BACKGROUND

The COVID-19 pandemic greatly affected training programs because of changes in patient load and service assignments. This posed certain challenges in the implementation of the pre-COVID-19 training curriculum recommendations by the Philippine Heart Association Specialty Board on Adult Cardiology.

This article describes the challenges, training adjustments and innovations, and the impact on the training program of these changes instituted by the University of the Philippines-Philippine General Hospital (UP-PGH) Division of Cardiovascular Medicine (DCVM) during the COVID-19 pandemic.

This is a descriptive article based on review of changes and improvements of the UP-PGH DCVM training manual and guidelines adopted during the COVID-19 pandemic.

The COVID-19 pandemic challenges provided opportunities for innovation of the training program. The program emphasized focus on maximizing team-based learning from every clinical encounter toward achievement of learning outcomes and competency. The training committee closely monitored the learning environment and trainee's learning progress to achieve outcomes beyond the traditional metrics such as census and procedural numbers. It adopted online clinical encounters, conference, and case discussion. To enhance learning, virtual engagement supplemented physical encounters between consultants and training fellows assigned to various clinical rotations. Real-world research results on the impact of COVID-19 on cardiovascular health were utilized to enhance knowledge. Risk mitigation and transmission reduction strategies were adopted to ensure safety of all staff. The division also incorporated a strong wellness program to provide holistic approach to trainees' and trainers' health. New competencies were developed such as telemedicine, infection prevention and control, and creation of virtual patient education programs.

The training institution met the challenges posed by the COVID-19 pandemic with resiliency and unity. The adjustments and innovations in training instituted by PGH DCVM proved useful in addressing the challenges posed by the pandemic. The situation was viewed as an opportunity to innovate and pursue a better program adaptive of the ever-changing environment, toward forming competent future cardiologists by enhancing focus not only on numbers but rather on the process of achievement of learning outcomes, embracing virtual and online strategies, institutionalization of wellness program, and development of new guidelines in the approaching patient management cognizant of both health care provider and patient safety and new competencies such as patient virtual education and telemedicine in cardiology.

BACKGROUND: Nosocomial TB transmission adversely affects inpatients and healthcare workers (HCWs). HCWs have a higher risk of tuberculosis and MDR-TB compared to the general population. Nosocomial TB outbreaks have occurred among patients with HIV/AIDS. Hospitals need to examine TB infection control measures in order to address this growing concern.

OBJECTIVE: This study aimed to evaluate the TB infection control strategies in the adult service wards of the Philippine General Hospital (PGH).

METHODS: This descriptive study was conducted on adult inpatients with bacteriologically-confirmed PTB admitted in April-August 2016. A data collection tool based on Center for Disease Control (CDC) guidelines was utilized for chart review. Baseline characteristics, diagnosis, treatment, and isolation intervals were obtained and compared between areas. In-hospital TB infection control practices were reviewed using the CDC TB Risk Assessment Worksheet with data from the TB-DOTS, UP Health Service, PGH Hospital Infection Control Unit, and PGH Department of Laboratories.

RESULTS: Of the 95 patients with bacteriologically-confirmed PTB, data from 72 medical records were available and included in the analysis. Majority were Medicine patients (55.6%) with a diagnosis of pneumonia (52.8%). Only 61.1% were PTB suspects on admission. The mean diagnosis interval was 5.82 days±5.473, the mean treatment interval was 0.77 days±2.941, and the mean isolation interval was 8.23 days±6.372. Only 41.7% were successfully isolated. The most common reasons for isolation failure/delay were lack of vacancy (ER, Medicine wards) and lack of isolation room (Surgical wards). Treatment initiation rate was 66.7% while TB-DOTS inpatient referral rate was 55.6%. The hospital is classified as having potential ongoing transmission of PTB.

CONCLUSION: In this study, TB treatment was promptly started but there were delays in diagnosis and isolation. Gaps included 1) lack of recognition of a PTB case, 2) limited isolation rooms, and 3) inadequate utilization of TB-DOTS. TB infection control measures need to be strengthened in order to prevent nosocomial transmission of PTB.

Background and Objectives: Heart Failure (HF) remains a major health concern worldwide. In the Philippine General Hospital (PGH), HF is consistently a top cause of mortality and readmissions among adults. The American College of Cardiology (ACC) and European Society of Cardiology (ESC) published guidelines for interventions that improve quality of life and survival, but they are underused and untested for local acceptability. Hospitals overseas used order sets created from these guidelines, which resulted in a considerable decrease in in-hospital mortality and healthcare costs. We aimed to develop an order set for adult patients with acute heart failure (AHF) admitted to the PGH Emergency Department (ED) to improve care outcomes. Methods: This study utilized a mixed methods approach to create the AHF order set. ESC and ACC HF guidelines were appraised using the AGREE II tool. Class I interventions for AHF were included in the initial order set. Through focused group discussions (FGD), clinicians and other care team members involved in the management of AHF patients at PGH ED modified and validated the order set. Stakeholders were asked to use online Delphi and FGD to get a consensus on how to amend, approve, and carry out the order given. Results: Upon review of HF guidelines, 29 recommendations on patient monitoring, initial diagnostic, and therapeutic interventions were adopted in the order set. Orders on subspecialty referrals and ED disposition were introduced. The AHF patient was operationally defined in the setting of PGH ED. The clinical orders fit the PGH context, ensuring evidence-based, cost-effective, and accessible care responsiveness to patients’ needs and suitable for local practice. Workflow changes due to COVID-19 were considered. Potential barriers to implementation were identified and addressed. The final order set was adopted for implementation through stakeholder consensus. Conclusion The PGH developed and adopted its own AHF order set that is locally applicable and can potentially optimize outcomes of care.
Quality Improvement ; Critical Pathways

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of admission and mortality in a tertiary care hospital in the Philippines. The significant burden of the disease necessitates that evidence-based care set by international and local guidelines be met to improve service delivery and quality of care (QOC). Institution-specific QOC studies showed gaps between guideline recommendations and compliance. Development and utilization of a clinical pathway are among the identified strategies to improve compliance. It is also crucial for implementation of standard-of-care set specific to a hospital setting based on its needs and resources. METHODS: This is a descriptive research on the development of a clinical pathway for ACS appropriate for the emergency room setting of a tertiary care hospital from March 2021 to August 2022. Local QOC studies and evidence behind the latest international guideline recommendations on the management of ACS were reviewed to create the interim ACS Pathway. Two-level content validation of the interim pathway was done: internal validation with the consultants and fellows of the Division of Cardiovascular Medicine and external validation through focused group discussions with different hospital units and stakeholders to assess applicability and feasibility based on the resources of the setting, identify hindrances, and propose solutions in its implementation. RESULTS: An evidence-based clinical pathway for ACS that encompasses identification and management of ST-segment elevation myocardial infarction and non–ST-segment elevation acute coronary syndrome with judicious use of locally available and feasible resources applicable for local emergency room hospital setting was created. CONCLUSION Review of local QOC studies and interdepartmental collaboration are necessary components in developing institution-specific clinical pathway for ACS.
Acute Coronary Syndrome ; Critical Pathways ; Quality of Health Care