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The development of the Philippine General Hospital as a referral center in the COVID-19 Pandemic: A qualitative study

Jean Anne B. Toral ; Michelle V. Alba ; Zaldy R. Reyes ; Al Joseph R. Molina

Acta Medica Philippina.2021;55(2):137-149. doi:10.47895/amp.v55i2.2851

Background. The University of the Philippines-Philippine General Hospital (UP-PGH) was designated as a COVID Referral Center for one cluster in Metro Manila during the pandemic. We reviewed and described how UP-PGH prepared for this endeavor. This can serve as reference for similar events in the future. Methods. We conducted a qualitative cross-sectional study with 20 key informant interviews and 5 focus group discussions involving 32 hospital front liners. All proceedings were transcribed and analyzed manually following the conceptual framework. Minutes of meetings, memoranda, and other official materials and communications were also reviewed. Results. The salient points of both internal (operations, structure, staff, supplies, and continuation of regular services) and external aspects (relation with other hospitals, the local government, the national health authority, and the general public) were enumerated and elaborated. Both best practices and areas needing improvement were identified. Conclusion and Recommendations. The UP-PGH tried its best to prepare and respond to the COVID-19 pandemic by protecting its hospital personnel and delivering evidence-based and quality care to patients. The response was not a perfect one and there were certain aspects for improvement.
Pandemics ; Referral and Consultation ; Qualitative Research

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Clinical profile and outcome of adult COVID-19- related consults at the University of the Philippines - Philippine General Hospital Emergency Department

Scarlett Mia S. Tabuñ ; ar ; Ronald Allan A. Magsino

Acta Medica Philippina.2021;55(2):150-156. doi:10.47895/amp.v55i2.2902

Background. Scarcity of early local clinical data of COVID-19 proved to be a major challenge as its course rapidly evolved over time. The information gathered from this study can be used in improving awareness and understanding a novel disease particularly in detecting demographic trends, vulnerable clinical profiles and potential clusters in order to be abreast on how the virus behaves in the local setting. Objectives. 1) To describe the clinical profile of COVID-19 adult consults at the University of the Philippines- Philippine General Hospital (UP-PGH) during the early months of the outbreak 2) To determine their association with the COVID-19 results and final outcome Methods. A retrospective medical record review was done on COVID-19-related consults of patients aged 19 years and above from 01 January to 30 June 2020 at the emergency department (ED). Statistical analyses were done using Chi-squared and Fisher’s exact test using STATA V15.1 with 95% level of significance (p<0.05). Results. The median age of the 901 COVID-19-related consults at the ED was 46 years; 55.49% were males mostly belonging to the age group below 60 years. Almost all were Filipinos (99.44%), majority residing in the city of Manila (64.93%) and only 2.22% had a history of travel outside the country. The most common chief complaint was fever (32.47%) followed by cough (27.58%) and shortness of breath (25.75%). Most had their onset of symptoms from 1-7 days (79.80%) before ED arrival and 86.07% (n=210) were COVID-positive after performing the confirmatory test. Patients with confirmed COVID-19 mostly resided in cities of the National Capital Region (p=0.046), either presented with fever or asymptomatic but with exposure to COVID patients (Fisher’s Exact test; p<0.001) and onset of symptoms was 4-5 days (p=0.007). Those identified with poor prognosis were those aged 60 years and older (p<0.001), with complaint of shortness of breath (Fisher’s exact test; p<0.001) and with delayed symptom presentation of 6 days or more (p=0.037). Conclusion. The COVID-19-related consults at UP-PGH during the first 6 months of the pandemic were mostly males, Filipinos, belonging to the less than 60 years age group (median age=46 years), residing in the city of Manila and no history of travel outside the country. The most common presenting complaint was fever and onset of symptoms was typically 1-7 days before ED arrival. The positive RT-PCR result was significantly associated to patients residing in Metro Manila, either presenting with fever or no symptoms but with exposure to COVID patients, and with onset of symptoms of 4-5 days. Older age (60 years old and above), shortness of breath and delayed symptom presentation of 6 days of more were also found to have significant association with poor prognosis. As not much is known of the behavior and course of COVID-19 particularly at the local setting, it is therefore crucial to be aware of emerging trends to respond adequately and achieve optimal outcomes.
COVID-19 ; Emergency Service, Hospital

