A clinical laboratories compound located in an underground fortified emergency hospital: the rambam health care campus model

Introduction

Rambam Health Care Campus in Haifa, Israel, is a major medical center featuring a unique three-level Fortified Underground Hospital (FUH). Activated on June 13, 2025, it protects patients and staff from ballistic missile threats capable of striking within 10 minutes. Designed as an underground parking structure, it can be converted to an operational emergency hospital within 48 hours, providing uninterrupted medical and diagnostic services during emergencies such as wars and pandemics. The FUH has essential infrastructure, including oxygen and medical gases, which can be activated for long-term patient care. During the coronavirus disease 2019 (COVID-19) pandemic, the FUH was adapted as a high-security isolation and treatment center.

Two of the three levels are dedicated to patient hospitalization and essential diagnostic services. Each level spans 20,000 m², housing clinical wards for internal medicine, surgery, pediatrics, nephrology (including dialysis), cardiology, oncology, hematology, and multiple intensive care units (ICU). These wards mirror their above-ground counterparts, enabling continuous patient care during emergencies. Departments such as the Emergency Room (ER), Blood Bank, Operating Rooms, Pediatric ICU, and Neonatal ICU are fortified and remain operational in their standard locations.

The Rambam Health Care Campus can treat approximately 1,000 inpatients, with a potential capacity of 2,000 by transferring patients from neighboring hospitals lacking protective facilities.

Laboratory services: relocation and operation

A vital component of emergency preparedness is ensuring the continuity of diagnostic laboratory services. Previous reports have described emergency laboratory models that primarily focus on the implementation of Mobile Field Laboratories, which play a critical role in responding to emergencies such as outbreaks and humanitarian crises. While mobile laboratories provide a valuable service, they are constrained by their confined spaces, limiting the type and quantity of equipment that can be used, primarily point-of-care testing (POCT) devices. This limited equipment may not meet the needs of fully operational hospitals, which require complex diagnostic capabilities. Additionally, establishing adequate infrastructure for emergency mobile laboratories poses challenges, including the need for refrigeration, analytical equipment, and effective information technology (IT) operational systems (1). The World Health Organization’s (WHO) guidelines for health laboratory facilities in emergency and disaster situations (2) emphasize the critical need for robust contingency plans and preparedness strategies. These measures are essential for ensuring prompt and effective responses to emergencies and for establishing efficient mechanisms for emergency preparedness and response within the health sector. Furthermore, emergency laboratory facilities that operate in disaster response scenarios encounter numerous challenges, including logistical constraints due to remote locations, shortages of reagents, limited access to equipment and power supplies, as well as insufficient trained personnel, particularly in the context of mobile laboratories. The objective of this report is to outline the planning protocols and operational activities involved in the activation of the Clinical Laboratories Division within the underground fortified hospital at Rambam Medical Center.

Rational and methods

Our rationale was to utilize active analyzers routinely used in our laboratories that could be easily relocated from our STAT lab, which primarily serves during off-peak hours. This lab features smaller, mobile equipment according to emergency policies. Essential microbiology equipment was also transferred as detailed in the hospital’s emergency logistics plan, ensuring immediate availability without delay typically associated with reactivating stored diagnostic equipment.

Utility and infrastructure readiness

Emergency protocols include precise equipment lists for transfer, predefined spatial allocations, and pre-installed digital infrastructure to facilitate seamless data transfer to the Laboratory Information System (LIS) (Table S1). Additional laboratory readiness features a dedicated water system, including reverse osmosis and filtration, to ensure adequate water quality for analyzers. Emergency standards mandated a stock of 2–3 months of supplies to counter potential supply chain disruptions.

Workflow

Samples were delivered manually to the receiving station or sent via a pneumatic system connecting to clinical wards and specialized laboratories within the hospital. POCT equipment, such as glucometers and blood gas analyzers, were consistently available and monitored by laboratory staff.

Specialized laboratory services

Additional specialized laboratory services, deemed less critical, such as molecular services (microbiology, virology and hematology laboratories), tissue typing for transplantation and flow cytometry, were relocated to provide faster and safer access to essential staff. Finally, cryogenic containers from the in vitro fertilization facility were moved to a protected area of the hospital.

Statistics

Data analysis presented was analyzed using Student’s t-test, two sample equal variance with a threshold of P<0.05.

Results

Timeline activation and description of the laboratory compound

On June 13th 2025, most of the essential routine laboratory services were transferred to the FUH and activated within a few hours, following pre-established emergency protocols (see detailed flowchart activation in Figure 1). The underground laboratories compound operated from June 14 to June 29, 2025. Key equipment used at the underground laboratory compound (Figure 2), included Alinity autoanalyzers (Abbott, Abbott Park, IL, USA) for biochemistry and immunochemistry tests (Figure 2A), DXH (Beckman coulter, Brea, CA, USA) and XN (Sysmex, Kobe, Japan) analyzers for complete blood count (CBC) tests (Figure 2B), ACL-TOP analyzers (Werfen, Barcelona, Spain) for coagulation tests (Figure 2C), Bactec instruments (BD, Franklin Lakes, NJ, USA) for blood culture tests (Figure 2D), and GEM gas analyzers (Werfen) for blood gas both in the lab, and as POCT (Figure 2E). A precise diagram of the laboratory footprint of the equipment is presented in Figure 3.

