I.

TITLE: Early experience with COVID-19 patients in a semi-private tertiary hospital in the Philippines: Implications on
surge capacity, healthcare system response, and clinical care
AUTHORS: Cybele L. Abad, Mary Ann D. Lansang, Cynthia P. Cordero, Ethel Dominique E. Viray, Beatrice J.
Tiangco, Jia An G. Bello,Jan Jorge M. Francisco, Marja B. Buensalido, Maria Fe R. Tayzon, Karl Evans R. Henson, Regina
P. Berba, Elizabeth Paz- Pacheco, and Mediadora C. Saniel
SOURCE: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813488/
YEAR OF PUBLICATION: 2021

II. SUMMARY
This study expands on the discussion of the healthcare system response in the Philippines in response to the surge of
COVID-19, particularly in tertiary hospitals. This study wants to know if there is a specific measure to prevent the virus
from spreading quickly and how healthcare institutions respond to help patients recover fast especially when all of the
rooms are occupied. This study used a descriptive-statistics and determined frequency distributions of demographic and
clinical characteristics for quantitative variables. The study found out the vast majority of patients recovered from COVID-
19. Poor outcomes were linked to older age and high-risk pneumonia. Adaptations to hospital structure and staff were made
quickly in response to surge capacity, though response was hampered by the lengthy time to COVID-19 confirmation. The
findings highlight the critical need for the healthcare system to respond quickly to the surge in cases.

III. NURSING IMPLICATIONS

A. To Nursing Practice
This study provides additional precautions for healthcare providers to avoid contracting the virus, such as wearing
proper protective equipment, having a swab test, and reshuffled and assigned to patients in COVID-19 units to limit cross-
contamination. This method of patient and staff cohorting is frequently used to control multi-drug resistant organism
outbreaks and emerging infections. As nurses we need to be careful in caring with our patient in a way that we should also
that care of ourselves because at the end of the day how could we even lend a hand if we ourselves cannot control the spread
of the virus.
B. To Nursing Education
This study is relevant in transferring a patient room to lessen the spread of emerging infections, such as patients in the
intensive care unit being transferred to the emergency room to make room for patients who tested positive in COVID to be
admitted to the ICU and private rooms for patients who tested positive and require critical intervention. In addition, as a
student nurse I could learn from this on educating my patient on the essential of transferring them from their desired room
to the appropriate on such as for them to not get infected and for healthcare providers also to not have a cross contamination
on one another.
C. To Nursing Research
The study's limitations are that, despite the large number of participants, it only focuses on the first forty confirmed
COVID-19 cases in a particular institution. The researchers then observe how the institution might respond to it and later
discover that the facility where patients are admitted needs to be reevaluated. On the other hand, the study claims that
appropriate safeguards and spacing could limit the virus's spread. For the recommendations the researchers should seek also
additional studies on what about the primary and secondary hospitals ways on accommodating COVID-19 patients.

IV. PERSONAL INSIGHTS

I agree with the study because all of the methods used in the studies they conducted somehow provided and proved
measures that we should put into practice, such as separating the positive patients from the negative ones and reducing the
private room to accommodate patients who are tested positive, the importance of donning PPE, and getting a swab test. This
study also reveals the fact that there was an early outbreak of an emerging virus, which was even observed in some
hospitals, as well as the methods used by these institutions to control the virus's spread, such as hospital reevaluation and
restructuring.

Checked and Received: (Signature of CI/Date)

Clin Epidemiol Glob Health. 2021 April-June; 10: 100695.

Published online 2021 Jan 17. doi: 10.1016/j.cegh.2020.100695
PMCID: PMC7813488
PMID: 33490719
Early experience with COVID-19 patients in a private tertiary hospital in the Philippines: Implications on surge capacity, healthcare
systems response, and clinical care
Cybele L. Abad,a,∗ Mary Ann D. Lansang,a,b Cynthia P. Cordero,b Ethel Dominique E. Viray,a Beatrice J. Tiangco,c Jia An G.
Bello,a Jan Jorge M. Francisco,a Marja B. Buensalido,a Maria Fe R. Tayzon,a Karl Evans R. Henson,a Regina P. Berba,a Elizabeth Paz-
Pacheco,d and Mediadora C. Saniela
Author information Article notes Copyright and License information Disclaimer
Abstract
Background
Our healthcare institution was one of the first to see SARS CoV-2 cases in the country. We describe the early COVID-19 experience
of a private hospital in the Philippines and discuss the healthcare system response in the setting of surge capacity.
