 Good afternoon, everyone, and welcome to the University of the Philippines and the Philippine Health Insurance Corporation's webinar series on Stop COVID Vets, Clinical Management Updates on how to manage COVID-19 cases in the Philippines and discussing the state of the art in terms of infectious disease management, renal management, cardiology management, and other specialties. Good afternoon. I am Dr. Raymond Francis-Sarmiento from the National Telehealth Center of the National Institutes of Health, University of the Philippines, Manila, and this is the sixth webinar in our series. And together with me, as always, in our Friday lunchday is my mentor and board member of Phil Health, Dr. Susie, Mercado. Dr. Susie. Hi, good afternoon. Raymond, and to all of you who are with us today, you seem to have registered a lot of things. I would just like to welcome everyone to the webinar, those of you who are watching on TVUP and those of you who are watching on the playback. We have a lot of seasoned clinicians who listen to this webinar and you have a lot of baguettes, not baguettes of words. Oh, Raymond, millennials who are watching. And this is, as Raymond said, the sixth in a series of our, what should I say, our efforts to try to bring the latest knowledge, information on management of COVID in the country to everyone. So we have people watching from all over the country, also from other outside of the country. Oh, this is just a welcome and Friday is always exciting because of this clinical management updates. Thank you, Dr. Susie. And of course, this webinar series will not be possible without the total team effort from the University of Philippines, the Office of the President represented herein by Executive Vice President, Dr. Jodoro Herbosa, from the Office of the Vice President for Public Affairs, Dr. Elena Purnia, from TVUP, which is our official, shall we say, conduit for bringing this to the public and represented herein by Dr. Gigi Alfonso. We also have our IT support group from UP and ITDC and also from UP Manila, the National Telehealth Center of the National Institutes of Health and from the field health side, obviously, Dr. Susie Mercadas, board member represents the Philippine Health Insurance Corporation. Today, we are very privileged to have, shall we say, a very special message from our opening remarks speaker. And I will give the floor to Dr. Susie for that short introduction of our opening remarks speaker. Okay, thanks, Raymond. So as you all know, this is a joint effort of the University of the Philippines and the Philippine Health Insurance Corporation. I think the other health is really doing its best trying now to reach out and not just be a financer of the health care services, but also an enabler and a facilitator for dialogue among practitioners. So it's my privilege to introduce the President and Chief Executive Officer of the Philippine Health Insurance Corporation, Brigadier General Ricardo Morales. Hi, good afternoon, everyone. Thank you very much for participating here at the web seminar that we are able to respond to our health workers. In a way, this COVID-19 pandemic is going to impact our lives in ways that we still do not know. They said, we still do not know what we do not know. So this effort is an attempt to shine a light into the dark room that is COVID-19. If it's any consolation, field health will shoulder at cost the health requirements, the cost of treatment of all health care workers during the pandemic. This includes all personnel who are required to serve in the operation of a health facility. So, as I said, we still do not know what we do not know, but nobody knows everything. But there is something that somebody knows that if we exchange this information, we share this information, it will increase our knowledge and it will make us respond to the emergency much better. This is the purpose of this web seminar to increase our knowledge by exchanging information with each other, sharing, and hopefully reach a synthesis, you know, as I've been telling you, one plus one is not two, but, you know, something more, maybe three or four. So it depends on the dynamics. And I would like to thank Dr. Susi Mercado for her initiative in this effort. She is a board member of our field health and Dr. Antonio Ramos for agreeing to be the facilitator of this activity. So again, from field health, serving 108 million Filipinos. Thank you very much for participating in this activity and we look forward to more engagement in the future. Thank you. Thank you. Thank you very much for the wonderful message from our field health president and CEO Brigadier, Richard Brigadier General, Ricardo Morales. I'm just going to say, CEO Morales, that this webinar series provides an avenue for our top clinicians to be able to provide state-of-the-art information on how to manage COVID-19 cases. And we are very lucky and privileged to be able to provide this channel to the public and also to our frontline workers who are at each step of the way and every day is fighting the COVID-19 fight. So before we proceed, I think this is the time when we, before we introduce our guest speaker, resource person, this is the time that we go ahead with our traditional pre-webinar questions. The pre-webinar questions that was given by our resource person, which is more important, patient care or personnel safety. So as the answers are trickling in, nearly 90% of respondents, they selected option B, which is personnel safety as opposed to option A, patient care. So later, our resource speaker will provide the correct answers for these pre-webinar questions. And then moving on to question number two, that's personnel safety. And when you leave the hospital, well, nearly 99% of our attendees, they answered no. So this does not stop there, let's say, from the hospital. So later on, we will be asking our resource speaker to provide the correct answers. And I will give the floor again to Dr. Susie Mercado to provide the brief introductions. Thank you very much. Thank you very much very much. So in our, in our informational material on this meeting, you know, we quoted some data from the Department of Health in late April that more than 1,000 healthcare workers have been infected by COVID. 422 of them, about half were doctors, 386 nurses and so on. And in late April, we had 19 deaths of doctors. So I think this has been really a very tragic season for us in the healthcare world. But there's always hope. I think part of our clinical webinar is really to move forward to charge on. And it's really an honor and a privilege for me to introduce our next speaker. He said he wanted me to keep the introduction short, which is difficult because he's highly accomplished. But so I'll make it short. I mean, I've known our speaker for more than 24 years in a time when we didn't know if we were going to become doctors. And even then when I knew him in college, he was already a leader. And I'm not surprised that he's leading the charge here on, you know, keeping our health workers safe. You've seen him on media. He always has a lot to say about the safety of healthcare workers. And I think that is something is fundamental to controlling the transmission of COVID and keeping the whole country safe. So it's my pleasure to introduce the manager of the Department of Administrative Services of the Lang Center of the Philippines, which is the premier institution for lung disease in our country. He's a surgeon and a dear friend and a champion advocate. And I would say a public servant, a true public servant who's always looking out for people even if, what should I say, the going gets rough. Anyway, my pleasure. Dr. Antonio Ramos, Tony, welcome to the webinar. Hi Susie. Long time no see. We'll see each other online. Good afternoon to everyone. Raymond, finally, I saw you. Yes, sir. Tony, I heard somewhere that you use 300 to 500 PPS per day in the Lang Center. Is that correct? Yeah, right now, I asked yesterday, it's closer to 500 and 300 because we have more critically ill patients now. And so the use is really high. And we do not scrimp on PPS. That's one way that we can really protect our personnel. So what do you think now that we're going into GCQ? What does it look like for you? Well, for the past few days, the numbers have been going up as far as admissions are concerned, but that's just us. We don't know if it's because people prefer to go to Lang Center. The triage numbers are going up also and maybe for the same reason. But we've always been thinking that when the