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Pulmonary manifestations and management of COVID-19 pediatric patients admitted in a tertiary government hospital

Wright H. Alborote ; Maria Cristina H. Lozada ; Kevin L. Bautista

Acta Medica Philippina.2021;55(2):157-163. doi:10.47895/amp.v55i2.2317

Background. Coronavirus Disease 2019 (COVID-19) presents with respiratory signs and symptoms in children. Presently, there are no local studies on the pulmonary manifestations and management of COVID-19 among children. Objective. Our study aimed to identify and describe the presenting respiratory signs and symptoms, oxygenation status, radiologic findings, blood gas analysis, and pulmonary interventions among children admitted for COVID-19. We also analyzed the clinical and radiologic variables associated with mortality. Methodology. This is a retrospective study using data obtained from a review of medical records from April 1, 2020, to June 30, 2020, at a tertiary government institution in the Philippines. All pediatric patients (0-18 years) hospitalized for probable or confirmed COVID-19 during the said time period were included in this study. Univariate and multivariate logistic regression was applied to determine factors affecting mortality. Results. A total of 25 pediatric patients with a mean age of 7 years old (age range: 11 days to 18 years) were admitted for COVID-19. Cough (44%) and dyspnea (24%) were the most common presenting respiratory symptoms, while tachypnea (68%), crackles (36%), and peripheral oxygen desaturation (36%) were the most common respiratory signs. Indeterminate findings for COVID-19 such as multifocal or diffuse ground-glass opacities and/or consolidations were the most common radiographic abnormalities. Invasive ventilatory support was administered to 6 cases of severe COVID-19 and 4 critical cases. There were no variables that correlated significantly with mortality. Conclusion. Respiratory signs and symptoms were prominent in our cohort of children admitted due to COVID-19. Mechanical ventilation was required in more severe cases. Larger prospective studies may help identify variables that significantly correlate with poor outcomes among children with COVID-19.
Child ; COVID-19

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Characteristics and outcomes of COVID-19 patients admitted in the medical ICU of a tertiary public hospital in the Philippines during the first two months of being a COVID-19 referral center

Aprille Anne O. Octaviano ; Blessie Marie B. Perez ; Jubert P. Benedicto

Acta Medica Philippina.2021;55(2):164-172. doi:10.47895/amp.v55i2.2671

Introduction. The University of the Philippines-Philippine General Hospital (UP-PGH) began its operations as a COVID-19 referral center on March 30, 2020. Local studies reporting characteristics of patients in the intensive care units (ICUs) are lacking. Objectives. 1) To describe the baseline characteristics and outcomes of the initial cohort of COVID-19 patients in the medical ICU. 2) To report the initial situation and strategies in the ICU during the first two months of being a COVID-19 referral center. Methods. We conducted a review of records of all patients with confirmed COVID-19 admitted to the medical ICU of UP-PGH between April 1 to May 31, 2020. Patient demographics, comorbidities, APACHE-II score, signs and symptoms, laboratory and radiologic results, respiratory and vasopressor support, and outcomes were collected. Results. Out of 35 patients with confirmed COVID-19, majority were above 60 years old (63%). Hypertension was the most frequent comorbidity (77%). Fever was the most common symptom (51%). The mean duration of symptoms prior admission was 9 ± 7 days. Anemia and leukocytosis with neutrophilia was common. Lactate dehydrogenase (LDH) and high-sensitivity C-reactive protein (HSCRP) were elevated in most patients. Majority of patients (66%) had moderate level of hypoxemia on admission. Bilateral pneumonia on chest radiograph was found in 34 patients. Hydroxychloroquine and chloroquine were the most commonly used drugs. A total of 24 patients (69%) required invasive mechanical ventilation while 15 (43%) needed pressor support. Twenty-two expired (63%) while thirteen (37%) patients were discharged from the medical ICU. Conclusion. The clinical characteristics in our set of patients are consistent with other studies on critically ill patients. Mortality in the medical ICU was high.
Philippines ; COVID-19 ; Coronavirus Infections ; Intensive Care Units