Methods
We reviewed the medical records of adult COVID-19 hospitalized patients admitted in March 2020. We reported their demographic
and clinical characteristics using descriptive statistics.
Results
Of 40 patients admitted, 23 (57.5%) were male and 19 (47.5%) were aged <60 years. Most (n = 27, 67.5%) had moderate-risk, 9
(22.5%) had high-risk, and 4 (10%) had low-risk COVID-19. SARS-CoV-2 testing took 5.5 (range 1–10) days. Overall mortality rate
was 6/40 (15.0%). Clinical cure was documented in all low-risk patients, 25 (92.6%) moderate-risk patients, and only 1 (11.1%) high-
risk patient. In response to the surge, the hospital rapidly introduced one-way traffic systems, dedicated screening, triage and
Emergency Department areas for COVID-19, a clinical pathway, engineering controls, patient cohorting, and strict infection
prevention and control measures.
Conclusion
Majority of patients recovered from COVID-19. Older age and high-risk pneumonia were associated with poor outcomes. Adaptations
to hospital structure and staff were quickly made in response to surge capacity, although our response was hampered by prolonged
time to COVID-19 confirmation. Our study underscores the urgent need for rapid adaptive response by the healthcare system to
address the surge of cases.
Keywords: COVID-19, Surge capacity, Healthcare response, Clinical profile, Outcome
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1. Introduction
The novel coronavirus, SARS COV-2, first isolated in Hubei, China in December 2019, has caused a global pandemic. 1 As of October
8, 2020 there were 36,002,827 cases worldwide, with 1,049,810 reported deaths by the World Health Organization (WHO) daily
tracker. Case series from China have been published, describing the epidemiology and early outcomes of COVID-19.2, 3, 4 The first
case of COVID-19 in the Philippines was confirmed on January 27, 20205 and local transmission was reported on March 7, 2020.6
The Medical City (TMC) was one of the first private hospitals in the Philippines to report a confirmed COVID-19 case. To date,
published data regarding healthcare system response in the Asia-Pacific region remain limited, with few published case series on
COVID-19 in the Philippines, and none in the private health care setting. We aimed to: (1) describe the clinical characteristics,
hospital course, and outcomes of the first 40 hospitalized Filipino patients diagnosed with COVID-19; and (2) describe healthcare
system measures undertaken to respond rapidly to the COVID-19 surge.
2. Methods
2.1. Patient selection
We reviewed the medical records of all hospitalized, confirmed COVID-19 patients ≥18 years old at TMC, Pasig City, Philippines
from March 5, 2020–March 28, 2020. We excluded the following: patients <18 years old, patients with suspected or probable COVID-
19 not confirmed by RT-PCR, and those admitted for <24 h. The TMC institutional review board (IRB) approved this retrospective
study (IRB # GCS-Med-2020-030) including waiver of patient informed consent. Through chart review, study authors (CLA, EDV,
BT, JB, JF) obtained demographic data, information on exposure or travel, clinical symptoms at presentation, relevant physical
examination findings, and laboratory and radiologic results on pre-determined days (Day 0, 3, 5 7, 10, 14, 21, and 28). All laboratory
tests, radiologic assessments and treatments were performed at the discretion of the healthcare team. For those patients still admitted,
patient data were censored at the time of data cutoff, on April 12, 2020. The study authors (CLA, EDV) created a database using the
Research Electronic Data Capture software (REDCap, Vanderbilt University) (https://redcapinfo.ucdenver.edu/citing-redcap.html ).
2.2. Definitions
For this study, the following definitions were used: ARI – persons with acute respiratory infection7; Probable COVID-19
– symptomatic individuals suspected to have COVID-198; Confirmed COVID-19 – any individual with a positive RNA RT-PCR test
for SARS CoV-2; Low-risk COVID-19 – any individual confirmed to have COVID-19 and fulfilling criteria for community-acquired
pneumonia low-risk (CAP-LR) as stated in the interim Philippine Society for Microbiology and Infectious Diseases (PSMID)
guidelines9; Moderate-risk COVID-19 – any individual confirmed to have COVID-19 and fulfilling criteria for community-acquired
pneumonia moderate-risk (CAP–MR) as stated in the interim PSMID guidelines 9; High-risk or severe COVID-19 - any individual
confirmed to have COVID-19 and fulfilling criteria for CAP-high risk as stated in the interim PSMID guidelines, 9 or admitted in the
ICU. We used standard definitions from the United States (US) Centers for Disease Control (CDC) for hospital-acquired infections
including hospital acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and catheter-related bloodstream infections
(CRBSI).10 Acute respiratory distress syndrome (ARDS) was defined using the Berlin Definition.11 We defined patient outcomes as
follows: Clinical cure – composite of clinical improvement (e.g., no fever for 24 hours, decreasing oxygen requirement, improvement
in cough/well being, improvement in imaging, decline in inflammatory parameters); virologic cure – repeat swab for SARS CoV-2
negative at least once at the time of discharge.