quarantine levels go down, we should be even more careful and we should be prepared, more even prepared. That is why if we're asked if we still need more PPS, the answer is always yes. We still need more. We still stock stock piling on these things and other things that we need like ventilators, air conditioning units, because we will only stop when we know that despite the relaxation of quarantine, there is really a flattening of the numbers. Okay, so a big challenge ahead. So Tony, please go ahead with your presentation. Thank you, Susie. First, I'd like to thank the University of the Philippines, of course, National Telehealth Center, the Philippine Health Insurance Corporation and you, Susie, for putting me up to this. Basically, it is sharing of the Lang Center experience. I don't want to call it best practice because I'm sure we all have, as the general said, you all know something better than the other people and I just want to share our experience and I hope during the open forum, we can also learn from the others. Well, I'd just like to share our experience and when I'm asked, is this best practice, I say, no, this is Lang Center practice and would like to learn from others. This is a picture of Lang Center. It looks clean and nice, but this is pre-COVID and as I mentioned earlier, we're at the Federal Center for COVID-19 and we concentrate on moderate to severe respiratory disease, such as like Pilping General Hospital. And I was talking about this earlier. We were thinking what would be our priorities, our objectives, our patient care and personal safety, but it really was a very long discussion and very vigorous discussion and personal safety won out and thankfully so. And so when we decided that personal safety was going to be number one, it was the basis of all our decisions later on and very important that you are not confused. The outline is I will tell you about the incident command system, safety officer and zoning, infrastructure modifications, equipment that we have, the supplies that we have right now and then the care for our personnel. Now, this is how an incident command structure looks like. You have an incident commander and then you have four sections, operations, planning, logistics and finance. This is the clean one, but after it was populated, you can see that you have an incident commander. The incident commander is Vincent Balanag is the director. I'm the assistant incident commander. We have a public information officer, safety officer, liason and other operations. You have everything. I'll tell you about these task forces, strike teams and the single resources. And then the next section is planning. Resources are planned here. Then you have the demobilization when everything is over and done with or we change to a different quarantine level. Then we have the the demobilization and of course documentation very important being so we should be able to say what we did and put it into a playbook so that hopefully not but if it happens again, we can just bring the playbook out and and you know, we can we can redo it. And then finally finance and administration, which is still also mine. It talks about HR, it talks about HR, it talks about costing, it talks about the business side of things. Now this is how the incident post looks like. I'm sorry, I'll just this is how the incident post looks like. If you notice, it's situated outside of the hospital because as as our CEO, we let CEO said, we don't know everything about everything. We don't know how we didn't know how the virus is going to be transmitted. So to play it safe, all key personnel are members of the incident command system. I decided let's put it outside. So in case somebody, you know, it's so hard to contaminate us. Because if somebody in the incident command gets sick in just imagine was gone around the hospital, the three whiteboards you still in the front, one is this structure, the one in the middle will be the daily briefings. I'll show you this to you later and the left will be the search planning. You can see the see, sir, a little about one meter apart and hopefully this end up for social distancing. And you have to put on electric fans to wow the heat is too much. And this is how the briefing goes. Either myself or Vince does the presiding. The one at the lower bottom on the right lower bottom is initially when we have the meeting. And the briefing is just what it is really. It's just a briefing. You can see the numbers. Please don't don't copy this so much because these are the crucial information. This is how we started. We have sections for beds to have sections for triage section ventilator use I'm talking from the right. And then the different task forces engineering support very important for the different task forces. And then we have the hotline, the COVID lab reports. How many days COVID negative at that point, April 20 something. It's two days and then task force personnel shelter vacancies and then the Facebook page you have to put up the lab and lung. This is how it looks like now. It's neater right over the weekend. We try to clean it, but you can see very clearly that we are on our nine days when we say nine days nine days since we had the positive personnel. Our highest was 30. Now it's nine. But unfortunately today this morning, we had one asymptomatic personnel tested positives over back to zero. We were running total of patients that we saw talking from the right. Okay, we're moving to the left. And then the different words you can see how many positives we have, how many probables, total, how many are intubated, how many vacancies and what's a total capacity. You can see we have 88. And we have a total of 15 vacancies in the COVID words. And in the non COVIDs, we have 35 and three intubated. So we already know what in the morning, how many are intubated, how many admitted, how many ventilators we need, how many seen at the triage non COVID and COVID, how many were admitted, how many mortalities. And then for the task forces, if you go back, we go to the middle now, you have the medical task force, they have their action plans, the plan for resurgence, plan for demobilization, we're doing OPD planning now, doctors clinics and return of diagnostic services, always at the bottom engineering support, very important. Same with the triage, what we're working now would be the shelter for the relatives and the guards because we have to reconfigure the grounds. On the left, we have the COVID laboratory and the gene expert lab, they have separate numbers. And then the logistics, if you notice, and I'll tell you about this later on, they do not count numbers, but the day supply that we have operations of the medical task force of the triage task force and personal task force, three very important things medical takes care of patients, triage, and the patients come in, they're classified as positive or negative, they're sent home or either admitted, very important section. And of course, personnel takes care of our people. There's a it's in the same order or level of importance as the medical and the triage. And then the strike teams are single single options, strike teams, the hemodialysis, we have to still operate our hemodialysis for COVID positives, the subnational laboratory, which is our COVID lab, and then of course, ECMO, we will do everything for our patients, ECMO being one of them. And we already tried ECMO on a patient, unfortunately, after two or three weeks, a patient did not survive, but we will not stop at anything to get these patients out of the hospital alive. Now, as I mentioned, we have a COVID response in the staff services, you already mentioned this, we have no private clinics, you have no PD service, you have no elective procedures, at least sleep studies and sleep and the pulmonary function test, they're still being not being operated now on limited services, you have your own clinics, radiotherapy, and then the pulmonary pulmonary therapy and the ambulatory oncology. For the task forces, of course, our priorities should be personal safety. If you look at the top of the slide, the picture, incident command and objectives, number one, personal safety, number two, patient care, these things are not just being said, it is stamped on everything that we do in the decisions that we make. And okay, when we started, we labeled all the areas of the hospital, red zone, very high risk, orange zones, high risk, yellow zone, medium risk, and the low risk is the blue. Actually, the no risk is green and there is no green zone