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Converting a Skilled Nursing Facility into an Acute Care Satellite Hospital During COVID-19

03/10/2022

By Michael G. Kantrowitz, DO, MS

In January and February of 2020, reports coming out of China and Italy described a startling picture of the strain that was being placed on their health care systems due to COVID-19. This offered a glimpse of the surge capacity that hospitals in the United States would require to accommodate the anticipated increase in severely ill patients. 

The challenges were three-fold: 

  1. physical plant to support health care delivery
  2. optimal deployment of skilled staff
  3. expanded access to critical care services due to the pathophysiology of the SARS-CoV-2 virus

The first laboratory-confirmed case of COVID-19 in New York City was identified on February 29, 2020.1 Over the next several days, our medical center diagnosed its first patients with the virus and in the ensuing weeks, inpatient volume increased exponentially with many patients requiring intensive respiratory care. Uncertainty persisted as to the level and length of time until peak. It is in this context that we detailed our experience converting a skilled nursing facility (SNF) into an acute care satellite hospital in the February 2022 issue of The Joint Commission Journal on Quality and Patient Safety.2

Sticking to the Plan
Our hospital relied on a comprehensive Emergency Operations Plan (EOP) that was written according to National Incident Management System (NIMS) guidance.3 The plan had been the backbone of previous disaster responses including after Hurricane Sandy when we received an influx of patients from local hospitals and SNFs damaged by the storm. As our COVID-19 patient census rose, the EOP was again relied upon to meet evolving needs. 

Multiple daily briefings across our incident command structure facilitated:

  • standing up new ICUs in previously decommissioned or repurposed units
  • redeploying staff from clinical areas with decreased volume
  • acquiring ventilators and personal protect equipment (PPE)
  • suspending elective surgeries to increase bed capacity, per local government guidelines4
  • allowing for alternative allocation of staff 

Problem Solving
We clearly needed to find additional physical capacity to safely deliver care, particularly to less acute patients who still required hospitalization, with the ability to accommodate those with greater severity if needed. 

In partnership with New York State, a recently renovated former hospital soon to be reopened as a SNF was leased by the state and designated to our medical center to operate. The site was five miles from our main campus with the potential to expand capacity up to 425 beds. The state provided on-site representatives to provide logistical and material support allowing us to rapidly prepare the facility to accept patients within approximately 10 days. Operational protocols were written from the ground up, detailing:

  • staff onboarding process
  • transfer procedure
  • daily care guidelines
  • emergency management

The existing infrastructure lacked imaging and laboratory services. To maximize our effectiveness, we needed to find ways of replicating these resources to avoid a revolving door of patients frequently being sent back to the main campus. Arrangements were made for virtual subspecialty consultation, a CT scan truck and portable ultrasound were parked behind the building, and a courier system was established to transport medications, labs, meals, and staff to and from the main campus. An EMS ambulance remained in front of the facility to provide basic and advanced cardiac life support services as well as transport patients back to the main campus if needed.

Building Our Team

Our staff was an eclectic group of nurses, patient care technicians, advanced practice providers, and physicians—many of whom had not worked together previously. Much of the nursing staff came from endoscopy and ambulatory surgery units and the physician/advanced-practice providers (APPs) were drawn from outpatient internal medicine specialists or subspecialists as well as neurologists. A group of psychiatry residents (my co-authors) volunteered to be redeployed to our site. Mutual trust was built by establishing multiple huddles throughout the day to quickly identify and escalate problems. 

Ultimately 170 patients came through our facility. We remained prepared to open additional units as needed. Our implementation was similarly replicated during the winter wave in 2021 by relying on many of the same procedures to open a surge unit in another SNF. While we hope there is no need to convert another facility, we are prepared and ready to do so should another surge occur.  

Michael Kantrowitz, DO, MS, is a gastroenterologist and Vice Chair for Quality and Safety in the Department of Medicine at Maimonides Medical Center in New York City. 


1. Thompson CN, Baumgartner J, Pichardo C, et al. COVID-19 Outbreak — New York City, February 29–June 1, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1725–1729. DOI: http://dx.doi.org/10.15585/mmwr.mm6946a2
2. 2. Vu T, Kantrowitz M, Boita C, Hayes S, Taub A, Jacob T. Conversion of a Skilled Nursing and Rehabilitation Facility into a Satellite Hospital in Response to a COVID‐19 Surge. The Joint Commission Journal on Quality and Patient Safety. 2022;48(2):108-113. doi:10.1016/j.jcjq.2021.11.001
3. United States. Department of Homeland Security. National Incident Management System Training Program. [Washington, D.C.]:Dept. of Homeland Security, 2017.
4. City of New York Office of the Mayor. Emergency Executive Order No. 100. Published online March 16, 2020. https://www1.nyc.gov/assets/home/downloads/pdf/executive-orders/2020/eeo-100.pdf