland Security (DHS) Federal Emergency Management Agency (FEMA).
Our experience demonstrated it is possible to rapidly assemble and manage a COVID-19 PAC facility. This report provides a guide for others confronting similar challenges.
Partnership with local government, military, and major health care organizations was essential for logistical and medical resource support. The government and military provided infrastructure and material support for construction and supplies, physical space, and security. The MHS and other local organizations provided administrative and clinical staffing, electronic health record, laboratory, and medical supplies. The emergent nature of the pandemic required strong collaboration that may not have been possible previously due to competition for patients, market share, and other resource constraints.
Positive clinical outcomes (low hospital readmission rate, zero mortality) were likely due to rigorous admissions screening processes, generous multidisciplinary staffing (including 24 hours per day availability of acute care physicians); and an incident command structure to provide clarity regarding communication, supply chain, and leadership of human resources.
One implementation challenge was the logistical complexity of providing in-patient care in a convention center. This was addressed by identifying the appropriate patient population, specifically patients with PAC needs and not acute or hospital level of care requirements. Off-site laboratory and pharmacy for most medications was appropriate for providing PAC but would have been challenging for acute care. Cubical room layouts and bathroom distance also created challenges to providing care. To address these concerns, bathrooms with handicapped accessibility were constructed closer to patients, and patients with long-term care needs such as advanced dementia were excluded from the admissions criteria.
The rapid time frame for implementation was another challenge. This was addressed by ensuring that clinical leadership had both PAC and acute care experience as well as expertise in operations and scaling. In addition, expertise in COVID-19 disease was necessary given ever-changing care guidelines. This was facilitated by having access to a large AMC's Infection Control and Division of Infectious Disease leadership.
Workforce challenges, such as staff with varied clinical backgrounds and experience, were optimized by using team-based care and supervision to balance clinical skills and experience. One unintended but useful outcome was that patients often had access to in-person sub-specialty care (eg, orthopedics and dermatology). Finally, electronic health care record challenges were addressed by providing concise guides, access to telephone support, and generous staffing ratios to allow for on-the-job training.
The COVID-19 pandemic has exacerbated existing racial inequalities, with higher infection rates and more severe illness among communities of color and immigrants.
- Anyane-Yeboa A.
- Sato T.
- Sakuraba A.
Racial disparities in COVID-19 deaths reveal harsh truths about structural inequality in America.
Our patient population reflected these demographics, with a younger, predominantly male and non–English-speaking population who often lived in densely shared housing, in contrast with most PAC populations who tend to be older adults and frail.
Prevalence of frailty in nursing homes: A systematic review and meta-analysis.
We suspect admissions were limited by patient perception that the field hospital was more of a shelter rather than a PAC hospital and other concerns around general comfort, privacy, and the no-visitor policy.
We recommend careful consideration of vulnerable populations and maximum effort to ensure equity and culturally competent care. In addition, mental health should also be prioritized as we noted that the mental and physical burden of recovery and quarantine was significant. Level of care provided should be adapted based on the facility and staff capability as well as local health care system needs.
- Meyer G.S.
- Blanchfield B.B.
- Bohmer R.M.
- et al.
Alternative care sites for the Covid-19 pandemic: The early U.S. and U.K. experience. NEJM Catalyst.
Our findings are limited in that we describe a single site that cared for fewer patients than expected, given the local epidemic improvement. In addition, this report lacks utilization data to determine precise clinical needs. Data analysis of patient and staff experience is in process. However, we feel this initial report provides important guidance for future COVID-19 PAC field hospitals.
The COVID-19 pandemic continues to threaten our most vulnerable members of society, including patients with PAC needs. This report describes the process that we developed for rapidly assembling a PAC facility for patients with COVID-19 and provides a road map for others facing similar challenges.