at the long center of the Philippines. I will show you what the, how these zones work. If it's a red zone, what is required? You should have full PPE, meaning to say cap, shield, mask, suit, gloves, and booties. This is for the COVID positive areas. Orange. Orange is a little difficult because you have COVID positives and negatives, you still don't know, they're waiting for the results. So full PPE with modification, what is the modification? You have to change your outer suit every time you enter one room. Meaning to say we have our full PPE suits, we put in a plastic cover or raincoat over it. Every time we leave a room, you remove your suit, you change your mask, you change your outer gloves because you have two gloves, and then change your cap and change your, your shield. Okay. And then yellow, these are the laboratories and the radiology areas, just masks. But if there is a COVID positive patient or a probable, everybody goes into full PPE. And then blue zone, you need mask and then that is for all the rest of the hospital. And then green zone, no mask, but we have no green zones. Now to show you, this is a hospital entrance. When you enter, it's already blue zone. Actually, when you enter the grounds of Plunk Center at the gate, mask required. So it's already a blue zone, mask is required. And there are reminders. If you look at the poster, blue zone, mask, and then there is a diagram showing cleaning of the hands. So always wear masks and perform frequent hand hygiene. You can see this all over the hospital. So we make no mistake, even if you're absent minded, if you're forgetful, you, you're not in the good mood, you will know where, where you are in the hospital in terms of zoning. And on top of that, we segregated our medical and non-medical personnel. We designated an entrance for the non-medical, we designated pathways, staircases, and hallways for them, so that they will not come in contact with our health personnel. And to make sure that they remember, there are pictures posted everywhere that if you're at this area, you should be seeing this picture, you should be using the staircase, you should be using this hallway and this grand staircase upstairs. And then going up to the third floor, fourth floor, you should use this staircase. So we don't want them to be crossing each other. And we did this from day one. I think not everybody is mapped. It's good with reading maps. So we decided to put pictures so they would realize or recognize where they are at the moment. This is what you see. If it's a blue zone, it says there always wear mask and perform frequent hygiene and you have a map at the bottom. It designates where are the yellow, the oranges, the red and the blues. Okay, I'll tell you about this later. That's why if it's a red zone, there's a warning it's a red zone in all corners in all walls, you will see this. And this is a layout, the floor plan of the Lang Center. G is the ground floor. If you can see, it looks like a T and then a diamond. Okay, in the diamond, the horizontal is yellow. That is the yellow zone that is the diagnostics, the radiology suite. But they're orange areas within the yellow. Those are the CT scan and the CT scan streets. And if you can see some red spots, those are the laboratories and the pathways to patients who are COVID positive, and we have designated a separate, separate elevator for COVID positives and personnel. Second floor, if you can see the second floor on the right up. All the rest are blue, but the horizontal, that's the operating room and the surgical ICU, they're yellow. And then the two the letter V at the bottom, those are the COVID words, I'll show them as you close up later on. And the third floor, the same, you have two diagonal words which are red. And then the fourth floor are executive offices that is blue. So all you need is a mask for this. This in during our early days, this is how our triage look like tense in the parking lot. Because we did not have the facility for triaging. Fortunately, we have an OPD building which has not been turned over yet. And the department manager allowed us to use it. This is how it looks like now we were fitting it out. This is how we started we put in concrete pathways, and we put in a lot of ramps. So there will not, there won't be any interaction or when you're coming in, it's a different way of going out. It's a one way flow of persons. This is how it looks like when we were doing it, you can see walls are being created now. And we have the beds on the lower right with oxygen tanks. And then the waiting areas and the tent that you can see on the left picture is the waiting room for patients who are going for triage. This is our triage area used to be supposed to be the OPD building. The one on the left is a red zone. It is where patients are examined. You have your intubation zone there, you have x-rays there. And then on the right, you have the orange zone. Still full PP at this point in time, the yellow one on the right would be the laboratory of a separate laboratory in the in the ER triage area. In the triage, you have separate donning and doffing areas. Very important. One, even in the separate triage, donning area and doffing area, there is a one way flow. And if you see here in the doffing area, we have the yellow bags for the discarded PPEs. And just to make sure they do not forget the steps on how to remove things. You have to remove your gown and gloves together, disinfect your hands, remove your face shield, disinfect your hands, remove hair cap, disinfect hands, and then you must disinfect hands. Always, always. And we drill this to them. Not only that, we have a poster everywhere on how to remove their full PPEs. Safety officer is very important. We have a safety officer and he can call our attention anytime. And there are three things that he does. He issues safety reports, incident reports, and near miss reports. Safety reports are action items. For example, he saw somebody walking or in the wrong zone or a person like me. I I strayed into a wrong zone, because I was fixing something, he will have to call my attention in and then when it was done, the description of Dr. Ramos going into a wrong zone, priority, not very much because it's not going to be a cost of mortality. I am the person responsible. And when am I supposed to correct it immediately? And I should be writing an incident report why it happened. And let there be incident reports, these are things which happened, like for example, we had an instance where in with an overflow of not overflow with too many bodies in our mortuary. It's an incident. Very important. So we had to investigate why and put the reasons how we can why it happened and so give the solutions how it should be the procedure should be changed so it will not happen again. Of course, near miss reports, these are extubations, which were found. Because of this, we did some things. So these are the near miss reports. Infrastructure modifications very important. The problem with infrastructure modifications is we all have different architectural designs and for long center, it looked like four clovers. So this is what we did. If we are going to convert our rooms into critical care rooms or IC rooms, we cannot have a watcher inside, we cannot have a nurse inside especially for COVID positives. So what did we do? All rooms of the long center Philippines have CCTV monitors, each and every room. And the central monitor can be found in the nurse's station. That there be patients monitor. We have 86 rooms. We have like about 60 rooms with patients monitor with telemetry and you can see them. The central monitors are in the lab in the nurse's station. What's the importance of this? You can see actually the patient without being in the room. And if you see the patient a bit agitated, you can check with the car jack monitor and the other vital signs monitor. And so you can, you can know immediately without being there just like being in the ICU where there's direct vision of each patient. And then translucent doors just like the ICU we can see through, we remove our wooden doors, we replace them with thick plastics. And so we can even if a patient is inside the room and the personnel is walking along the corridor, you can just glance inside and see what's happening to the patient. That are the air change per hour. Very important. Our minimum is 12. You can compute this by getting the volume of your room times 12. And then you see the flow air flow as done by your exhaust fan. And then so the total