OBJECTIVES

Clinical pathways (CPs) ensure adherence to heart failure (HF) management guidelines. To optimize quality care in a low resource setting, an evidence-based care pathway for the management of acute HF was implemented at the emergency department (ED) of the Philippine General Hospital (PGH), the designated national tertiary hospital and referral center. This study aimed to describe the characteristics of adults with acute HF admitted at the ED and evaluate the quality of care they received, measured using physician adherence to the hospital’s acute heart failure CP.

METHODS

This was a retrospective, descriptive cohort study. We reviewed the inpatient charts of all adult patients with acute HF admitted to the ED of the PGH and referred to the Division of Cardiovascular Medicine between December 1, 2022 and May 31, 2023. Quality of care was assessed based on adherence to quality indicators adapted from routine and conditional order sets detailed in the pathway. Descriptive statistics was utilized to describe patient characteristics, quality of care, and outcomes.

RESULTS

Two hundred thirty-six (236) patients were included, with a mean age of 51.8 years. Majority were male (53.4%); hypertension (61.4%) and ischemic heart disease (53.8%) were the most common comorbidities, and infection the most common precipitant of decompensation (60.6%). There were optimal adherence rates to routine orders, which included referrals to Internal Medicine and Cardiology, baseline vital signs monitoring, fluid intake and output monitoring, chest radiograph, complete blood count, blood urea nitrogen, sodium, potassium, prothrombin time, partial thromboplastin time, arterial blood gas, urinalysis, and N-terminal pro b-type natriuretic peptide. Conditional orders, such as oxygen support, focused echocardiography, thyroid - stimulating hormone, and the use of vasopressors, diuretics, and venous thromboembolism prophylactic agents, were optimally performed when warranted. However, we noted suboptimal adherence to certain resource-intensive conditional orders, such as hourly monitoring of urine output (61.4%), hooking to cardiac monitor (53.8%), and performance of 12-lead ECG within 10 minutes (56.8%). Further, only 43.9% of patients were referred to the intensive care unit. Troponin I, calcium, magnesium, and albumin were ordered in excess.

CONCLUSION

Overall adherence rate of physicians to the hospital’s Acute Heart Failure Pathway was satisfactory. Work is needed to improve adherence to hourly urine output monitoring, consistent hooking to cardiac monitor, and timely performance of 12-lead ECG – an effort that begins with expanding in-hospital diagnostic equipment and human resource supply. We recommend continuous pathway implementation with periodic evaluation and stakeholder feedback to further improve quality of care.

Human ; Male ; Female ; Middle Aged: 45-64 Yrs Old ; Adult ; Albumins ; Blood ; Blood Urea Nitrogen ; Calcium ; Cardiology ; Chart ; Charts ; Cohort Studies ; Critical Care ; Critical Pathways ; Diagnostic Equipment ; Disease ; Diuretics ; Echocardiography ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Equipment And Supplies ; Evaluation Studies As Topic ; Feedback ; Heart ; Heart Diseases ; Heart Failure ; Hormones ; Hospitals ; Hospitals, General ; Humans ; Hypertension ; Indicators And Reagents ; Infection ; Infections ; Inpatients ; Intensive Care Units ; Internal Medicine ; Lead ; Magnesium ; Male ; Medicine ; Myocardial Ischemia ; Natriuretic Peptide, Brain ; Natriuretic Peptides ; Nitrogen ; Overall ; Oxygen ; Partial Thromboplastin Time ; Patients ; Peptides ; Philippines ; Physicians ; Potassium ; Prothrombin ; Prothrombin Time ; Quality Of Health Care ; Referral And Consultation ; Sodium ; Statistics ; Tertiary Care Centers ; Thorax ; Thromboembolism ; Thromboplastin ; Thyroid Gland ; Time ; Troponin ; Troponin I ; Universities ; Urea ; Urinalysis ; Urine ; Venous Thromboembolism ; Vital Signs ; Work ; Workforce

BACKGROUND AND OBJECTIVE.

Severe Acute Respiratory Syndrome - Coronavirus-2 (SARS-CoV-2) was initially known to affect the respiratory system and has been reported to also involve the cardiovascular system leading to myocardial damage. Remdesivir is one of the approved treatments for COVID-19, wherein viral replication is inhibited by terminating the RNA transcription prematurely. According to studies, the primary electrocardiographic effect of remdesivir in COVID-19 patients are sinus bradycardia and QT prolongation. The use of electrocardiogram (ECG) is an essential diagnostic tool in assessing the electrical conditions of the heart. The objective of this study is to describe the electrocardiographic profile of adult patients with COVID-19 who were given remdesivir and admitted in the University of the Philippines-Philippine General Hospital (UP-PGH). To this date, this is the only study done locally identifying the electrocardiographic profiles of adult patients with COVID-19 who were given remdesivir.

