Telemedicine and Competency-Based Training to Maximize Resources in the Face of a Pandemic, without Losing Humanization

Abstract

The COVID-19 pandemic has exposed global concerns about healthcare system capacity. The World Health Organization sets readiness standards for pandemics, but disparities in healthcare infrastructure and a shortage of medical professionals hinder responses. The pandemic has overwhelmed healthcare systems worldwide, leading to a shortage of healthcare workers. Countries like Mexico, Colombia, and Peru have recruited temporary healthcare professionals to address the shortage. Even countries with relatively high doctor-to-patient ratios, such as El Salvador, struggle to find Critical Care Medicine specialists. El Salvador’s response includes the 2020 inauguration of El Salvador Hospital (ESH), using telemedicine to connect specialists with non-specialists in intensive care. Competence-based training is crucial in rapidly educating a large healthcare workforce, with a course tailored to local needs—however, the pandemic challenges humanizing patient care due to limited family interactions. Telemedicine offers emotional support and spiritual accompaniment through video calls. The Social Work Unit at HES helps maintain patient-family communication, with post-discharge surveys assessing humanitarian support effectiveness. In summary, the COVID-19 pandemic has exposed healthcare system challenges, necessitated innovative training, emphasized telemedicine’s role, and promoted efforts to maintain humanized care while assessing patient satisfaction.

1. Introduction

1.1 Pandemics and the capacity of healthcare systems

The definition of a pandemic, as outlined by the World Health Organization (WHO), involves the global dispersion of a novel ailment [1]. According to WHO’s standards, an effective healthcare system necessitates an approximate ratio of 4 beds per 1000 inhabitants, along with 23 doctors, nurses, and obstetricians per every 10,000 residents, to deliver comprehensive essential healthcare services [2]. However, WHO’s data from 2018 reveals that the number of doctors per 10,000 inhabitants stands at 12.3, displaying notable disparities across countries and regions [3].

Given this data, it appears improbable for a healthcare system to be adequately equipped with the requisite number of beds and appropriately trained medical and paramedical professionals, essential for an effective response to a pandemic.

The worldwide progress of COVID-19 has inundated healthcare systems on a global scale and continues to be the main driving force behind the current scarcity of skilled human personnel. According to records from the Pan American Health Organization in September 2020, approximately 570,000 healthcare professionals in the Americas have been infected with COVID-19, leading to 2500 deaths [4].

1.2 The deficiency of physicians and specialists in critical care medicine

In reaction, various nations, such as Mexico, Colombia, Peru, Guyana, Trinidad and Tobago, among others, have enlisted healthcare practitioners, even retired ones, to temporarily join the public sector.

The primary methods employed by healthcare personnel to combat the pandemic, in addition to their unwavering dedication to their work, include (a) Education in personal cleanliness and strict adherence to procedures concerning the wearing and removal of Personal Protective Gear. (b) Instruction in the recognition and management of specimens, cases, and contacts, as well as the proficient use of medical apparatus, such as ventilators and monitors.

Healthcare experts across 20 countries in the Latin American and Caribbean Region (often referred to as the LAC Region) have expressed their concerns regarding deficiencies in infrastructure, personal protective gear, and the absence of assistance [5].

Within the realm of Intensive Care Medicine, this shortfall has prompted the expedited training of doctors from diverse specialties through rapid (sometimes online) courses. Nonetheless, this approach provides a partial remedy, as the provision of intensive care necessitates comprehensive training.

Even in the case of El Salvador, which proudly touts a proportion of 16.36 medical professionals per every 10,000 residents [6], along with 1.2 healthcare facilities for every 1000 residents [7], it has not evaded this particular dilemma.