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Characteristics and factors associated with mortality of 200 COVID-19 patients at a Philippine COVID-19 tertiary referral center

Maria Sonia S. Salamat ; Anna Flor G. Malundo ; Cybele Lara R. Abad ; Joanne Carmela M. Sandejas ; Johanna Patricia A. Cañ ; al ; Julian A. Santos ; Marissa M. Alejandria ; Jose Eladio G. Planta ; Jonnel B. Poblete

Acta Medica Philippina.2021;55(2):173-182. doi:10.47895/amp.v55i2.2845

Objectives: To describe the clinical profile and factors associated with mortality among the first 200 patients confirmed to have COVID-19 infection admitted in the University of the Philippines – Philippine General Hospital (UP-PGH) Methodology: We conducted a retrospective review of adult patients with confirmed COVID-19 infection admitted in PGH, a designated COVID-19 referral center. Demographic, clinical data, and clinical outcomes were extracted from medical records. Frequencies and distributions of various clinical characteristics were described, and factors associated with mortality were investigated. Results: Of the 200 patients in our cohort, majority were male (55.5%), and more than half (58%) were over 60 years old. Underlying co-morbid illnesses (67.5%) included hypertension (49.5%), diabetes mellitus (26.5%), and cardiovascular disease (20.5%). Most frequent presenting symptoms were cough (69.0%), fever (58.5%), or shortness of breath (53.0%). Most patients presented with mild (n=41, 20.5%) to moderate illness (n=99, 49.5%) and only 60 were considered severely (n=32, 16.0%) or critically ill (n=28, 14.0%). Many (61%) received empiric antibiotics, while 44.5% received either repurposed drugs or investigational therapies for COVID-19. Bacterial co-infection was documented in 11%, with Klebsiella pneumoniae commonly isolated. In-hospital mortality was 17.5%, which was highest for critical COVID-19 (71.4%). Mortality was observed to be higher among patients age 60 and above, those requiring oxygen, ventilatory support and ICU admission, and among those who developed acute kidney injury, acute stroke, sepsis, and nosocomial pneumonia. Conclusion: Our study confirms that COVID-19 affects males, older individuals and those with underlying co-morbid conditions. Empiric antimicrobial treatment was given for majority of patients, despite documentation of bacterial infection in only 11%. K. pneumoniae was commonly isolated, reflecting local epidemiology. Mortality rate during this early period of the pandemic was high and comparable to other institutions. Factors associated with mortality were related to critical COVID-19 and are similar to other studies.
COVID-19 ; Philippines

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Maternal and neonatal outcomes of pregnant women with clinically confirmed COVID-19 admitted at the Philippine General Hospital

Mary Judith Q. Clemente ; Melissa D. Amosco ; Ma. Bernadette R. Octavio ; Sybil Lizanne R. Bravo ; Esterlita Villanueva-Uy

Acta Medica Philippina.2021;55(2):183-190. doi:10.47895/amp.v55i2.2863 Keywords:

