Disaster may be fading from other New Yorkers’ minds, but hospitals like Beth Israel have been forced to permanently re-examine their operations.

Before the antiseptic smell even has a chance to reach your nose, the first thing you notice about Beth Israel’s ER is the sheer number of people occupying it. Bodies fill every chair in the cramped waiting room and every bed in sight; bodies linger in corridors. Months after Hurricane Sandy’s New York landfall, one of the few hospitals fully up and running in downtown Manhattan is still bearing the brunt of the storm’s devastation.

Jim Mandler, vice president of public affairs and communications at the hospital, says there’s a method to all this madness.

“That happens over time,” he explained, indicating that however chaotic things may appear, sufficient practice has smoothed out the hospital’s routines.

While Beth Israel never closed during the disaster, it felt the effects of being the only hospital open for a time in the area.

About two weeks after the hurricane that shook Lower Manhattan to its core, Murray Hill resident Brett Shanley was moving into a new apartment when he felt a persistent shooting pain in his back. He knew he’d pinched a nerve. Shanley immediately made his way to NYU Langone Medical Center a few blocks from his apartment. There were sandbags around the hospital; it was still closed. Shanley hopped in a cab to Beth Israel, where a nightmarish scene awaited him.

“I had never seen [an ER] this crowded or this foul. Sneezing and bleeding and shouting, snoring and crying and muttering—it felt like an asylum,” Shanley said.

“People kept streaming in with nowhere to sit … the room maybe held 50 people comfortably and there were 80 to 90 people in it. The ceilings were low and it was poorly lit.”

“The staff seemed hard-working, curt and exhausted,” he added.

After three hours, Shanley was able to see a doctor. “Ultimately I was called back deeper into the depths of the hospital which, in comparison, felt like a high-end resort. The halls were clean, well-lit and uncrowded. People even smiled and joked. It was hard to believe it was the same building.”

Shanley said he spent about six hours in the ER that day.

While Shanley’s visit to Beth Israel did not coincide with the worst of the storm, it reveals the dire circumstances of a facility still facing the fallout of a disaster which shut down every other hospital in the lower third of Manhattan.

The media spotlight on the impressive evacuation efforts of NYU Langone Medical Center during the storm has overlooked the pressure put on other facilities due to overcrowding, say hospital administrators. This pressure has been enormous, particularly at Beth Israel.

“We’re getting a different population than we’re used to,” explained Mary Walsh, the chief nursing officer for Beth Israel. “Psychiatry has probably been the major difference.”

In addition to added psychiatry services, the hospital has had to take on more emergency patients, provide extensive obstetrical (OB) services and even house some of Bellevue’s prison population.

“[Admitting] four to five patients under arrest at one time is unusual,” said Walsh, compared to standard procedure.

Throughout the storm and its aftermath, Beth Israel was forced to meet many very specific and unusual needs. The hospital served not only as an emergency room, but a pharmacy, a dialysis center, a methadone clinic, a place to sleep and a place to charge cellphones. Displaced people throughout the city made their way to Beth Israel, often simply wandering in off the street, said John Samuels, the administrative director for emergency services. He pointed out that it became a real security issue.

“People would come in and say, ‘Can you go pick this person up in the street?’ People couldn’t call 911,” Samuels said.

Anything for which someone might ordinarily call their doctor, they turned to the only open hospital—and one of the few open establishments at all—downtown.

“We weren’t just meeting medical needs, we were meeting social needs too,” Mandler said. The hospital became a sort of community center; no one was turned away.

Perhaps counterintuitively, though, the real spike in patients—and in the severity of their cases—came after the storm had receded. At that point, the social needs had been met, many could return home, and those who were seriously sick or injured came to the hospital for the first time.

“That’s when people woke up and realized, ‘I need to get to the hospital,’” Samuels said.

Prior to the storm, Beth Israel saw approximately 320 patients a day; during the storm, the hospital was seeing highs in the mid-400s. Ambulance volume doubled as well. According to Samuels, an ambulance is more ominous—indicative of a sicker patient.

The current patient load remains substantially higher than usual, with between 75 and 100 extra patients per day.

Beth Israel brought on other doctors—many from NYU—and purchased more resources, including beds and linens, to meet increased need. The hospital also opened up additional units and fed its employees around the clock while they were holed up inside. Samuels said it was hard to place a price tag on the added costs.

