On the occasion of our 10th month-sary as a COVID Referral Center, we share our most important lessons and best practices (#6-10) on coping with COVID-19. This is a continuation of Lessons #1-5 which we released last August 2020. 

Lesson 6: It is possible to get the numbers of infected persons in the workplace very close to zero; but only with a high level of consistent compliance, perseverance in tempering exposures, and cooperation from all.
 
The PGH epidemic curve through the months showed that COVID-19 affected a significant number of our staff (orange bars for HCWs who got the virus from the community and blue bars for those who got it from PGH).

The risks our staff have been exposed to have indeed been considerable! As of January 31, 2021, we have admitted 2677 COVID-19 patients and discharged 2109 survivors! Despite best efforts, a total of 471 cases (10%) did not make it— most of whom were critically-ill patients in the ICUs. The high quality of care, dedication, and compassion our frontliners as well as the support service providers gave to all these patients have been phenomenal. In the 10 months, 689 HCWs became infected with the SARS CoV2. The trend has since slowed down specially in the months of December and January, with less than 20 infections each month! And we have had several days without any new HCW infection detected! 

This confirms that even in a highly exposed, high risk setting such as a COVID-19 referral center, the risk for COVID-19 could be managed – but ONLY with the cooperation of all staff and a unified institutional action! 

Lesson 7: We need to be one step ahead of the COVID-19 virus. Think like the SARS COV2! And never for even a moment let our guards down.

Outsmarting COVID is difficult but doable using these strategies:

• Testing all patients for admission – because we need to know where to best safely place them
• Testing all watchers of patients – because we need to make sure they can safely watch their patients
• Screening all outpatient consultations for symptoms– because we need to protect our clinics
• Engineering controls for the wards, ICUs, clinics, callrooms, offices, laboratories, eating spaces- because the virus spreads efficiently in the 3Cs of closed, crowded, and confined spaces 
• Prudent, supervised, and controlled use of Personal Protective Equipment (PPE) for all staff in COVID and non-COVID areas– because we need to protect our staff in a science-guided and cost-efficient way, mindful of its impact to the environment
• Zealous hand hygiene + cleaning and disinfection of all areas- because we now have proof that these result in making frequently handled surfaces free of the SARS-CoV2! 
• Strengthening laboratory capacity with new tests to address our needs such as BD Max, GenXpert, Rapid antigen, saliva as specimen;
• Fast and efficient laboratory testing workflow for optimal COVID-19 test turn-around times.
• Aggressive and systematic contact tracing activities
• A centralized command center- because someone must oversee and make it easy for our patients, both COVID and nonCOVID, to access our caring services. 
• A COVID Crisis Committee which continues to meet every Tuesday – because we need to keep on planning, improving, and anticipating. 
• Keeping staff engaged and informed through dialogues, meetings, and workplace visits
• Safety Officers in various departments, units, offices, and donning and doffing areas
• Safer staggered meal schedules – because it’s during meals when risk for transmission of infection occurs
• Integrated travel arrangements with shuttles ferrying staff from their homes to PGH and back.
• Decreased length of bedside exposure without compromising patient care
• Better work environments
• Use of Technology – Electronic medical records for an efficient and paperless work environment
• Cooperative interdepartmental and integrated work environment created by breaking down traditional silos and units
• Support for mental and physical health
• Low threshold for testing HCWs – an efficient system for scheduling and testing symptomatic, inadvertently exposed and anxious staff, and for all other reasons we call simply “for peace of mind”.
• Targeted testing of asymptomatic most at-risk staff – because we need to know status of our HCWs
• Learning together how to best care for COVID and all other patients; promoting compassionate care for COVID patients; aiming to provide not only excellent medical care but service which is also comforting; leaving no one behind and healing as one.

We share these lessons not to suggest that all hospitals duplicate our strategies which may not be relevant to their settings; but to stress how crucial it is to study one’s own system and design response accordingly. There were harsh realities of unpreparedness, inequalities, and inefficiencies which made our initial responses difficult. At the same time though, we were pleasantly overwhelmed with the outpouring of generosity from individuals and organizations from within and outside both UP and PGH and the valuable material donations as well as manpower support which provided expertise, time, and service. This mix of recent COVID-related experiences reassure us that amidst the most distressing challenges, if we search hard enough, we will find solutions according to what we need and inspiration from the beautiful Filipino spirit of bayanihan and the willingness to work towards the greater good. 

Lesson 8: Pandemic precautions work! They keep our workplace a safe place! We cannot relax our level of precautions. 

PGH has gradually resumed normal operations. Most of all, we try to take care of each other all the time. All of these happen under an overarching understanding that we all observe what is called the  Universal Pandemic Precautions (UPP), a term adopted from the John Hopkins University. The PGH institutionalized the UPP as the newest set of Infection Control precautions on October 1, 2020. 

• The prevailing mindset should be that everyone is possibly infected and everyone should thus act accordingly. There are no exceptions.
• The objective of the UPP is to further reduce the risk of transmission of COVID-19 in PGH, thus protecting oneself and those around
• UPP imposes that HCWs always use the proper level of PPE according to area and task being performed (except in the brief meal periods); 
• UPP also requires all to observe the 5 moments of hand hygiene and distancing rules. 
• UPP defines the screening, testing, and assessment of high- versus low- risk exposures in contact tracing
• Because all are expected to follow UPP, this reduced the catastrophic effects of wrong perceptions of risk, silent spreaders, undiagnosed or asymptomatic COVID-19 among us, and inadvertent exposures to cases not immediately detected by current tests. 
• UPP does not allow overcrowding and social gatherings in closed spaces. 
• UPP does not tolerate underground parties and similar “secret” events which give the virus opportunities to spread. UPP may be the correct mindset not only in PGH but in many workplace settings.

Lesson 9: Well-thought of and timely COMMUNICATION is KEY! 

Because a unified voice of essential and reliable information needs to be relayed to all staff, a very creative and dedicated IEC committee has been working consistently since we started being a COVID-19 referral center.

The timely and regular release of carefully crafted infographics with accurate information content and style which emotes compassion and sincerity, coupled with a well thought-of formatting is a crucial component of pandemic response!
 
Lesson 10: There is life beyond COVID-19. We cannot be paralyzed by our fear of the virus. We must move forward…to Learn more, Protect More, and Serve More. 

Since August 2020 we have moved our COVID operations back to cater to more non-COVID patients. There are now new residents and more students this 2021! We now have repositioned our lenses and now also see and begin to address the collateral damages of COVID: antimicrobial resistance; neglect of other infections like TB, HIV; and noncommunicable diseases like diabetes, hypertension, and so on. 

While clearly limited by standards for physical distancing and more experienced with virtual meetings and learning online, the PGH university community enjoins all in our efforts to start moving towards a “new future” which the  WHO offers as a sustainable next step to go from where we are now. While we continue to be vigilantly prepared for the entry of new variants and surges as well as mitigate the risks for the occurrence of small and big clusters and outbreaks within our own departments, we must also move towards recovery and improving our entire health system to address not only COVID-19 but also the other pressing health concerns of the larger Filipino population. We definitely know more now, so we can select our daily actions with calculated risks.

The forthcoming vaccination of PGH HCWs is a most welcome boost. It feels like we are beginning a new chapter in our journey! A new chapter of hope and resilience!  Here is to a safer, healthier, stronger PGH!

Regina Berba, Eric Berberabe, Rodney Dofitas, Bill Veloso, Lilibeth Genuino, and Director Gap Legaspi

Published in UP Manila Healthscape Special COVID-19 Issue No. 25