Figure 1 Detailed timeline flowchart activation of the laboratory underground compound at the Rambam Health Care Campus. LIS, Laboratory Information System.

Figure 2 Equipment used at the laboratory compound within the Rambam Health Care Campus Fortified Underground Hospital. (A) Biochemistry and immunochemistry tests were performed in Alinity autoanalyzers. (B) CBC tests were performed using DXH and XN analyzers. (C) Coagulation tests were performed on ACL-TOP analyzers. (D) Blood culture tests were performed using BACTEC instruments. (E) Blood gas both in the lab, and as POC remote equipment were performed using GEM gas analyzers. CBC, complete blood count; POC, point-of-care.

Figure 3 Diagram of the underground laboratory compound footprint of the equipment. CBC, complete blood count; TEG, thromboelastography.

Diagnostic capabilities and volume

The underground laboratory compound provided a comprehensive array of diagnostic services, as described in Table 1. It is important to note that the overall number of hospitalized patients was not different between the actual underground service and our regular service, allowing us to compare the two.

As expected, most test numbers were lower in the underground service compared to the regular service. However, the differences were not significant, as we maintained nearly the same testing capacity (and the overall number of hospitalized patients was almost similar).

While all of the routine testing was reduced by 25% to 30% (including Biochemistry, CBC, coagulation and bacteriology analyses), POCT was higher by 29% in the underground compound. This can be attributed to both the need for rapid diagnostics and the ability to deliver results directly at the patient’s location. It highlights the critical importance of POCT services during emergencies. Blood culture tests and epidemiological screening were slightly higher by 13% in the underground service. This reflects a focused effort on rapid monitoring of critically ill patients and the early detection of major infections and the implementation of infection control strategies.

During the activation of our diagnostic compound, we monitored turnaround time (TAT) of specific tests for the ER and for internal medicine departments (Table 2), from sample receiving to results dispatching to the patient’s medical records.

We used TAT monitoring as one of the quality indicator of our diagnostic services at the underground laboratory compound. TAT results did not exhibit significant changes only increase in standard deviation, between the regular service and the underground service as shown in Table 2 for routine biochemistry and troponin. TAT for ER increased by 2 minutes for routine biochemistry and Troponin, while in internal departments, TAT increased by 6–7 minutes. A significant increase of 7 minutes (P<0.05, one-sided test) was noted for CBC testing in ER in the underground service compared to regular service, while no significant difference was observed regarding Internal department services (Table 2). Therefore, in spite of transferring our services in a constrict area, and of changing drastically some of our working flow protocols, we were able to ensure almost the same level of efficiency of laboratory services. These results relate to our activities 24 hours after the first stages of moving the laboratories activities. In the first 24 hours of activities in the underground compound, while some activities remain in the upper part, to allow for continuity of service, we observe a significant delay of up to 45 minutes especially in biochemistry testing.

During all the time in the underground compound, Control quality processes were carried out at exactly at the same level of performance as during regular times, remaining a key process in all our laboratory services.

As presented in Table 3, there were 29 laboratory scientists and technicians on the morning shift, 7 on the evening shift, and 3 on the night shift. The staff comprised original personnel from the operating laboratories in the underground facility (STAT and microbiology labs), along with additional support from other routine labs, including biochemistry and hematology.

Twice a year, a scheduled drill is conducted in the relevant laboratories relocated to the underground facility in the event of war. These drills simulate laboratory responses to multiple casualty incidents, training staff to activate emergency protocols and integrate backup personnel from other labs. However, these drills do not involve the redeployment of instruments to the underground location; such relocation is only tested during actual events. Since the size of the relevant equipment is a critical consideration for efficient relocation of the labs in the underground facility, it is a point raised at the time of purchase to facilitate the potential transfer of equipment through the hospital’s lift systems.

Discussion

The Rambam model: autonomous, underground hospital laboratory

The Rambam model demonstrates the feasibility of fully autonomous, lab-capable underground hospital. Integration of pneumatic sample transport systems, automated reagent management, and real-time IT connectivity enhances laboratory operational efficiency and safety. This design allows for continuous delivery of comprehensive routine and specialized diagnostic laboratory services, even under the threat of ballistic missile attacks, while significantly minimizing staff exposure.

To our knowledge, there is limited literature specifically addressing laboratory operations in such fortified medical infrastructures. Most available information pertains to operation of mobile field laboratories (1,2) which limit the ability to give laboratory services to a full operating hospital. Advances in technology have allowed for much more portable, capable and compact clinical testing systems designed to perform well routine tests in emergencies and disasters, but they lack the ability to perform more complex tests. A critical element in emergency preparedness is ensuring the availability and protection of Blood Bank services, whether deployed in the field or as part of a hospital-based system (3). A key consideration in our emergency preparedness model was the capacity to provide a comprehensive range of laboratory services, beyond just routine emergency diagnostics. Unlike traditional models that assume a reduction in hospital operations during crises, Rambam Hospital continues nearly all of its clinical activities in emergency situations, including trauma care, elective surgeries, oncology and hematology clinics. As a result, our laboratory infrastructure had to support both routine diagnostics and specialized testing to meet the diverse needs of the hospital.

