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

In Situ Simulation

In situ simulation, whereby drills are carried out within a team's actual working environment, provides a further means of identifying site-specific hazards.[15,16] It is an efficient, cost-effective tool to facilitate interprofessional team-based training.[17–21] In situ simulation drills were conducted in Boston Hope to facilitate staff training, assess workflow efficiency, evaluate the performance of the rapid response team, and identify deficiencies and hazards in our set up.

When designing in situ drills, we considered the diversity in training and skill set among our personnel. Providers at Boston Hope were effectively practicing in an alien environment; many of them were never trained in the management of a deteriorating patient (e.g., outpatient practices). Moreover, the safety regulations preventing the initiation of chest compression and ventilation in the common area mandated the design of a site-specific emergency sequence. We therefore chose to scope our training and simulation scenarios to focus on the identification of the unresponsive patient and the required management until arrival into the resuscitation area. Outcomes were set to reflect the steps required to complete this task.

In situ simulation drills were conducted on alternate days and covered each patient care area. Our first scenario took place in the patient pod located farthest from the acute care–ICU area; subsequent scenarios were held in patient pods closer to the resuscitation area. A separate simulation drill was performed with physical therapists within the rehabilitation area, where patients perform their daily physical activities. This rehabilitation area was chosen specifically for simulation drill because of the additional concerns of hazards resulting from the activities performed by patients in this area and the distance from medical providers.

The plan to conduct a simulation drill was discussed during daily staff briefings, which included reviewing the emergency management workflows and confirming the location of the automated external defibrillator and stretcher. Simulation briefings also included the recommendations for safe conduct during drills. Participants would then return to their routine daily assigned roles and tasks. A short while after the morning briefing, the mock scenario would begin when a facilitator would ask a provider to obtain vital signs from a patient, which in this case was a mannequin placed in the bed space. These drills lasted approximately 3 to 4 min, focusing on the action sequence that included patient identification, call for help and activating the rapid response pagers, automated external defibrillator placement, and transfer to the negative pressure room. Timing of automated external defibrillator placement and arrival to the negative pressure room were recorded using a mobile phone by the drill facilitator. A short debrief was held after every simulation drill to review improvement opportunities, to identify hazards and implementation barriers, and to provide participant feedback. In situ simulation drills were considered successful if automated external defibrillator pads were applied to the mannequin within 2 min of the recognized emergency, as recommended by the American Heart Association guidelines for resuscitation,[22] and on completion of a timely transfer to the negative pressure room for further management.

Six simulation drills were performed over a 2-week period to cover the entire site. Participants in each drill included the personnel assigned the patient area where the mannequin was "found'' and the assigned on-call rapid response team of that day. The mean time for placement of automated external defibrillator pads and time to arrival into the negative pressure resuscitation room were 42.7 s (range, 30 to 75 s) and 150.2 s (range, 128 to 167 s), respectively. This result was reassuring in that delivering a defibrillation shock within the recommended 2-minute window is within our process capabilities.[22]

Despite what we perceived as successful drills supporting our newly designed workflows, several issues were revealed during the process of in situ simulation (Table 1). Delays in the paging activation process resulted in noticeable delays in the assembly of the rapid response team. During two simulation drills, the rapid response call was placed seconds after recognition of the emergency; however, the pagers were activated only after the patient's entrance to the negative pressure room several minutes later. Investigation of these events revealed that extensive time was lost in exchanging information between the caller and the operator, such as the patient's name, location, call-back number, and the read-back by the operator. The timely donning of personal protective equipment for a rapid response call was complicated by the need for the members of the rapid response team to locate their own reusable face-shield and N-95 respirator mask, which were placed on numbered shelves. This created a further delay in response. Difficulties were also seen when attempting to open automated external defibrillators, because it was not intuitive for most providers to lift an unmarked latch to open the box. This contributed to a delay in the delivery of a simulated shock.

Actions and Mitigation Strategies

To address the issues identified through in situ simulation, a further 12 solutions were implemented (Table 1). Information exchange during a rapid response call was minimized and standardized. Pagers were activated by simply requesting the "Boston Hope Rapid Response Team." The stat line number was programed into every landline phone to enable speed dialing, and a protocol was established that the rapid response team report directly to the negative pressure room, thus eliminating the need to provide specific location details. Implementation of a rapid personal protective equipment donning station for rapid response team members was established near the entrance to the hospital hall and included prepackaged personal protective equipment kits in several sizes and the allocation of a new role of a personal protective equipment attendant to aid the responders. Labeling was applied to automated external defibrillator boxes ("lift to open") to identify the latch and facilitate opening the box. Further training on opening and operating the automated external defibrillator was provided to staff, both ahead of and during simulated scenarios.