New York City has emerged as the global epicenter for the coronavirus disease 2019 (COVID-19) pandemic. The city's public health system, New York City Health + Hospitals, has been key to the city's response because its vulnerable patient population is disproportionately affected by the disease. As the number of cases rose in the city, NYC Health + Hospitals carried out plans to greatly expand critical care capacity. Primary intensive care unit (ICU) spaces were identified and upgraded as needed, and new ICU spaces were created in emergency departments, procedural areas, and other inpatient units. Patients were transferred between hospitals to reduce strain. Critical care staffing was supplemented by temporary recruits, volunteers, and Department of Defense medical personnel. Supplies needed to deliver critical care were monitored closely and replenished to prevent interruptions. An emergency department action team was formed to ensure that the experience of front-line providers was informing network-level decisions. The steps taken by NYC Health + Hospitals greatly expanded its capacity to provide critical care during an unprecedented surge of COVID-19 cases in NYC. These steps, along with lessons learned, could inform preparations for other health systems during a primary or secondary surge of cases.

Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P < 0.001) among patients who had surgery during the pandemic. The adjusted odds of death were higher during than before the pandemic (odds ratio (OR) 2.72, 95 per cent c.i. 1.58 to 4.67; P < 0.001). In mediation analysis, 54.8 per cent of excess postoperative deaths during the pandemic were estimated to be attributable to SARS-CoV-2 (OR 1.73, 1.40 to 2.13; P < 0.001). Conclusion Although providers may have selected patients with a lower risk profile for surgery during the pandemic, this did not mitigate the likelihood of death through SARS-CoV-2 infection. Care providers must act urgently to protect surgical patients from SARS-CoV-2 infection.

Introduction It is difficult to determine illness severity for coronavirus disease 2019 (COVID-19) patients, especially among stable-appearing emergency department (ED) patients. We evaluated patient outcomes among ED patients with a documented ambulatory oxygen saturation measurement. Methods This was a retrospective chart review of ED patients seen at New York University Langone Health during the peak of the COVID-19 pandemic in New York City. We identified ED patients who had a documented ambulatory oxygen saturation. We studied the outcomes of high oxygen requirement (defined as >4 liters per minute) and mechanical ventilation among admitted patients and bounceback admissions among discharged patients. We also performed logistic regression and compared the performance of different ambulatory oxygen saturation cutoffs in predicting these outcomes. Results Between March 15–April 14, 2020, 6194 patients presented with fever, cough, or shortness of breath at our EDs. Of these patients, 648 (11%) had a documented ambulatory oxygen saturation, of which 165 (24%) were admitted. Notably, admitted and discharged patients had similar initial vital signs. However, the average ambulatory oxygen saturation among admitted patients was significantly lower at 89% compared to 96% among discharged patients (p<0.01). Among admitted patients with an ambulatory oxygen saturation, 30% had high oxygen requirements and 8% required mechanical ventilation. These rates were predicted by low ambulatory oxygen saturation (p<0.01). Among discharged patients, 50 (10%) had a subsequent ED visit resulting in admission. Although bounceback admissions were predicted by ambulatory oxygen saturation at the first ED visit (p<0.01), our analysis of cutoffs suggested that this association may not be clinically useful. Conclusion Measuring ambulatory oxygen saturation can help ED clinicians identify patients who may require high levels of oxygen or mechanical ventilation during admission. However, it is less useful for identifying which patients may deteriorate clinically in the days after ED discharge and require subsequent hospitalization.

Author Contributions: KMD, MS, DC, DS, TM, EJ, MS, and SZ contributed to the study idea. KMD and DS obtained funding for the study. KMD led survey data collection with assistance from RG and IW. EJ and MS of NYC CIDI performed administrative data linkage. TM and KMD conducted data analyses. KMD drafted the manuscript and all authors contributed to its revision and approved the final version. KMD takes responsibility for the work as a whole.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.