METHODS

This was a retrospective descriptive study involving adult patients with COVID-19 who were given remdesivir and admitted in UP-PGH from June 2021 to June 2022. Demographic profiles and 12-lead ECG done during the hospital admission were gathered. Descriptive statistics was used to summarize the clinical characteristics and the electrocardiographic findings of the patients.

RESULTS

There were 412 confirmed COVID-19 patients who were given remdesivir (mean age 56 years old; female 52%) included in this study. The most common comorbidities were hypertension, diabetes mellitus, and stroke. Majority of the patients had severe (58%) to critical (22%) COVID-19 infection. Most of the patients had sinus rhythm (94%), normal rate (72%), and normal axis (93%). The most common baseline ECG findings were non-specific ST-T wave changes (42%). Some patients had atrioventricular blocks (3.4%), bundle branch blocks (3.6%), prolonged QT interval (1.9%). Among those with repeat 12-L ECG (136 patients) during admission, ECG changes observed were sinus bradycardia (6%), prolonged QT interval (4%), and both (1.5%).

CONCLUSION

Based on this retrospective review, which to our knowledge is the only study done locally investigating the effects of remdesivir on ECG of adult Filipino patients with COVID-19 infection, majority of the patients had sinus rhythm, normal rate, and axis. The most common ECG finding was non-specific ST-T wave changes. This study demonstrated a low incidence of adverse ECG changes that would preclude the administration of remdesivir when indicated. These include sinus bradycardia and QT interval prolongation which did not require further interventions. ECG remains to be useful, low-cost noninvasive tool that can help monitor electrophysiologic adverse events of remdesivir.

Electrocardiography ; COVID-19 ;

INTRODUCTION

Stroke is the leading cause of disability worldwide and remains a major cause of death among Filipinos. Despite being the most common neurological disease, wide variations in management persist among clinicians. This CPG aims to provide evidence-based recommendations for the diagnosis and management of acute stroke.

METHODS

A systematic synthesis of evidence was conducted to address the diagnosis and management of both acute hemorrhagic and ischemic stroke. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was followed. The process included: (1) generation of critical questions and outcomes (2) retrieval of current and relevant evidence, (3) synthesis and appraisal of the evidence base, (4) formulation of draft recommendations, (5) deliberation by a multi-sectoral stakeholder panel on feasibility, values and preferences to assess the strength of recommendations and (6) planning for dissemination, implementation, impact evaluation and updating.

RESULTS

Sixteen clinical questions were addressed leading to 21 recommendations. Most were strong recommendations supported by moderate to high certainty of evidence. The recommendations span the spectrum of acute stroke care, including early diagnosis with imaging, admission to stroke units, reperfusion therapies, surgical options, prevention of complications and the role of adjunctive treatments.

CONCLUSION

The recommendations in this CPG are intended to guide clinicians and other stakeholders in the diagnosis and management of acute stroke. They are meant to supplement, not replace, the sound clinical judgment of healthcare providers.

Ischemic Stroke ; Cerebral Hemorrhage ; Hemorrhage ; Hemorrhagic Stroke

BACKGROUND

Ischemic heart disease is the leading cause of mortality in the Philippines. Despite strong recommendations from clinical practice guidelines for reperfusion for acute myocardial infarction (AMI), local data reveal low rates of primary percutaneous coronary intervention (PCI) and early invasive strategies due to financial constraints and system inefficiencies. The recent expansion of the Philippine Health Insurance Corporation (PHIC) AMI benefits package presents an opportunity to improve access to appropriate care. A standardized, evidence-based national clinical pathway is needed to guide healthcare providers and ensure consistent, high-quality care of AMI across various healthcare settings.

OBJECTIVE

To develop a standardized, evidence-based national clinical pathway for the management of AMI patients eligible under the PHIC IHD-AMI benefits package.

METHODOLOGY

Existing AMI clinical pathways from nine public and private hospitals in the Philippines were collected and reviewed. A multidisciplinary Technical Working Group (TWG) appraised current guidelines using the AGREE II tool and evaluated the collected pathways to identify strengths, gaps and variations in practice. A draft pathway was created and refined through consensus-building with cardiology experts and stakeholders to develop the final pathway.

RESULTS

The final national AMI clinical pathway integrates evidence-based best practices and accounts for differences in institutional resources. It standardizes the use of ECG and cardiac biomarkers for diagnosis, provides clear criteria and timelines for reperfusion therapy, defines indications for coronary angiography and PCI, and recommends optimal medical therapy and cardiac rehabilitation.