2.3. Specimen collection and testing
Clinical specimens for COVID-19 diagnostic testing were obtained in accordance with the PSMID guidelines. All clinical specimens
were tested using Sansure Biotech diagnostic kits (PCR-Fluorescent Probe). The kit is an RNA-based one-tube technology mobile
platform equipped with an automatic nucleic acid extractor, shortening detection time and allowing recognition of suspected
cases.12 All RT-PCR tests were run by the Research Institute for Tropical Medicine (RITM), Philippines.
2.4. Data analysis
For this case series, we used descriptive statistics and determined frequency distributions of demographic and clinical characteristics
for quantitative variables. We used median as our measure of central tendency in a small patient population with small and large
values. For measures of dispersion, we provided the range of the quantitative variables, and added information on the interquartile
range (IQR), particularly for skewed distributions and variables with outliers.
3. Results
3.1. Characteristics of the study cohort
Of the first 40 confirmed cases of COVID-19, 23 (57.5%) were male, with a median age of 60.5 (range 22–86) years. Most (n = 27,
67.5%) were diagnosed to have moderate-risk COVID-19; 9 (22.5%) had high-risk; and 4 (10%) had low-risk COVID-19. Among
those ≥60 years (n = 21), 15 (71.4%) had moderate-risk COVID-19; 6 (28.6%) had high risk COVID-19; and none were low-risk
(Table 1 ). Majority of patients (n = 27, 67.5%) had at least one co-morbid illness, the most common being cardiovascular disease
(CVD) (n = 23, 85.2% and diabetes mellitus (DM) (n = 14, 51.9%).
ALT – alanine aminotransferase, AST – aspartate aminotransferase, IQR – interquartile range, NI – not indicated, TMC – The
Medical City.
We also noted a cluster of cases within a family with possible secondary transmission to a health care worker (HCW) (Supplementary
Appendix A Fig. A.1). Only five patients (12.5%) had a history of international travel within 14 days of symptom onset – two arrived
from the US and one each from Thailand, Saudi Arabia, and the United Kingdom.
3.2. Signs and symptoms
Nineteen patients (47.5%) consulted in the ambulatory setting or at another hospital prior to hospitalization; median time from
symptom onset to date of first ambulatory consult was 4 days (IQR = 5).
Majority (n = 39, 97.5%) of patients had symptoms. Median time from onset of first symptom to date of admission was 7 (range 0–42)
days. The most common symptoms were: cough (n = 33, 84.6%) and fever (n = 28, 74.3%), followed by dyspnea (n = 15, 38.5%) and
generalized weakness (n = 15, 38.5%) (Table 1). Among patients with details on the nature of their cough (n = 29), it was described as
dry (n = 14), productive (n = 15), or intermittent (n = 7). Dyspnea was described only in a few patients (n = 7), characterized as
occurring at rest (n = 3) or progressive (n = 7), while no further details on the symptom of weakness were available. The temperature
was <38°C among 24 (60%) patients, with overall median temperature of 37.8°C (range 36.0–39.7°C). Fever occurred in 19 patients
during hospital admission, with a range of 37.8–39.7°C and median duration of 3 (range: 1–29) days. Median time to confirmation of
COVID-19 diagnosis by RT-PCR was 5.5 (range 1–10) days.
3.3. Diagnostic findings
On admission, 37 (92.5%) had a baseline complete blood count. Median (min-max) white blood cell count and absolute lymphocyte
count were 5.8 × 109 cells/L (3.6–22.4), and >1 × 109 cells/L, respectively. Viral film array (6/40) and rapid influenza tests (3/40) were
negative. Admission chest radiographs were obtained in 38 patients (95%), showing bilateral interstitial infiltrates in 18 (47.3%),
normal radiographic findings in 10 (26.3%) and unilateral infiltrates in 5 (13.1%) patients. Only 12 patients had high-resolution
computed tomographic (CT) scan of the chest with majority (11/12, 91.67%) showing bilateral findings (Table 1).
