this, it was easy to believe that somehow our situation would be different; that we would learn 28 from Italy's mistakes and it would never reach the same point. Less than three weeks later, NYU 29 Langone Orthopedic Hospital is now a COVID treatment center, we are a department of COVID 30 doctors, and elective surgery seems like a distant memory. 31
The first cases of the current coronavirus pandemic presented in Wuhan, China in November of 34 cases in the state with over 9,385 deaths (as of 4/13/2020). To put this in perspective, New York 46 has more confirmed cases of COVID-19 than any other country in the world and represents over 40% of the current US death toll. Medical centers here in New York have been under enormous 48 stress as they work to create new beds, increase staffing, and provide personalized protective 49 equipment (PPE), while providing care for thousands of admitted patients. We would like to 50 share our experiences here at NYU Langone Health, and more specifically, the response of our 51 Department of Orthopedic Surgery and the Division of Adult reconstructive Surgery as we of 10 3
NYU Langone Health is one of the largest health care systems in the country and, similarly, the 56 Department Orthopedic Surgery is also one of the largest nationally. Our department includes 57 187 faculty, 72 residents and 21 fellows covering 6 hospital sites with over 3,000 inpatient beds. 58
All of our sites have seen an influx of COVID patients, including Bellevue hospital which is the 59 flagship hospital for the New York City public hospital system. Our institution has been 60 proactive regarding implementation of COVID protocols and our administration has had open 61 lines of communication with staff which has helped to minimize some of the confusion reported 62 at other hospital systems. Personalized protective equipment (PPE) has been readily available 63 with conservation strategies that involve some restrictions on duration of usage, but are in 64 accordance with CDC guidelines. Administrators have sent frequent video updates from inside 65 hospital facilities which serve to let the staff know that they are in the fight with them, and that 66 their efforts are greatly appreciated. Our leadership has been transparent with data by openly 67 sharing the number of emergency department (ED) visits, admissions, inpatient census, intubated 68 patients, discharges and deaths related to COVID. This transparency at all levels has helped 69 remove some of the fear of the unknown for our staff. 70 71 On March 9, New York City mayor Bill DeBlasio announced that no elective surgery would be 72 allowed at any hospital or surgery center in New York City. The exact definition was not 73 specified, but the guidance put out by NYU defined elective surgery as "a surgical procedure that 74 the physician and patient believe can safely be postponed for at least three months." Each 75 department, was then asked to create a list of procedures that would be permitted under these 76 guidelines. Within our department each division formulated a detailed list of essential surgical 77 procedures. The cases that were initially deemed as non-elective within the Division of Adult 78
Reconstructive Surgery are summarized below: 79
• Periprosthetic joint infections 80
• Periprosthetic fractures 81
• Acute post-operative dislocation due to implant malposition 82
• Recurrent instability causing disability 83
• Implant fracture/failure of 10 4
• Total hip replacement for intractable hip pain secondary to femoral head collapse or fracture 85
• Disabling hip or knee pain that impairs mobility to a degree that places the patient at risk for 86 additional problems such as recurrent falls, or the ability to be in self quarantine. 87 88 As the Pandemic evolved and resources became scarcer, we in turn, further restricted the types of 89 surgery permissible. Chronic periprosthetic infections, joint replacements for "intractable pain" 90 and disabling hip or knee pain were postponed. There were concerns regarding performing 91 surgery during this time period due to the consumption of PPE, the risk of asymptomatic COVID 92 transmission to patients and staff, inpatient bed and staff availability and whether our operating 93 rooms and anesthesia staff would be available or instead repurposed for the care of COVID 94 patients. To date, we have been able to perform all required urgent and emergent surgeries 95 without any substantial delays. The patients that we have been able to treat during this time have 96 been extremely grateful for our ability to provide care. We have also accepted patients in transfer 97 from Bellevue Hospital Center, an important part of our department, to provide timely and 98 needed orthopedic care. 99
