The True Mandirigma

 

Lessons from the COVID-19 Pandemic Response

Thru the Eyes of the VSMMC Chief Implementer

Helen V. Madamba, MD, MPH-TM, DHPEd, FPOGS, FPIDSOG

 

In times of crisis, leadership is important to keep the team together.  The novel coronavirus originated at Wuhan City of China early December 2019.  It changed the world, and we will never be the same again.  As we faced the uncertainties with fear, we had to make sure we were not paralyzed by that fear.  On March 20, 2020 the Vicente Sotto Memorial Medical Center Incident Command System was activated on emergency mode, for a unified chain of command in the management of COVID-19 infections. 

One of the functions of planning section chief was to write policies and guidelines into hospital orders to document and disseminate the direction of management.  To ensure proper implementation, we must be sure to give clear understandable instructions that employees can follow.  It is also important to follow the rules that we set.  During times when following minimum health protocols of wearing face shields, physical distancing and hand hygiene can spell the difference between life and death, it is life-saving to follow rules.

Surge capacity planning involved looking into zoning beds (space) to segregate COVID-19 (red zones) and non-COVID-19 (yellow and green zones), putting on hold private and elective admissions to allocate more beds for incoming symptomatic patients.  It meant looking into logistics (stuff) necessary to protect healthcare workers for infection prevention and control measures, and arranging manpower (staff) in alternative work arrangements to ensure 24/7 operations while maintaining social distancing, allowing quarantine post-duty and minimizing employee exposure risk to the hospital.  The world stood still, and we had to prioritize triage, algorithms and our COVID-19 pandemic response down to essential services.   The medical center chief conference room was converted to our war room operation command center where everyday data was submitted, analyzed and disseminated.  Hard decisions were made every day, when we headed for work before the sun rose and called it a day wee into the night.

 

An effective COVID-19 pandemic response takes a whole community doing its part to contribute.  The elderly and the children stayed safely at home, many occupied their time praying, writing encouraging notes, creating inspirational drawings to boost the morale of both patients and healthcare workers separated from their families.  Families started sewing cloth face masks and preparing food packs to donate to the hospitals.  Medical students and allied health professionals volunteered to help out at the hospital to man non-COVID-19 wards so that employees can focus on working in the red zones. 

The economic law of supply and demand jacked up prices of personal protective equipment and supplies.  Government hospitals were constrained by the procurement process.  Coveralls, gloves and N95 respirators became the new gold.  Volunteers collected hospital supplies at drop-off points and distributed equitably among the government hospitals.  When we least expected it, there was an outpouring of donations from the community.  In the true spirit of Bayanihan, everyone pitched in to help as the shared identity of Vicente Sotto Memorial Medical Center (VSMMC) was born.  Maximizing responsible social media use, hashtags like #BeatCOVID19, #weHEALasONE, #sharedidentity and #sottobrandofcare were utilized.

Quality health data analytics and effective risk communication and is at the heart of efficient command operations. To combat infodemic during COVID-19 pandemic, VSMMC developed daily Facebook Live programs, dubbed as SOTTO LIVE Productions, utilizing social media to connect with the stakeholders (our ka-QUARANTeams) to provide the general public a reliable source of information.   To stop fake news and bashing of healthcare workers, we went on facebook live every afternoon to provide briefer updates on what was happening on the ground at the hospital to help people understand.  As the Hospital Epidemiology and Surveillance Unit (HESU) collected and submitted data to the Department of Health and the Inter-Agency Task Force (IATF), this live dashboard was updated on our facebook page and presented daily on our social media platforms for transparency and accountability.  By having experts discuss in the local dialect what little we know about COVID-19, we improve the level of knowledge of the viewers.  These programs also serve to maintain transparency and accountability.  

