Hello everyone! Good morning, good afternoon, good evening! Kung nasanman po kayo sa Paratina Mundo, welcome po sa ating 85th episode of the Stop COVID-Dets webinar series brought to you by the University of the Philippines. Thank you for being part of our credible online community and to all those who have just discovered us for today, welcome po! An sano po masihahan po kayo sa ating mga topics na pag-uusapan po today and for future webinars. As the Omicron variant swept the National Capital Region, scores of doctors, nurses, frontline workers had to self-isolate or quarantine because they were sick or had family members who were sick. Some hospitals had to close down entire wards or certain parts of their hospital with heavy food traffic to avoid the spread of infection. Of all the different parts of a health facility, yung pung emergency department po natin is the one that works 24-7 at absolutely cannot stop functioning. So for today's webinar, we will be tackling the issue and the question, how do we prevent our emergency rooms or emergency departments from shutting down? So if you're looking for the latest science-based and evidence-based information from the most distinguished experts, then keep it right here. I'm Dr. Raymond Francis Sarmiento, director of the National Telehealth Center, National Institutes of Health, University of the Philippines, Manila. Always a pleasure to be with all of you during our regular Friday lunch date. I see familiar names po dito po sa ating webinar and for all those who are watching us in YouTube and in Facebook, welcome din po. Atsano po ay masamahan yung po kami dito po sa ating Zoom webinar. I always look forward to Fridays because I get to share hosting duties with my partner and beloved mentor, our adjunct research faculty from the National Telehealth Center, who's also international renowned as a public health communications expert, Dr. Susie Pineda Mercado. Dr. Susie. Right. Good afternoon, partner. Partner batang ba po yun? Hi, Raymond. Magandang hapon po sa in lahat sa lahat ang mga nahigine. We are just delighted that you're here with us again. It's a Friday and bilis ng panawan, parang kailan lang and dito tayo, pero I hope bumabuti naman yung situation. Although we said this time, we wanted to talk about emergency rooms and emergency conditions, parang pre-hospital care kasi nung kasag saganong nung surge talaga sa Metro Manila, medyo na puno yung ating mga emergency room. Mukhang hindi na daw masyado ngayon, pero mukhang dumadami sa mga provincia at marami tayong mga kasama ngayon na nasa mga lalawigan, nabaka sila ang nga ngailangan ng informasyon kung anong gagawin nila, para hindi makunong mga emergency room at hindi magkasakit yung mga frontliners natin. Anyway, so welcome to the webinar. We are here because you are here and we have very good speakers for you today. Mukhang yung alias, manami po tayong matutunan at meron tayong mga, at akamon na may announcement yata, ande, akamon na. Una, binabati ko yung USORIA, Philippine College of Emergency Medicine. Kasi sila po ang co-sponsor ng ating webinar ngayon, so I'm extending a warm welcome to everybody from PCEM at sa tulong punila na ako po tayong informasyon papano ko nung gagawin dito sa pre-hospital care. And we just want to thank them for all the work they have been doing and for all our emergency frontline workers. Sabihan ni Raymond, pwede magsarang ibang word pero ang ER hindi. So, salamat nang marami sa ating mga frontline workers emergency. Over to you, Raymond. Thank you, Dr. Suzy, for those who are joining us po, for the very first time, which we often see lalo na po kapag may mga nag-request po ng certificate, meron po tayong tinatawag na persons on the street video just to put our discussion into context. But for this webinar, we will be calling it the frontline beat, voices from the frontline healthcare workers po, ating tawag for this video. Developed by TVUP. And the questions that were posed to the interviewees were, what is the most challenging part of your work? How do you balance your work and your family life? And how do you prevent the emergency room or emergency department from shutting down? Please watch this. Every day is a challenge for us because there is no way of knowing what will happen during your shift. It's not only the physical exhaustion, it's more of the emotional and mental exhaustion. During the surge, singuro, the most challenging part para sa aming is to give yung best care for the patient. And for me, in all honesty, as a nurse, the hardest part of it is being able to work under pressure. You have to know how to handle stress. You are going to be exposed to different hazardous materials, of course. Nursing has taught me on how to balance work and family life. You always have to know when to rest and when to stop. So to prevent burnout is... Pinatingan mo rin yung mga traba ako mo if okay lang sila kung tumakain na ba. So, but during naman sa off duty times, or ginagawa ako kasi is to tulog, tumakain ng healthy, adigoy stress tapos matawag ako sa family ako kasi na sa province. I always make sure that I still have time to relax, to celebrate and reward myself and to spend my extra time with my family. Of course, I have to take care of myself, too. Number one pose, kung bakit mong sasara yung ERs? Wulang staff. Daka-sakit yung mga doctors and nurses. So, ang ginawa namin doon is to make sure na healthy ang lahat. So every duty, naki