Alan D. Aviles, president of the Health and Hospitals Corp. (HHC), said the cost to repair New York City public hospitals and ensure against future damage would likely exceed $800 million.

The exhausted staff Shanley encountered had been sleeping side by side on the floor of the hospital, often in four-hour shifts, throughout the worst of the storm.

“The nurses did a yeoman job,” said David Bernhard, the senior vice president of medical affairs. “Employees were sleeping in the hospital who might have gone home … it was really a remarkable effort.”

Beth Israel also took in about 140 evacuees from sister hospitals, but running on a generator still didn’t mean everything functioned properly. Walsh explained Sandy was different than other disasters because not only was the environment affected, but so were the hospital’s usual techniques.

New York City Council members have introduced a bill in the aftermath of Sandy which aims to strengthen flood-proofing requirements for health-care facilities in the city. Hearings have been under way to address these issues.

Administrators agreed emergency planning, including the hospital’s emergency management committee, was helpful, but everything could be better the next time around.

Hospital administrators realized, for instance, post-Sandy, the ER demanded certain necessary modifications. For one, they needed to re-examine their fast track system, which aims to move patients with less serious ailments in and out quickly. They transformed one of their three treatment pods into the fast-track area during the storm, a change that has remained in place. The hospital also opened up a private VIP room into a space where several patients could be treated side by side.

“We will still need to reassess the fast track,” explained Lisa Dyer, Beth Israel’s nursing director, adding with the new changes, non-urgent patients are already not waiting as long as before. She described it as a work in progress.

Despite its severity, Hurricane Sandy wasn’t the first event in recent years to spur much-needed change at Beth Israel.

Mandler described a recent decision by the hospital he called fortuitous. After Cabrini Medical Center closed in 2008, Beth Israel expanded their space, allowing them to take in many more patients. After the 2010 closing of St. Vincent’s hospital, the added space was a major help, as Beth Israel patient numbers saw an immediate surge. However, Hurricane Sandy has taught administrators at Beth Israel they still need to address surge capacity issues.

Lisa Cannistraci, who is something of a West Village staple as the owner of Henrietta Hudson bar and a member of Community Board 2, recently had to confront these issues firsthand.

Cannistraci broke her thumb in a freak accident two weeks ago and went to Beth Israel around 11 p.m.

“There was no seating, it was packed to the gills,” said Cannistraci. “They alluded to the fact that I’d be there all night … I did the intake and then after I sat down I said to myself, ‘I gotta go.’”

Cannistraci had a friend drive her to a hospital in New Jersey where she was in and out in under two hours.

“The ambiance was very dismal among people waiting [at Beth Israel],” said Cannistraci. “There had to be 120 people there.”

Cannistraci noted the staff at Beth Israel was “fantastic” despite the overcrowding.

“St. Vincent’s closing was a tragedy to everybody,” she added.

With regard to long-term plans for the hospital, including additional facility construction, Mandler said Sandy will definitely influence the outcome.

Beth Israel’s president, Harris Nagler, agreed with this assessment. For all Beth Israel’s response efforts, “Sandy really tested the system,” he said. “We need to ask if we’re currently at the tipping point of responding.”

While most New Yorkers may have moved on from the hurricane, Beth Israel and other downtown hospitals do not share that luxury. Bellevue, which closed for the first time in 275 years according to Aviles, has resumed many of its services but is still not taking ambulances. The VA hospital is closed with plans to reopen in mid-February.

Even so, Walsh believes Beth Israel’s patient load is likely to be higher for good. “When Bellevue opens again some patients will still come back,” she said. “Because of our care.”

The impact of Sandy on the hospital will not be forgotten by Beth Israel staff members anytime soon.

“Here,” said Bernhard, Hurricane Sandy “is still on everybody’s mind every day.”

Barbara Warren heads LGBT health division at Beth Israel

Barbara Warren, the director of LGBT health services for Beth Israel, is a humble woman who, according to Vice President for Public Affairs Jim Mandler, “has spent her entire career advocating for individuals in the LGBT community.”

