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Hi. This is Paige Twenner, assistant editor with

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Becker's Health Care. I'm so, so excited to

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be joined by Andrew Wallach,

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an ambulatory care leader at NYC Health and

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Hospitals.

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I don't wanna take your thunder. So,

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doctor Wallach, if you can just, you know,

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briefly introduce yourself, tell us a bit about

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your organization, and then we'll dive right in.

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Wonderful. Well, thank you, Paige, for having me,

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today.

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Indeed, my name is Andrew Wallach, and I'm

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a board certified,

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internist. I like to describe myself as a

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recovering hospitalist,

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who's now working clinically,

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solely in the outpatient arena.

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And at my institution, which is New York

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City Health and Hospitals, I currently

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serve as the system's ambulatory

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chief medical officer.

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You may or may not know, but New

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York City Health and Hospitals,

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often known as H and H, is the

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largest municipal health care system here in The

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US.

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We operate as a public benefit corporation,

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and essentially serve as a safety net for

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New York City,

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and provide care for over 1,000,000,

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New Yorkers regardless of their ability to pay

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or their immigration status.

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And interestingly, we provide over 60% of all

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behavioral health care,

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here in New York City, so really, are

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at the the the forefront, of that. We

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have 11,

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acute care hospitals. We have five post acute

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or long term care centers. We have a

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federally qualified health center.

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We run a correctional health service,

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operation, and we also have our own,

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high quality, low to no cost health insurance

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plan called MetroPlus. So all that to say,

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we are big, and we reach all, all

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parts of New York.

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Big and mighty. And, I'm excited to hear

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about, Jarls' strategy

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through,

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this particularly

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severe,

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flu season currently.

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We were talking before the for listeners, we're

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doctor Wallach and I were talking before the

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podcast, and it sounds like New York's data,

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latest kinda shows that,

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the state has just passed its peak in

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flu hospitalizations.

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That's correct.

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I would love to hear, and I'm sure

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listeners would love to hear,

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what you all saw on the grounds. Like,

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what did you see in your

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in, H and H in terms of capacity

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and,

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flu acuity?

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Yeah. No. That's exactly right, Paige. Thankfully, at

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least, here in New York state, not only

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are total number of flu cases that are

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reported weekly,

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down, but so are hospitalizations,

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which, as we know, oftentimes lags,

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the number of cases.

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But as you alluded to, New York City

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was hit really hard,

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and early this year, by the flu outbreak,

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perhaps earlier than other jurisdictions,

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across the country. And in fact, on December

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2,

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of last year, our health commissioner declared influenza

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prevalent throughout the state,

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which is really kind of the activation, if

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you will, of our flu season.

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If you look at the data, the number

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of reported

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cases here in New York

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peaked at over seventy thousand affected individuals in

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a week.

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And, again, just to give you some comparison,

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last year's flu season in New York state,

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at its peak only had fifty five thousand

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cases reported per week. So pretty significant,

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you know, increase compared to to previous years.

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And in fact,

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not only these case counts, but the hospitalizations

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are the highest ever recorded in our region,

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dating back to 2004 when we started tracking

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this information. So it hit early,

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and it hit hard. Now interestingly,

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as of the week of January 3,

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as I mentioned a moment ago, a little

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bit of a lag in hospitalizations, but those

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started to come down. And then today's data

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actually showed,

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continuing decrease in hospitalizations

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related to flu. So what did we see

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here, at New York City Health and Hospitals?

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Well, our experience really mimicked

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very closely,

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you know, what we were seeing in the

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reported numbers. Our emergency departments,

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really, started seeing large numbers of folks presenting

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with respiratory symptoms.

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Our virtual express care, which is something that

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we have really grown out,

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since the pandemic,

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was also very busy in taking calls and

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patients who weren't feeling well,

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many from the flu.

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And then lastly, our outpatient practices also saw

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large influx

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of individuals, you know, presenting with these symptoms.

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Now interestingly,

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the the piece that we don't always talk

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about is not just the patients,

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but certainly kinda wearing my,

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health care system cap, if you will, is

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we wanna make sure that our staff also

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are protected. Right? Because they're people too. They

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get sick. We're, you know, we're not immune

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to all things.