flow should be equal or more than 12 times the volume of your room. We've learned how to do this. And fortunately for us, our ICC is very strict. So when we were designing our air flow, even before this pandemic, Dr. Galvez I want to give her the credit for this really was founding us on 12 HCH. So when this thing happened, we had 12 HCH in our rooms, temporary walls. See if you see in the picture on the right, we had no time to put in concrete walls or even wooden walls. So we made use of thick plastic. We put in the frames put in thick plastic and put in a doorway. So we can control the flow of air. And as I mentioned, that letter F dawning and dawning areas I'll show you this to you very separate dawning and dawning areas we learn from experience that they cannot be beside each other in the single flow of one way flow of personnel dawning and then dawning is on the other end. And then letter G no crossing of non health personnel and patients and health personnel, as I mentioned earlier. This is a typical setup and I'll tell you, these are two words. The blue is the entry or the dawning area. The personnel don the PPE is there and they can do the rounds. But at the end, at the exit, they doff and then they have to go out. When you go out, you want to come back, you cannot go back the same way to go around and go through the entry again. And then you don again, and then you go around. It's a bit tedious. But I think it lessens our contamination. Initially, our entry and exit dawning and doffing were just side by side. And when we looked at it, they were coming together. So it was not good. So we learned from the end users. They said, sir, let's put entry one and exit on the other and then lung centers fortunate, they have the architecture this way, the corridors are interconnected, we can afford to have one one way flow of personnel. As I mentioned to you earlier, your plastic walls, covering the hallways and you have labels on each zone. This is a red zone, where proper PPE because it's a red zone. This is a COVID word. This is our dawning area. You can see the dawning area is actually a blue area, just the mask needed. But this is where they put on the PPE is clean PPE is they put on their booties and everything you can see on the side they're hanging their N95s we've taken to preserving the number of PPEs include especially the N95s because it's in very short supply right now. And we're looking at ways of doing UV sterilization and heat sterilization of the things that we do. This is how our COVID word looks like. You can see abundant use of plastic to control the flow of air and outside each room. You have your separate segregated trash cans and all the needs of the patients are in the in the table right outside the door. And of course, a disinfecting solution. So the nurse does not have to go back and forth. You can just get all the supplies right outside the door before he or she enters the ward. These are resupplied every after every shift, making sure that all these tables are are adequately supplied to this with the needed things of the of the nurses. This is our typical COVID ward. You can see the nurse is in full PPE gear, cap, shield, mask, PPE, so double gloves, and booties. This is how the nurse station looks like as I was mentioning earlier. We have rewards which have like 10 patients monitor, some with six, it all depends on how much the oxygen system can tolerate as far as supplying ventilators are concerned. So if you can see in this picture on the right, you have the monitor for the CCTVs. And side by side, we have the monitors for the patient's cardiac monitor. So we can see at all times how the patient is doing agitated moving around trying to extubate polling for help. Okay, because if they're extubated, all they have to do is, you know, maybe wave their hands if they're awake, and they're supposed to be sedated, then we will know also, and it will be it will be seen also at the it will also be seen in the patient's cardiac monitor. Did you see the keyboard keyboard on the left? It's covered in plastic. It's another innovation of the of our nurses. They change the plastics every so often because even if they're wearing gloves, they want to be extra careful. So this is how it looks like in a red zone. What do you see? This is warning red zone where proper PPE and the minimum required PPE is their mask, shield, suit, cap, gloves, and booties. So we know that our people are mindful, but we do not want to take any chances at every time they turn, they will see what they need need to be wearing. And additional patient care, are you protected? Overall, if you need extra gloves, put in extra gloves. The reminders are always there. And aside from plastic, we use tarpulin for our medical ICU, we could not cover the whole hallway, it used to be a hallway, but to to control the airflow, we place double layer tarpulins as a temporary wall. Now this is the entrance to the ICU. We took this picture because on the right, you can see a HEPA filter. In case you cannot achieve the ideal ACH of 12, then having a HEPA filter would be very useful. And I think it gives added protection. This is how it looks like in the ICU. Outside outside, they say it's an orange zone. Inside, because there's a glass in intervening glass panel, you can see inside the nurses in a red PP that's inside the ICU. All the monitors are in the nurse's station. We brought out the nurse's station from inside the ICU to outside. And then we made use of the glass windows. So from outside, we can see inside. There were two beds which we could not see. And to make up for that, we placed two extra CCTVs so that we can see those two beds on both sides, which cannot be seen directly from the nurse's station. This is how it looks like. Even our radiology department, which is a yellow zone, it is, although we minimize our exposure by putting up X-ray machines in the different areas. Now the portable X-ray machines are more less stationed permanently in the triage area in the second floor. If they really need to go for CT scan, they control air flow. And of course, equipment, we can never overemphasize the need for ventilators. And then the day what we count would be the number of ventilators because in its worst form, it's respiratory failure, and you can only serve patients as long as you have ventilators. So until now, we're still receiving donations of ventilators. Why? Number one, we don't know how many patients would be needing them. Number two, nobody would come to you to repair your ventilators. And even if a repairman would come in, there are no spare parts to be bought now. So I think the thing to do is to really really save up on ventilators. More important than patients So every time we have high flow oxygen machines and ventilators, we're so thankful. As I mentioned earlier, supplies are measured in day supply. So total number of units divided by the daily use. And that is your daily supply. The most critical being PPEs. And of course, you need your sanitizing disinfecting solution. But the PPE is really number one. And we still are looking for more PPEs because as mentioned by Susie earlier, she asked, how many do we use? 500 per day. And we need to give our personnel the confidence of working because they know we will have addict with PPEs for them all the time. If you look at this, this is in an orange zone. These nurses have on top of their PPE suits, a plastic suit, which they can remove when they leave a room in which the patient is not yet classified as positive or negative. This was a picture taking two weeks ago. We're fuller now. We have even more PPEs. Right now we have four months supply of 500 PPEs per day. Of course, lastly, patient caring for our healthcare workers, shelter, food, transportation and psychosocial issues. Fortunately, we have donors who are lending us or giving us vehicles which we can use to send our patients home or personal home or fetch them. And of course, you have to provide shelter for them. Initially, if you look at the left lower picture, this used to be our AVR. But now we can use our AVR because outside now we have our container van dormitories, donated. We can house 32 in these two structures, air conditioned, nice beds with the portlets outside and shower areas. This is another type of LCP shelter we had to donation from the WTA group. Each structure can house 16 to 30. So we can house total of 60 individual cubicles with beds, their showers, there are toilet baths, facilities, there's Wi-Fi, air conditioned also. We can