Objectives. The effect of COVID-19 infection in pregnant women and her neonate is not well-understood, with no clear evidence for vertical transmission. This study aims to determine the maternal and neonatal clinical characteristics and the dyad’s outcomes among those infected with COVID-19 infection. Methods. An ambispective cross-sectional study involving pregnant women with confirmed COVID-19 infection was conducted at the Philippine General Hospital from April to August 2020. Two hundred nine obstetric patients were included, 14 of whom consented to specimen collection to determine vertical transmission. Results. The majority of pregnant women with COVID-19 infection and their neonates had good outcomes. Labor, delivery, and the immediate postpartum course were generally uneventful. The all-cause maternal morbidity rate was high at 75.6 per 100 cases during the five-month study period. COVID-19 related morbidities included the development of Guillain-Barré Syndrome. The in-hospital all-cause maternal mortality rate was 1.91 per 100 cases. The causes of maternal death were acute respiratory failure, septic shock, and congenital heart disease (atrial septal defect with Eisenmengerization). The in-hospital, all-cause neonatal mortality rate was 1.04 per 100 neonates of cases. The lone mother and infant deaths were in a postmortem rt-PCR swab negative mother with an rt-PCR swab positive live neonate who eventually succumbed after nine days of life. All 14 dyads with collected specimens that included amniotic fluid, placental tissue, umbilical cord, and neonate nasopharyngeal swab tested negative for SARS-CoV-2 rt-PCR. Conclusion. The prognosis for COVID-19 infected pregnant patients was generally good, with most of the patients discharged improved. Almost all of the neonates born to COVID-19-infected mothers were stable-term infants. There was no evidence for vertical transmission, as shown by negative rt-PCR results for all the additional specimens obtained. In general, the prognosis for COVID-19 infected dyads was good. The majority of the mothers were discharged well with their term infants. All possible maternal sources of COVID-19 infection to the neonate tested negative. This study provided no evidence for vertical transmission.
regnancy ; Female ; Infant, Newborn ; COVID-19 ; Family

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Are vaccines effective and safe for the prevention of COVID-19 infections? A living systematic review

Marie Carmela M. Lapitan ; John Jefferson V. Besa ; Leonila F. Dans ; Maria Teresa Sanchez-Tolosa ; Marissa M. Alejandria

Acta Medica Philippina.2021;55(2):191-210. doi:10.47895/amp.v55i2.2875

Introduction. In the attempt to control the spread of the disease and the pandemic, numerous COVID-19 vaccines are in development. A review of the evidence on their efficacy and safety are critical. Methods. A search for trials was done using the COVID-19 Living OVerview of Evidence (L·OVE) platform. We also searched for relevant authorization documents and trial reports for COVID-19 vaccines of the US-Food and Drug Authority (US-FDA), the European Medicines Agency (EMA), the United Kingdom Medicines and Health Products Regulatory Agency (MHRA), and the WHO website. We included studies that fulfilled the following inclusion criteria: population – humans; intervention – COVID-19 vaccines; comparison – control or placebo; outcomes – efficacy and adverse events; methods – phase 3 randomized trials. Two reviewers independently screened the reports, assessed the methodological quality, and extracted the data on the trial characteristics and results on vaccine efficacy and safety. The date of last search was March 11, 2021. Results. Interim results of trials investigating five vaccines were identified and included in the review. All five vaccines demonstrated satisfactory vaccine efficacy (VE) against symptomatic COVID-19 infection among adults in the short term with moderate certainty of evidence: BNT162b2, VE 95% (95% CI 90.3, 97.6); mRNA-1273, VE 93.6% (95% CI 88.6, 96.5); ChAdOx1, VE 66.7% (95% CI 57.4, 74.0), Gam-COVID-Vac, VE 91.1% (95% CI 83.6, 95.1); and Ad26.CoV2.S, VE 67.2% (95% CI 59.3, 73.7). Data on the efficacy against severe COVID-19 infection and asymptomatic COVID-19 infection are still inconclusive, except for Ad26.CoV2.S, which demonstrated good efficacy in preventing moderate and/or severe COVID-19 infection and acceptable protection against asymptomatic COVID-19 infection 28 days after vaccination (moderate certainty of evidence). Efficacy data on preventing death from COVID-19 infection are still inconclusive. Very limited phase 3 trial data is available to inform vaccine efficacy against the different variants of SARS-CoV-2. Vaccination with these five vaccines was associated with higher adverse reactions compared to control. These adverse events, due to reactions to the vaccines, were mild to moderate and of short duration. Available evidence on vaccine efficacy and safety is limited, mainly due to the short follow up and the small sample size of specific populations. Conclusion. BNT162b2, mRNA-1273, ChAdOx1, Gam-COVID-Vac and Ad26.CoV.S vaccines demonstrated satisfactory vaccine efficacy against symptomatic COVID-19 infection among adults in the short term with moderate certainty of evidence. Data on the efficacy against severe COVID-19 infection, asymptomatic COVID-19 infection, and death from COVID-19 infection are still inconclusive. Long-term efficacy and safety data, and data on the efficacy against variant strains of SARS-CoV-2 are still lacking.
Humans ; COVID-19 Vaccines ; COVID-19