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And so we really wanted to protect our

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workforce to make sure they were able to

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show up to work, to be able to

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take care of folks, who weren't doing well.

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Were you all expecting

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the early, like,

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season of flu or expecting,

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you know, that weekly caseload to exceed last

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year's record? Yeah. It's a really great question.

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So the short answer is yes. You know,

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based on experience that we saw in the

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Southern Hemisphere earlier this year and then certainly

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reports coming out of Japan and The United

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Kingdom. We knew about,

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you know, kind of the variant that was,

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you know, circulating the subclade,

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subclade k,

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variant, which we knew was causing, you know,

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havoc, if you will, overseas and down under.

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So we had the anticipation that it would

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be a rough flu season this year, but

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I don't think we appreciated just how quickly,

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it would fall upon us here in New

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York.

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You mentioned both the,

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virtual express care and,

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investment in protecting

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staff,

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to be able to care for this influx

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of patients. Can you kind of

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dive further,

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into those kinda care coordination strategies?

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Yeah. No. Sure. You know, I think one

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of the you know, I'm I'm definitely a

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glass half full kinda guy. And if you

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look back, over the COVID pandemic, which was

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so traumatic

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on so many levels for all of us,

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you know, in healthcare,

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one of the good things, or one of

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the several good things, that we learned and

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were able to develop was the role of

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virtual care. You know, we really weren't doing

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very much of it,

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before the pandemic. And quite honestly, we turned

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it on essentially overnight. And, you know, in

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the years since, we've been able to fine

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tune and grow it. And it has really

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become such an important

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aspect,

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of our care delivery model to

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allow patients

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to seek healthcare,

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without having to physically come in, to a

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facility. So it's something that we've continued to

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grow over time.

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And in a situation like this, really lends

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itself very nicely, especially in conjunction with the

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fact

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that there is so readily available, you know,

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in 2025

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and 2026,

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the ability for one to go to a

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retail pharmacy and purchase an over the counter,

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you know, flu test, if you will. So

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somebody can test, themselves if they have symptoms

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in the comfort of their home and then

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can pick up the phone,

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you know, and speak to a to a

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clinician,

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to get treatment if appropriate, and if nothing

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else, to get guidance.

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Now, with regard to our staff, again, to

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your point that we knew that it was

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going to be,

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a rough flu season,

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we really, this year,

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earlier than ever, really pushed with our staff,

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the importance of getting vaccinated. We really, you

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know,

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did full court,

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press, to let people know how important it

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was to get the vaccine. And although we

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know that the vaccine is not a perfect

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match this year, to the circulating strains, we

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do know that it still offers protection,

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certainly in decreasing severity of disease and certainly

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hospitalization and death. So those are some of

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the strategies that we kind of use this

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year in anticipation.

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Speaking on a broader lens outside of, New

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York,

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the day we're recording

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this podcast,

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you know, we're talking of, New York's kinda

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dip, but other, regions in the in The

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US are expecting,

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or have not yet hit their peak likely,

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in flu cases and hospitalizations.

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For hospital leaders out there that, you know,

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are reading the research, like, you know, we're

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watching the Southern Hemisphere data. We're, you know,

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watching what's happening in,

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New York and a a few other states.

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What

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top recommendations would you give them?

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Yeah. It's it's a really great question. And

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so, you know, from my perspective, again, I

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can't overemphasize. And I know I'm speaking, you

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know, to the to the converted,

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but making sure that staff and patients are

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vaccinated is just so critical. So I just

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wanna say that again and again and again

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because I think, you know,

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getting the word out is just so critical.

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So I can't under or overestimate, rather,

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the importance of that. Now that said,

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you know, when hospitals face a sudden surge,

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in in things like flu, for example,

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you really need to shift your strategy from

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what I call routine care to surge capacity

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management. And oftentimes, when we talk about surge

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capacity,

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I think of it in the four s

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framework, and that's really staffing,

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space,

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supplies, and systems. And so I'll go into

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a little bit more of what I mean

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by that. So space, again, lessons learned from

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the COVID pandemic is the ability to repurpose

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nonclinical areas, right, in order to maintain patient

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flow and safety. So there are areas and

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and parts of our facilities where we can

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readily flex back to active clinical care,

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to be able to take care of patients

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as needed.

