NYC Health + Hospitals is the largest municipal health system in the United States, serving over three million patients, with over 500,000 of them uninsured. It operates 11 acute care hospitals, 5 post-acute facilities, one Long Term Care Hospital (LTACH), and over 70 community-based primary care sites. The system provides services interpreted in over 130 languages and dialects. Its oldest hospital spans back to 1736. This chapter includes the rich history of NYC Health + Hospitals and its experience with responding to the various needs of its communities. It also covers the unique role each hospital plays within the nation’s largest safety-net hospital system, the millions of lives the system touches, and the role it plays in healthcare access and health equity.

As the amount of patients in Emergency Departments surged, the ED Action Team formed and led the emergency response to the crisis. How the Action Team formed and how it sprang into action to create a unified response at all of the 11 NYC Health + Hospitals acute care facilities.

The COVID-19 crisis shifted to inpatient, and soon the facilities were all critical care COVID treatment centers. How the largest public health system in the United States accommodated the massive, prolonged surge of high-acuity patients.

In early January, before the pandemic was even declared later that month, the System Office of Emergency Management activated its incident management structure in anticipation of a high-impact event to the healthcare system. As time went on, the ICS structure developed plans, protocols, and guidance, and moved resources from one hospital to another to meet facility demands and provide an organized leadership structure. The creation of the incident management structure, cadence of meetings, and communication of leadership from the Central Office level to the facility level and down to the staff was an unprecedented feat. Read this chapter to learn how the NYC Health + Hospitals leadership came together to unify the response and coordinate the entire system.

Level-loading was brought to new heights during this pandemic. The workflow and technique were revised and refined as the marathon of the surge continued. This is an account of how it began and how it transformed as the months of the surge drew on and on.

With massive surges of patients showing up to all of the acute care facilities, keeping up with critical care supplies, PPE, and airway equipment was a massive undertaking. How the health-system supply-chain leadership navigated global shortages while keeping providers safe and caring for patients.

The supply-chain shortages of wave 1 slowly dissipated and transformed into a staffing crisis in wave 2. With workers exhausted from the first wave and lured by surge staffing prices, the attrition was high after the first wave, and the vendor staff were in demand all over the country. The health system navigated this new crisis with teams that worked 24/7 to mitigate this challenge and get the facilities the relief they needed.

The first surge led to a prolonged response of patients with incredibly high acuity in numbers the staff had never seen before. Many patients waited too long for care, therapies were not known, and some COVID-19 sufferers did not survive. How the system handled the mass fatalities in a coordinated response with the city during the initial wave and lessons learned.

Coordination had to be mapped out from the system’s acute care Level 1 trauma centers, community hospitals, post-acute facilities, long-term care sites, and outpatient clinics. How the plan of coordination was pulled together to keep it all in balance.

Standing up the situational awareness platform for the system and how it changed everything. Coordination of the response could be fine-tuned, with leadership and frontline staff kept informed every step of the way.

From alternate care sites to surge space to vaccine pods. The team’s IT leadership had to coordinate and keep up with the ever-changing technology surveillance and response during the prolonged surge. How it began and transformed.

When news of the unprecedented surge at NYC Health + Hospitals hit the media, donations from all over the world poured into the facilities and health system. It was a heartwarming and heartbreaking response, and overwhelming all at the same time. How the system was able to handle the massive influx of well-intended goods from around the globe that were suddenly on the hospital’s doorstep.

Keeping persons in custody and staff safe from a rapidly spreading, lethal, novel virus presented particular challenges in a carceral setting where physical distancing is virtually impossible, communal activities are not only unavoidable but are the few remaining privileges, and individual agency is largely curtailed. Correctional Health Services cared for a highly vulnerable patient population within a closed yet porous congregate setting where health and security imperatives may be misaligned, and in the face of extraordinary pressures and expectations among the public, oversight entities, and persons in custody.

From quarantine to isolation of patients and staff to staff-respite hotels. How the health system stood up alternate care sites during the COVID-19 pandemic, including a massive hoteling response to help contain the spread of the virus, keep New Yorkers safe, and keep the hospital’s staff healthy.

Coordinating the response in the behavioral-health community was no small task. Keeping the behavioral-health population safe and planning the response for the entire health system took foresight, skill, and ever-changing strategies.

With the onslaught of COVID-19, healthcare providers and other stakeholders had to replace regulatory restrictions with innovation. Elected officials, bureaucrats, community leaders, and consultants helped ease the administrative burden so hospital workers could focus on their patients. State officials were dedicated to NYC Health + Hospitals’ success, and many helped brainstorm ideas that didn’t appear in regulatory code in order to meet the shared goal of keeping people safe. With all the teamwork, the hospital took steps to streamline internal communications and facilitate compliance.

NYC Health + Hospitals stood up the largest-scale testing and tracing operation in the country. With 5,000 workers and a 24/7 operation, Test and Trace (T2) was instrumental in keeping people healthy and safe, and getting New York City back to normal operations. T2 started a massive undertaking of community engagement, reaching out to New Yorkers to provide COVID-19 assistance in all forms and facets, from mobile testing units to isolation hotels for those unable to safely isolate at home, to wraparound services and connection to healthcare services, and much more. Taking into account the unique makeup of NYC, the immigrant population, the disproportionate impact on people of color, and the significant burden of disease and death, T2 rose to the challenge to encompass every aspect of this daunting situation.

From putting vaccine pods in all of the system’s acute care facilities, to standing up vaccine sites throughout the city, vaccination became the key to curtailing the pandemic. But the variants continued to emerge, and the race was tight as to who will win out.

Many people at the hospital felt like they have aged 5-10 years in the past few pandemic years. No one would be the same when it was over. But the system’s wellness leads set forth to keep everyone’s mind and spirit, along with the team going, and let the healing begin. It wasn’t over yet, but NYC Health + Hospitals continued to fight, thanks to the wellness team.

As the safety-net healthcare providers in the United States, public health systems serve a vital role in caring for the country’s most vulnerable populations. The crack that was in the foundation became a wide canyon during this pandemic, highlighting the need for investing in this crucial infrastructure of society. Abolishing healthcare disparities and social inequities starts with building up public health systems into strong, durable institutions that can weather all future emergencies no matter what the scale or the duration for generations to come.