temperature checks, tapos nag-adjust ng duty schedule. So, instead of 24 hours for the residence, ginawang every 12 hours yung ER officer. So... I believe, expand hospital capacity. That's number one for me. Number two, we have to stop regulating the hospital so it's extreme, providing care only to true emergency. We have to do proper triaging or proper evaluation screening for the patient. It will help if we follow the minimum standard health protocol by wearing masks, avoid crowded places, get vaccinated and not be complacent even though you have already have your vaccination done. Manpower or dispersals in the medical field in the frontline cannot be replaced not even artificial intelligence nor robots. Due to limited bed capacity, patients are being admitted in the ER. And this must be prevented because it will result to congestion and it will show poor outcomes for healthcare management. I'm hopeful that the next surge won't be as fatal as Delta. I think we are gearing towards the year of technology and that technology could actually help healthcare. For me, ang sinasabi nalang ng family ko, prayer ko talaga naka always eat healthy foods ko para pandaban dito sa kinakaharap natin pandemic. You just have to keep going just pursue your passion and your purpose in life and that's gonna be, you know, my motivation or my inspiration to be the better nurse. That I can do. Mary inspiring, thank you so much. TVUP and thank you so much for our frontliners who were willing to share some of their thoughts for the webinar. Alam mo rin mo, na isip ko tuloy, baka dapat anyayahan natin yung mga members ng ating community na kung meron kayong gusto nga ishare na kuyento nyo, baka pwede yung record nyo at patutugdug natin. It's really good to really good to know what our frontliners are thinking. Sila po ay merong mga pamilya, sila po ay napapagod na rin at kung anong matutulong natin na information karagdagan para tayo ay, ano pa, ano bang tawad ng parang maitawid natin to Rimoan nyo naman sinasabi natin yung matatapos din to, matatapos din to, kailangan lang natin magporsigay at sya ka, sama-sama tayo kung tayo mo awalin ng pagasa. So, thank you so much to our frontliners and maybe in the future we should ask anybody who wants to tell their story to to share with us. And speaking of sharing stories, we do have an announcement about our coming anniversary, Rimoan, dalawantawon na. We will be two years old in April and this is our announcement. Okay, this is have an audio, guys. I don't think so. I think this is just like a part of it. Okay, okay. So, kikwento ko nalang. Okay, so nalalan nyo last year ng anniversary nag-lemas putay ng ano ng memorial, COVID-19 Heroes Memorial na pinakita po natin na iban yung mga mahal sa buhay, mga kaibigan, mga kamagana na binigay ang buhay nila sa linya ng servicio. At patuloy natin gagami nyo and kasi ayaw natin makalimutan kung bakit tayo bakit natin ginagawa ang ginagawa natin. Otherwise, sabi nga nila, all our frontliners would have died in vain. So, for those of you who would like to add to our COVID-19 Heroes Memorial, padalan nyo po dito sa television at up.edu.ph before April 9 kasi gagawa kami ng bagong anong ayun ng bagong video tungkol dun sa mga mga naunan na na mga health workers natin. Lagay nyo po yung full name, date of birth, date of death, chahanong occupation nila. And in particular, we would like to make this call for those of you who are watching us from outside of the Philippines because we have so many health workers outside of the Philippines who have also given up their life in service, nakakalimutan nang ay wag po natin kalimutan ang samahan, sacrificial nang mga nagbuis ng buhay nila para sa salvation ng natin mga kambabayan ng yung pandemiya. Okay, so medu-serious nang nang pero serious naman tayo eh di ba? Parang pag anniversary natin, we just take that moment to remember and to continue to do to do what we have to do. Okay, Raymond, sorry mag-imut na ako. Oh, not Raymond. Thank you. Thank you, Dr. Suzie. So the anniversary lang naman po is not really something celebratory in the sense na dahil may COVID but it's much more of remembering the information, all of the knowledge that we have gathered in the past two years muntod na nagsasama-sama po tayo sa ating online community and hopefully that's something that we will be taking with us even after the pandemic po has ended. So we hope that you'll still be with us. We'll be tackling a bit more in terms of the of health topics but that's something in the future po and for those who are just hearing this for the very first time, we, the stop COVID deaths or webinar series team have really made it a point to prioritize essentially memorializing po and keeping in mind and remembering the sacrifices made by our frontline workers po. So ba, rinig nyo po sa ibat-ibang bansa, sa mga balita, the Filipino healthcare workers being recognized as one of the best if not the best in the world in terms of providing that service to their patients and that's something that we want to be able to remember their selfless contributions po in the fight against COVID-19. So to let everyone know our webinar po can accommodate up to a maximum of 3,000 participants so please join us lalo na po yung mga nandob po sa YouTube at saka sa Facebook po no but it doesn't mean that you won't be able to participate that's something that we always prepare for but hopefully if you were able to join us in Zoom then you'll be