Development of Rapid Response Capabilities in a Large COVID-19 Alternate Care Site Using Failure Modes and Effect Analysis With In Situ Simulation

Nadav Levy, M.D.; Liana Zucco, M.B.B.S., F.R.C.A.; Richard J. Ehrlichman, M.D., F.A.C.S.; Ronald E. Hirschberg, M.D.; Stacy Hutton Johnson, Ph.D., R.N.; Michael B. Yaffe, M.D., Ph.D.; Col. (ret); Satya Krishna Ramachandran, M.D.; Somnath Bose, M.D.; Akiva Leibowitz, M.D.

Disclosures

Anesthesiology. 2020;133(5):985-996.

Limitations

We delineated our single-center experience of rapid capacity expansion in the setting of a pandemic. It is likely that the logistic and safety considerations highlighted in our experience may have been influenced by local and regional factors and interventions and thus may not be completely extrapolated to other rapidly deployed systems developed for similar function. Nonetheless, the framework developed through use of established quality improvement tools and multiple iterations could be used to guide, develop, and refine strategies for rapid development of capabilities outside normal clinical arenas. Modifications according to local resources may be needed to account for considerations unique to other centers.

Our ability to measure the effect of our efforts and the implementation processes were limited by the time frame. Because the rapid response capabilities were developed in an active site with a growing number of patients, our main goal was to establish, distribute, and train our staff with the optimal pathways for patient rescue.

Conclusions

Using a combination of quality improvement tools for proactive hazard detection, testing through in situ simulation, and debriefing real-life cases, we successfully uncovered several operational failures and hurdles within our newly developed care environment. Through continuous quality improvement, stepwise cycling, and iterastive change, we implemented more than 30 appropriate mitigation strategies to improve the efficiency of our workflow and establish rapid response capabilities. We hope this framework may act as a guide for future rapid capacity expansion in emergency situations. Reassessment of this framework at regular intervals is warranted to ensure its continued robustness in the setting of rapidly evolving scenarios.

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Acknowledgments
The authors thank all the devoted volunteers from Partners HealthCare (Boston, Massachusetts), Beth Israel Deaconess Medical Center (Boston, Massachusetts), Atrius Health (Newton, Massachusetts), United States Army Medical Reserves, Massachusetts National Guard, city of Boston, Boston Convention and Exhibition Center (Boston, Massachusetts), and many others who stepped up to plan, design, staff, and support Boston Hope, and to serve on the front lines, at time of global pandemic. Special thanks to Boston Hope leadership spearheaded by the "Home Base" team, directed by Brigadier General (retired) Jack Hammond, M.A., Executive Director, Red Sox Foundation and Massachusetts General Home Base Program (Boston, Massachusetts), and to Dr. Regan Marsh, M.D., M.P.H., Brigham and Women's Hospital (Boston, Massachusetts) and Partners In Health (Boston, Massachusetts). The authors thank Shira Leibowitz Schmidt, M.Sc. for her assistance in editing this article.

Research Support
Support for this study was provided solely from institutional and/or departmental sources.

Competing Interests
Dr. Ramachandran reports the following financial relationship: FK USA (Lake Zurich, Illinois, unrelated to this project). Dr. Bose reports funding from the United States Department of Defense (Washington, DC, unrelated to this project) and National Institutes of Health (Bethesda, Maryland, unrelated to this project). The remaining authors declare no competing interests.