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Validation of snort-spit saliva in detecting COVID-19 using RT-PCR and Rapid Antigen Detection Test

Ryner Jose D. Carrillo ; Abigail D. Sarmiento ; Mark Anthony C. Ang ; Michelle H. Diwa ; Cecille C. Dungog ; Daniel I. Tan ; Jan Alexis C. Lacuata ; Jacob Ephraim D. Salud ; Ramon Antonio B. Lopa ; John Mark S. Velasco ; Regina P. Berba ; Charlotte M. Chiong

Acta Medica Philippina.2021;55(2):211-215. doi:10.47895/amp.v55i2.2779

Objective. To determine the diagnostic accuracy of self-collected snorted and spit saliva in detecting COVID-19 using RT-PCR (ssRT-PCR) and lateral flow antigen test (ssLFA) versus nasopharyngeal swab RT-PCR (npRT-PCR). Methods. One hundred ninety-seven symptomatic subjects for COVID-19 testing in a tertiary hospital underwent snort-spit saliva self-collection for RT-PCR and antigen testing and nasopharyngeal swab for RT-PCR as reference. Positivity rates, agreement, sensitivity, specificity, and likelihood ratios were estimated. Results. Estimated prevalence of COVID-19 using npRT-PCR was 9% (exact 95% CI of 5.5% - 14.1%). A higher positivity rate of 13% in the ssRT-PCR assay suggested possible higher viral RNA in the snort-spit samples. There was 92.9% agreement between ssRT-PCR and npRT-PCR (exact 95% CI of 88.4% to 96.1%; Cohen’s Kappa of 0.6435). If npRT-PCR will be assumed as reference standard, the estimated Sensitivity was 83.3% (exact 95% CI of 60.8% to 94.2%), Specificity 93.9% (exact 95% CI of 89.3% to 96.5%), Positive predictive value of 57.7% (exact 95% CI of 38.9% to 74.5%), Negative predictive value of 98.2% (exact 95% CI of 95% to 99.4%), positive likelihood ratio of 3.65 (95% CI of 7.37 to 24.9), negative likelihood ratio of 0.178 (95% CI of 0.063 to 0.499). There was 84.84% agreement (95% exact CI of 79.1% to 89.5%; Cohen’s Kappa of 0.2356) between ssLFAvs npRT-PCR, sensitivity of 38.9% (exact 95% CI of 20.3% to 61.4%), specificity of 89.4% (exact 95% CI of 84.1% to 93.1%), PPV of 26.9% (95% CI of 13.7% to 46.1%), NPV of 93.6% (exact 95% CI of 88.8% to 96.4%), LR+ of 3.67 (95% CI of 1.79 - 7.51), LR – of 0.68 (95% CI of 0.47 - 0.99). Conclusion. Our data showed that snort-spit saliva RT-PCR testing had acceptable diagnostic performance characteristics and can potentially be used as an alternative to the standard nasopharyngeal/oropharyngeal swab RT-PCR test for COVID-19 in certain situations. However, our data also showed that snort-spit saliva antigen testing using lateral flow assay did not offer acceptable performance.
Saliva ; SARS-CoV-2 ; Reverse Transcription ; Reverse Transcriptase Polymerase Chain Reaction