able to get the full experience of our online community. For those who are asking, we understand marabi po talagang nag-chat-chat sa ating Facebook page mga mag-e-emmel din po to call sa certificates of attendance. Only those who have spent at least 50% of the webinar duration will be provided with an electronic certificate po. So kung may mga hindi po po naka-received kasi po may mayro pa rin po naga-ask about the webinar 83, please let us know we have not completed naman po yung pag-distribute for webinar 84 which was last week and we hope to be able to finish distribution of all certificates over the course of time. Ako yun na. Ako yun sa certificate na yun na. Yes, that's you. That's you, Dr. Suzy. So that's a little bit of ano, no? Ay, may mga nag-tanong din po in terms of bakit po kung ando yung nilagay nila sa registration yun din po ang nag-appear kasi yun po it's automated so please be very careful when you have to put in your name in the registration. Aho, yung mga angyasa in tutong pangharan. May mga ano po kasi initials ang gamit Dr. Suzy do sa we hope that we get those fewer and fewer at this time goes on. We also would like to invite everyone eto na po lalo na po yung mga nandu po sa Facebook asa ka sa YouTube na sumali po sa ating fun quiz or fun poll especially through www.menti.com meron po tayong code for today ang ating code for today is 3789790 that's 3789790 so hopefully lahat po kayo ay makajoin yung pong na sa zoom po meron po tayong zoom poll so wala naman pumintis hindi naman po sya nagkakarun ng problems with regards to our fun poll and hopefully you'll be able to join us. For today's webinar we will be using our standard panel discussion format so we have a set of speakers presenting and then a reactor weighing in followed by question and answer portion hopefully we'll be able to tackle a whole lot more questions similar to last week during the pediatric COVID-19 vaccination topic for our webinar for today. Yung pong na sa Facebook at YouTube ilagayon nyo lang po in section meron po mga nag mo monitor ng ating mga social media pages po with regards to ano po mga katanungan ang pwede po nating ibat po sa ating mga panel of experts but for those who are in the Zoom please feel free to put them in a Q&A box. Dr. Susie. Okay let's get this started nandito po ang ating President of the Philippine College of Emergency Medicine P-C-E-M Dr. Richard Henry Santos who will give the opening remarks. Dr. Rich welcome nasalasi Dr. Rich Dr. Rich nasalasi Dr. Rich The video cannot be and start video. Welcome Dr. Rich and welcome to everybody from P-C-E-M please go ahead with your welcome remarks. Let me just share my slide first there. So good afternoon everyone and thank you for that introduction and I would also like to meet everyone who is watching this online webinar and it is my distinct honor to be opening for our colleagues in the Emergency Medicine Practice who are serving as leaders or chairpersons of their respective emergency departments. So speak of which I would like to take this opportunity to educate our reviewers on the terminology we now use in practice. The use of the term emergency room is actually outdated even the WHO is not using the term any longer. Some examples of acceptable terminologies include emergency department, emergency unit or accidentally emergency department among others. So why is this? Ever since Emergency Medicine became a distinct specialty in the early 90s we are trying to veer away from the concept that emergency care can only be delivered or given within a prescribed location. In fact, emergency care can be delivered outside the emergency room as in the case of the pre-hospital care as well as provision of resuscitation in other areas of the hospital like the wards or the operating theaters for example. So this infographic is a visual representation of the WHO emergency care system framework designed to support policy makers wishing to assess or strengthen national emergency care systems. It is the result of global consultations with policy makers and emergency care providers across all regions and provides a reference framework to characterize system capacity, set planning and funding priorities and establish monitoring in evaluation strategies. The framework captures essential emergency care, care functions at the scene of injury or illness during transport and through the emergency unit and early in patient care. The same framework can be utilized in the 80 response to the COVID-19 pandemic as a component of overall hospital and health system planning. The AD should operate in coordination with local, regional and national partners from across the medical response system. Planning and action for a pandemic response flow both vertically and horizontally. And AD leadership should be well versed in incident command management and the incident command structure in order to facilitate interdepartmental operations to ensure the AD efforts aligned with the latest effort response. So later in this webinar, our colleagues in emergency medicine will discuss their recommendations and best practices and how to keep our emergency departments from closing down. But let me take this opportunity as well to emphasize how our emergency medical services and pre-hospital care can directly and indirectly affect our ED operations as part of our regional response strategies. For example, emergency medical response transport decisions and policies may