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.


Anesthesiology. 2020;133(5):985-996. 

In This Article


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.


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.