 In the middle of March of this year, several hospitals were overwhelmed with COVID-19 patients. Most of the ERs in these top hospitals were inundated by critically ill COVID-19 suspects. They needed help and all pointed to the director of the largest medical center in the Philippines to help out. The Philippine General Hospital is a teaching hospital under the University of the Philippines. It took up the big challenge to help out the nation and become a COVID-19 referral hospital. Today, we will listen to the stories behind the making of UP-PGH as a leading COVID-19 referral hospital in the National Capital Region and the Philippines. Welcome to TV UP, Health Issues and this is your host, Dr. Teddy Herbosa. Our guest today is the best Filipino surgeon clinically and academically. He is a graduate of the UP College of Medicine and took his residency of neurosurgery at the UP-PGH. He had been president of the Academy of Philippine Neurosurgeons and the Asian Association of Neurosurgeons. He was also a former medallist of the UAAP UP track and field team in running in the event 400 meter low hurdle. He is a skilled saxophonist, but most importantly, he is the current director of the largest teaching hospital of the Philippines, the UP Philippine General Hospital. Welcome, Dr. Gap Legaspi to this particular episode of Health Issues. Hi, Gap. Hi, Gap. Good afternoon. I'm happy to be here. It's my honor to be sharing our experience here in the Philippine General Hospital. So let's talk about it directly and give me the story behind how UP-PGH became a COVID-19 referral hospital. Well, I think it started and we started reading the signs. Our ERs being swamped by people with upper respiratory tract symptoms. But we call regularly in the ERs severe acute respiratory illness or SARI. And that was the time, middle of March, when the COVID pandemic was getting out of hand. And it was reflected mainly in the private hospitals as an overwhelming overcapacity of their emergency rooms, their ICUs. So if you read that, it was a matter of time before it got to the government hospitals, mainly because the first wave was from people who traveled abroad and probably well off people who went to private hospitals. So we were assessing the situation and we thought that this is a matter of time before us government hospitals got overwhelmed themselves. So I got to talk to some of the directors of the government hospitals, the DOH hospitals. And I got to talk to the directors of the private hospitals that we were all in agreement that maybe the Wuhan formula where they built a mega hospital of 1000 plus beds might be what we needed at that point. Because we needed to save a health system, hospital system. We cannot let all of these hospitals fall down at the same time because of overcapacity. So we had a meeting and I brought it up with the special assistant of the secretary of health who mentally set up a meeting with the secretary and we explained the concept itself. And I ended up talking to the technical advisory group the next day who already was also thinking about it. And in fact, when I got to the table with them that was March 19, they already had the idea of assigning PGH, Jose and Rodriguez Memorial Hospital in Lang Center as the exclusive COVID referral centers. So that's around I met the secretary March 18. I met the technical advisory group March 19 and I met the field implementation team of the DOH and CR hospitals also on March 19. And that's when finally we were assigned different quadrants of Metro Manila. We had the biggest coverage because we committed 130 beds, scale up to 200. And so we got the southwestern part. So that's Las Pintas, Paranyake, Pasay, Mandaluyong, Makati, Manila, and parts of the gig, Ensan Juan. So that's quite a big area. So that's how it ended up. But coming out of that meeting, I thought we could probably do our work better if four conditions were agreed on. One, there should be full support of financial funding from the DOH. Number two, there should be manpower augmentation. Number three, there should be a good referral system to take the non-COVID patients from those hospitals. And number four, a command center. Luckily for us, three of the four were instantly given and the fourth was we worked on the fourth one in the coming weeks. So those are the next questions I'd like to find out. What were the engineering requests to convert the Philippine General Hospital into a COVID hospital and the creation of a command center as you described? Yes. So again, going back to the Wuhan manual, they believe that a negative pressure environment made their infection rate really low for their health workers. They have a surprisingly low infection rate compared to the initial phase. Of course, the first part, they had quite a number. But that's impossible in the wards of PH because of the turn of the century design, high ceiling, big windows. So we employed three groups of engineers and architects, a hospital architect, engineering expert, and UP experts as well. And they all agreed that natural ventilation will also work as long as the air exchange is ensured. So what we did was we blew air into the ward. It's a long 200, 100 meter long ward. We blew air into the ward. We sucked in air from one side with reverse exhaust fans. And then we blew out air onto the other side with the regular exhaust fans. And then we turned on the elect fans from the ceiling so you can now imagine a net effect of going in one direction. So institution of some kind of a positive pressure so that the air doesn't stay within that particular ward. So it's the air exchange that was correct of the key to