3.4. Drugs used for treatment
3.4.1. Medications for COVID-19 
After routine consent was obtained, at least one investigational drug for COVID-19 was administered (n = 29, 72.5%). Chloroquine
(CQ) (n = 18) or hydroxychloroquine (HCQ) (n = 9) was given most frequently, followed by lopinavir/ritonavir (LPV/r) (7). Only 5
patients (18.5%) received tocilizumab.
Most patients (35/40, 87.5%) were given at least one antibiotic for bacterial pneumonia. Out of 14 patients given azithromycin, 6 were
given concomitant CQ and another 6 received HCQ. Only 6 patients were given corticosteroid therapy (Supplementary Appendix B
Table B.1).
3.5. Intensive care unit admission
Nine (22.5%) patients needed admission to the intensive care unit (ICU), with 1 unable to transfer from the Emergency Department
(ED) for 3 days due to bed unavailability. Of those admitted to the ICU, 5 had at least one co-morbid disease (2 CVD, 2 CVD/DM,
and 1 CVD/DM/chronic lung disease). Five patients were given corticosteroids. All ICU admissions except 1 required at least 1
critical care intervention, including initiation of pressor support (n = 8), invasive mechanical ventilation (n = 8), renal replacement
therapy (n = 6), and proning (n = 6). Median length of ICU stay was 14 (range 3–24) days. Initial sequential organ failure assessment
(SOFA) score was calculable for 8 patients, with median SOFA scores increasing with length of stay: on Day 0 – median score of 3
(range 1–4); on day 3 –median score of 5.5 (range 0–11); and on day 7 – median score of 8 (range 0–14).
3.6. Outcomes
At the time of reporting, 30 (75%) patients were discharged improved; 1 (2.5%) was discharged against medical advice; 3 (7.5%)
remain hospitalized; and 6 (15%) died, all of whom had high-risk COVID-19. Mortality rate was 12.5% (6/40), with five deaths
attributable to COVID-19. Median hospital length of stay among survivors (n = 31, 3 still admitted) and non-survivors (n = 6) was 12
(range: 3–32 days) and 14 (range: 8–24) days, respectively (Table 2 ).
Table 2
Complications and outcomes according to severity of COVID-19.
AKI – acute kidney injury, ARDS – Acute Respiratory Distress Syndrome, CRBSI – Catheter Related Bloodstream Infection HAP –
Hospital Acquired Pneumonia, IQR −interquartile range, LOS – length of stay, RRT – renal replacement therapy VAP – Ventilator
Associated Pneumonia.
a
VAP (3), HAP (2), CRBSI (2).
b
Encephalopathy (1), pneumomediastinum (1), pneumothorax (1).
3.7. Complications
Twelve (30%) patients developed at least one complication during the hospital course (Table 2). Of those with complications, 8
developed ARDS; 6 developed acute kidney injury needing renal replacement therapy; and 5 were diagnosed with septic shock and
secondary bacteremia. Hospital-acquired infections including HAP/VAP developed in 5, and CRBSI occurred in 2. Eight of the 12
patients (66.7%) who developed complications had CAP–HR while the remaining 4 had CAP–MR, of whom 3 acquired HAP, and 1
developed encephalopathy. More patients in the >60 age group developed complications (8/21 [38.1%] vs. 4/19 [21.05%]) and needed
ICU level care (7/21 [34.09%] vs. 2/19 [10.53%]).
3.8. Clinical and virologic cure
Clinical cure was documented in all low-risk COVID-19 patients; 24 out of 27 moderate-risk COVID-19 patients (88.9%); and only 1
of 9 high-risk patients (11.1%). Time to clinical cure for low to moderate risk COVID-19 took a median of 18 (5–54) days. Time to
virologic cure was also shorter in the low and moderate-risk categories, taking a median of 16 (range 14–24) and 13 (range 8–27)
days, respectively, compared to a median of 19.5 (range 13–26) days in the high-risk group (Table 2).
Among survivors, median length of hospital stay between the two different age groups was similar [12 (range 4–30) days vs. 11 (range
3–32) days]. The younger age group had a higher frequency of clinical (17/19 [89.5%] vs. 13/21 [61.9%]) and virologic cures (15/19
[78.9%] vs. 10/21 [47.5%]), and a lower mortality rate (2/19 [10.5%] vs. 4/21 [19%]) compared to the older age group
(Supplementary Appendix B Table B.2).