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Some, facilities, depending on how severe, things may

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be, you want might wanna put up, temporary

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structures like tents, heated tents, outside your emergency

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departments, but really think creatively,

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of how you can add,

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clinical space, to be able to, adjust and

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flex,

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for the incoming.

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The other thing that we did, and, again,

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I would highly recommend to other health systems

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out there, is the idea of cohorting patients.

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Right? So historically, we always think of one

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patient

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to one room, especially when you're talking about

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isolation.

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But that's not always possible.

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We don't have enough isolation rooms for each

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individual person. So you can move towards cohorting

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together

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flu patients

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in a multi bedded room,

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to kind of help,

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get with space and flow.

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Oftentimes, they're called respiratory pods or dedicated wards.

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It also helps streamline

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your nursing care, right, because your nurses can

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really be dedicated to these folks. They know

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what they're doing, and can, be very attentive,

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to the needs of those, folks all with

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the same same diagnosis.

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From a staffing perspective, you know, that's always

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the crux, of all of our facilities. Right?

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And we rely so heavily

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on our amazing nursing staff. They really are

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the ones that keep us moving forward,

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and making sure patients are well cared for.

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And so developing things like internal float pools,

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have been very effective,

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in being able to kind of, again, flex,

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and manage, when you have these surges,

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and be able to focus on those areas

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of the hospital that that need it.

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Other things from a systems perspective, I like

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to really, you know, tend to think about

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kind of, performance from a system perspective

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is what can we do,

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to kind of implement,

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you know, kind of triage to treatment orders,

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if you will, like non patient specific orders.

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That includes things like having nurses when patients

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come in with respiratory symptoms, you know, go

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ahead and do swabs and test folks, start

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hydration protocols,

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even before the provider starts to see the

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physician. You don't wanna lose any time. So

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whatever you can do upfront,

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to kind of work as a team, I

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think really goes a long way.

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And then similarly,

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again, what's really important,

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is the use of our antivirals. Right? So

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we wanna get the message out to staff

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and to patients that if you're not feeling

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well, get tested early

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so that we know what we're dealing with.

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And if you're eligible, there are antivirals,

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that, that we can give you to shorten

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your

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course and certainly decrease the severity. So again,

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getting that message out and working,

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with, our clinicians,

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to make sure folks are getting treatment, as

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appropriate.

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And then, of course, lastly, you know, everything,

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you know, boils down to supplies and infection

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control. So maintaining,

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a system and monitoring your PPE supply so

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you don't get to the point where, oh

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my goodness, we only have a day's worth

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of, you know, N95 masks available, but really

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to make sure that you've got hard

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triggers,

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that let you know in advance so that

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you can order, and make sure that you

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always have a good supply, of these needed

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items.

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The last thing that I will mention from

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an infection prevention,

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and control process and something we actually did,

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at my hospital

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is when we saw this large surge,

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we actually moved to universal masking policies,

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meaning that, during the surge when we saw

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so many cases,

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we moved to the fact that you needed

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to wear a mask,

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regardless of whether you've had a flu vaccine

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during every direct patient, encounter. Again, the goal

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is to mitigate further transmission,

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keep our, patients and our staff, healthy, and

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and and not have others get infected.

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Yeah.

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And also on that note of supply, I

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would imagine, like, the antiviral, just supply of,

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you know, Tamiflu and other,

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common flu medications.

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I shortages are, popping up in different regions

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of different areas of The US, so I

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know also just something to keep track of.