One of the concepts we espoused on SOTTO LIVE was that no one hospital could handle the pandemic by itself.  All hospitals needed to work together to provide essential services to make sure that patients had easy access to healthcare.  Hospitals in Cebu had to learn how to function as one healthcare system.  Cebu was lucky to have the Central Visayas electronic referral system and the functioning healthcare provider network with VSMMC as its apex hospital.  The electronic referral system was strengthened to ensure the right patient was at the right facility at the right time.  The private sector organized temporary treatment and monitoring facilities with the support of businessmen in Cebu and the members and alumni of medical societies and private schools.  The BAYANIHAN Center at the Sacred Heart School and at the International Eucharistic Center (IEC) were developed safe for both patients and healthcare workers.  The beds were spaced two meters apart with an industrial grade ventilation system with HEPA filter.  The local schools were converted to barangay isolation centers for asymptomatic COVID-19 positive individuals.  Contact tracing of the emergency operation centers were intensified with the goal to test (to diagnose COVID-19 positive cases), transport (to isolation centers to stop transmission), and treat (if symptoms progress and there is a need for hospital admission).

The community workers at the grassroots level are the true frontliners, hospital workers are in reality, endliners.  Public health information dissemination is pivotal in prevention of transmission.  The idea of “chismis for disease control” took advantage of the stigma and discrimination of people who test positive for COVID-19.  Neighbors would alert authorities if patients in home isolation would break quarantine or isolation.  The pressure ensured that infected people avoid exposing other people around them.  The paradox of expressing love and care was to stay away from people.  When patients get sick and need hospital admission, healthcare workers become the endliners, struggling to provide intensive care resources to help patients survive.  At the beginning, mortality rates were high because patients would consult late and there was limited armamentarium against COVID-19.  Later on, we discovered which reformatted drugs worked against the cytokine storm.

The main message was simple: stay at home (pagpuyo sa balay), wear face mask (pagsul-ob ug mask), physical distancing at least one meter (distansya ug usa ka metro) and hand hygiene (paghugas ug kamot).  By sharing these information, we help authorities make good decisions to prevent transmission.  The goal was to limit the movement of people.  Malls were closed.  We communicated with the bishop of the archdiocese of Cebu that we needed to temporarily close the churches to protect the elderly from exposure risks.  Difficult decisions and sacrifices had to be made, but with open communication lines, people understood the reasons why.  Open dialogue worked much better than enforced orders that don’t make sense to the public and brought out more resistance, negativity and feelings of oppression.

On March 27, 2020, the VSMMC Sub-National Laboratory (VSMMC SNL) was given certification by the Research Institute for Tropical Medicine to perform independent COVID-19 RT-PCR Testing. This was just in time for March 28, 2020 when mayor Edgardo Labella ordered an enhanced community quarantine (ECQ) in Cebu City for one month.  Hours after, the Cebu province was placed under enhanced community quarantine by Governor Gwendolyn Garcia in a bid to contain the spread of the COVID-19, effective March 30, 2020.  Knowledge is power when dealing with an unknown.  The ability to process nasopharyngeal and oral swab specimens for RT-PCR SARSCoV2 locally cuts short the turnaround time for availability of results.  This was a big boost for hospitals with admitted patients waiting for results.  The VSMMC SNL also provided training for molecular laboratory staff of other hospitals to assist in their accreditation to run RT-PCR SARSCoV2 as well. 

Having the ability to test admitted patients afforded us the chance to test the patient watchers as well, only to discover that a high percentage of watchers were testing positive, resulting in potential nosocomial infection.  This is the reason why on June 9, 2020, the “No Watcher Policy” was implemented.  This perhaps was one of the most unpopular decisions we had made, however patient safety took precedence over patient convenience.  We were also running out of space, so we prioritized patients over their watchers, and healthcare workers committed to improve nursing care to do away with the added helping hands of the watchers.  With the second surge with more patient case load, it also became too risky for volunteer to continue exposing themselves to COVID-19 positive patients, so we sent our volunteers home.  To assist the community for testing with the second surge, VSMMC SNL initiated the country’s first drive-thru/walk-thru swabbing for RT PCR testing for SARSCoV2 in compliance with DOH Memorandum No 2020-0258-A on July 24, 2020.  This innovation provided ease of access to RT-PCR results free of charge for the general public, with a commitment to send results to the patient’s registered email within 24-48 hours.  