Table 1. Failures and Hazards Detected Using Quality Improvement Methodology and Solutions Implemented
Failures and Hazards Detected through Process Mapping and On-site Walkthrough	Failures and Hazards Detected through In Situ Simulation and Debriefing from Real-life Cases	Implemented Solutions
General workflow and resources
• Workflow issues: • Low-acuity setting not equipped to deal with escalation of care, if required • Absent workflows for the management of deteriorating COVID-19 patient • Lack of awareness that standard practice cannot be adopted in common areas (e.g., chest compressions) • Staff unfamiliar with management in this setting • Equipment, resources, and infrastructure: • Only 1 automated external defibrillator in the facility • No backboards	• Workflow issues: • Delays in donning personal protective equipment during a rapid response activation • Difficulties when attempting to open automated external defibrillators • Design: • Challenges staffing the negative pressure room while managing patients requiring continuous monitoring rather than acute/emergency intervention • Equipment, resources & infrastructure: • No intraosseous access device • Poor lighting in observation bays	• Establish acute care-ICU capabilities within Boston Hope • Design negative pressure rooms for aerosolizing procedures • Create workflow for the management of deteriorating patients • Redesign patient spaces to a high-dependency observation unit, equipped with oxygen, vital sign monitors, and intravenous access materials • Create checklists for acute care observation and emergency scenarios • Implemented in situ simulation training to promote standardization of care • Acquisition of resources required (automated external defibrillators, backboards, intraosseous access devices, installation of overhead lighting in observation bays) • Implementation of a rapid personal protective equipment donning station • Prepackaged personal protective equipment bags and allocation of role of personal protective equipment attendant • Automated external defibrillator training implemented • Automated external defibrillator latch labeled ("lift to open") • Opening and operating the automated external defibrillator added to the simulated scenarios
Communicating the need for help
• No rapid response activation system, lack of awareness that help is needed • No call buttons at the bedside • No phones nearby the patient's bed spaces • Help is far because the size of the facility	• Difficulty in being heard when calling for help during emergency; combined effects of the size of the facility, the distance between providers, and speaking through personal protective equipment • Delays in the rapid response paging activation process resulted in delayed assembly of the rapid response team, caused by prolonged exchange of information between the caller and the operator	• Implementation of a relay method to activate a rapid response team scenario • Established an education and communication plan for providers • Implementation of rapid response pagers • Information exchange during a rapid response call minimized and standardized • System now activated by requesting the "Boston Hope Rapid Response Team" • Protocol established that rapid response team report directly to the negative pressure room • Nursing station phones programed to speed-dial the rapid response pagers
Movement of the patient to a place of safety
• Patient bed/cot unsuitable to use for patient transfer, requires the use of a stretcher • Insufficient space in patient bed space to fit the bed and stretcher, need to move the bed out • Additional team members required to safely transfer patient to the stretcher and then to the negative pressure room	• Pathway to negative pressure room blocked by scattered mobile vital-sign devices • Similar appearance of the acute care room (negative pressure) and the adjacent therapy rooms	• Created workflow outlining sequence of actions to transfer a patient onto a stretcher and into a negative pressure room • Implemented training sessions for transfer workflow • Docking area created and marked on the floor for equipment, near each nursing station, to clear obstacles and allow a clear passage • "Resuscitation" signage created and posted to distinguish between negative pressure room and the other acute care rooms.
Assembly of team and management during an emergency
• No method to identify and assign available skilled personnel to rapid response team each day • No means to alert rapid response team	• Overcrowding of providers in and out the negative pressure room during emergency patient management, could increase risk of viral exposure to staff unnecessarily. • Delayed availability of controlled substances during a rapid response call	• Volunteer scheme initiated, later transitioned to a daily assignment of individuals to the rapid response team, during a team huddle in every shift • Allocation of specific responsibilities during rapid response • Distribution of pagers to rapid response team • Pharmacist included in the rapid response team • Creation of a "rapid response box" with essential supplies and controlled substances • Assignment of a safety officer during a rapid response activation, to perform crowd control and maintain communication in and out of the negative pressure room

COVID-19, coronavirus disease 2019; ICU, intensive care unit.