Before arriving at Beth Israel 11 months ago, Warren spent ten years as a policy advocate, doing research and policy work. The position at Beth Israel was “an opportunity to actually implement this work in a real-world setting,” she explained. “That’s what’s gratifying.”

Since joining the hospital, she has overseen training in LGBT cultural competency to over a thousand employees. The hospital will also be piloting data collection for clinical management of gender identity this spring, under Warren’s supervision.

She noted in the past year there has also been increased community wellness programming.
Warren explained that the Services and Advocacy for GLBT Elders group (SAGE) opened the first LGBT senior center in the world.

“We got a small grant from a donor to do a wellness series called ‘Ask the Docs’ at the SAGE senior center starting this winter,” Warren said. “We’re doing similar stuff with the LGBT center and Gay Men’s Health Crisis.”

Despite these successes, Warren’s time at Beth Israel has not been without its difficulties.
“It’s a huge challenge to take good intentions and policies and translate them into sustainable practice in an institution where over 8,000 employees across a variety of disciplines have a lot of other things they’re working on,” Warren said.

“There’s a lot of competing demands on time and interest,” she added.

One of the biggest challenges facing Warren is balancing the delicate art of meeting patient needs, while also protecting their safety and confidentiality.

She explained it’s a sensitive process, addressing these many factors. “It’s not just training,” she said. “It’s new systems, outreach in the community, grappling with issues in order to do quality assurance and document both emerging needs and best practices.”

These new systems include the implementation of electronic health records.

Warren explained that for health reasons it can be important to identify people who are lesbian, gay and transgender in these records, but there are confidentiality concerns, as it’s not simply “the same as saying your age or ethnicity.”

“We still don’t live in a world where people feel totally safe about being out and having their sexual orientation in an electronic health record,” Warren explained. “Even in a city like New York, where there’s equal protection under law.”

“I hear people say: ‘I don’t mind telling my provider, but if it’s on my electronic health record, what if I’m in the emergency room, unconscious, in Oklahoma, and it’s on my record that I’m a lesbian,’” Warren said. “That’s a challenge.”

Warren plans to continue addressing these issues as aggressively as possible, saying the challenges will not stop her or her colleagues.

“We’ll never have to worry again with this [electronic database] system about people being treated inappropriately in any setting … but there are related issues, particularly when you’re talking about sexual orientation.”

She continued: “There isn’t equal protection all the way across the board. Experience says it’s better to be out, [but] it’s still anxiety-provoking.”

“We’re still at the cutting edge in the real-world setting,” she added.

Nonetheless, Warren believes there’s broad support across the institution for improving services to LGBT patients.

“This institution is 100 percent behind working through the problems,” Warren said. “It’s really motivated by doing the right thing. A lot of people are motivated by getting patients, but [Beth Israel and its partners] are motivated by quality of care.”

While grappling with these tough issues on a regular basis, Warren even devotes some of her free time to providing medical care to others, including taking care of her elderly mother.