1.3 El Salvador Hospital

The inauguration of the El Salvador Hospital (ESH) transpired on June 22, 2020. This hospital stands as the Central American region’s pinnacle in terms of bed capacity and cutting-edge technological equipment. It houses medical and technological resources suitable for 105 Intensive Care Unit beds and 295 Intermediate Care Unit Beds. Furthermore, the hospital possesses the capacity to extend its infrastructure to include an additional 1000 ICU beds and 1000 beds for general patient care. In addition, HES is equipped with supplementary facilities such as radiology and imaging centers, a dedicated dining area, pharmaceutical services, departments specializing in anesthesiology and inhalation therapy, a clinical laboratory, a blood bank, and social support services. Moreover, it offers two designated relaxation zones for healthcare staff.

An advanced information technology framework, supported by a fiber optic network, interconnects all areas of the hospital, granting access to each patient’s medical records and electronic prescriptions, resulting in a 90% reduction in paper usage.

The primary strategy of ESH revolves around telemedicine and is implemented through a Central Monitoring Center where intensive care medicine specialists monitor and oversee the care of hospitalized patients (Table 1 and Figures 1 and 2). Non-specialized physicians in intensive care medicine, such as general practitioners and internists, are responsible for carrying out the hands-on care activities. The Intensivist guides these healthcare providers in updating the clinical, hemodynamic, and respiratory status of patients.

Sector	Intensive care unit	Intermediate care unit	General ward
Supervise Doctor*	Nine (9); ICU Medical Specialists	Five (5); ICU Medical Specialists	Nine (9); Internal Medicine Medical Specialists
Physician Supervisor in Hospital Department	Single Monitor Expert; (total 9)	Single Monitor Expert; (total 5)	Single Monitor Expert; (total 9)
Attending physician	12 General practitioners per coordinator; (total 108)	15 General practitioners per coordinator; (total 75)	13 General practitioners per coordinator; (total 117)
Number of beds available per hospitalization area	143	104	721

Table 1.

Distribution of medical personnel to cover assistance for COVID-19 patients.

^*

Monitoring room single physical space, physically separated from the hospitalization area.

Figure 1.

Monitoring center El Salvador Hospital.

Figure 2.

Intermediate care area monitoring detail.

In response to the shortage of intensive care medicine specialists, the objective has been to train approximately 1000 healthcare professionals in basic life support measures for COVID-19 patients.

2. Competence-based training, an alternative to preparing health personnel in a short time

An expedited training approach, formulated around the framework of concise courses, was opted for, aiming to rapidly educate a substantial workforce within a condensed timeframe. This pedagogical approach, rooted in competency-driven education, seeks to convey fundamental understanding and industry-relevant proficiencies while fostering students’ enthusiasm for continued education [8]. A couple of instances of these educational methodologies include Foundational Crucial Assistance (FCA, Critical Care Medicine Society) and Progressive Trauma Life Sustenance (PTLS, American College of Surgical Specialists). However, the implementation of such courses, which cater to a limited number of individuals every 48 hours and do not delve into precise particulars concerning severe COVID-19 treatment, demands an excessive allocation of time and resources that is unfeasible within the current healthcare emergency context. Hence, a novel course, tailored to local requisites, was devised under the overarching principle of “training professionals from practical experience to theoretical understanding.”

2.1 Course design

Within the initial week, a diagnostic process was undertaken, comprising the following steps:

Collaborating with Monitoring Specialists to identify areas for enhancement in executing hands-on tasks.

Convening personnel from the Teaching and Research sectors, including Intensive Care Physicians, Nursing Graduates, and Respiratory Technicians, to formulate an optimal skills training approach through practical workshops. This was achieved through the examination of “lessons learned,” exchanged via a WhatsApp group.

Synergy was fostered with the Medical Emergency System (SEM), an entity affiliated with the Ministry of Health of El Salvador, well-versed in CPR and rescue operations. Likewise, collaboration extended to the personnel from the Andalusian Health System (SAMU), a contingent of 30 professionals from Sevilla, Spain, extensively trained in COVID-19 management, who were partaking in a health-focused collaborative endeavor at the hospital.