4. The TMC healthcare systems response
As a Joint Commission International-accredited hospital, TMC has established systems in place for health disasters and emerging and
re-emerging diseases such as SARS in 2003, leptospirosis in 2009, and dengue in 2018. The surge of COVID-19 cases in the TMC ED
and the critical care units posed a unique healthcare challenge like no other. In response, TMC made initial preparations by convening
its Epidemic Rapid Response Team on January 20, 2020, subsequently meeting weekly to prepare the hospital for the surge of
COVID-19 patients.
After confirmation of the first case in TMC and a rapidly growing number of cases, several changes were made to the hospital system.
A one-way hospital traffic system was created by sealing several entry ways and designating a single point of entry and exit. A
screening area in the ED was set up, and separated into COVID-19 and non-COVID areas, with the appropriate engineering controls
and uni-directional flow of traffic. A supplemental triage area was built near the ambulatory area in order to effectively direct febrile
patients to the ED, instead of the outpatient clinics. Several units, including the acute stroke unit, and two general medical floors were
designated as dedicated units for probable and confirmed COVID-19 cases, with each unit having assigned donning and doffing areas,
and one-way traffic. Finally, a clinical pathway with clear case definitions was created in order to easily capture COVID-19 patients
and integrate rapidly evolving evidence on clinical management (Fig. 1 ). Enhanced infection prevention and control measures,
including intensive training of HCWs on donning and doffing of full personal protective equipment (PPE), and patient and staff
cohorting were also implemented. HCWs with advanced age and co-morbid disease were also assigned to non-COVID-19 areas.
Legend: Graph showing probable and confirmed COVID-19 cases and hospital response.
Footnote:
Number of probable COVID-19 cases from March 6–11 and March 13 not captured.
^ Only one entrance-exit and uni-directional flow allowed.
* Triage clinic for patients entering the ambulatory area.
~ Units w/negative pressure rooms or rooms with hepa filters assigned for probable or confirmed COVID-19 patients only.
5. Discussion
We describe the first 40 confirmed COVID-19 cases admitted in our institution and highlight several clinical findings and
observations regarding our health systems response to surge capacity. TMC admitted patients during the early course of the COVID-
19 epidemic. Our first few cases were from a family cluster and portrayed person-to-person transmission among close contacts. The
study by Chan et al.13 documented familial transmission by showing that genome sequences from two different family members
showed almost identical nucleotides with each other. In our cluster, although we were unable to perform genomic analysis, the index
patient and his wife stayed with a family of five – and only the three who spent more time with the index patient were confirmed to
have COVID-19 infection. (Supplementary Appendix A Fig. A.1). This validates existing data that transmission risk is more likely
with recurrent, close contact.13 That the index case and the rest of his family sought consult late also suggests that the index of
suspicion for COVID-19 was low despite informational campaigns, the presence of travel history, and compatible symptoms. At this
time, many were likely unaware of community transmission, and there remained a need to significantly raise the awareness of people
about the signs and symptoms of COVID-19.
The median time from symptom onset to admission was 7 days (range 0–42 days) in our cohort, mirroring the findings in other
studies.3 , 4 However, 19 patients first presented a median of 4 days after symptom onset but were not hospitalized. This suggests that
persistence or progression of symptoms was necessary before patients were considered for hospital admission. This was consistent
with the Philippines' Department of Health directives, which mandated prioritization of older and sicker patients. However, 4 of 19
patients who were seen in the ambulatory setting died from COVID-19; this potential delay in admission may have contributed to poor
outcomes in these patients.
From a clinical perspective, we confirm the findings of a recent meta-analysis14 that fever, cough and weakness are the most frequent
symptoms, and that severe disease is more common in the older age group and those with co-morbidities. 3 , 4 Our rates of
complication, severe illness, and ICU admission are also comparable to other case series.3 , 4 , 15
Majority of patients, including all patients in the high-risk group, were given at least one drug repurposed for the treatment of COVID-
19 infection, despite the lack of robust evidence to support their use. Several clinical guidelines 9 , 16 cautioned against the routine use
of these drugs outside of clinical trials, since the benefits from these drugs were unproven. Recent evidence from the Solidarity and
Recovery randomized clinical trials17 , 18 show that the use of HCQ, CQ and LPV/r were indeed unwarranted, and these are no longer
recommended. Despite the poor quality of evidence,16 , 19 however, physicians are often compelled to start these drugs because of
many reasons-- the severity of illness, external pressure from other physicians or patients’ family and relatives, and social media.
Moving forward, the urge to use unproven treatments based on anecdotal success and outside of well-designed randomized clinical
trials needs to be resisted, especially in light of doing possible harm.