Appendix: Modified Failure Modes and Effect Analysis Worksheet

Failures Modes Identified	Potential Effects	Severity	Scope for Intervention	Prioritization
General Workflow: • Low-acuity setting not equipped to deal with escalation of care, if required • Absent workflows for the management of deteriorating COVID-19 patient. • Lack of awareness that standard practice cannot be adopted in common areas (e.g., chest compressions) • Staff unfamiliar with management in this setting	• Inability to provide higher level of care • Lack of workflow standardization creates variability in care, increases potential for medical errors and harm. • Lack of awareness of COVID-19 related safety precautions can increase the risk of nosocomial transmission • Delay in delivering shock owing to possible long distance from single automated external defibrillator • Delay in administering IV medications during emergency resuscitation	High	• Workflow design, and distribution, communication, and in situ interprofessional simulation training • Resource requirements: High (design, scheduling, provider time, simulation equipment) • Comments: Considered imperative to providing acute-ICU level of care in a safe manner	Immediate
Resources and infrastructure: • Only 1 automated external defibrillatorin the facility • No backboards	• Delay in delivery of emergency care or resuscitation	High	• Log of necessary resources and rapid acquisition through the organization • Resource requirements: intermediate (budget) • Comments: imperative for emergency treatment, simple process to acquire	Immediate
Communication: calling for help • No call buttons at the bedside • No phones nearby the patient's bed spaces • Help is far owing to the size of the facility	• Delay in rapid response and rescue management	High	• Infrastructure modification to create an overhead system/call buttons in each patient space • Resource requirements: High (not included in preliminary site plan) • Comments: Infrastructure modifications were not possible after opening because of logistical and technical constraints	Deferred
Communication: activating rapid response team • No rapid response activation system, lack of awareness that help is needed	• Delay in rapid response and rescue management	High	• Acquisition and distribution of rapid response pagers • Resource requirements: intermediate (time, design) • Comments: Pagers were issued and supported through the existing network of Massachusetts General Hospital	Immediate
Movement of the patient to a place of safety • Patient bed/cot unsuitable to use for patient transfer, requires the use of a stretcher • Insufficient space in patient bed space to fit the bed and stretcher, need to move the bed out • Difficult to move patient with minimal staff members present; 4 members required to perform this safely	• Delay in transferring patient to negative pressure room and consequently delayed resuscitation • Moving patients onto stretchers may increase risk of patient falls • Risk of injury to staff • Delay in providing care while waiting for helping team members/transferring patients	High	• Workflow for patient transfer to the negative pressure room, including rapid placement of automated external defibrillator • Training of team members in safe patient transfer • Acquisition of required items (backboards) Resource requirements: intermediate (design, provider time, budget) • Comments: Optimal workflow for patient transfer required several iterations through onsite Walkthrough	Immediate
Assembly of team & management during emergency • No framework in place to identify and assign available skilled personnel to rapid response team each day	• Lack of awareness of assigned role in rapid response team • Delay in initiation of rescue treatment	High	• Assignment of rotating providers to rapid response team. Implementation of a team huddle at each shift change to identify rapid responders • Resource requirements: Low (based on existing system) • Comments: Enabled by identifying and scheduling appropriately qualified personnel in each shift	Immediate
Location-specific team training and skills • Acute care providers are not trained in airway management for COVID-19 patients in the negative pressure room • Rapid response team composed of qualified providers who have not worked or trained together	• Communication gaps while managing a deteriorating patient • Delays in airway management • Risk of viral exposure to providers	Intermediate	• In situ interprofessional simulation specific for rapid response team • Resource requirements – Intermediate (design, provider time, budget- advanced simulation equipment). • Comments: Anesthesia and emergency medicine providers staffing the acute care team were trained in airway management and resuscitation and were oriented to the specific setting at Boston Hope.	Deferred
Management of a non–life-threatening event • No workflow or resource allocation for non–life-threatening events requiring a multidisciplinary team (e.g., psychiatric emergency)	• Risk of injury to patient or gap in care • Risk of injury or viral exposure to staff	Low	• Workflow design, involvement of security, simulation training specific for this scenario, creation of a psychiatric code box with sedatives • Resource requirements: High (design, scheduling, provider time, simulation equipment) • Comments: requires coordination with public safety, respite personnel	Deferred
Training in use of new equipment • Lack of training and skills in the use of point of care laboratory	• Delay in lab results	Low	• Would require training of each member of medical team. • Resource requirements: Intermediate (scheduling, provider time, quality assurance) • Comments: Sufficient external laboratory services in place	Deferred
COVID-19, coronavirus disease 2019; ICU, intensive care unit.

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Development of Rapid Response Capabilities in a Large COVID-19 Alternate Care Site Using Failure Modes and Effect Analysis With In Situ Simulation

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Appendix: Modified Failure Modes and Effect Analysis Worksheet

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