CONCLUSION

The national AMI clinical pathway is a critical step toward improving the quality, equity and efficiency of AMI care in the Philippines. Developed through a collaborative, evidence-based process, it aligns clinical management with international standards while addressing local healthcare system realities. Adoption by PHIC as a quality standard is expected to enhance guideline adherence, inform health policy and financing, and drive improvements in health outcomes. Continued implementation support, monitoring and evaluation are necessary to ensure its impact, particularly in under-resourced or geographically isolated settings.

Myocardial Infarction ; Myocardial Ischemia ; Infarction

BACKGROUND

Acute myocardial infarction (AMI) is the leading cause of morbidity and mortality among Filipinos. The guideline-recommended treatment for AMI includes emergency care, early electrocardiogram, emergent coronary angiogram and angioplasty, intensive care, medical management and cardiac rehabilitation. However, the cost of treatment is very high and not affordable for most Filipinos. To address this, the Philippine Health Insurance Corporation (PHIC) released the ischemic heart disease – acute myocardial infarction (IHD-AMI) Benefits Package under Circular No. 2024-0032 on December 21, 2024. This package significantly increased the insurance coverage for AMI to include invasive procedures and cardiac rehabilitation. The UP-Philippine General Hospital (UP-PGH) was the first to implement this package. This paper documents the initial planning, system changes and innovations undertaken by UP-PGH to support implementation.

METHODOLOGY

This qualitative descriptive study used retrospective document review to detail revision of the existing acute coronary syndrome (ACS) pathway and development of the AMl pathway, restructuring of patient flow and upgrades in infrastructure and hospital capabilities. Meeting minutes from the Division of Cardiovascular Medicine and UP-PGH were reviewed to describe the hospital's preparation and implementation process.

RESULTS

UP-PGH established an efficient, evidence-based ACS and AMI pathway. Hospital protocols, staffing, infrastructure and equipment were aligned to implement the PHIC IHD-AMI Benefit Package. Key steps included resources upgrade, stakeholder consultations, pathway redesign, workflow development, process alignment and monitoring systems.

CONCLUSION

The PHIC IHD-AMI Benefit Package can be successfully implemented in a tertiary hospital with catheterization laboratory. The documented process at UP-PGH can serve as a model for other institutions planning to utilize the package.

Myocardial Infarction ; Myocardial Ischemia ; Acute Coronary Syndrome ; Insurance, Health ; Philippines

INTRODUCTION

Stroke is the leading cause of disability worldwide and remains a major cause of death among Filipinos. Despite being the most common neurological disease, wide variations in management persist among clinicians. This CPG aims to provide evidence-based recommendations for the diagnosis and management of acute stroke.

METHODS

A systematic synthesis of evidence was conducted to address the diagnosis and management of both acute hemorrhagic and ischemic stroke. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was followed. The process included: (1) generation of critical questions and outcomes (2) retrieval of current and relevant evidence, (3) synthesis and appraisal of the evidence base, (4) formulation of draft recommendations, (5) deliberation by a multi-sectoral stakeholder panel on feasibility, values and preferences to assess the strength of recommendations and (6) planning for dissemination, implementation, impact evaluation and updating.

RESULTS

Sixteen clinical questions were addressed leading to 21 recommendations. Most were strong recommendations supported by moderate to high certainty of evidence. The recommendations span the spectrum of acute stroke care, including early diagnosis with imaging, admission to stroke units, reperfusion therapies, surgical options, prevention of complications and the role of adjunctive treatments.

CONCLUSION

The recommendations in this CPG are intended to guide clinicians and other stakeholders in the diagnosis and management of acute stroke. They are meant to supplement, not replace, the sound clinical judgment of healthcare providers.

Ischemic Stroke ; Cerebral Hemorrhage ; Hemorrhage ; Hemorrhagic Stroke

BACKGROUND

Ischemic heart disease is the leading cause of mortality in the Philippines. Despite strong recommendations from clinical practice guidelines for reperfusion for acute myocardial infarction (AMI), local data reveal low rates of primary percutaneous coronary intervention (PCI) and early invasive strategies due to financial constraints and system inefficiencies. The recent expansion of the Philippine Health Insurance Corporation (PHIC) AMI benefits package presents an opportunity to improve access to appropriate care. A standardized, evidence-based national clinical pathway is needed to guide healthcare providers and ensure consistent, high-quality care of AMI across various healthcare settings.