From these collaborative efforts emerged the course “Fundamentals of Life Support in COVID-19 Patients.” Noteworthy for its original design and alignment with the discerned needs in patient care, this course was uniquely tailored.

The course is structured around four stations, each spanning 50 minutes, with topics encompassing:

1. Patient’s Clinical Assessment

2. Respiratory Assistance

3. Heart Rhythm Irregularities and Cardiac Revival (CPR)

4. Medication Science and Infusion Devices.

In preparation for each workshop, a conceptual structure was established, providing the groundwork for instructors to lead their instructional sessions (Table 2). Moreover, instructors were provided with anatomical replicas, simulated respiratory devices, infusion apparatus, and commonly used drug formulations, all of which were utilized to enhance practical training for students.

Training session with a respiratory therapist instructor; Oxygen therapy and management of the airway; Various ventilation support systems: venturi system, non-rebreather mask, high-flow oxygen, orotracheal tube. PaO2/FiO2 ratio calculation. Saturation monitoring. Identifying the indicators of ventilation strategy “failure.” Assessment of artificial airways: venturi system, high-flow oxygen, CPAP, orotracheal tube. Operating and programming ventilators, understanding alarm signals, and grasping the adjustment-maladjustment concept. Analysis of arterial blood gases. Utilizing the prone position in patient care.

Training session with a degree in nursing; Intravenous medication session; Intravenous drug types. Methods of packaging. Approaches to dilution. Modes of administration: quantity, injection, ongoing delivery. Computation of infusions in mg/kg. Application of infusion pumps.

Training session with emergency physician specialist; Cardiopulmonary resuscitation; Identification of potentially fatal cardiac rhythms. Methodical strategy for Cardiopulmonary Arrest (CPA). Order of medications to administer. Quantity of personnel. Duration of Cardiopulmonary resuscitation (CPR). DNR principle (Do Not Intervene Directive).

Training session with ICU specialist; Clinical evaluation (top to bottom); Neurological assessment: conscious, agitated, agog, under anesthesia (Check pupils). Hemodynamic assessment: BP, heartbeat, peripheral perfusion, urination rhythm. Respiratory assessment: at ease, uneasy. Adapting to mechanical ventilation. Evaluate respiratory exertion. Abdominal area: swollen, sore. Medication administration: Kind and quantity during the examination. Dietary assistance: consumes/does not consume. Endures/does not endure. Glucose level. Inducing bowel movement. Well-being: Patient orientation (Head support, lower limbs). Discomfort.

Table 2.

Conceptual content of the COVID-19 patient life support fundamentals course workshops.

2.2 Strategy for the course implementation

Given the substantial number of students slated for training (approximately 1000), encompassing a variety of roles including doctors, community service medical doctors, nurses, and respiratory technicians, and considering the workshop’s knowledge-building nature, the following approach was adopted:

Twenty participants were assigned to each group, with a maximum of five individuals per station (totaling four stations). This design ensured optimal utilization of the instructional session, bordering on a personalized experience.

Two sessions were conducted per day—morning and afternoon—each accommodating 40 participants, resulting in a combined total of 80 participants per day. Over a week, this format enabled the training of approximately 400 professionals from Monday to Friday (Table 3).

	Commission 1	Commission 2	Instructors
Morning shift; 08:00–12:00 hs	20; students	20; students	4; (1 per station)
Afternoon shift; 13:00–17:00 hs	20; students	20; students	4; (1 per station)
Total students/shift	40	40
Total instructors/shift			8

Table 3.

Number of students and instructors per day.

This system, which facilitated the instruction of 80 participants daily, was supported by eight expert instructors, along with assistants (comprising 3–4 members) stationed at each station. These assistants were responsible for monitoring completion times, ensuring the administration of pre-post achievement tests (as described below), and orchestrating breaks that allowed for refreshments and meals for both instructors and collaborative staff.

The course implementation adhered to the ensuing protocol:

1. Assistants: oversee completion of the pre-test.

2. Medical Coordinator’s welcome address to participants: provide an overview of the course’s structure, detail station timings, and outline the roles of collaborators.

