The health sector has been the most strained during the emergency generated by COVID-19. The entire structure of hospitals and health centers in the region and in the world has been put to the test by the arrival of this virus and the rapid rise of contagions. As a first containment measure, it has been required to establish strict quarantines, having as one of its purposes to gain time, not to collapse the health system and to have the possibility to provide care to the population.
In this high-level coordination exercise, significant efforts, relevant innovations and profound transformations have been made in the operation and structure of the hospitals, under pressure from the current circumstances. This has also required the rapid adaptation of the medical and nursing staff to a completely different reality from the one they were used to. This process is beginning to generate valuable lessons.
This is the case of the San Rafael Hospital in Alajuela, which represents a model for adaptation actions in response to COVID-19 and has shared lessons learned with other hospitals in the region. This is explained by Dr. César Chaves, CAHI Fellow from Costa Rica, who currently serves as Assistant Medical Director and Hospital Coordination of the Donation and Transplantation Program:
"We had to quickly create flows for the management of hospital staff, patients and all internal processes. That experience and its associated documents we were able to share with the Santa Ana Hospital in El Salvador, in direct contact with its director Jorge Jimenez, with whom I have already had several conversations. In this way we are helping each other among hospitals in different countries." (Interview conducted on 04/20/2020)
This is just one example of how innovations and best practices are being produced and shared through the action that health professionals and CAHI Fellows are developing.
The management team and physicians of the Hospital San Rafael de Alajuela were already visualizing the future: telemedicine as a way to care for most of the patients, video call with the physicians, virtual consultation with the specialist, activation of the digital file, all administrative processes online, remote diagnosis, sending the prescription to the pharmacy, distribution of drugs directly to the patient's home.
This scenario may seem like science fiction, but it is not a description of something far in the future, it is what is happening today. At the San Rafael Hospital in Alajuela they were forced to implement a series of changes due to the circumstances; the state of emergency demanded quick adaptations and indispensable innovations.
The set of transformations that have been implemented did not occur as they expected and have exceeded their initial estimates. The entire medical and nursing team created a plan for what was going to be the arrival of the first positive case of COVID-19 through the emergency room, the protocols were established and everyone was clear on how to proceed in this scenario. But the unexpected happened, the virus was already present in the hospital and when they performed the initial tests they identified some infected hospital workers. Dr. Chaves narrates it like this:
"It happened unexpectedly. We started on March 6 with an intervention and management team, a line of order under which we have already completed 45 days. We started generating divisions of contaminated areas and clean areas, establishment of patient flow, staff flow, referrals of consultations for areas outside the hospital because we went into quarantine." (Interview conducted on 04/20/2020)
How were they going to reorganize all the processes under these circumstances? How would all the staff organize themselves? What would be the reaction of the other hospital staff? How could they continue to provide care to the population in this scenario? These are some of the questions that arise from the reality they faced at the beginning of March. The first patient positive for COVID-19 was working on the fourth floor of the hospital; once identified, they had to take immediate action. They went into a state of emergency and total quarantine.
"You have to take into account that usually you expect the emergency to come from outside, but this time it came from inside the hospital. We had to create specific flows and a new operating structure. The first measure was to close the entire hospital entrance, to control the number of contagions that could occur inside the facilities." (Interview conducted on 04/20/2020)
The Incident System Command was immediately created, considering four key areas: logistics, planning, communication and operations. This initiated the coordination of the emergency with 1,300 active staff members at the hospital.
Logistics is responsible for the management of supplies and personal protective equipment. The planning processes led them to make changes in the hospital structure, demolish walls, create new rooms, seal spaces with glass panels, seal the intensive care units, all in a period of no more than 48 hours. Communications is responsible for the management of social networks, information given to staff and their families, conversation with positive patients for COVID-19. In the case of operations, determining which spaces are open and which remain closed, how the doctors and nursing staff will work, what the work flow will be.
"Many things had to be rethought, which required a major effort from all the teams, from the hospital management to the medical, nursing, pharmacy, administrative and maintenance staff." (Interview conducted on 04/20/2020)
The needs of the hospital workers also had to be addressed, as there were a wide range of reactions to the situation and the risk of internal contagion. At the beginning of the emergency, there was internal resistance, complaints about the way in which personal protective equipment was distributed, refusal to take shifts in the room specially equipped for COVID-19 positive cases. This situation showed the need to consider the approach to human resources and to open channels of attention and response to existing concerns, worries and fears.
Support was provided to personnel through the psychology and social work services, and informative talks were given to explain the levels of risk in the various areas of the hospital and how this determines the type of PPE to be used. Protection and safety protocols were explained in detail and an open dialogue was maintained at all times on the functioning of all services and the responsibility of each staff member. These measures significantly improved the situation and clearly reduced internal tensions, as well as helping to create an environment of clear communication and trust.
"We created the sanitary police, assigning people who are in charge of training, dialoguing compliance with standards and protocols in all areas of the hospital, explaining what type of protective equipment should be used, the correct way to do it, in which places it is safer to be or go around, in which there is more risk, among other essential things at this time. This has been very well received by everyone." (Interview conducted on 04/20/2020)
The whole process has generated diverse reactions, some of them fearing to be infected or to take the virus to their homes, others more positive in the process of the response that has been implemented. In the words of those responsible for the changes developed, the most challenging element has been the human factor.
"The most difficult thing has been the process with the people, with the officials, the work of providing security and confidence, of transmitting tranquility. It has been important to put ourselves in the place of the personnel, to give them the necessary orientations and all the information that allows them to understand the way we are proceeding, as well as to strengthen everyone's commitment." (Interview conducted on 04/20/2020)
But there has also been a lot of solidarity and great support, both internally and externally, in a sort of virtuous circle that has allowed them to develop important advances in the hospital.
While actions have been taken with the personnel and within the facilities, there has also been cooperation from outside. Important companies present in Costa Rica have made donations for the remodeling work and to provide the necessary supplies for the physical and technological adaptations.
The support of the public and the solidarity of nearby companies has also been essential, as the hospital staff has been provided with food and care while they have been kept in total quarantine. This, added to expressions of recognition of their courage through messages on social networks and notes of support, has boosted the morale of all the teams, in times of high demand.
In the weeks that they have been facing the emergency, this has turned the response into a collective act of cooperation, where each actor becomes indispensable. Finally, this is becoming an operation in which public officials, the private sector and the citizenry participate. Dr. Chaves concludes:
"This has shown us what we are capable of, it has allowed us to discover new capabilities and the high flexibility we possess as a team. Now we feel very proud of what we have achieved, we know we can be innovative and bring new techniques for the benefit of patients." (Interview conducted on 04/20/2020)
