Keys to confronting crises, from a hospital fighting COVID-19

Anticipating problems, protecting your people, and working in close cooperation with your stakeholders: these are some of the lessons the University of Navarra Clinic takes from its fight against COVID-19 in Spain.

The hospital had been expecting just such a case. In late February, the global healthcare agency Joint Commission International (JCI) had upped its infectious disease protocols, advising the Spanish hospital to prepare itself as the coronavirus made its way west from China to Europe. Northern Italy was already under quarantine.

Anticipating problems is the first key for dealing with a crisis, says Jose Andres Gomez Cantero, general director of the University of Navarra Clinic, with hospitals in Pamplona and Madrid. As the saying goes, an ounce of prevention is worth a pound of cure. Having been alerted, the Clinic immediately adopted extra protection measures and mobilized stakeholders in advance.

They worked out contingency plans with their infectious diseases unit. "We had already been building protocols to prevent outbreaks of Legionnaires' disease and other infections," says Gomez Cantero. "And we had already been working with our nursing services in preventing infections via catheters and intravenous tubes."

Thanks to those previously laid foundations, after COVID-19 hit, the contagion rate among Clinic healthcare workers ended up being 7% and the mortality rate among admitted patients was 5%, compared with the national average of 20% for both.

Redoubling their efforts

Ana Isabel's lungs failed. She became the Clinic's first patient to be put on a ventilator in the ICU. The Clinic expanded its capacity, making 300 beds available in Pamplona (although only 200 were ultimately needed). In Madrid, the expansion was organized around three units: ER, Hospitalization and ICU. ER was expanded to 33 places. The number of single-occupancy rooms was tripled. And the ICU quadrupled in size, annexing part of the surgery recovery area.

Even so, the end of March and beginning of April were "the most difficult times we have ever experienced," says Gomez Cantero, recalling at one point there were more than 20 patients waiting to be admitted to the ICU and only nine free beds. Staff had to get creative, using nasal cannulas to provide oxygen to patients without a ventilator. This may have contributed to the lower mortality rate at the Madrid hospital, he says.

Ingenuity and flexibility flourished across all departments. The clothing service repurposed reusable Gore-Tex gowns, initially designed to be worn over surgical pajamas, to make new masks, hoods and neck coverings to protect workers and avoid infections. The laundry service increased shifts to keep up with the need for protective equipment.

The Clinic had already used ultraviolet lamps to disinfect rooms for years, and these came into their own for disinfecting rooms with COVID-19 patients. Also, through their links with the university's Pharmacy Faculty, they were able to (literally) get their hands on extra supplies of sanitizing gel, which they also distributed to others.

All staff were repeatedly tested for COVID-19. Gomez Cantero proudly reports that, "No doctor at the Clinic has been infected since the end of March, and no healthcare worker since the end of April."

We're all in this together

Cooperation involving all stakeholders is another key. All personnel — from doctors and nurses to cleaners and maintenance staff — were enlisted in the effort.

After receiving the first COVID-19 patients, "everything accelerated," says Gomez Cantero. "We met daily to organize care based on the number of patients in Pamplona and Madrid." Another committee made up of department reps from infectious diseases, preventive medicine and occupational hazards made decisions at each step. The Clinic also coordinated with other area hospitals and with the Health Department.

In Pamplona, a COVID-19 unit was established, involving experts in pulmonology, internal medicine and infectious diseases but also others from oncology and cardiology who wanted to collaborate. They lent support to Madrid, sending beds, medical supplies, pharmaceuticals and even willing staff.

Everyone pulled together for the greater good. It was not uncommon to see renowned surgeons whose operations were on hold taking orders from more junior doctors in charge of coronavirus patients.

Still, some things couldn't be delayed, even with a crisis. "One of our COVID-19 patients gave birth but she couldn't see her baby until after she had fully recovered three weeks later," says Gomez Cantero. A new proton therapy unit at the Madrid Clinic went into operation, treating its first cancer patient on April 17, at the height of the crisis. In Pamplona, 13 critical transplants were carried out, despite the pandemic.

At the end of April, Ana Isabel was discharged, which gave everyone a much-needed morale boost. "She was our first patient to go through it all, from ER to the ICU, the first to be placed on a ventilator, and the first to be removed from one. Seeing her leave on her own two feet really lifted our spirits."

Not everyone was so fortunate, however. In cases where patients succumbed to COVID-19, the Clinic found ways to accommodate family members being present with their loved ones during their final days — a level of palliative care that earned them positive recognition from the World Health Organization for still delivering
humane, effective, compassionate care, even under exceptional circumstances.

Another way that Gomez Cantero has seen people expressing solidarity is in relation to the cooperative effort of the healthcare and scientific communities around the world — from China, Singapore and South Korea to Italy and the United States — in sharing their knowledge of the virus, learning from each other's experiences, and working together on clinical trials in the pursuit of a vaccine.

He hopes this spirit will continue. For their part, the Clinic is embarking on new lines of infectious disease research. "We must be prepared for new pandemics," he says, "because, as we have seen from this experience, preventing the next new outbreak will be easier than trying to cure it."

Going viral

A second pandemic has raged in parallel with COVID-19: fake news.

Even before the arrival of the coronavirus, trust in traditional sources of authority — the government, scientific experts, mainstream media — was down, while dubious information, "alternative facts" and memes shared by family and friends were where people put their faith. So, when COVID-19 hit, although there was plenty of accurate healthcare information to be found online, users weren't looking for it. Instead, many turned to their favorite social media influencer. IESE professor Josep Valor writes about this in his Media Matters blog with Carmen Arroyo: "There's a gap in social media that needs to be filled by doctors who are also savvy social media users."

Recognizing this, the University of Navarra Clinic published a series of video Q&As about the coronavirus on their media channels, which racked up hundreds of thousands of views.

Besides this need for more medical experts to make their voices heard online with the facts, there's also a need to combat confirmation bias — i.e., tending to believe news that's consistent with your prior beliefs, regardless of whether it's true or not — as a recent study by Josep Valor and his IESE colleague Ines Alegre attests.

They asked individuals to self-identify their political persuasion, and then showed them 40 news headlines, some real, some fake, asking them to judge which was which. As suspected, individuals tended to rate a news item as being true if it confirmed their political beliefs, even if it was actually false. However, when asked to judge the veracity of an item that was far from their own political beliefs, people were more likely to call it correctly. The suggestion is, "perspective helps."

The study also found that self-described liberals and conservatives differed in their ability to spot fake news, owing to the extent they exhibited dogmatism, which the authors found to be more the case in their sample of U.S. conservatives than liberals. So, when trying to discern the snake oil from the science on the coronavirus, before you click and share, take a step back and exercise more critical thinking, especially if you lean conservative.