Hi. This is Paige Twenner, assistant editor with
Becker's Health Care. I'm so, so excited to
be joined by Andrew Wallach,
an ambulatory care leader at NYC Health and
Hospitals.
I don't wanna take your thunder. So,
doctor Wallach, if you can just, you know,
briefly introduce yourself, tell us a bit about
your organization, and then we'll dive right in.
Wonderful. Well, thank you, Paige, for having me,
today.
Indeed, my name is Andrew Wallach, and I'm
a board certified,
internist. I like to describe myself as 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 health care 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 1,000,000,
New Yorkers regardless of their ability to pay
or their immigration status.
And interestingly, we provide over 60% of all
behavioral health care,
here in New York City, so really, are
at the the 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, all
parts of New York.
Big and mighty. And, I'm excited to hear
about, Jarls' strategy
through,
this particularly
severe,
flu season currently.
We were talking before the for listeners, we're
doctor Wallach and I were talking before the
podcast, and it sounds like New York's data,
latest kinda 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, H and H in terms of capacity
and,
flu acuity?
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
2,
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 seventy thousand 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 fifty five thousand
cases reported per week. So pretty significant,
you know, increase compared to 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 3,
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,
you know, 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, you know, presenting with these symptoms.
Now interestingly,
the the piece that we don't always talk
about is not just the patients,
but certainly kinda wearing my,
health care system cap, if you will, is
we wanna make sure that our staff also
are protected. Right? Because they're people too. They
get sick. We're, you know, 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.
Were you all expecting
the early, like,
season of flu or expecting,
you know, that weekly caseload to exceed last
year's record? 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 subclade,
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.
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 kinda care coordination strategies?
Yeah. No. Sure. You know, I think one
of the you know, I'm I'm definitely a
glass half full kinda guy. And if you
look back, over the COVID pandemic, which was
so traumatic
on so many levels for all of us,
you know, in healthcare,
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. You know, we really weren't doing
very much of it,
before the pandemic. And quite honestly, we turned
it on essentially overnight. And, you know, 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 healthcare,
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, you know,
in 2025
and 2026,
the ability for one to go to a
retail pharmacy and purchase an over the counter,
you know, 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 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.
Speaking on a broader lens outside of, New
York,
the day we're recording
this podcast,
you know, we're talking of, New York's kinda
dip, but other, regions in the 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 in,
New York and a a few other states.
What
top recommendations would you give them?
Yeah. It's 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
wanna say that again and again and again
because I think, you know,
getting the word out is just so critical.
So I can't under or overestimate, rather,
the importance of that. Now that said,
you know, when hospitals face a sudden surge,
in 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 four s
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
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 want might wanna 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.
Right? So 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 kind of help,
get with space and flow.
Oftentimes, they're called respiratory pods or dedicated wards.
It also helps streamline
your nursing care, right, 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 same diagnosis.
From a staffing perspective, you know, that's always
the crux, of all of our facilities. Right?
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 kind of, again, flex,
and manage, when you have these surges,
and be able to focus on those areas
of the hospital that that need it.
Other things from a systems perspective, I like
to really, you know, tend to think about
kind of, performance from a system perspective
is what can we do,
to kind of implement,
you know, 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, you know, go
ahead and do swabs and test folks, start
hydration protocols,
even before the provider starts to see the
physician. You don't wanna lose any time. So
whatever you can do upfront,
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, there are antivirals,
that, 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 supply 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
and and not have others get infected.
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.
I 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 concern
for that. Yeah. It's a it's a really
great point. Right? And and again, you know,
looking back, not to 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?
We have about one minute left for our
podcast recording. Is there anything
we haven't talked about yet that you'd love
to, you know, share with other hospital execs?
Yeah. I mean, I think from my perspective,
you know, 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, you know,
from your peak. But, you know, there there
are four main essentials that I think of,
kind of wearing, you know, my health care
executive cap, and that is to make sure
that there's tight communications. Right? 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 efficiencies.
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
in the flu wards, if you will, day
after day. Give folks a break,
and consider
that, to be able to have sustainable positions
and keep your workforce healthy.
To keep patients healthy in the end of
the day. Yes. Exactly.
Right. Well, thank you so much, doctor Wallach,
for joining us on the Becker's podcast.
It was my pleasure. Thank you for having
me.