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

Redefining the Mission of Boston Hope

During planning and development, there was an early recognition of the need to be able to provide higher levels of care or critical care for potential respiratory deterioration in patients recovering from COVID-19.[8] An innovative hybrid acute care–intensive care unit (ICU) was therefore created to address the anticipated critical care needs of these patients and provide rapid response and rescue capabilities in the event of an emergency.[9] The acute care–ICU was originally designed as two negative pressure resuscitation rooms which were later expanded with a four-bed high-dependency observation unit (Figure 1). Because of the limited availability of critical care providers during the pandemic, the staffing model for this unit relied on support of providers with essential critical care training, such as anesthesiologists and emergency medicine physicians who augmented the intensivist group. More specifically, most elective surgical activity in the region's hospitals was placed on hold, hence the increased availability of anesthesia providers to supply this service, and their versatile ability in delivering comprehensive care, made them natural candidates to fulfill this role. Additional training, guidance, and oversight was provided by certified intensivists.

The concept of establishing critical care services within the framework of a low-acuity civilian setting is innovative and had not been widely implemented. Herein, we describe the framework for implementation of critical care and rapid response capabilities within the setting of a civilian building at a time of significant resource constraints. We highlight the challenges and outline a pragmatic step-wise approach using quality improvement methods to improve the efficiency of care in the unfamiliar setting posed by the pandemic.