that. In fact, there is a WHO manual that supports that. Actually, the WHO article that supports that saying that good ventilation is even better than the PPE. That's what they were saying. And the enclosed space, right? The enclosed spaces that reported high incidence of health care working. So what were the other things aside from creating those designs? The command center. The command center. So that's where the system comes in. I think we were just lucky that the president had the foresight to create a command center. Because around that time also we were asking for a lot of help both from the government and private. And it was quite overwhelming at some time. The president asked Chancellor Menchit Padilla, the UP Manila Chancellor, to create some sort of a call center that will function as one. A donations coordination center and two as a patient communication center. Like a call center. Like a call center with multiple purposes. So we had that, we used that to communicate with patients and communicate with other centers as well. And I think that communication center helped not plug up the ER of the PGH. The idea was that the doctors could talk to them and tell them if they should go to the hospital or they should stay at home and just wait it out, right? Yes, remember at that time the DWH mandate on us was to send the mild PUIs home. Yeah, that was the old protocol. They were advised not to come here anymore. That really helped a lot because we were not swamped with PUIs. Correct, correct. How about in terms of equipment, PPE and supplies? Ventilators, PPE and equipment. What equipment was needed to be stockpiled to be COVID-19 hospital? So based on our estimates, if we had 130 beds, 30% of that will become critical. So we were thinking maybe 100 beds of regular warmth and 30 beds of ICU. We actually had around 22 high-end Puritan Bennett respirators but we were able to acquire 10 more of the same nature. And then on standby, actually 12 more. And then on standby we kept our private partners in the outsourced respirator supply. On standby with 30 respirators and correspond to respiratory therapies. So I think one of the things that really made the difference also was the high-flow auto-nasal cannula. Correct. Because it's a new device. A certain point, the belief of early intubation turned around to late intubation. And the high-flow auto-nasal cannula helped in preventing a lot of patients from being intubated. Of course we bought monitors, oximeters. We bought equipment to move patients around, transport ventilators. And of course, millions and millions of pesos worth of PPEs also. So what was your utilization of PPEs at the height of COVID patient? How many PPEs did you need in a day? For the 130 beds, it was initially estimated that we probably would have needed 3,400, 1,800 a day. For the 130 patients if they were in single rooms. But because we put them in cohorts, in the wards, 22 per ward at 6 feet apart, we were able to bring down our PPE consumption to 600 to 700 a day. So we were able to save at least three times of what we would have needed. And before declaring us open, we said that we will not open unless we have at least one month supply of PPE. So we had one month only stock open. Yes, we had at least 20,000 PPEs and 95 goggles. So only then when we declared the wards open on March 30, we started preparing March 22. I know that in the beginning there was a lot of uproar in social media. Several of our own doctors and healthcare workers weren't in agreement with your idea of becoming a COVID-19 hospital. So they were ranting on social media about why PGH should be the COVID hospital. How did you handle this descent from our own specialists and our own healthcare workers in PGH? So I think the concerns were quite valid because we were serving 1,500 patients a day in the hospital. And they were thinking that we became COVID hospital. All of these services we got. Yes, actually they were affected. But my reading of the situation that time is even if we did not become a COVID hospital, we would have lost those patients because it was ECQ. The OPD was true. We were banned from doing elective surgeries. And then the ER patients weren't going to the ER because of the EUIs. The numbers were actually decreasing already. In fact at one point private hospitals had 20% of their admissions already. So even if we did not become a COVID hospital, we would have lost our patients. And we would have been swamped with COVID patients because we were the big government hospital that people would probably go through. So the other one of course is the fear, the fear of COVID. And because of all the doctors who passed away, our friends, our colleagues and friends. So it was managing the fear really that probably was the first step. And I think the fear was managed by telling them that we had the systems in place. Our ECQ gave information campaign. Our PPE supply as I said was one month and our PPE level was 0.5 to 1 on top of WHO recommendation. And I saw of course your official letter to the PGH community and joining them and rallying the troops. That this is part of national and they were nationalistic to help out our country. So that was a struggle. That was an obstacle, right? It was an obstacle. Making sure that there was a buy-in. Yeah, so I think the most important thing is there were people who eventually he did the call. Well, when we were organizing it, of course, you cannot help but doubt if you made the right decision. But one of the crisis team members said, The advantage of our PGH, he said, The advantage of our PGH, That's not what we call it. After the initial fear and it was the