never emphasize food. We'd like to thank the many donors who still support us right now because it's hard for us to provide food for all our employees. But right now we are doing that just so they do not have to go out and worry about their food. These are best record 30 days from last COVID positive personnel, but sadly now it's back to zero. And we always, we always work for a COVID free workplace. And we have also our task force personnel having taken care, caring for the carers. We have, we have an episode day when we had hair stylists. And you can do your manicure pedicure. This is where I got my haircut. You can see that the stylists are in PPE, but the personnel are not protecting them from us. It looked insurmountable at the beginning. But I saw this in a book. They say when you face a difficult task, you have to do it. It's impossible to fail. If you're going after Moby, they don't forget your tartar sauce. Now what have we learned? Our last positives are engineering personnel. And when we did contact tracing, we learned that they got it from their homes. So while we were protecting our personnel inside the hospital, we were neglecting them when they go home. So number one, we now have to do personal symptom monitoring. When they come in, we have to know what's their temperature. Do they have cough, sore throat, difficulty breathing? And every day this has to be filled up and reported by the safety officer in that office. Every day we have lots of non-contact thermometers. So this is a new thing. And this is how we were able to get our asymptomatic personnel who are positives. And because of this, we now have this Stay Safe At Home Reminders. We have a Tagalog version in the works. Reminders for them. And this is for them. And the next version will be for their relatives to change their clothes, avoid unnecessary stops on the way home, keep social circles small, avoid crowded places, perform hand hygiene often, always wear masks outside your house, often checked for COVID symptoms. These are given and all employees are reminded about this. So when they go home, they will teach their relatives about this. And eventually, we will have monitoring for their relatives at home, which they have to submit to us. So we will have some sort of control of their home situation. So these are new posters, precautions during mealtime, and also how to remove and take off your mask precautions during mealtime, wash hands, schedule meals, as to minimize number, individual portions, no sharing, not talking while eating, no face to face during eating. We know that we have reminded them about this, but we know that they will forget. We have to have a campaign of maintaining awareness and this is part of it now. So this is posted everywhere at the lung center of the Philippines. You'd say, you already know how to remove or wear our masks. No, we have to put it one, two, three, four, five, clean your hands before doing it, clean your hands before removing or putting in your mask, hold the mask by the ear loops and place a loop. We cannot trust everyone to be doing the right thing. So we even teach them how to put on and remove their surgical masks. This is how important personal safety is for us. And we know and they say it's action research. So she says it's common sense. I agree with her 100%. And we take suggestions from everyone. End of the day. This is a photo by a good friend, Shara Sambrano. The best way to take care of our patients is to take care of our personnel. She is our angel in red. And we are so serious about taking care of her because our human resource is our number one resource. The bottom line is if you cannot protect your workers, and they get sick, the whole system goes down. I'd like to thank again the organizers of this for allowing us to share our practice. And hopefully I want to learn from the practice also of the other people participating. Good afternoon. Thank you very much, Tony. I think that was a very inspiring, a very inspiring presentation in radius a lot that we have learned from you. And we'd like to pick up some of the questions of people who are in the webinar. I'll take off first of you, Raymond. So first question, Tony is, how often do you test your health workers? Okay, we get baseline. We use RTPCR. And then as often as every two weeks, we do testing, especially for the front lines, less frequently for those in the admin or in the backroom operations. But every time they register something in the patient's monitor, they're tested immediately, and we're very fortunate to have the gene expert. So we have the results within the day. Okay, there's another question here before we go into our assessment of the webinar. Question is how do you do? How do you manage airflow if you're in a centralized air conditioned hospital? Very difficult. Fortunately, our number one, we did the review of our air handling units. We don't want sharing between clinical and non clinical areas. So only clinical, the clinical areas, most of our air conditioning units are stand alone. Our centralized air conditioning is in the is in the non clinical or administrative air regions areas. Now, if you already have that centralized air conditioning, I think you should look for other ways of maintaining your ventilation. But in case you cannot do adequate HPH, they say HEPA filters the best way to go. But I would be very worried. And I would even check the direction of the air in your air handling units. Very important. You might be taking care of your patients, but you might be contaminating in non non clinical era. And I'll give you an example. There was one hospital, we're also helping other hospitals, they keep on calling me, they get keep on getting positives. And I said, look at your air handling units and throw in up a conference room or sharing, because you know, it rooms are hospital was not or we're not designed for pandemics. It for usually the TTP dial. So sharing the back. So there was a clinical area, where it was sharing an air handling unit with a non clinical area. And we saw that and I told them, this is a no no. Don't do this. So there to stop supplying to the clinical area and then put in window type or split type air conditioning units. Yeah, good question. Yeah, because I know I think even when there's been some discussion around this, even in other countries, if you look at the way the hospitals are designed in China, or in the very developed countries, it's all highly centralized, you can't even open windows. And, um, it's a blessing on our partner. We have old buildings where you actually have compartments, no, and you can actually manage or reengineer parts of the hospital. But this is a part of the management of COVID that we will probably later on, when we look back, you look at what's happening in the US, for example, many of these hospitals have highly centralized air airway systems and are not really meant for for pandemics. Anyway, so I think Raymond wants to put in the assessment questions. You want to do that Raymond If I may, can I go ahead Dr. Ramos? Because the way they designed it is to save on money on energy. A lot of our air is recirculated air. That is why if you're going to design a building, a long center designing a new wing, it's going to be totally different. It's going to be a building within a building. The non-health will have their own building inside the building. And then the health section will have a totally separate section, but you can see just one structure recirculated air. So even in the States, because they want to save on energy, the heat is recirculated. Yes. Okay, thank you very much. Yeah, okay. Thank you, Dr. Ramos. Go ahead. Good. I thank you. Thank you, Dr. Suzie. So for a tradition, we also ask our attendees to provide their answers to our, well, essentially an assessment of the webinar. So based on the questions, so more than 80% of our attendees found that the presenter demonstrated thorough knowledge of the webinar topic, and that he was well prepared and organized, as well as spoke clearly and audibly. The presenter also showed that he was able to use appropriate language with technical, medical jargon adequately explained and use appropriate webinar techniques. So it's overall, it was very well received, Dr. Ramos. And it was very much appreciated all of the learnings and experiences that people learned from San Las Ropo. So for the questions I think I'll take over from Dr. Suzie in terms of the questions. Sir, San Las Ropo, in terms of the reuse of the N95, how many times