3. Participant distribution: each group consists of five members (totaling 20 participants), specifically designed to ensure the inclusion of a doctor, community service medical doctor, nurse, and respiratory technician. This approach aimed to cultivate a transdisciplinary team-oriented environment.

4. Closing remarks by the coordinator: highlighting the undertaken efforts and encouraging the exchange of newfound knowledge. Each session concluded with applause directed toward the instructors and assistants, followed by reciprocal applause from them to the participants. This practice served as a motivating gesture, acknowledging the exertion invested throughout the 4-hour course.

5. Assistants: verify completion of the post-test.

Because of the attributes of the program crafted by the HES Department of Education and Research, it garnered the official approval of the Ministry of Health in El Salvador, along with the backing of the following entities: 1. Universidad José Matias Delgado in El Salvador, thus attaining the status of a University Program; 2. The Central American and Caribbean Consortium of Intensive Therapy (COCECATI), expanding its reach on an international scale; 3. The Latin American Council for Neurointensive Care (CLaNI).

2.3 Program assessment

Assessment of Course Utility: A pre-post analogical-visual knowledge perception survey, structured as a “before and after” comparison, was formulated. In this survey, students rated various domains identified as areas with potential for improvement in care. Participants were assigned scores on a scale of 0–10 before and after completing the course. The survey tool was transitioned into a digital format to streamline the process. Tablets were utilized and equipped with online pre-post testing capabilities. This facilitated the real-time recording of responses, ensuring anonymity and centralizing data collection. This approach effectively curbed the risk of data loss and registration inaccuracies. Assistants were entrusted with overseeing the pre- and post-tests to guarantee an unequivocal reception rate of 100%.

During the period spanning from August 17th to August 21st, August 24th to August 28th, and September 7th to September 11th of the year 2020 (which comprises 15 working days), a total of 981 professionals underwent training. This training encompassed the entirety of professionals dedicated to caring for COVID-19 patients, namely doctors, medical doctors specializing in community service, nurses, and respiratory therapy technicians. The gender distribution among these professionals was 66.3% female and 33.7% male, with an average age of 29.92 years and a standard deviation of 5.82 years.

Out of the 981 professionals who received training, 44.9% were doctors, 42.9% were nurses, 7% were respiratory therapy technicians, and 5.2% were community service medical doctors who expressed their interest in participating in this educational initiative.

The comparative analysis between the results of the assessments conducted before and after the training exhibited a significant discrepancy in the perception of knowledge across all areas. This was confirmed through a Mann-Whitney U test with a p-value < .0001, as illustrated in Table 4.

	Item	Concept	Score
			Pre-test	Post-test
1	Airway Oxygen Therapy and Respiratory Assistance	How much do you consider your knowledge about management of venturi mask	6.39	8.75
		How much do you consider your knowledge about management of Non-Rebreather Mask	6.42	8.80
		How much do you consider your knowledge about management of High-Flow Nasal Cannula	5.24	8.68
		How much do you consider your knowledge about management of artificial airway (Orotracheal tube)	5.12	8.38
		How much do you consider your knowledge about management of ventilator	4.70	8.24
2	Cardiology	How much do you consider your knowledge about cardiopulmonary resuscitation	6.32	8.84
		How much do you consider your knowledge about arrhythmia detection	5.40	8.55
3	Drugs	How much do you consider your knowledge about titratable intravenous drug use	5.69	8.53
		How much do you consider your knowledge about the use of infusion pumps	5.88	8.75
4	Therapeutic intensity	How much do you consider your knowledge about the handling of moderate-gravely sick patient	6.07	8.52
	Mean		5.72	8.60
	Dst		0.59	0.19
	Median		5.78	8.61
	r		4.70–6.42	8.24–8.84

Table 4.

Pre- and post-course perception of knowledge scores by domain. Mean, Dst., med, and r. Mann. Mann-Whitney U test p < .0001.