After the moratorium on elective surgery was enacted, it became clear that the facilities and 102 resources at Langone Orthopedic Hospital (LOH) would be underutilized and could be 103 repurposed in NYU's fight against COVID to help with the substantial number of COVID 104 patients expected at the main campus. For example, our department maintained two free 105 standing ambulatory surgery centers. Not only were the staff at these centers repurposed, but so 106 of 10 5 redeployed to the converted medical COVID floors treating patients. Each medical team 116 consisted of one hospitalist, two orthopedic surgeons and two APPs, caring for 20-30 COVID 117 patients per shift. A multi-disciplinary leadership group worked to develop the structure and 118 work flow of the medical teams to help clarify roles and ensure maximum safety for both 119 patients and staff and efficiency for the teams. Selected APPs were trained in PICC line 120 placement, to assist due to decreased availability of the radiology PICC Line teams. Proning 121 teams to help care for ventilated patients were also created and deployed. All personnel received 122 updated training, including PPE training, through our online training system. All of our orthopedic faculty have converted most, if not all, of their office visits to telemedicine. 146 NYU Langone Health had recently completed a comprehensive initiative to convert select office 147 visits to telemedicine. We are able to use a smart phone application, home computers and office 148 computers to complete telemedicine visits. Although some in person patient visits still occur for 149 post-operative patients or when urgent issues arise, every effort has been made to minimize 150 unnecessary travel for our patients and staff. Our department still has active outpatient office 151
locations that are open for urgent patient visits functioning with a skeleton crew. All of our 152 schedulers and back office staff were instructed to work from home and were equipped with any 153 needed technology, such as laptops, ipads and phones. 154
Each surgeon worked with his staff to reach out to their patients that had scheduled surgery dates 155 and discuss the current situation, answer questions and help decrease anxiety. We offered our 156 patients a few options including rescheduling their surgery to a new future date in the summer, 157 being placed on a waiting list to be scheduled as soon as possible when elective surgery resumes, 158 or to be contacted when we resume activity to discuss options (this was reserved for patients who 159 felt too overwhelmed with the situation and wanted to avoid any decisions at this time). Patients 160 were advised to inform their surgeons of any change in their condition as urgent and emergent 161 orthopedic procedures continue to be performed. 162
At the graduate medical education (GME) level, NYU initially sought to minimize house staff 165 involvement with COVID patients by creating new non-teaching pulmonology and critical care 166 teams in the hospital. As the number of patients began to exponentially grow, it became clear 167 that this was no longer a viable option and NYU began to recruit house staff from all 168 departments to enlist in what is referred to as the "COVID Army". NYU has also taken the 169 extraordinary step of graduating the 4 th year medical school class early and offering them 170 positions as interns with full pay and benefits to aid in the institutional response. 171
In the Department of Orthopedic Surgery, we have reduced orthopedic house staff coverage to 173 the absolute minimum number required for orthopedic responsibilities including taking in house 174 call and operating room coverage at the six hospitals where we provide care. We have worked to of 10 7 our orthopedic teams at each location as insular as possible. Of our orthopedic residents and 177 fellows (all of our adult reconstruction fellows are involved in some fashion in COVID care 178 teams), we currently have 33 trainees participating in COVID care teams across our health 179 system on a 4-week rotating basis. All of our orthopedic surgery trainees were given the choice 180 of working on a medicine team, ICU team, or in the emergency department. The majority 181 electing to work on the medicine floors with some deployed to ICU and ED coverage. Although 182 treating COVID patients was initially out of their comfort zone, our house staff have performed 183 admirably and our medicine colleagues have expressed gratitude for their assistance, level of 184 effort and contributions. 185 186 NYU has expanded its offering for mental health support through webinars, virtual mental health 187 clinics and direct provider care. Within our department we have been conducting weekly online 188 faculty and trainee meetings for our residency and fellowship programs. This includes a review 189 of the current hospital and department status as well as an open question&answer (Q&A) 190 discussion between the trainees and department leadership. We have allowed anonymous 191 question submission to help trainees express their fears and anxiety comfortably. We have 192 noticed that these weekly on line meetings where we can see all of our colleagues on video helps 193 keep everyone connected and relieve individual stress. We should not forget that many trainees 194 may be living far from their families and social support with the potential to feel very isolated in 195 these times. In this context, it is essential that we provide all of the support we possibly can. 196 197 EDUCATION 198 