fear was tempered by the PPEs. The hotels that they were staying on in, the buses that were provided to them, the food that they were getting. Eventually they were making suggestions already on how to make it work. But of course those who stayed home probably will not feel the same involvement. That's why even as it was going on, it was really difficult to temper the expectations of our other members. But two months down the line, I think the problem is not the COVID ward anymore. The problem is how to get back to how we were before working on that. So you had the setup already, you had the engineering, you had the equipment, you had the command center. You had convinced the people to open up. What was next? The next was to make the necessary guidelines, protocols, and training. Tell me more about how you did that. How did you train people? How to don and adopt the PPE? How to enter and avoid places that are COVID part of the hospital, etc. How was that done, the training and the protocols? Like in true UP fashion, when you do something, you try to do the best. So you wanted to be the best, had the best system in all of this. So one was we had a very good hospital infection control unit headed by Dr. Nina Berba. And we relied on her because she is a well-written researcher. She makes decisions based on evidence. And I think people respect her when she talks about these protocols. So the way we did spread out the protocols is by having an information education committee, with very attractive infographics. And I think regular communication was done through here because no one was in the hospital. We just got through them through Facebook or Viber. So there was a regular progressive instruction campaign on how to don and adopt. There were actual donning and docking courses given by nurses and residents. And to make it even safer, I think the positioning of a safety officer in the donning area, that makes sure that all the steps are taken just like flying an airplane. You cannot fly until all the steps are checked. So that was one of the safety measures. Number two, we allowed them to change because we know we're only humans. We allowed them four hours of break. Because also they found this really useful in maintaining well-being of the nurses, of the staff, and also maintaining performance level. But lo and behold, most of them decided to stay for eight hours in the same PPE. Maybe to help us in. And some of them even wore diapers because they didn't want to take out the PPE. Oh, I see. Yes, yes, yes. For eight hours, that's right. So the way to make it safe is they entered only in one area and exited in another. So they never went back the same door to DOF to remove the PPE. So after they get infected, they only move in one direction towards the other end of the pavilion where the doffing station is. But before they get out of the door to be assisted by another safety officer, they go through a nano mist tent that for 30 seconds is sprayed with isopropyl alcohol. It's still in full gear and hoping to decrease the viral load on the surface of the PPEs. And then they doff. And then they go straight to a shower that was built at the entrance of Ward 3. So they shower right after doffing. So the life of the healthcare worker totally changed. The behavior, the practice on how to care for patients totally changed. Yeah, so there were people who painted, there were people who, you know, panicked as soon as they put on the N95 mask because it's hard to breathe. And then we had initially, we had sisters on the face because of the N95. I think that a lot of these officers are dermatologists. They got into consultation and intervention there. So I guess the other ways that you made it safe as we, I think we're one of the few hospitals to do fit testing of face masks. Of the N95. So what is the fit test? Can you describe to us what the fit test is all about? So you choose a mask that is comfortable to your face. N95, 8210 model, you put it on your face, mold it. They put a hood on top of it on your head. It's like very much like with our kids, we put a plastic bag on our head. But this one had a clear shield. And it had a hole near the mouth. And the bitter solution was aerosol was sprayed inside the hood. And you start breathing deeply. You start turning your head, chewing, moving your lips. If you feel any bitter taste inside, that means there's a leak. That's a leak. So that test is not a good fit. That mask is not a good fit. That's a good fit. So only when you don't taste the bitter taste any more, then that's your mask. So you keep that with a weak supply of that. So I think that also lessens the infection rate. By the way, how many of the healthcare workers have been infected? How many have been infected so far? The total number? Caring at the PGA. So for those who work in the COVID-19 ward, and there are 1,050 of them, around 24 healthcare workers have been infected already. So that's around 2%, 2.1%. And for the whole hospital, around 4%, 4.5%. So meaning more healthcare workers were getting infected outside of the COVID ward in the community rather than the COVID ward itself. So when we investigate that, they will eat. Yeah, you did also something different in terms of duty of the healthcare worker. I think you changed the usual duty mode to beat the incubation period and exposure. Can you describe that for our viewers? So when we didn't know exactly how the infection will get into the hospital because we were still open at the time, very porous. And MEQ was declared, ECQ was declared. We adopted a one week on two weeks of duty schedule for two reasons. One, you decrease the personnel that