Dr. John Andrilli Consults with Denis Tejada, RN

by David Gibbons

For many observers, the closing of St. Vincent’s Hospital—one of the oldest community hospitals in the nation and a New York City icon throughout the 20th century—was a disaster, a disgrace, a moral failure, an avoidable tragedy. After its demise at the end of April 2010, professionals in other downtown medical centers noted a surge in ER visits and ambulance runs. Now, just over two years later, the question is: Have the others been able to fill the gap?
The two major area players are Beth Israel Medical Center, part of Continuum Health Partners (CHP), and the North Shore-LIJ Health System. Beth Israel had already doubled the size of its emergency room after the closing of Cabrini Medical Center in 2008, so it was well prepared for the St. Vincent’s surge; other local hospitals also expanded and adapted to pick up the slack. Meanwhile, both CHP and North Shore-LIJ, as well as several independent partnerships of doctors, have begun to offer more options for urgent care.
In March, 2011, North Shore-LIJ partnered with VillageCare to open an urgent care center at 121A W. 20th St. Around the same time, North Shore-LIJ announced its trump card; plan to convert the O’Toole Building—the white wedding cake-like landmark on 7th Avenue between 12th and 13th streets that was part of the St. Vincent’s complex—into “the first stand-alone emergency and ambulatory facility in the New York City metropolitan area.”
“We developed what we felt was a realistic proposal to restore comprehensive health care to the West Side,” said Terry Lynam, a North Shore-LIJ spokesperson. “We’re investing $110 million to build a true community resource that will go a long way toward giving people access to health care that has been lacking since the closing of St. Vincent’s.” It is scheduled to open as The Lenox Hill Hospital Center for Comprehensive Care in early 2014.
“North Shore is doing a commendable job trying to rebuild some services,” said Dr. Fred Hyde, clinical professor at Columbia University’s Mailman School of Public Health and an expert on management and policy. “Still, the closing of a hospital is irrelevant to the utility of urgent care centers, since hospitals were never much good at outpatient care in the first place. Urgent care is a substitute for available primary care physicians, of which we may have too few—local, state and national.”
Hyde estimates that an individual physician, depending on how “muscular” a schedule he or she is willing to tackle, can serve a primary care base of
2,000 to 2,500 patients. These figures, together with a projection from the Urgent Care Association of America of one clinic per every 40- to 50,000 people, suggest that roughly 50 hardworking doctors staffing urgent care clinics in an area the size of southern Manhattan
could have a significant impact.
“If St. Vincent’s was like a lot of hospitals, it had an ER half-full of non-emergency patients who could have been treated in an urgent care clinic,” said Lou Ellen Horwitz, the Urgent Care Association’s executive director. “So while urgent care can’t replace hospital beds, it can create access for a lot of patients who would have gone to an ER.”
CHP’s strategy is to build neighborhood primary and specialty care practices that accept walk-ins, one of the many ways it strives to meet the needs
of the community, according to spokesman Jim Mandler. Marked by their familiar awnings with the blue Beth Israel logo, they are currently located in the West Village (222 W. 14th St.), Chelsea (202 W. 23rd St.) and lower Midtown (55 E. 34th St.).
The Chelsea practice is expanding and will relocate to the northwest corner of 23rd Street and 8th Avenue on Sept. 1 with 12,000 square feet of space on two floors.
Tom Poole, vice president of Continuum Medical Groups, who oversees development and operation of CHP’s community medical centers around
Manhattan, calls it “our newly renovated state-of-the art facility for walk-in primary and specialty care, one-stop shopping sorely needed to serve Chelsea and Penn South,” a neighborhood development with a large elderly population.
In November, Continuum will open another new Beth Israel facility on 8th Street in the West Village, able to handle 36,000 patient visits per year at full capacity.
“Our model for the future is easy, open access,” said Poole. “We’ve found this is what patients increasingly expect; they don’t want to wait six weeks to see their doctor. We aim to treat patients who need immediate or urgent care and create an environment that provides a satisfactory experience for everybody. To put it simply: We want happy patients, happy physicians and happy staff.”
“We’re able to see this with our practice on 14th Street, and we hope it will continue with the new locations on 23rd and 8th streets,” Mandler added. Poole says he feels a year from now will be a good time to re-evaluate the success of this new model; he also expects the increasing demand for urgent care to grow hand in hand with new housing development along the West Side.
(For more information on Beth Israel’s practices, visit www.bethisraelmedicalgroup.com or www.wehealny.org.)
At CityMD (www.citymd.net), they are equally bullish: “From our perspective, we see a major need for quality urgent care throughout the city and
particularly in the downtown area,” said COO Dr. Nedal Shami, adding that business is good. The company opened its new Flatiron branch at 37 W. 23rd St. on May 8 of this year, has another scheduled to open on 67th Street in the fall and is actively seeking a location in Tribeca or the Financial District for the near future.
Other private partnership practices along the lines of Beth Israel’s primary care walk-ins are opening up, among them the One Medical Group (www.
onemedical.com), which has five locations, including in the West Village, at 408 W. 14th St., and the Wall Street area, at 30 Broad St.
Additional urgent care options in Manhattan’s Lower West Side include New York Doctors Urgent Care, 65 W. 13th St.; Emergency Medical Care, 200 Chambers St. (www.emcny.com), and Medhattan Immediate Medical Care, 106 Liberty St. (www.medhattan.com).
According to rules of thumb and guesstimates from several experts, it appears that southern Manhattan’s urgent care needs are being addressed, and that the closing of St. Vincent’s, in the cold light of history, may one day be considered more of a transition than a
debacle.