affect arrival patterns of patients at the hospital level. In addition to regional policies and procedures around ED diversion, hospital level policies may also be marked with hospital level policies may also markedly shift the arrival burdens in a community. At the start of this pandemic, the Philippine College of Emergency Medicine issued a guide for our pre-hospital providers to help them in their approach to COVID-19 patients. The goal of pandemic search planning and operations to enable effective care of patients while keeping staff, clinicians and patients safe in spite of increasing demand on healthcare resources, disability to provide search capabilities when pandemic conditions arise is the difference between a system's failures or success. Although all critical departments such as the ICU in the ED will have an independent plan, ideally this plan is integrated with other hospital and regional resources. ED leadership should advocate for ED-based considerations. In hospital search planning including inpatient-related triggers that are developed based on ED arrivals and census of pandemic patients. So with this, I welcome everyone to the webinar and I hope you will learn a lot from our resource speakers. I will see everyone again to answer some of your questions during the panel discussion. Thank you very much. Okay, that was Dr. Richard from our Philippine College of Emergency Medicine. Maraming salamat sa paliwana at saka sa pagbibigay ng bagong informasyon. Raymond ako kasi pinanot ko lahat yan ng ER, no? George Clooney. Yes. George Clooney, pero hindi alam mo that was created by Michael Crichton who was a Harvard medical school graduate. He was also the one who created Jurassic Park but he passed away anyway. Ano trivia lang ko yan ngayon. Sige, Raymond. Tundra tayo sa Panquis. Thank you for welcoming us and for inspiring message, Dr. Rich. Please stay with us. Alam ko po for our Q&A and thank you po for your time and also for the Philippine College of Emergency Medicine members who are also tuning in. So just to remind everyone ang ating Q&A questions po, these are questions we're in. We will be choosing which ones have been most upvoted kung meron man po do na napili or kung na talagang marami po talagang gusto, may kagustuhan ng katanungan na yan. We will be asking that member of the audience to ask the question live to our panel of experts. So if your question is selected, you will receive a notification or a message at least inviting you to be part of the panel. So we hope you'd be able to accept our invitation. So please type in your questions po gaya po na nasabi ko not just here in Zoom but also sa comment section po ng ating Facebook pages tap-covidets at sa TV UP din po and also in the TV UP YouTube channel. Before we proceed sa ating webinar proper, we'll be asking everyone to participate in our fun quiz both in Zoom and in Mentimeter. Marami na po sa inyo ang medyo expert na po dito. As always, we have two questions here in particular with regards to science and the other one is on precautions po. For our first question, what are the science that you need? Emergency management. So atopo ito, multiple siya may pwede po kayong pumili ng mga kasagutan dito. The options are elderly with comorbidity, option B, generalize weakness, option C, difficulty of breathing, option B, confusion, and then option E, behavior change. So marami pwung pwipili sa ngayon ng difficulty of breathing although yung iba po ay medyo magkakapantay naman po ang pagkakapili at least dito po sa aking tiyitignan sa Zoom and also of the 101 people who have participated sa ating Menti. So before we proceed, the question number two I'd like to greet those who are joining us from the Balawan District Hospital in Balawan La Union, southern Isabella Medical Center in Sanchago, Isabella. The Commission of Population and Development in Region 3 in San Fernando, Pampanga, Eastern Summer Provincial Hospital, Borongan, Eastern Summer, the LGU of Gerald Santo City in South Kotobato. And then for our question number two, question number two reads, what precautions are necessary before transporting a patient to the emergency department or emergency room without an ambulance? Ang apatpo na choices here or as follows, treat everyone as COVID-19. So specs, option B, take antigen test before proceeding to the emergency room. Option C, use an N95 mask for the patient and the driver and option D, open the car window. So ito po yung gagawin po pag bago nyo po i-transport ng isang paciente kapag wala po talaga ambulance at kailangan na po madala sa hospital. Mr. Raymond, dek kami nagtatangong dito. Pwede bang more than one answer daut on dalawang tanong? Yes, yes. That's correct, Dr. Suzy. So kung anubman po yung inyong mapili, we'll be asking our experts po kung ano po for each question, ano po yung mga tamang sasagutan for each of those questions. We'd also like to greet those who are joining us from Chonin Hospital in Taipei, city in Taiwan, Semarang Indonesia, Kotakinabalu in Malaysia, Kanto City in Vietnam, Bangkok, Thailand, Damam Saudi Arabia, Dubai, United Arab Emirates, Lunichi Alley University of Bleda II, Algeria, the University of Fiji in Lautoka, Fiji and KBR, Diego Garcia, LLC, British Indian Ocean Territory and from Venice, Italy. Maraming, maraming salamat po. We will not be closing our fun quiz as we move on to our webinar proper. Dr. Suzy. Thank you very much Raymond and let's continue to try to