can you reuse? What do you do in between the reuse? How do you push it clean? Is it a centralized way or is it clean? How do you do that, sir? That's for me. Yeah. Right now, we're still developing the protocol for that. We're looking at UV light. But they say in a certain temperature 37 degrees, the virus will die in two hours. So we're looking at putting in what we call this heat, heat boxes. So we can put in the the the N95 masks. And not only that, we realize that paper is a good format. And even the CIF forms. So we have we're now designing boxes for each ward. So they can put in their masks, they can put in the papers, the patient's records. So when they transfer from one area to another, it is stumped disinfected. So we use heat and then we're going to put up a UV light room so we can do more sterilization of masks. It doesn't really stop. In the actual PPE, even if you're using it in hospital like the CIF forms, they also will be Yes, yes. Very good sharing Dr. Tony. Next, sir, as part of, let's say, being an advocate for personal safety, how do you take how many nurses can handle how many patients, you know, the ratio, the health worker to patient ratio, but how did you arrive at assigning that, you know? That's a very big challenge because I'm sure there are nurses here. The level of care for the usual wards is one is to four, one is to five. If you go to ICU care, it's about one is to three, sometimes one is to two. So that's the reason why we had a call for nurses to come in because our regular beds are now critical care beds. So we need more nurses to maintain the one is to three, one is to four ratio of nurse to patients because we cannot toy around with that because if you still have one is to four and you have critical care beds, your nurses will get tired, they'll become careless and if they're careless, they'll become sick. So we're still needing nurses right now. So we can do that number one. Number two, so we can have rotation of nurses. If we do a computation, we need 200 more nurses, but I know that our budget cannot take it. So we try to be creative as creative as we can, but we cannot rotate COVID to non COVID. That is a very big challenge. We still maintain the nursing critical care level of nursing and we use the ratio that they have. Okay. Thank you, Dr. Ramos, that was a very enlightening The next question, you may find it a little bit controversial in the sense, sir, with the proliferation of rapid antibody tests, although the DOH does not really recommend it. Many people use that, sir. So how do you reconcile all of that that's happening outside of the hospital, but also at the same time, we are using RT-PCR for the front line How do you reconcile all of that, sir? How do you reconcile everything that's happening around LCP, sir? Basically, we don't use antibody tests. The reason why we got antibody tests was to use for our convalescent plasma treatment. We don't even use it to screen people, the antibody tests. We don't even use it to screen people, the antibody tests. We don't even use it to screen people, the antibody tests. As Susie mentioned, I'm a thoracic surgeon, so I think the infectious people are a better way to answer it, but I can tell you, we don't use antibody tests because RT-PCR is the way to go. Although it is not 100%, it's a lot better than antibody tests. So I would like, no, I will not give my opinion regarding that because I'm not the author of it. Tony, I have a question. To say it seems from, we've heard several hospital presentations. Yours is really, really quite interesting in terms of engineering, innovations, how you're using technology, how you're visualizing patients with CCTVs. But I'm really very intrigued by the safety officers because I think as we progress, this is going to be increasingly important that you have people who are sort of like enforcers because it's very easy to forget that. I think the thing about this is behavior is very difficult to change. And even among the best of us, it is always a challenge to remember that you have to do a certain thing. So do we have, I mean, how did you develop your safety officers? Do you have a training program for them? What are their qualifications? What do they do? Are they on shifts? How does that whole thing work? It'd be surprised. We have a young pathologist who we just assigned as a training officer. I just gave him one marching order. Don't be shy. You can call our attention anytime or anything. And so he started going around based on the rules that we have on the zoning that he made. Violators are cited every day, including myself. And these are published. They are a little bit shy. And then to replicate himself, we assigned safety officers for individual units to make sure that the people in that unit are wearing the proper attire, PPE, masks. They're washing their hands, distancing. So he is replicated. Training, there is no training, but I'm willing to share him. He can even give a seminar. Yeah. Yeah, his name is Gerald Tejada. He's a fantastic guy, he's young. And he's not afraid of me, even if it's me. Sir, you're wrong. Okay, sign with me. And I appreciate it. Keep everyone honest. The safety officer keeps everyone honest. I'll tell you. If the engineering people have to work in a ward, say, nurse, please change the air conditioning unit because we don't repair anymore. The safety officer has to go ahead and say, yes, it's clean, yes, it's disinfected. And then go ahead, it's not that we do not trust. We do not depend on the nurses because we know that they want it done immediately. They say, it's okay, you can go ahead and work. So the safety officer will have to vouch for it and say, yes, it was clean, yes, it was disinfected. Go ahead and work. Yeah, Dr. Tony, for instances when there are violations, do you have a sanction for that violation? I don't have any, because when I suspect a person, there's no one to leave. But peer pressure, really, peer pressure is a lot. I'm tired of it, I'm tired of it. So I remembered. Yeah, I think, Tony, this is really important moving into general quarantine, that businesses, for example, could also have safety officers. And at some point, we're seeing that our health workers should be their own safety officer at home. Yes, I agree, Susie, 100%. We should have a designated safety officer in each home, in each office, and the corporation, in the CEO, CIO, and then you have a safety officer who will not be called by any manager. No, he's not answerable to the manager, but he's answerable to the CEO. But he can still cite the CEO for a violation. Very important, I agree with you. Yeah, good, good, good. Okay, so we have some more questions, Rima on the, and I mean questions, of course, Tony, but I just want to tell everyone that what we typically do for the webinar is, we send you the PowerPoint presentation. Is it all right to share your PowerPoint, Tony? Yep. Can you just fill out our figures on the whiteboard because the number of patients and everything? Yes, sir, yes, sir. Okay, that's fine. Okay, so Dr. Ramos will remove some of the slides, and then we're going to be posting that on, we're going to send it to you for email, but Tony, if you look at your chat box, thank you very much. I mean, I think really there's a hunger for information about what to do to keep our health workers safe. Okay, Rima, there's more questions you wanted to ask. I can see that. Yes, sir. So regards for zoning, so zoning is regarded as one of the more important factors to mitigate or prevent the wastage of PPE as released for the DOH department memo 2020, 0176. Sir, the question is, so other hospitals only have three categories, you read yellow, green. So the center is a different amount. So the question is, is that based on international standard, or is that something that LCP came up with their own? And then also in terms of, let's say assuring our frontline workers, who will need to go to specific zones, what is the statement or assurance to be able to alleviate their fears because they have to go to this or that location, sir? Okay, nice question. Zoning, I think Gerald was the one who thought about it, our safety officer, because we just told him, you know, you segregate our areas based on what PPE they have to wear. So it came up with the zones. I don't know if you copy it somewhere, but this is what we're doing. Now, what is the proof? There is no proof that it is effective, except for the fact that we have a low number of healthcare personnel testing positive. Aside from doing viral