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00:13:41,829 --> 00:13:43,669
I'm not sure if that's a big concern

378
00:13:43,669 --> 00:13:45,669
for that. Yeah. It's a it's a really

379
00:13:45,669 --> 00:13:47,829
great point. Right? And and again, you know,

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looking back, not to to,

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beat a dead horse, but to look back

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to the pandemic,

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you know, again, another lesson learned from us

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is don't put all of your eggs in

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one basket. So historically, like, we would have

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one supplier, right, for antivirals. Right? And so

387
00:14:02,125 --> 00:14:04,440
our supply chain now has gotten very adept,

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00:14:05,320 --> 00:14:08,059
at making sure that if our main supplier

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is out of a particular medication, do they

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have a backup? Do they have a second

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and a third tier,

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to make sure that we're always, well stocked,

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00:14:15,159 --> 00:14:16,379
with the needed medications?

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00:14:18,165 --> 00:14:20,245
We have about one minute left for our

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podcast recording. Is there anything

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00:14:22,804 --> 00:14:24,565
we haven't talked about yet that you'd love

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00:14:24,565 --> 00:14:27,225
to, you know, share with other hospital execs?

398
00:14:27,365 --> 00:14:29,065
Yeah. I mean, I think from my perspective,

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00:14:29,205 --> 00:14:30,660
you know, here at New York City Health

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00:14:30,660 --> 00:14:33,460
and Hospitals, my recommendation to my colleagues out

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00:14:33,460 --> 00:14:35,379
there, and again, I hope that you guys

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00:14:35,379 --> 00:14:37,779
quickly follow us, in coming down, you know,

403
00:14:37,779 --> 00:14:39,860
from your peak. But, you know, there there

404
00:14:39,860 --> 00:14:41,860
are four main essentials that I think of,

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00:14:41,860 --> 00:14:43,414
kind of wearing, you know, my health care

406
00:14:43,414 --> 00:14:45,095
executive cap, and that is to make sure

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that there's tight communications. Right? And so one

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00:14:47,414 --> 00:14:49,195
of the things we did is we conducted,

409
00:14:49,735 --> 00:14:51,894
bed huddles on a regular basis just to

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00:14:51,894 --> 00:14:54,215
understand our census and our discharges to be

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able to plan,

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00:14:55,509 --> 00:14:56,649
how to run our house.

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Again, from a safety perspective,

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making sure that you get the message out

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to folks that if you don't feel well,

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if you're sick, stay at home. We don't

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00:15:05,429 --> 00:15:06,730
want you coming to work,

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00:15:07,190 --> 00:15:08,570
infecting other individuals.

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00:15:09,565 --> 00:15:12,605
Again, we talked about efficiencies, using standing orders

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00:15:12,605 --> 00:15:14,684
where appropriate and allowed, you know, by your

421
00:15:14,684 --> 00:15:17,004
state legislatures. But that really goes a long

422
00:15:17,004 --> 00:15:18,945
way in helping, with those efficiencies.

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And then lastly, I would just remind all

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00:15:22,284 --> 00:15:24,899
of us that it's hard, to being a

425
00:15:24,899 --> 00:15:27,700
healthcare provider in 2025 and 2026.

426
00:15:27,700 --> 00:15:29,940
And so, you know, be aware of what

427
00:15:29,940 --> 00:15:32,519
the toll that has taken upon our staff,

428
00:15:32,740 --> 00:15:34,679
and, you know, make sure that you recognize

429
00:15:34,740 --> 00:15:37,245
them, that you rotate people out. You don't

430
00:15:37,245 --> 00:15:38,785
want the same people working

431
00:15:39,165 --> 00:15:40,845
in the flu wards, if you will, day

432
00:15:40,845 --> 00:15:42,545
after day. Give folks a break,

433
00:15:43,165 --> 00:15:43,985
and consider

434
00:15:44,764 --> 00:15:47,485
that, to be able to have sustainable positions

435
00:15:47,485 --> 00:15:49,424
and keep your workforce healthy.

436
00:15:50,529 --> 00:15:52,690
To keep patients healthy in the end of

437
00:15:52,690 --> 00:15:54,389
the day. Yes. Exactly.

438
00:15:54,929 --> 00:15:56,929
Right. Well, thank you so much, doctor Wallach,

439
00:15:56,929 --> 00:15:58,789
for joining us on the Becker's podcast.

440
00:15:59,490 --> 00:16:01,089
It was my pleasure. Thank you for having

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00:16:01,089 --> 00:16:01,589
me.