An inventive approach to train healthcare personnel in managing critical COVID-19 patients was successfully conceptualized and executed. The training initiative achieved full coverage of HES’s COVID-19 patient management team. Its effectiveness, centered around a competency-based pedagogical framework, was measured through the assessment of knowledge perception in 10 distinct domains. These encompassed proficiencies in organizing emergency care, and identification of available medications and equipment within the institution, among others [9].

The integration between the monitoring center and the hands-on staff was substantially improved, enhancing communication coherence, and bestowing a higher degree of autonomy to the latter group, allowing the use of telemedicine as a strategy in the absence of specialized hand resources.

3. Maintaining humanization in patient care in the context of isolation due to a pandemic

3.1 Telemedicine

As we previously mentioned, and like the rest of the world, our healthcare system had to overcome the lack of trained workers during the COVID-19 pandemic [5]. The use of telemedicine turned out to be a fundamental tool for dealing with this scarcity [10]. Telemedicine avoided the loss of qualified personnel and maintained the bond between families and their loved ones.

Telemedicine is the delivery of health services via remote telecommunications; this includes interactive consultative and diagnostic services. A multidisciplinary team is needed to achieve the goals set forward by telemedicine [11].

Satisfactory results have been reported with telemedicine, which is great at providing healthcare services as well as facilitating communication between the patient and his family [12].

3.2 The intensive care unit

Since the 1970s, the Intensive Care Unit (ICU) has been defined as the hospital unit providing continuous surveillance and care to acutely ill patients who require uninterrupted medical and nursing care, in addition to specialized human resources and equipment [13].

Admission to an ICU is a stressful event, both for the patient and his family. They perceive the environment as an aggressive and threatening space because it represents the risk of the patient dying [14].

Furthermore, the family structure is deeply changed by the estrangement of one of its members [15]. Notably, family involvement in patient care provides emotional support to the patient reducing both anxiety and depression [16, 17].

Healthcare workers have made efforts to improve comfort for patients and their families, both during hospitalization and in early convalescence. An example of this effort is the more flexible visiting hours [18, 19, 20].

The COVID-19 pandemic was declared a public health emergency by the World Health Organization and is the largest global health crisis at the moment [21]. Due to the nature of the disease, interactions between patients and their families have been limited. In addition, they needed to maintain isolation, and contact protocols did not allow for family visits, face-to-face medical reports, and the usual interactions with the nursing staff. The social fear caused by the pandemic enhanced the usual symptoms of anxiety, depression, and post-traumatic stress already prevalent in ICU patients. This environment further complicates the grieving process [22, 23].

The environment created by the COVID-19 pandemic has highlighted the importance of a global approach when attending to the patient’s needs.

3.3 Maintaining humanization in patient care in the context of isolation due to a pandemic

Humanizing care implies considering all the dimensions of a person (biological, mental, spiritual, and social). Addressing the spiritual needs of a person means giving emotional support as well as listening and is not the practice of religion.

Different studies show a connection between spirituality and physical and mental health [24].

For these reasons, our hospital provides spiritual accompaniment to patients and their families. As of November 2020, spiritual visits are made to patients every 15 days to listen to their existential concerns, support them spiritually, and give them comfort. These visits are always conducted with absolute respect for the patient and his beliefs. As of March 2021, family members of the patient can participate in these spiritual visits if they so choose.

These support sessions are carried out through video calls. During these video calls, concerns, fears, and uncertainties are heard, to discover the existential meaning of the moment and give spiritual comfort.

3.4 The Social Work Unit

The mission of the Social Work Unit in our hospital is to create a bridge between doctors, patients, and family members in a professional, timely, and decisive manner. Among the objectives of the Social Work, Unit is to help the emotional state of patients during their hospital stay by facilitating communication with their families through video calls, giving daily updates to each family member about the health status of their loved one, and coordinating patient discharge, among others.