cultures, which we cannot do, I think that is the only determined or the measure that we can, for ourselves that we are doing the right thing. I think we're being overly careful and I'd like us to err on that side. So the zoning is, I've not seen it anywhere else, but I think we made it. But anybody, please feel free to copy it. It's free for everyone to replicate. Okay, thank you, Dr. Ramos. So just for the benefit pouring point, to give Dr. Ramos a breather, for the benefit of our participants, please use the Q&A and the chat box for your questions. So we will not be using as tradition for the raise hand option to be able to, let's say, be able to live question our resource speakers, but nevertheless, a lot of questions because they get processed and get filled in. And as part of our tradition, we are sharing to our group that we have a lot of attendees or registrants from not just from within the Philippines, but also from the other countries. So Dr. Ramos, you are international, sir. In the Philippines, we have attendees from the rural health unit of Jaen, Nueva Ecija, in Region 3, from Metro Health Specialist Hospital in Sorsogon City in Sorsogon, Region 5, from Amay-Pak-Pak Medical Center in Marawi City. Marawi, yeah. Yes, sir. But for your international exposure, Dr. Tony, we have one from St. Vincent's Hospital in Melbourne, Australia, from the Prince Sultan Military Medical Center City from Riyadh, Saudi Arabia, and also for Juanilla Hospital in Kuwait. So traditionally, through the webinar series from other Middle East, we are really interested in learning about the state of the art for managing COVID-19, sir. So thank you, Paul, for taking that time. And then for the questions, Paul, we have another one. Would you recommend even for level one hospitals, sir, that it is mandatory, you make it mandatory for them to have a safety officer and what would be, shall we say, the qualifications of that person, Paul? Yes. All hospitals should have a safety officer because there is no COVID-free hospital. Qualifications, I think the number one qualification is commitment and passion. You can be a surgeon, you can be an internist, you can be an anesthesiologist, you can be a safety officer. In fact, you can be a nurse, you can be a medic, as long as the passion is there and the commitment is there to keep on learning. Our safety officer, you know, I'm amazed. He keeps abreast of the latest pronouncements from WHO, and he's a pathologist. And, you know, my admiration grows every day. So every hospital, every organization, every business, every home should have a safety officer. Tamai Sinabi Mosusi, everyone should have us. And everybody should be a safety officer eventually. We should acquire the values of safety, right? Nobody should remind us anymore if it is already ingrained. And then, that is success as far as I'm concerned. Yeah. Because we cannot make this virus go away, we can just protect ourselves. Yeah, I think as we move forward, Tony, you know, because we're all looking at, quote unquote, the new normal, but the new normal is not something fixed, it's something that's always moving. So I think having a safety officer, designating that and having a culture or a system where that's acceptable to call out the manager of admin, right, for going into the wrong place. This is a very important shift for us. We don't have a virus, and therefore, we don't have safety measures. Tony, I have a question. Well, there's some more interesting questions here, but I have another one, which is actually my question. And I was talking about this earlier with some colleagues that really, I think one of the risky behaviors we have, whether it's in the hospital or in the workplace, is going to be eating together. Because unlike the Japanese and the Koreans who can sit somewhere and just eat and finish, Filipinos, they're eating alone, there's something wrong with you. You have to be sitting, you have to be talking, you have to be sharing, like you're still eating. So I was very intrigued with your, when you said that you had all these reminders about that, I wanted to know, how are you managing with that? Because that's going to be an issue in all workplaces, hospital or not hospital. It is a second nature that eating is a social behavior for us. So in the hospital, are people following that, or do you have your safety officer putting in more citations because of you? Very difficult, very difficult. Because as you mentioned, it's cultural. So right now, I tell you, last time, if I go inside the different offices and I look at the pantries, I will see some violations, a lot of violations. So we're setting the stage for it. That's why initially we put up the posters knowing this is the stand of the safety committee. And then after that, when they know about it already, then we start moving and really checking. And then after that, if we find that there are problems, then as mentioned by Raymond, sanctions are going to be instituted, but that's going to be the last. We want to stay positive as far as these things are concerned because maybe you demoralized these people. So if you put sanctions insult over injury. So we try to be positive about it. We put a positive spin on everything. I told you, we made this song. We made the song, we uploaded it on YouTube. It's called Notats Plugging, N-O-T-A-T-S Notats. You search it, Notats, TTJ Band. It's a group of mine in med school. And it's about not touching and washing your hands before touching anything and keeping social distance. Cultural, the Filipino is a very social person, right? We keep, when we talk to each other, we even tap people on the shoulder. That's a habit, right? But we have to live with it and change our culture if we want to survive. Yeah. Okay, Raymond, there was another question here. Dr. Ramos, if a husband and wife are doctors, should they still be segregated at home? We are, we are, we are segregated at home. That's the sad thing. I see my wife and she waves goodbye if she's far away from my house. And then she opens the door. She let's, I remove my outer clothes on the porch. Then I enter, I go straight, I open the door, I close the door, take my shower, take my meals inside. And, but it's enough. There is Zoom and there is YouTube and there's Viber. That's the sad part of the story. But, you know, I cannot forgive myself if I bring it home. Yeah, okay. Some more questions, Raymond, on your part. About, so for this question, it's about the recommendation of not using, it's a over-alls versus gowns question, Dr. Ramos. So, based on the recommendation, it's not recommended over-alls because the infection is more common, especially through doffing. So, is that something that LCP is also doing, sir, that gowns for routine care are used? For COVID areas, over-alls. It's very hard. Okay, I'll tell you what we did. We put a maximum for hours. For hours, especially in our triage area, it's not air-conditioned. So, if you're in the triage area, your full PPE covers, after four hours, you're mandated to leave the area. Doff, okay. There is an air-conditioned tent. You lie down, you sit down. I place, you place a table with the hot water. You can have your coffee. There's a shower. You can take your shower. Then, we even have pull-up diapers for them. So, after four, after resting, then they go back. But, nothing more than four hours. We tell them, no, don't do it. It's not worth it. Because I've tried it. I put on a PPE inside an air-conditioned room. Only the younger guys can take it. I'm a senior citizen, so it's very difficult. We still use the cover-alls, Raymond, because we want to protect them. There you go, okay. Thank you, Dr. Tony. And there's something, sir, in light of the IATF resolution, sir, and the recommendation to move into GCQ status starting on Monday. How does this translate in terms of, shall we say, services in LCP, sir? Does this mean that you will start taking in elective surgeries, Puba, or elective cases? Is that, how is LCP, Lang Syed of the Philippines, preparing for the shift in quarantine, sir? I think Lang Syed will always be two weeks late. We already did planning for OPD, Return of Father Services, and then surgery. We were discussing it this morning. But when we're going to trigger it, I think we're going to be late because if there's an increase in the number, we will have to defer that one. And just between you and me. We targeted maybe the first tick of June as an increase in the number because of the May 16 modified is TQ. And then now it's a June 1, June 