April 19 2022
Mauren esquivel

Experience of the San Rafael de Alajuela Hospital in Costa Rica

The health sector has been the most demanded 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 in infections. As a first containment measure, it has been required to establish strict quarantines, with one of its purposes being to save time, not collapse the health system and have the possibility of providing care to the population.

In this high-level coordination exercise there are significant efforts, relevant innovations, deep transformations, which have been made in the operation and structure of hospitals, pressured by the current circumstances. This has also required the rapid adaptation of medical and nursing staff to a completely different reality from the one they were used to. This process begins to generate valuable learning.

This is the case of the San Rafael de Alajuela Hospital, which represents a model in adaptation actions for the response to COVID-19 and has shared learning with other hospitals in the region. This is how Dr. César Chaves, CAHI Fellow of Costa Rica, who currently serves as Assistant Medical Director and Hospital Coordinator of the Donation and Transplantation Program, explains it to us:

“We had to quickly create flows for handling hospital staff, patients and all internal processes. We were able to share this experience and its associated documents with the Santa Ana Hospital in El Salvador, in direct contact with its director Jorge Jiménez, with whom I have already had several conversations. This is how we are helping each other between hospitals in different countries.” (Interview conducted on 20/04/2020)

This is just one example of how innovations are being produced and good practices are being shared through the action that health professionals and CAHI Fellows are developing.

The irruption of innovation

Already the management team and the doctors of the Hospital San Rafael de Alajuela envisioned tomorrow: telemedicine as a way to care for most patients, video calls with the doctors, virtual consultation with the specialist, activation of the digital file, all online administrative processes, carrying out remote diagnosis, sending the prescription to the pharmacy, distribution of drugs directly to the patient's home.

This scenario may sound like science fiction, but it is not a description of something that is far in the future, it is about what is happening today. In the Hospital of San Rafael de Alajuela they were forced to implement a series of changes due to the circumstances; the state of emergency required quick adaptations and essential innovations.

The set of transformations that have been implemented did not occur as expected and have exceeded their initial calculations. 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 outlined and everyone was clear about how to proceed in this scenario. But the unexpected happened, the virus was already present in the hospital and when they carried out 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 command under which we have already completed 45 days. We started by generating divisions of contaminated areas and clean areas, establishing patient flow, staff flow, referrals from consultations to areas outside the hospital because we entered quarantine.” (Interview conducted on 20/04/2020)

How were they going to reorganize all the processes in this circumstance? How would all the staff be organized? What would be the reaction of the other hospital officials? How to continue providing 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 positive patient for COVID-19 was working on the fourth floor of the hospital, once identified, they had to take immediate action. They thus entered a state of emergency and total quarantine.

deep internal changes

“You have to take into account that generally one expects 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 all hospital admissions, to control the number of infections that could occur within the facilities.” (Interview conducted on 20/04/2020)

The Incident System Command was immediately created, considering four key areas: logistics, planning, communication and operations. In this way, the coordination of the emergency began with 1.300 active officials in the hospital.

Under the responsibility of logistics is the management of supplies and personal protective equipment. The planning processes led them to make changes to the structure of the hospital, knocking down walls, creating new rooms, sealing spaces with glass panels, sealing the intensive care units, all of this in a period of no more than 48 hours. Communications is responsible for the management of social networks, the information given to staff and their families, conversation with positive patients for COVID-19. In the case of operations, determine which spaces are open and which remain closed, how the doctors and nursing staff are going to work, what the flow of work will be.

“Many things had to be rethought, which required a significant effort from all the teams, from the hospital management to the medical, nursing, pharmacy, administrative and maintenance staff.” (Interview conducted on 20/04/2020)

The needs of the hospital workers also had to be met, since the most diverse reactions to the situation and the risk of internal contagion were presented. In the initial moments of the emergency, internal resistance was generated, complaints about the way in which personal protection equipment was distributed, refusal to take turns in the room specially set up for positive cases for COVID-19. This situation evidenced the need to consider the approach of human resources and open channels of attention and response to existing concerns, worries and fears.

Thus, support for staff was opened through the psychology and social work services, informative talks were implemented to explain the levels of risk in the various areas of the hospital and how this determines the type of PPE used. The protection and security protocols were explained in detail and an open dialogue was maintained at all times on the operation of all services and the responsibility of each official. 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 health police, assigning people who are in charge of training, discussing 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 travel, in which there is more risk, among other essential things at this time. This has been very well received by everyone.” (Interview conducted on 20/04/2020)

Major challenges and great support

The whole process has generated various reactions, some from the fear of getting infected or bringing the virus to their homes, others more positive in the response process 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 staff, give them the necessary guidance and all the information that allows them to understand how we are proceeding, as well as strengthen everyone's commitment.” (Interview conducted on 20/04/2020)

But there has also been a lot of solidarity and great support, both internally and externally, in a kind of virtuous circle that has allowed them to make significant progress in the hospital.

To the extent that actions have been taken with staff and within the facilities, cooperation has also come from outside. Important companies present in Costa Rica have made donations for the remodeling carried out and have the necessary supplies for the physical and technological adaptations.

The accompaniment of citizens and the solidarity of nearby companies has also been essential, because thanks to this the hospital staff has had food and care while they have been kept in total quarantine. That, added to expressions of recognition of his value through messages on social networks and notes of support, has raised the morale of all the teams, in moments 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 citizens participate. Dr. Chaves concludes thus:

“This has shown us what we are capable of, it has allowed us to discover new capabilities and the high flexibility that we have as a team. Now we feel very proud of what we have achieved, we know that we can be innovative and bring new techniques for the benefit of patients.” (Interview conducted on 20/04/2020)