Israel Medical Association Journal

Background: During Operation Roaring Lion, Carmel Medical Center, a 500-bed tertiary hospital, relocated nearly half of its inpatient activity to the fortified underground facility of Rambam Health Care Campus while maintaining independent clinical and managerial responsibility. Returning patients after hostilities subsided represented a complex organizational transition requiring preservation of patient safety and continuity of care.

Objectives: To describe a multidisciplinary operational leadership model and evaluate the use of failure mode and effects analysis (FMEA) to support safe wartime hospital relocation.

Methods: A prospective quality improvement study used multidisciplinary FMEA before patient relocation. The relocation pathway was divided into four phases, and potential failure modes were scored by severity, occurrence, and detectability to prioritize mitigation strategies. Interventions included centralized command, real-time patient tracking, structured clinical handoffs, standardized transfer checklists, medication reconciliation, risk stratification, and enhanced post-transfer monitoring. Outcomes included patient safety events, falls, resuscitation events, unplanned intensive care unit (ICU) admissions within 24 hours, multidrug-resistant organism (MDRO) cross-transmission, and departmental feedback.

Results: During 55 days of wartime activity, 843 patients were hospitalized in the underground facility. In total, 84 medically complex patients were relocated in three operational waves. The highest-risk domains involved communication, documentation, operational coordination, staffing, and clinical monitoring. No predefined patient safety events, falls, resuscitation events, unplanned ICU admissions within 24 hours, or documented MDRO cross-transmission were identified. Department leaders reported high organizational preparedness and improved operational control.

Conclusions: A multidisciplinary operational leadership model integrating proactive FMEA enabled coordinated management of clinical, informational, operational, and infection-related risks during complex wartime hospital relocation.

Objective: To assess the ability of TREC and KREC counts to identify patients with combined T and B cell immunodeficiency in a pilot study in Israel.

Methods: We studied seven children born in Israel during the years 2010–2011 and later diagnosed with SCID, and an additional patient with pure B cell immunodeficiency. TREC and KREC in peripheral blood upon diagnosis and in their neonatal Guthrie cards were analyzed using real-time quantitative polymerase chain reaction, as were Guthrie cards with dried blood spots from healthy newborns and from normal and SCID-like controls.

Results: The first features suggestive of SCID presented at age 3.1 ± 2.4 months in all patients. Yet, the diagnosis was made 4.1 ± 2.9 months later. Their TREC were undetectable or significantly low at their clinical diagnosis and in their originally stored Guthrie cards, irrespective of the amount of their circulating T cells. KREC were undetectable in six SCID patients who displayed B cell lymphopenia in addition to T cell lymphopenia. KREC were also undetectable in one patient with pure B cell immunodeficiency.

Conclusions: TREC and KREC quantification are useful screening tests for severe T and B cell immunodeficiency. Implementation of these tests is highly important especially in countries such as Israel where a high frequency of consanguinity is known to exist. 

At the WHO meeting on primary immunodeficiency held in Orvetto, Italy in 1994, mutations in the genes involved in the classical PID disorders, such as X-linked agammaglobulinemia (Bruton).