are in the hospital. So just in case you get someone to spread something, you have one third of the workforce only in the hospital and two thirds can substitute the one third that will get sick. So that's the first one reason for doing that. The second one is if they go on duty and they somehow get infected and they feel the symptoms, at least they have the two weeks to rest to be relieved of the symptom. And hopefully days after that, they'll be able to go back to work again. One step is negative. So that's the reason why we introduced the one week on two weeks of, of course, the other ones for them to rest. And this is really very new to them. They can barely move during their duty. They were suffering from heat and exhaustion. So they were given a longer time to recover. So how about the Bayanian Center? That was the command center, right? It's better called the UTI Manila. Can you describe to me where it is? Who manned it? Who were the people there? What type of transactions happened in the Bayanian Center? So it's quite interesting also because the chancellor set it up like a professional call center. So you have 20 computers there with 20 interns who volunteered. So there's some medical know-how. So people will call for two reasons, as I said. There were scripts that she wrote to answer almost all types of queries. So that it's all consistent and very professional. So they will ask on how to proceed with the donation. So they were given instructions on that. So they went on 24-hour duties for that. So we got a lot of donations from there going through there. And also they were given scripts on how to answer medical questions. From patients or patients' families. Those that they cannot answer at their level are referred to consultants or to the services and duty. So it could be like a call center. It was operating like a call center for medical. It was also the place to give donations, right? Because people wanted to help. Yes, it was in the university's home. That is the 1938 Kamasma Poova building in the northern part of the hospital. Where the huge social house donations were gathered by this group. So now it's evolving to our portal for the telemedicine of PGH. That was my next question to you. How does telemedicine help the safety and treatment of COVID-19 patients? How does telemedicine work? I was going to say telemedicine in terms of continuing outpatient care for our patients who cannot come to PGH anymore. So the Bayanian Center is one portal of getting your doctor or an appointment to the clinic. But as far as telemedicine is concerned, I think you saw in some of our infographics or our announcements that our in-house masters in computer science, Dr. Dr. Homer, developed one, a telekomustahan modulver. The laptop is wheeled to the patient and he starts talking to his relative via Zoom. That was really very effective and the social workers cried with the patient. They were crying. The other one is he created an EMR for the COVID patient. Doctors don't have to go into the ward and write the order. So he developed an EMR outside the ward. And number three, our C-ball group, Dr. Ewang and the orthopedics group, they developed an iPad-based telehealth module where they wheel in an iPad on a tripod into the patient in the ICU with the pulmonologist or the intensive care specialist outside the ICU. Now remember, our ICU doesn't have a window or we can peek through and see our patients. So the iPad camera afforded the internist or the pulmonologist outside the ICU to see the monitors, the patient themselves. If the mask, they were using the venti mask, the snorkeling mask. It was fitted well. If needed, the adjustment. So those are the things that how telemedicine was used also. When we take an X-ray, we don't have to pay for the film anymore. So we can view it together here. I think that's what the patients who recover say. They never recognize the face of the people, the nurses and the doctors that took care of them because they're all wearing PPE and face masks and goggles. So they don't recognize who took care of them. Plus, they're all isolated from their relatives. And this telemedicine portal allowed them to communicate with the relatives. Yes, the telecom was really very ingenious for Dr. Humberkot to come up with it also. So innovations being put out by our doctors at the Philippine General Hospital for better care. Better quality of care for the patients. So what are your learning points in this endeavor? I think you're the only PGH director that faced the pandemic. This will go down in history. So why don't you tell us what are your introspection? What are the things you learned about this very unique experience of running a Covid-referral hospital for the Philippines? Okay, I guess the first pitfall was lack of communication. I think communication is really key. I think that was why a lot of the alumni and our faculty were also ranting about it because we didn't have time to communicate. We had one week to set it up. So how can I meet all of them? And I refused to explain anything on Facebook. So I was banking on the chairs and my fellow alumni to explain to them. So communication is still key. And we found out that no matter how distinct the departments are, given the challenge they rise up to it. I think being mindful of statistics, of reading the sign, that helps you make the right decisions is very important also. So having very well-researched ideas helps to make the right decision for a decision-maker like a director. The other one is we realize that no one is indispensable. For those of us, we just look for another one who can do the same job. So nurses didn't