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

Abstract and Introduction


Preparedness measures for the anticipated surge of coronavirus disease 2019 (COVID-19) cases within eastern Massachusetts included the establishment of alternate care sites (field hospitals). Boston Hope hospital was set up within the Boston Convention and Exhibition Center to provide low-acuity care for COVID-19 patients and to support local healthcare systems. However, early recognition of the need to provide higher levels of care, or critical care for the potential deterioration of patients recovering from COVID-19, prompted the development of a hybrid acute care–intensive care unit. We describe our experience of implementing rapid response capabilities of this innovative ad hoc unit. Combining quality improvement tools for hazards detection and testing through in situ simulation successfully identified several operational hurdles. Through rapid continuous analysis and iterative change, we implemented appropriate mitigation strategies and established rapid response and rescue capabilities. This study provides a framework for future planning of high-acuity services within a unique field hospital setting.


The Morbidity, mortality, and rapid pace of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has led to an unprecedented health crisis. In anticipation of the projected surge of COVID-19 cases, the Commonwealth of Massachusetts and city of Boston set up a plan to establish alternate care sites (e.g., field hospitals)[1] to meet the needs of COVID-19 patients requiring acute and subacute care.[2,3] Local models based on data from Wuhan, China[4] projected an estimated 0.7% to 2.5% of the population of the state of Massachusetts to be infected, with a peak incidence estimated to occur between April 10 and April 20, 2020. This projection predicted the need for 2,500 to 7,500 acute care hospital beds, a number which would have exceeded the established bed capacity of the catchment area.[5,6] A field hospital named "Boston Hope" was rapidly deployed within 2 weeks as a collaborative venture between the major city hospitals and federal and state government agencies to serve the emergent anticipated needs of the Greater Boston and eastern Massachusetts areas.[7]

Boston Hope was initially set up to provide care for low-acuity patients and was equipped and staffed according to the level of a skilled nursing facility. The need to provide a solution for a large number of patients, as well as a predicted large number of COVID-positive undomiciled persons, led to the design of a 500-bed medical facility (Figure 1) alongside a 500-bed shelter for those not requiring continuous medical care. Care units were designated as pods of forty patients each, staffed with one medical doctor (only in higher-level moderate acuity pods), two advanced practice providers, five registered nurses, five to 10 certified nurse assistants, three to six physical/occupational therapists, and a resource specialist/unit coordinator. In addition, respiratory therapists, pharmacists, social workers, mental health specialists, and case management workers shared coverage across the pods. Of note, because of the limited availability of clinicians actively practicing in inpatient settings, most of the clinical staff hired were from low-acuity outpatient settings.

Figure 1.

Boston Hope and hybrid acute care–intensive care unit. An overhead photograph of one of the patient areas (A) taken just before opening and a preliminary schematic of the layout of Boston Hope patient area (B). The patient space outlined in the red circle was redesigned to function as a high dependency/observation unit (C), which was equipped with a hospital stretcher, vital sign monitor, oxygen regulator, intravenous access/fluid kits, and newly installed overhead lighting. These observation bays were established adjacent to the negative pressure room (D), fully equipped for resuscitation, airway management, and ventilation if necessary.