3.5 Contact with discharged patients

The social work unit sends a list of confirmed discharged patients and their contact information (phone number and email). Subsequently, the contact information is incorporated into the electronic telephone book of the ORH, together with the information related to the survey (password, discharge date, patient name, and telephone number).

Each patient receives a greeting message and an invitation to participate in the survey for patient satisfaction after discharge. If, after 24 hours, there is no response, a second message is sent.

Finally, in coordination with the Quality Organizational Unit (QOU), the results are monitored monthly. All this is registered in the Integrated Management Information System (SIIG-eTAB of the Ministry of Health (MINSAL).

3.6 Satisfaction survey to assess the effectiveness of humanitarian support

The QUO works with the Social Work Unit to collect data from discharged patients. With patient-collected data (WhatsApp number and email), an electronic record is created with the patient’s name, discharge date, telephone number, and password to access the survey.

Algorithm.

1. Each patient receives the following message: “Hello. We greet you from El Salvador Hospital. We are interested in knowing the opinion of the person who received our services during hospital admission; for this, we invite you to participate in a survey about the services received. If you agree to participate in the survey, please say yes.”

2. If no response is received that day, a new message is sent: Would you like to participate in the post-discharged patient satisfaction survey from El Salvador Hospital?

3. If the person answers yes, 4 messages are sent:

   • You can take the survey anytime you deem convenient or request support from a person you trust. It is recommended that you copy the password and then paste it for entry, the password is:

   • A message with the password to access the survey is sent.

   • A message stating: “Avoid typing the password letter by letter, it is better to copy it completely. Then we invite you to enter our survey website and paste the password in the indicated place.” Site link: encuestas.salud.gov.sv/index.php/371221?lang=es

4. If the respondent expresses difficulty in carrying out the survey procedure, then assistance is provided so that the respondent can participate on the day and time they deem convenient; guidance is provided via text message or phone call.

5. If no other option is available, support is given to assist in the participation of the survey, sending question by question and subsequently registering it with the password assigned to the respondent.

6. Daily activity related to the survey is recorded:

   • The number of discharges reported by social workers.

   • The number of discharged people registered with a telephone number or email.

   • The number of discharged people to whom the message was sent.

   • Number of people who agreed to participate in the survey.

7. In coordination with the Quality Organizational Unit, monthly monitoring of the results of citizen participation in the survey is carried out, which is registered in the MINSAL’s integrated management information system.

8. The results are periodically published in the transparency portal: https://www.transparencia.gov.sv/institutions/hes

The respondent analyzed Eight domains and scored from 0 to 100%. Corresponding “0%” to the worst impression and “100%” to the best-perceived impression (Table 5).

	Domains	Percentage perceived from 0 to 100
1	Staff treatment
2	Perceived staff knowledge
3	Clarity of the information received regarding your health situation during your stay
4	Privacy
5	Recommendations or instructions provided by the staff to be followed at home for your care and treatment
6	Interest shown by healthcare workers when attending requests and complaints
7	Therapy duration
8	Facility comfort.

Table 5.

Domains are evaluated as the perception of care during hospital admission.

From January 1 to May 31, 2021, 58,297 telephone and/or video calls were made to relatives of those admitted to El Salvador Hospital (Table 6).

	January	February	March	April	May	Total
Number of phone calls	13.090	9.143	10.388	12.387	13.285	58.297

Table 6.

Number of phone calls and/or video calls done by social work.

These calls had the following objectives:

1. To inform relatives about the patient’s condition.

2. Video calls between patients and relatives for emotional support.

3. Informed consent request for special procedures.

4. Hospital discharge management:

1. Discharge destination (home, rehabilitation);

2. Treatment;

3. Follow-up plan.

A total of 2865 discharges were reported by the social work unit, of which 2019 were contacted with 1500 agreeing to participate in the survey.

The MINSAL’s integrated management information system (SIIG-eTAB) recorded a total of 859 completed surveys during the study period, which is 30% of the discharges reported by Social Work.