1, GCQ. It's an increase on top of an increase. So even if some words are not filled up, we're not giving it back to the non-COVID areas because we want to be sure that we will not need them anymore. And because of this GCQ, our sense of awareness and alarm is heightened. It's not relaxed, it's even heightened. Okay. Dr. Suzy, do you have any questions, Pa? There's another question here. Let me just read it. It's from Rem. I recently participated in a webinar. This was answered already. I'm sorry, this was answered already. So there's another question here. Okay. Are you planning to do RT-PCR for elective surgery when you start? I think we will need to do that. GeneXpert is the nice way to do it because you can get it in an R. I think that's... And I think the government is very fortunate to have a lot of GeneXpert machines, if I'm correct. Because it gives you that flexibility to test the patient if it's negative and go for elective surgeries. I think that's the way to go. Okay, so it's gonna be GeneXpert. So there's another question here. If a patient or sorry, if staff are a staff member, a healthcare worker is diagnosed as positive, but asymptomatic, when do you ask them to return? We ask them to go on quarantine either here in the hospital or at home if we can verify that they have a good quarantine facility at home. We test them after 10, 14 days. If they're negative, we do another test where we work on the conservative side. We know that the WHO says about 10 days in single test, but we still do two negatives before they're allowed to go back to work. And from their last negative, quarantine for 14 days. Wow. And we can accommodate them here because it would be so unfortunate if we're, you know, if we are taking care of them from the side of the patient and then we're getting hit, we call it a hit. We get hit from our own, from our own personnel. We don't like that to happen. Right. Okay. So I think Raymond, we're good. We've covered most of the questions. Just one more question, Dr. Suzie. What? The question is about understaffing. So obviously, because of the preparations that you have had at LCP, Dr. Tony, it's very, it has been very impressive and it has been able to, let's say, prevent for very overburdening and overwhelming of the system. But also, you really have not reached the true understaffing. But obviously, you have had certain plans in mind or studies in mind. If you reach, let's say, more than 50% or 60% of the staff become COVID-positive, sir. So would you mind sharing, sir, that what were the proposals or the plans of LCP in case that you were able to go on to understaffing because of a lot of infections? Search plan, you mean? Number one, we're very fortunate that we have a lot of doctors who volunteered to come in. Like we have, if I'm not mistaken, 25 contractual doctors. And I'm not talking about just new graduates. These are consultants already in big hospitals. I was so surprised they came in. They say, why are you doing this? You're forsaking your practice and said, we want to be where it is. And this is where it is, they say. So we want to be where the action is. And when we give them a tour of our facilities and I include the warehouse for PPEs, then they say, we really stay because you know, you're going to protect us. Now, we have a search plan, but we have to know that it will only be up to as many ventilators as we have. For example, right, we started with 27. We have now 64 ventilators. After 64, that's it. So we hope that the numbers don't go up. We have maximized the search plan. We have maximized it already. It's just a matter of opening the rooms now, but it's there already. And right now we have our numbers. I think we have 22 vacancies, so we're still good. We hope the numbers don't go up, please. We're praying every day. Okay, so thank you very much, Tony. Raymond, do you want to answer the questions in the quiz? Oh, yes. I think it's time that we answer the questions and ask Dr. Ramos. So maybe we could get that up on the screen right now. There you go. Wow. So what is more important, Dr. Ramos? I mean, definitely the answer, patient care or personal safety, so we can hear from you, sir. Of course, personal safety, but it shouldn't be lip service. It should be evident in the policies and guidelines of the hospital. It should not be something that is placed on the wall. It should be something in the minds of all the leaders, managers, and even our personnel. If there's a choice between a patient, I'm sorry. If there is a choice between patient care and personal safety, I'd go for personal safety because without personnel, no patient care. Like the policy, no PPE, no CPR. Incomplete PPE, no CPR. Patient may die. Well, that's it. But I want to preserve our personnel because that's the number one resource, the human resource. I cannot get it from anywhere else. Now, does personal safety end when you leave the hospital? No, and that is why I agree with Susie. We should all have safety officers in all hospitals, all departments, all units, all homes, all businesses. So they have a safety officer. So personal safety will be taken care of all the time. Yeah. Okay, thank you, Dr. Tony. Any parting words or concluding remarks? Dr. Susie, please. Okay, well, Tony, thank you. Thank you, I think on behalf of everyone who's listening, on behalf of the Filipinian Children's Corporation, I think your point about personal safety comes above everything else is a very strong position that we all need to take because we have no use for dead healthcare workers. We have to have healthcare workers who are safe, who are happy, who are productive. And before we close, your parting words, Tony. Yeah, I don't want any more dead healthcare workers. In fact, we don't want them to die because of this. No more of those, please. So please take care of your personnel. Take care of your families and pray to God that we get the vaccine soon because, you know, we're doing our best, but I think you have to pray so God will help us along the way. Thank you very much, Raymond. Thank you, thank you, Susie, for putting me up to this. And I wish that the other people would share also their practices because I want to learn also. I want to learn from them. Thank you very much, and everyone, please stay safe. Okay, so very inspiring. I'm crying because of you, Tony. I'm crying because of you. I think it's a difficult time for everyone, but I think we draw strength from what you're doing in the long center that you get up every day, you do what you need to do, and to hear that there are so many frontliners like you who are not going to give up and you're going to fight and you're going to protect all the health workers. That is a bright moment for our country, and we are just grateful for all that you're doing, and thank you for your time. We know you're busy. Thank you for your time. So on behalf of the whole group, the UP team, the Philippine Health Insurance Corporation, and all of those who are listening on this webinar, thank you very much. Stay safe, and we'll see you next Friday. So next Friday, we're going to have a cardiologist, Chito Permejo, from the Heart Center, who's going to talk about COVID and the heart. We know that heart disease is a huge risk factor for individuals who get COVID. So please be with us again next Friday. Let's make that our Friday habit to be on the clinical updates, top COVID deaths, clinical updates of UP and field health. Over to you, Raymond. Thank you so much, Dr. Tony. Very inspiring, Paul, as Dr. Susi Mercado said. Just a takeaway for those who are still with our broadcast, that safety is always paramount, and you have to have that top of mind whether you are in the hospital, in your businesses, and especially in your homes where you are likely to maybe expose them potentially to your loved ones and family members. So thank you very much again, Dr. Tony Ramos and Dr. Susi Mercado, and let's meet again next week. Hopefully, we will be able to have more participants because for this webinar, we had at our peak more than 250 participants. For spending your lunchtime and your lunch hour with us, and hopefully, you will be able to apply that in real life. So thank you very much. Next week will be our seventh webinar, and it will be on cardiology and the effects of COVID-19 on the heart and the circulatory system. So on behalf of the University of Philippines and the Philippine Health Insurance Corporation, let's meet again next week. Maraming salamat po. Keep safe, keep healthy, and see you online. Thank you.