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

Reflection and Debriefing After Real-life Cases

In event of a real emergency, activation of the rapid response pagers, or the use of the negative pressure resuscitation room, an immediate debrief was held with the relevant members of the care team. Postevent debrief and feedback were obtained directly from each team member after patient encounters. The purpose of the debrief was to generate a conversation around perceived barriers and to prioritize actionable items to correct hazards and improve safety and efficiency.

During the first few days of operation, unwell patients were brought into the negative pressure room where they were assessed and monitored. Designed for airway management and resuscitation, the negative pressure rooms were secluded from the outside environment, which limited the ability of staff to monitor patients unless physically present in the room, restricting their ability to attend to other patients.

Through reflection and debriefing after the management of the first patients in Boston Hope, it became apparent that mild to moderate issues, such as rising oxygen requirements or desaturations, may not have required the use of a negative pressure room, but instead, an intermediate option, where patients could be monitored, receive supplemental oxygen, or be proned.

Actions and Mitigation Strategies

The patient area closest to the negative pressure rooms was redesigned as four high-dependency observation bays (Figure 1) to allow continuous monitoring, management, and evaluation of patients until a decision was made to either transfer or return to their patient pod. These upgraded patient spaces allowed us to provide care for patients with higher acuity based on the routine staffing model and overseen by providers with experience in acute care. The escalation of care workflow was updated to include this area within the management algorithm. On reflection, these observation bays, which were populated daily, were an important contribution to our ability to hold and assess patients and likely obviated the need to transfer patients to higher level of care.

Other issues and mitigation strategies after the management of real patients in the acute care area are described in Table 1.