The patient satisfaction survey shows an average from January to May of 91.6% for the Wards, 92.4% for the ICU, and 90.3% for the IMCU.

Discharged patients, on average, perceived higher service quality in March to May compared to January and February. Notably, from March to May, opportunities for improvement in care were evaluated and implementedTable 7, Acknowledging that some readers will not be experts in your field of research.

	January	February	March	April	May	Average (5 months)
General perception (average 8 domains)	89.5	89.8	92.5	92.4	93.3	91.4
Hospital wards (average 8 domains)	90.07	89.62	91.76	93.06	93.73	91.6
ICU (average 8 domains)	89.95	90.53	95.14	92.78	93.83	92.4
IMCU (average 8 domains)	88.35	89.27	90.63	91.25	92.22	90.3

Table 7.

Overall satisfaction and level of care. Average of eight domains and scored from 0 to 100%. Corresponding “0%” to the worst impression and “100%” to the best-perceived impression.

4. Conclusions

4.1 Telemedicine as a strategy in pandemic times

The COVID-19 pandemic exposed vulnerabilities in healthcare systems globally, particularly concerning healthcare workforce and infrastructure. The shortage of doctors and specialists in critical care medicine has become a critical issue in several countries. In response, innovative strategies were developed, like the creation of the El Salvador Hospital (ESH), a cutting-edge medical facility designed to combat the pandemic. Telemedicine also emerged as a vital tool for managing the scarcity of trained healthcare workers while maintaining the connection between patients and their families.

4.2 Competence-based training

To address the urgent need for trained healthcare professionals, a competence-based training program was introduced, rapidly educating a substantial workforce within a condensed timeframe. This program was specifically designed to impart foundational knowledge, job-specific skills, and motivation to students. Through this initiative, healthcare professionals could efficiently manage COVID-19 patients, resulting in a significant improvement in their knowledge perception.

4.3 Maintaining humanization in patient care

The COVID-19 pandemic imposed restrictions on patient-family interactions, challenging the humanization of patient care. However, efforts were made to address this issue through telemedicine, which helped maintain connections between patients and their families. Additionally, the El Salvador Hospital introduced spiritual accompaniment for patients and families through video calls, recognizing the importance of addressing patients’ spiritual needs. The Social Work Unit played a crucial role in facilitating communication between patients and their families during hospitalization and in early convalescence.

The satisfaction survey results indicated that the implementation of these initiatives had a positive impact on patient care, with higher service quality perceived in the later months of the study period.

In conclusion, the COVID-19 pandemic forced healthcare systems to adapt rapidly to address challenges related to healthcare workforce shortages and maintaining humanization in patient care. The innovative approaches described in this study, such as the competence-based training program and the use of telemedicine, provide valuable insights into addressing similar challenges in future healthcare emergencies. The focus on maintaining a holistic approach to patient care, including spiritual support and communication with families, highlights the importance of addressing patients’ emotional and social needs during a pandemic. These strategies can serve as a model for other healthcare systems aiming to enhance their preparedness for similar crises in the future.

Acknowledgments

The authors extend their appreciation to all the workers of the El Salvador Health System. From administrators, technicians, nurses, doctors, and physiotherapists for their commitment and dedication to the first high-impact event in public health, their resilience and willingness to sacrifice have marked a milestone.

Also to the pastors of the different religions who unceremoniously accompanied the sick and their families in this impressive event.

The development of this manuscript has not received funding.

Conflict of interest

The authors declare no conflict of interest.

Notes/thanks/other declarations

The authors thank the staff of the Ministry of Health for their commitment to the containment and treatment of the COVID-19 pandemic.

He also wishes to thank the staff of El Salvador Hospital, especially social workers and the Office for the Right to Health for their collaboration in the manuscripts.

Appendices and nomenclature

WHO	World Health Organization
ESH	El Salvador Hospital
SII-eTAB	Integrated Management Information System
MINSAL	El Salvador Ministry of Health
QUO	Quality Organizational Unit