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Hospitalization expenditure of COVID-19 patients at the University of the Philippines-Philippine General Hospital (UP-PGH) with PhilHealth coverage

Scarlett Mia S. Tabuñ ; ar ; Tamara Michelle P. Dominado

Acta Medica Philippina.2021;55(2):216-223. doi:10.47895/amp.v55i2.2809

Objective. This research aimed to determine the in-patient expenditure of COVID-19 adult patient s and their out-of-pocket (OOP) payments at the University of the Philippines-Philippine General Hospital (UP-PGH) after the new PhilHealth case rate coverage was instituted last 15 April 2020. It also intended to present the preliminary data on the expenses incurred by COVID patients during the initial phase of the pandemic in the country. Methods. This study was a retrospective chart review of admitted COVID-19 patients aged 19 years old and above from 15 April to 14 August 2020 at UP-PGH that availed of PhilHealth COVID-19 case rate benefits package (C19C1-C4). Data were analyzed to extract overall expenses, out-of-pocket (OOP) charges, cost centers utilization, and other hospitalization expenditure sources. Results. Of the 691 COVID-19 patients included during the study period, 55.72% were male, mostly belonging to the 61-70 age range with a median age of 58. The average in-hospital stay was 14.20 days, and 76.99% were under charity services, with the moderate (42.84%) and mild (25.33%) pneumonia cases accounting for 68.17% of the admissions. Total hospital expenses clustered around Php51,000 to 200,000 (~USD 1,041 to 4,156), most spending between Php101,000 to 150,000 (~USD 2,078 to 3,118). The top three cost centers and expenditure sources were pharmacies, personal protective equipment (PPE) usage, and laboratory. The average OOP payment for patients less than 60 years old was higher, ranging from Php 25,899 to Php 44,428.63 (USD 538 to USD 924.44) compared to patients older than 60 (Php4,005.60 to Php 32,920.20 ~ USD 83.35 to 684.98). The most OOP charges were for the age group 19-30, amounting to Php 44,428.63 (USD 924.44). Conclusion. Preliminary findings of this study gave an actual representation of the expenses of COVID-19 patients, which can guide future utilization of the national health insurance during unexpected pandemics. Early price regulation of new therapeutic interventions, diagnostic tests, and medical supplies, e.g., PPEs, disinfectants, air filters, are measures that can be implemented.
Health Expenditures ; COVID-19 ; Insurance, Health

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A time-motion study on the operating room processes among pregnant COVID-19 patients undergoing cesarean section in a tertiary government hospital

Ma. Evita D. dela Cruz-Tabanda ; Maria Angela R. Bandola

Acta Medica Philippina.2021;55(2):224-230. doi:10.47895/amp.v55i2.2797

Objective. This study aims to determine time and motion in the operating room in emergent, urgent and scheduled cesarean section surgeries among pregnant COVID-19 patients. Methodology. A time and motion performance evaluation study was done by computing the following parameters: pre-induction time, pre-incision time, opening time, closing time, for both decision-to-delivery interval (DDI) and overall operative time. Results. During the study period, emergent DDI average was 2 hours and 38 minutes, emergent overall operative time was 1 hour and 31 minutes, urgent DDI average was 3 hours and 51 minutes, and urgent overall operative time of 1 hour and 57 minutes. However, in both urgent and emergent cases, the recommended DDI of 30 minutes, and the average duration of 44.3 minutes for CS were not feasible. Conclusion. The COVID-19 pandemic has negatively affected the provision of surgical obstetric care and OR utilization. Due to the new safety protocol for healthcare workers and patients, there was a significant delay in DDI and overall operative time. The causes were preparation, anesthesia factors or obstetrician factors. Identifying modifiable obstacles may improve the DDI, overall operative time, and the quality of maternal and child birth care during this pandemic.
Pregnancy ; Female ; Cesarean Section ; Time and Motion Studies ; COVID-19 ; Time Perception ; Motion

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