Infrastructure

This pillar serves as the foundation for care delivery. Digital integration is integral to translating hospital-level standards to decentralized settings.Reference Wang, Lian and Ji^3, Reference Sultani, Smeulers and de Vries⁵ Accordingly, operational workflows utilized a laptop equipped with the hospital’s full computerized systems, including the virtual ward within the Chameleon Electronic Health Record (EHR)—an enterprise-wide digital platform utilized for comprehensive patient data management, clinical ordering, and medical documentation. This allowed for seamless patient tracking and maintained rigorous clinical oversight in the field. Clinical safety was continuously monitored through real-time digital auditing of vital signs and adherence to standardized assessment protocols within the EHR, ensuring that care delivery remained consistent with inpatient safety benchmarks. Beyond digital integration, hospital leadership prioritized staff safety by providing dedicated vehicles specifically equipped for the HaH unit, creating a secure and highly organized mobile workspace.

However, the reality of field nursing during conflict often demanded immediate adaptation. While traveling between patients’ homes, sirens frequently blared, forcing the team to stop the vehicle and seek immediate shelter. Despite these abrupt interruptions and the constant threat, we ensured that equipment was secured and patient care continued without compromise once the immediate danger passed. Furthermore, when formal structures reached their limits, adaptive, on-the-spot adjustments became necessary; for example, using available household materials to stabilize IV therapy. Aligning with findings that characterize disaster nursing through high levels of resourcefulness and adaptive clinical judgment,Reference Fink and Milbrath⁶ these moments highlighted the nurse’s ability to adapt both the environment and operations, demonstrating how flexible, presence-driven leadership maintains clinical standards even under extreme conditions (see Figure 1).

Figure 1.

Operational adaptation in a high-threat environment. During the “Lion’s Roar” conflict, operational volatility occasionally hindered access to standard medical supplies. This image illustrates the improvisation of an IV pole using available household items (a broom and mop) to ensure the continuity of essential intravenous therapy for a clinically stable patient. This adaptation exemplifies the practical resourcefulness and adaptive clinical judgment required of nursing leadership to maintain hospital-level care standards within nontraditional, resource-constrained settings. This improvisation represents a crisis-driven adaptation, not standard clinical practice; it was employed only when professional equipment was inaccessible, while maintaining strict hand hygiene and aseptic technique to mitigate infection risks.

It is critical to clarify that such improvisations represent emergency adaptations rather than standard clinical protocols. Under routine conditions, the use of household items would violate established safety and infection control standards. However, during the “Lion’s Roar” conflict, maintaining continuous therapy was prioritized. To manage this, the nursing team adhered to rigorous hand hygiene and protective site management, ensuring that the improvised solution did not compromise patient safety. This balance highlights the ethical and clinical complexity of disaster nursing, where the priority is to maintain life-saving interventions when formal resources are inaccessible.

Operational logistics were supported by specialized kits containing required acute medications and portable monitors. Communication was maintained through secure, real-time mobile applications synced with the hospital’s Chameleon EHR, ensuring constant clinical oversight. During missile alerts, a strict stop and shelter safety protocol was mandated: teams were instructed to prioritize immediate personal protection before resuming patient care once the threat cleared.

Human Resources

The second pillar addresses the human capital required to sustain acute care outside hospital walls. This was reflected in a professional transition from an administrative, office-based role back to direct clinical practice in the field. Aligned with evidence suggesting that the success of Hospital at Home (HaH) models depends on the workforce’s ability to operate in unpredictable environments,Reference Wallis and Shepperd⁷ the transition required rapid integration into this unique setting. To ensure clinical competency for this rapid deployment, all nursing staff recruited to the HaH emergency unit underwent a mandatory, structured training program. This curriculum was specifically designed to adapt clinical skills to the home setting, ensuring that all staff including those transitioning from research or administrative backgrounds, possessed the necessary competencies for acute clinical management, patient assessment, and strict adherence to hospital-level safety protocols. Operating within this model enabled the independent application of advanced clinical skills and professional judgment, requiring evidence-based decision-making under the extreme pressures of armed conflict and continuous sirens.

Echoing findings that underscore the specific professional attributes required in conflict zones particularly resourcefulness in disregarding environmental hazards,Reference Fink and Milbrath⁶ our team’s adaptability was critical. Maintaining continuity and safety in these environments often required what has been described as organic innovations, a concept that describes the flexible prioritization of clinical workflows necessitated by severe system stress.Reference Gustavson, Miller and Boening⁸ As established in the literature, this shift of hospital-level care to the community necessitates skills often absent from conventional curricula, requiring a fundamental reappraisal of how nursing standards are upheld in noninstitutional environments.Reference Knight and Lasserson² The team comprised a multidisciplinary mix of physicians, nurses, and logistics coordinators, maintaining a staffing ratio that allowed for intensive follow-up while ensuring clinician safety. Workload adaptations included flexible shift scheduling to match peak conflict intensity, allowing for increased visit frequency for clinically unstable patients while maintaining standardized care intervals for others.

Policy

The third pillar emphasizes policy and clinical governance established by hospital management to ensure that the HaH model delivers safe, high-quality care equivalent to traditional inpatient hospitalization. To address implementation barriers regarding robust governance frameworks, we anchored our field operations in Joint Commission International (JCI) benchmarks. Adopting these standards created a professional safety net that allowed the team to maintain consistent care protocols, such as standardized medication management, despite the conflict-driven volatility. Hospital management implemented rigorous admission protocols, including comprehensive assessments of clinical stability. These procedures reflected a broader institutional strategy of organizational adaptation, a concept critical to maintaining service continuity during public health emergencies.Reference Wang, Lian and Ji³ Aligned with principles of structured systemic management, emphasis was placed on developing uniform admission criteria and standardizing workflows. We utilized this approach to bridge the gap identified in the literature, where the absence of clear definitions and standardized protocols constitutes a major barrier to optimal care.⁴ Within this framework, clear International Patient Safety Goals (IPSG), such as patient identification and medication management, were defined. Detailed guidance materials were also developed for patients and families to ensure their active and safe participation in the therapeutic process. Our proactive management policy enabled efficient and structured frontline operations, mitigating clinical risks even under the complex conditions of active conflict.Reference Knight and Lasserson² Patient selection criteria focused on subacute conditions (e.g., infectious diseases, heart failure, and post-surgical recovery) where clinical stability could be maintained. A clear escalation pathway was established: patients whose condition deteriorated or who required advanced diagnostics were rapidly transferred back to the hospital. This policy provided the team with definitive operational boundaries, ensuring that Hospital at Home remained a safe and viable alternative to inpatient care.