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

Failure Modes and Effect Analysis, Process Mapping, and on-site Walkthroughs

An initial process map was created to identify the proposed sequence of events in the event of clinical decompensation, specifically from the recognition of a deteriorating patient to their arrival into the negative pressure resuscitation room (Figure 2). Within this simple flow diagram, barriers for safe patient care were identified and reviewed using a modified failure modes and effect analysis approach.

Figure 2.

Process mapping. A process map, created during the initial planning phase, outlining the proposed sequence of events from the recognition of a deteriorating patient to their arrival into the negative pressure resuscitation room. The stars identify areas of risk or anticipated hazard. ICU, intensive care unit.

Failure modes and effect analysis is an efficient means to prospectively evaluate and identify opportunities for failures within a design or complex task. It is aimed at prioritization of corrective measures.[10–12] Traditional healthcare failure modes and effect analysis requires the assembly of a designated team to review each step within a complex task, identification of potential failure modes, and the assignment of a numerical value to each for severity, probability of occurrence, and detectability. When these values are combined, a risk priority number is generated, which helps guide prioritization of interventions.[13] We adopted a modified failure modes and effect analysis process because of the constraints of time and the inability to assess the occurrence of emergency events while managing a unique care site during an evolving pandemic. Failure modes were identified by a team of medical and nursing leaders, along with the site managers in charge of operations. Using a group deliberation approach, failures and their potential downstream effects were assigned a severity (high, intermediate, low) and prioritization (immediate, urgent, or deferred action required) and the scope for intervention was evaluated (appendix). Finally, an on-site walkthrough was performed with medical and nursing leads.[14] The purpose of the walkthrough was to assess workflows, detect safety issues, and determine the most efficient means for urgently transferring an unstable patient into a negative pressure room to receive appropriate care.

During the initial planning phase and process mapping, the absence of a standardized workflow for the management of a deteriorating or complex patient was noted. Recognition that standard rescue practices could not be adopted because of considerations unique to COVID-19 were noted. For example, aerosolizing procedures such as chest compressions and airway management could not take place in the common areas. Additionally, care teams redeployed ad hoc from different institutions were not required to be Advanced Cardiac Life Support certified and had limited training and experience in managing acute patients.

The box bed within each patient bed space was difficult to mobilize and was restricted to an unadjustable height. Therefore, to facilitate a safe transfer to a negative pressure room, transfer to a stretcher was deemed necessary. With both the stretcher and the bed present, the small size of the bed space limited the staff mobility within the room. The walkthrough also highlighted the limited supply of automated external defibrillators and backboards for assisting in the transfer of patients not found on their bed or in nontraditional areas (e.g., restrooms, rehabilitation area).

Communication on the floor posed a significant challenge for multiple reasons, arising primarily because the patient care area was a repurposed exhibition hall lacking the standard communication panels found on hospital floors. Patient bed spaces were not equipped with call bells, nor were central monitoring devices available. The size and structure of the hall at times made it impossible to maintain direct visual contact with the nursing station while with patients. This was further complicated by the use of personal protective equipment, muffling the sound of a call for help by masks and the acoustics of a huge hall with a loud venting system. These constraints required immediate solutions to enable timely signaling for help or triggering of the rapid response team.

Actions and Mitigation Strategies

Nearly twenty solutions were implemented to address the issues identified through the proactive measures described above (Table 1). Failure modes identified as high severity and immediate priority were targeted for intervention, whereas other issues were deferred (appendix).

Workflows for the escalation of care and the management of an emergency were refined and distributed (Figure 3), to help distinguish between clinical deterioration requiring a higher level of care (e.g., patients with moderate respiratory symptoms brought to the observation area for continuous monitoring and supplemental oxygen) and perceived life-threatening situations prompting the activation of the rapid response team. An emergency action sequence, once a life-threatening condition is recognized, was included in training and team huddles. These actions included the identification of the emergency situation, leaving the patient alerting the nearest nursing station to call for help, activating a activating a rapid response call, returning to the patient, and placing automated external defibrillator pads onto the chest while waiting for help to arrive with a stretcher. Once help arrived, the bed was moved out of the bed space and a four-member team assisted in transferring the patient onto the stretcher before transporting to the negative pressure room. Meanwhile, the activated rapid response team will have assembled, waiting to receive the patient in the negative pressure room and assume care.

Figure 3.

Workflow for escalation of care. The final version of the escalation of care workflow, including the rapid response activation number. Personal contact details of the acute care consulting and emergency medical services have been removed from this image. CPR, cardiopulmonary resuscitation.

Urgent requests for equipment acquisition were made to ensure an adequate number of automated external defibrillators were available (e.g., one for every nursing station) as well as enough backboards for patient transfers. Rapid response pagers were issued using the existing telecommunication system and the emergency stat-line of Massachusetts General Hospital. Pagers were all programmed to the same number and assigned to all members of the rapid response team, including the acute care physician, two nurses, a respiratory therapist (or experienced provider), and the medical team leads from each patient pod.