OBJECTIVE

To develop a standardized, evidence-based national clinical pathway for the management of AMI patients eligible under the PHIC IHD-AMI benefits package.

METHODOLOGY

Existing AMI clinical pathways from nine public and private hospitals in the Philippines were collected and reviewed. A multidisciplinary Technical Working Group (TWG) appraised current guidelines using the AGREE II tool and evaluated the collected pathways to identify strengths, gaps and variations in practice. A draft pathway was created and refined through consensus-building with cardiology experts and stakeholders to develop the final pathway.

RESULTS

The final national AMI clinical pathway integrates evidence-based best practices and accounts for differences in institutional resources. It standardizes the use of ECG and cardiac biomarkers for diagnosis, provides clear criteria and timelines for reperfusion therapy, defines indications for coronary angiography and PCI, and recommends optimal medical therapy and cardiac rehabilitation.

CONCLUSION

The national AMI clinical pathway is a critical step toward improving the quality, equity and efficiency of AMI care in the Philippines. Developed through a collaborative, evidence-based process, it aligns clinical management with international standards while addressing local healthcare system realities. Adoption by PHIC as a quality standard is expected to enhance guideline adherence, inform health policy and financing, and drive improvements in health outcomes. Continued implementation support, monitoring and evaluation are necessary to ensure its impact, particularly in under-resourced or geographically isolated settings.

Myocardial Infarction ; Myocardial Ischemia ; Infarction

BACKGROUND

Acute myocardial infarction (AMI) is the leading cause of morbidity and mortality among Filipinos. The guideline-recommended treatment for AMI includes emergency care, early electrocardiogram, emergent coronary angiogram and angioplasty, intensive care, medical management and cardiac rehabilitation. However, the cost of treatment is very high and not affordable for most Filipinos. To address this, the Philippine Health Insurance Corporation (PHIC) released the ischemic heart disease – acute myocardial infarction (IHD-AMI) Benefits Package under Circular No. 2024-0032 on December 21, 2024. This package significantly increased the insurance coverage for AMI to include invasive procedures and cardiac rehabilitation. The UP-Philippine General Hospital (UP-PGH) was the first to implement this package. This paper documents the initial planning, system changes and innovations undertaken by UP-PGH to support implementation.

METHODOLOGY

This qualitative descriptive study used retrospective document review to detail revision of the existing acute coronary syndrome (ACS) pathway and development of the AMl pathway, restructuring of patient flow and upgrades in infrastructure and hospital capabilities. Meeting minutes from the Division of Cardiovascular Medicine and UP-PGH were reviewed to describe the hospital's preparation and implementation process.

RESULTS

UP-PGH established an efficient, evidence-based ACS and AMI pathway. Hospital protocols, staffing, infrastructure and equipment were aligned to implement the PHIC IHD-AMI Benefit Package. Key steps included resources upgrade, stakeholder consultations, pathway redesign, workflow development, process alignment and monitoring systems.

CONCLUSION

The PHIC IHD-AMI Benefit Package can be successfully implemented in a tertiary hospital with catheterization laboratory. The documented process at UP-PGH can serve as a model for other institutions planning to utilize the package.

Myocardial Infarction ; Myocardial Ischemia ; Acute Coronary Syndrome ; Insurance, Health ; Philippines

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.

Human ; Quality Of Life ; Critical Pathways ; Quality Improvement

BACKGROUND AND OBJECTIVES

Depression and anxiety are common among patients with cardiovascular disease. With increased stress from the ongoing pandemic, it is important to evaluate these conditions. Hence, this study aimed to identify the prevalence of depression and anxiety among outpatient consults via telemedicine through the HADS-P questionnaire and to compare the clinical and socioeconomic profile of patients with HADS-P score of >/=11.

METHODS

This is a cross-sectional descriptive study including participants, outpatients in the cardiology clinic through an online survey regarding their socioeconomic demographic profile and the HADS-P questionnaire. Patients with scores of >/=11 for anxiety or depression were identified and the two groups were compared using a chi-square test analysis.

RESULTS

One hundred and twelve patients were recruited. Majority were females, with a partner, unemployed and living below the poverty line. The most common cardiovascular condition was ischemic heart disease and most patients were at least functional class II. The measured prevalence of probable anxiety and depression were 22% and 8%, respectively. A significant difference between the presence of both anxiety and depression was seen in participants with no partners; and for depression alone, in employed participants.

CONCLUSION

Anxiety and depression are common in this sample population. HADS-P is a simple way of screening patients for these conditions so that holistic care may be instituted and appropriate referrals for psychological intervention may be done.

Human ; Anxiety ; Depression ; Telemedicine