come, doctors didn't come. So there's someone who's going to replace them. And I think in that case, the DOH volunteers, given by the Department of Health, really helped a lot. There are 130 of them. You know, our organization, the Crisis Committee, was created outside of the Director's Advisory Board. It's all surgeons. Oh, no, our surgeons are designed for crisis intervention. That's what my mentor said. You've been trained all your life to solve problems. Solve these problems. So they were your problem solvers, right? This is the situation. There was no organizational chart. There were just four people that I talked to. I told them do what you need to do. And it just proved that it is the people who really work and not the committee. So you just choose the right people and they did a fantastic job. Denis Serrano on the... Donations, the donations. Logistics. On manpower. And so easy. Anything that moves, Rodney will take care of that. Anything that does not move. Equipment and manpower, human resources. If they need to travel. That's safe. That's a man on a bicycle. That's Rodney. And both of them put all the flows together. Flow the system. That's wonderful. Those are interesting golden nuggets. I do hope you will write that in a big book one time. And become the playbook of how to convert a big teaching hospital into a COVID deferral hospital. Question. When are you returning to the new normal? When will you start doing elective surgery? When will you start admitting the other critically ill patients that PGH caters? Okay. Again, as I said, you have to read the signs. So when they say they're going to leave the modified ECQ on the 31st, you cannot admit everyone on the first. We all know that a second surge is really possible. Yes. So my initial gut feeling is going to be bad. But I think right now, because of the testing, we're able to handle the PUIs better. So, confidently, this afternoon, just before coming to this interview, we just finished the director's advisory board. And we agreed that in one, we'll start piloting our system. We changed everything. There are no more departments in PGH. Only service ones. So there's a surgical service and a medical service. So they agree who comes in for surgery first. Malignant tumors over benign or non-deferable or deferrable, non-blood requiring versus blood requiring. Or those that you require. You've been able to do what no other PGH director has done to break the silos. Break the silos of the different specialties in the hospital. Yes. And they now talk and work together as one. Wonderful. Yes. So it's really, as a director, when I saw all the problems of PGH, maybe in the middle of my directorship, I said, the only way that we can solve PGH is probably if we reboot PGH. I think this is the rebooting of PGH. This is the rebooting. It's like turning off the computer. Yeah. Well, the final word. Tell me about how PGH will be in the new normal. I mean, you've discussed some of it already with the removing of the departments, et cetera. Yes. What will happen to training? What will happen to research? What will happen to patients? What will be the new normal life for the Philippines general? The new normal life is there will be less patients, I think, because of the physical distancing until the vaccine comes in. So we reduce everything at least by 50%. Hoping if we get the 60% resumption, I'll be happy with that. So the key is to remove the COVID patients from the wards. So we're building a 40-bed ideal isolation unit so that we put all the COVID wards there. The operating room is going to be in the outpatient department, so they're all outside the main building. So we plan to resume COVID-free Philippine general hospital. So that's a big thing. So what we foresee is that we become what we've always dreamed of to be a truly tertiary center. We only take in those who will get robotic surgery, interventional cardiology, interventional radiology, stemting, coiling, and leave the ecolysis and appendectomies and the pneumonias and the diaries to other hospitals that will be able to handle them. So the new normal will be a higher level number of cases. Our residents will have to go out to train the basic and come back here to finish off with the advanced training. As of now, I'm looking at this as to our, finally, our primary health care program to take off because we will be forced to send our internal medicine and family med doctors to the community, to the areas, to the people who cannot come to PGH anymore because they are not tertiary care requiring. That's right. Thank you very much, Dr. Gap. I think I envy your position. You are in a position like the captain of a big battle, the general of a big battle in a historical. Congratulations on your victories. And I do hope that you've learned a lot and that you can share that wisdom to the rest of the medical community and other hospital administrators. Thank you very much, Dr. Ligasti. Thank you very much. Thank you very much. Thank you. Thank you, gentlemen. Thank you. We'd like to thank Director Gap Ligasti for his surge in terms of his volunteerism to lead the Philippine General Hospital from a university teaching hospital to the leading COVID referral hospital in the Philippines. There were many lessons learned. He described all of them, some golden nuggets of advice and wisdom. And with all of that, we bid you all thank you for listening to us. We do hope that you will support the Philippine General Hospital and all the doctors and healthcare workers that sacrifice there and show their heroes. Maraming salamat. This is Dr. Teder Bosa for TV, UP Health Issues. Goodbye and thank you very much.