By 3^rd week of June 2020, the Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF) and the Department of Health (DOH) Secretary Duque descended upon us in Cebu City to intervene on the control of transmission of infections, down to the community level.  Hospital data was presented, which showed mortalities <48 hours from admission indicating delayed consultation.  The “happy hypoxics” phenomenon was coined for the occurrence of hypoxemia with no symptoms among infected individuals.  The IATF/DOH accepted that VSMMC continues to provide basic essential health services to non-COVID19 as well as responding to COVID-19 positive patients.

This is why on June 26, 2020, the VSMMC COVID-19 Health Facility was created as a facility within VSMMC.  Infrastructure for the COVID-19 health facility was identified as the RED ZONE areas where COVID-19 positive patients are admitted.  The hospital bed utilization follows the accordion-type contingency plan, meaning as soon as bed utilization reaches 70%, we expand the COVID-19 health facility to other ward areas.  As the COVID-19 positive cases decrease down to less than 50%, we contract the red zone by closing, cleaning and converting back for COVID-19 negative patients.

The VSMMC North District (VND) Extension building is the nearest building still under construction, but already utilized for patients considering this is preferable to heated tent accommodation.  The specialized rooms for emerging-reemerging infectious diseases (EREID) with linear air flow were renovated to accommodate more patients.  Other rooms in the hospital were improved with CCTV, patient monitoring systems, fiberglass barriers and floor plans to also be ready in case there is a need to expand the COVID-19 positive areas.

As the Department of Health rolled out its national vaccination operations, intensive planning and coordination meetings were done with stakeholders from different government agencies.  By March 4, 2021, healthcare workers of VSMMC were among the first in the country to receive COVID-19 vaccines.  Vaccine hesitancy was another barrier to breach.  Massive orientation and town hall meetings were conducted.  Infomercials and electronic posters saturated our social media platforms, and expert speakers formed a panel for the SOTTO LIVE discussion on COVID-19 vaccination.  In this regard, we were considered influencers: influence through one’s actions, not just one’s words.  Media publicity for the ceremonial vaccination placed the spotlight on the healthcare workers of our hospital getting their jabs.  Veering away from setting up tents for our vaccination post, we utilized a newly constructed but still unfinished building for the Center for Behavioral Sciences for our #SOTTOVax COVID-19 vaccination program. The top management, members of the VSMMC Executive Committee led the first vaccines of the VSMMC COVID-19 Vaccination campaign dubbed as #SOTTOVax.  Eventually we were able to vaccinate more than 90% of our employees and the members of their household, another victory to be celebrated in a coffee table book to commemorate the event.

By the 3^rd surge with the threat of the more virulent delta variant, there was a need to integrate all the efforts for COVID-19 pandemic response to a patient navigation system to ensure patients have ease of access to healthcare to reduce delays and improve survival.  The Cebu COVID-19 Telegabai  was created from volunteer medical specialists and post-graduate interns, patterned after the PGH Telegabay and the Office of the Vice President (OPV) e-konsulta programs.  In coordination with the DOH 711 emergency healthline to access the Central Visayas electronic referral system and the LGU emergency operations cen
ter to mobilize forces on the ground, the facebook-based Cebu COVID-19 Telegabai provided medical advice to patients who needed to be connected to the healthcare system.  Statistics showed that this system, although utilizing cellphone calls and texts to patients, but with heartfelt service by the doctors and post-graduate interns, is effective in providing timely intervention for patients.

The COVID-19 pandemic has affected us all.  COVID-19 changed us.  We will never be the same again.  This disaster exposed the weaknesses of our healthcare system.  We’ve lost a lot of patients as well as fellow healthcare workers.  This time has allowed us the opportunity to step up to improve and establish more efficient health systems policies based on data.  The new programs, policies and guidelines are aligned to the goals and performance indicators of the VSMMC quality triangle that VSMMC.  Quality service is our pride!