Time to virologic cure took several days, and was longer with greater disease severity and older age. Current guidelines 9 , 20 report the
need to document 2 negative RT-PCR results before patients are declared “virologically cured.” In our study, we chose at least 1
negative test result since the subsequent test is usually performed elsewhere and we are unable to capture that data. Studies 21 , 22 have
shown that although viral shedding can last several weeks, this virus could be non-viable by day 822. The test-based strategy – having
to repeat RT-PCR until twice negative has been revised and a “non-testing-based strategy” considered instead. Except for high-risk
and severely ill patients, discontinuing isolation along with universal source control and standard precautions may be more cost-
effective than recurrent testing, especially in resource-poor settings.
The abrupt increase in both probable and confirmed COVID-19 cases during the first month highlighted the need for the hospital to
adapt quickly to the surge. Surge capacity, often defined as the ability of a healthcare system to respond to a sudden increase in patient
care demands, conceptually contains the following components: supplies, personnel, physical space, and management infrastructure,
sometimes referenced as “stuff, staff, and structure”. 23 , 24
In our study, “stuff” in the form of testing capacity took too long, with confirmation of SARS-CoV-2 infection by RT-PCR taking a
median of 5 days. In the US and China, turn-around time is usually within a few hours of testing.3 , 15 The long delay was primarily
because the test was sent out and performed at a reference laboratory. This prolonged turn-around time (TAT) had several healthcare
and infection control implications, including the inability to effectively triage non-COVID-19 patients outside of airborne isolation
precautions and ration the use of PPE. The long wait also caused increased anxiety for HCWs, the patients, and their family members.
At the time of this report, testing is now done at TMC, and TAT is much shorter at 2 days. Nationally, from one reference laboratory
performing RT-PCR at the start of the COVID-19 outbreak in the country, the number of licensed RT-PCR laboratories has grown to
108, supplemented by 34 licensed cartridge-based PCR or GeneXpert laboratories (as of October 9,
2020, https://www.doh.gov.ph/covid19tracker).
Our staff were also reshuffled and assigned to patients in COVID-19 units to limit cross-contamination. This method of patient and
staff cohorting is often used to curtail outbreaks of multi-drug resistant organisms25 , 26 and emerging infections.26 However, isolation
and cohorting are difficult to sustain because of higher cost and increased workload for the healthcare team. 27 , 28 In addition, adverse
events such as increased patient anxiety, anger or feeling of isolation, increased falls, and less time spent with the healthcare team,
have been reported29-- events that we also observed for some of our patients.
Adequate physical space and appropriate structures are often underestimated needs in surge capacity. 23 However, our hospital space
was rapidly re-organized to accommodate the rise in COVID-19 cases -- several units were dedicated for probable and confirmed
COVID-19 cases, with each unit having assigned donning and doffing areas and one-way traffic. These adaptations made it easier for
the staff to safely and adequately manage these patients.
Our study has some limitations inherent to a retrospective study reporting on the first 40 patients in our institution. We used categories
of COVID-19 severity based on national guidelines, but which are comparable to international definitions. Despite these limitations,
our study is the first to describe COVID-19 patients hospitalized in a private tertiary-level hospital in the Philippines. Our experience
may not necessarily represent the patient profile and health care system in the Philippines’ public sector, but illustrates the challenges
that even well-resourced health facilities in developing countries face.
We validate findings from studies in Wuhan, China during the early days of the pandemic that both older age and presence of a co-
morbid disease are associated with more severe disease and poor outcome.2, 3, 4 We identified specific issues that affected initial
response to surge capacity, including the prolonged TAT for disease confirmation, the need to re-organize the hospital space and staff,
and the need to increase level of awareness of ongoing COVID-19 community transmission. Finally, our report highlights the need for
rapid adaptive actions by the healthcare system to respond to the surge of COVID-19 cases and for long-term, innovative strategies for
continuing essential hospital services in the new health context created by the COVID-19 pandemic.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
The authors declare that there is no conflict of interest.
Author contributions
All authors contributed to study design; CLA, CPC, MAL – contributed to data analysis, manuscript writing;
CLA/JB/JF/EV/MFT/BT/MBB – data collection and management; MCS/NPB/EPP/BT/KH – protocol feedback, manuscript writing.
Acknowledgments
We would like to acknowledge Kathy Rayos, clinical pharmacist, for her help with the manuscript.
Footnotes
Appendix A
Supplementary data to this article can be found online at https://doi.org/10.1016/j.cegh.2020.100695.
Appendix A. Supplementary data
The following are the supplementary data to this article:
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