This shift in approach represented a new axiom in our preparedness strategy, as it was previously assumed that hospital activities would significantly decrease during missile attacks. However, given that Rambam was able to maintain almost all of its operations, particularly essential services like oncology clinics, the management directed us to ensure the continuation of specialized services, in addition to first-line diagnostic testing for emergency treatment.

Moreover, these specialized services were also extended to external healthcare providers, including smaller hospitals and medical clinics, that were unable to perform these activities during emergencies. This model not only ensured continuity of care within the hospital but also supported the broader healthcare ecosystem in times of crisis.

A major challenge in operating such a facility is the prevention of resistant bacterial infections among patients. During mass patient crowding, there is an elevated risk of cross-transmission of infections (2,4), notably those caused by antimicrobial-resistant pathogens. Implementing effective patient screening protocols is essential to curb the uncontrolled spread of infections. While the hospital implemented a strict isolation policy, the microbiology laboratory played a pivotal role in minimizing the spread of resistant organisms, through proactive screening of high-risk patients for colonization with multidrug-resistant bacteria (5).

Finally, during emergencies, as in routine operation, quality control policies remain a cornerstone of laboratory services. Ensuring the accuracy and reliability of laboratory results is essential, and maintaining a high level of analytical performance under emergency conditions was a critical priority. Rigorous internal and external quality control procedures were continuously applied, reinforcing the credibility of diagnostic data and supporting clinical decision-making, even in high-pressure situations. This also underscores the importance of using the same routine laboratory equipment rather than relying on separate, stored devices intended solely for emergencies. Regularly maintained systems offer greater reliability and consistency, reducing the risk of analytical errors when precision is most needed (6).

Model limitations

A significant limitation of our model is that the redeployment of critical equipment may result in malfunctions and issues during transport. Therefore, it is essential to handle the transportation with not only regular logistics personnel but also dedicated biomedical engineering technicians and the supplier company’s technicians to minimize damage during the transfer of equipment.

Additionally, the discontinuation of the supply chain presents a relevant limitation, as none of the reagents are produced locally, necessitating shipments from other countries. This issue is particularly pertinent in Israel, where flight disruptions can occur, leaving no land borders available for the transport of supplies. Consequently, it is crucial to establish clear contracts with supplying companies, expecting them to maintain extensive stock during wartime.

The well-being of staff working in confined underground spaces is another relevant limitation that requires careful attention from laboratory directors to identify potential distress situations. It is also critical to allow staff the opportunity for breaks outside of the compound when it is safe to do so, promoting their mental and physical well-being.

Conclusions

Emergency preparedness of diagnostic services is a holistic and multidimensional process. It requires comprehensive planning across several domains, including infrastructure, equipment, emergency stockpiles, and staff training. Clear policies must define priority scenarios (i.e., types of emergencies) and establish specific objectives for laboratory medicine during such events. The Rambam Health Care Campus FUH exemplifies state-of-the-art emergency preparedness, ensuring uninterrupted, high-quality medical and laboratory services under extreme threat conditions. Its infrastructure, operational protocols, and adaptability provide a model for resilient healthcare delivery and diagnostic laboratory services in crisis situations, offering valuable lessons for global health systems facing similar challenges.

Acknowledgments

We would like to acknowledge Mrs. Stephanie Zagori for operational support throughout this project.

Footnote

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-73/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-73/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Mushasha R, Paez Jimenez A, Dolmazon V, et al. Existing operational standards for field deployments of rapid response mobile laboratories: a scoping review. Front Public Health 2024;12:1455738. [Crossref] [PubMed]
2. Health laboratory facilities in emergency and disaster situations Second edition, WHO Regional Publications, Eastern Mediterranean Series. Available online: https://iris.who.int/bitstream/handle/10665/327297/EMROPub_2017_EN_20195.pdf
3. Van Denakker TA, Al-Riyami AZ, Feghali R, et al. Managing blood supplies during natural disasters, humanitarian emergencies, and pandemics: lessons learned from COVID-19. Expert Rev Hematol 2023;16:501-14. [Crossref] [PubMed]
4. Fernando SA, Gray TJ, Gottlieb T. Healthcare-acquired infections: prevention strategies. Intern Med J 2017;47:1341-51. [Crossref] [PubMed]
5. Verdugo-Paiva F, Otaiza F, Roson-Rodríguez P, et al. Effects of screening strategies to detect carbapenem-resistant gram-negative bacteria: A systematic review. Am J Infect Control 2022;50:1381-8. [Crossref] [PubMed]
6. Plebani M. Quality indicators: an evolving target for laboratory medicine. Clin Chem Lab Med 2025;63:1889-90. [Crossref] [PubMed]