answer those questions. Actually may nagtatanong na, but kayo nagpa-fun quiz? Sabi ko kasi parang matandaan yung matandaan yung main lessons. Binsan dapat parang may test, parang maalalam ko ano yung parang di mo masyadong naintindihan para tapos pag nakikinigga. Uy, ganong palayon, di ba? So I think this is really an adult learning technique for us na tinatanong kasi namin yung mga question na yan sa mga main speaker. Sila po ang gumagawa ng mga question na yan. Hindi kami ni Raymond. Hindi na. What kailang? Kaya yan. So anyway. Alright, let's go to our first speaker. We promise to, we always promise to have great speakers and for today we have heads of three very, very important emergency roles and I emergency department pala si na tuto ako kay Dr. Richard Department. And we have first of all the immediate past president of the UPPGH Department of Emergency Medicine na mitinapos siya datin nong pinagusapan natin yung COVID-19 innovations and nakatrabaho ko na rin itong doktora natin talagang kakaibarin inong magaling talaga siya. So we'd like to welcome Dr. April Lannetta from the Philippine General Hospital. April, welcome. I'd like to say thank them to the organizers for inviting me to this webinar and also to say that I am honored to be part of the panel that includes two amazing leaders in emergency medicine, Dr. Datinginong in Dr. Jimenez. So our share of slides.  Why it is important to keep emergency departments up and running even during difficult times such as major disasters and public health emergencies is to understand the role of emergency departments and or emergency units within the larger community. Traditionally, ePs are designed to care for the publicly ill and injured. However, as any emergency care will tell you they have become providers of primary care for many of our underserved kababayans. So for hospital, public hospitals in particular, the EDs have become Suspiced Health Safety Net. In mga wala talag mapuntahan at emergency emergency po punta talala sa nga sa nearest emergency department. So what the pandemic highlighted the fragmented healthcare system but it also forced hospitals and emergency departments all over the world to swiftly adapt and innovate in order to bring the staff and the patients and be able to continue providing emergency. So just to show you the census of the Philippine General Hospital emergency department prior to the pandemic. So this is in 2019. We see about 8,000 patients every year. Okay, even before the PGH was designated the sub-preferosent in March of 2020 and we started COVID-19 in April. The ED was the ED including its pre-hospital care services was already shifting gears to manage potentially infected patients. So the challenges included one, how to protect the staff and the patients from this novel coronavirus and initially especially at the start of the pandemic we need to address the fears and anxiety of emergency department personal and hospital staff as well. As they adapted to new ways of doing things not just new ways but constantly changing protocols and policies to deal with the pandemic. Then we needed to coordinate with the rest of the hospital services. As you know emergency department is a cold point. Of this Trans 24-7 it coordinates with all services of the hospital. We needed to coordinate the end of the pandemic for an efficient entirely provisional emergency care. We also needed to coordinate with the communities forces available to other hospitals through the LHUs particularly the isolation and quarantine facilities the national government as well as healthcare providers. But we also needed to manage our patients with the challenge brought by the pandemic. We needed to manage such as the undifferentiated patients which is a challenging pack in itself but to feed them alongside the COVID-19 cases and the COVID patients. So the general hospital is an end referral hospital. When we were declared as a COVID-19 center we had to limit the other services which were also badly needed by our regular patients. So it was what we had to do in order to provide care for the COVID patients so to limit our services. But especially during in between surges we are able to increase our services for the non-COVID or the regular patients. So all of these COVID-19 response activities to be aligned and managed effectively. So there has to be an emergency management system in place. So for the emergency department we made use of what we call the hospital incident command system. And of course this is coordination with the crisis management committee of the hospital. So in the incident command system this is a command and control structure that provides for proper communication channels as well as accountability. So for the you designate a leader for the response which we call the incident commander. Under the incident commander you have these positions that will provide the critical tasks. The information officer a liaison officer or to the different hospital services and agencies. The safety officer and then the four major activities under operations, planning, logistics and finance. So most of the management tasks would be under the operations team. Planning would provide the direction for the impact team setting the goals and objectives. And then the logistics of course would be the one in charge of the supplies the PPEs that were critical during the pandemic and other needs of the staff and services. And of course the finance. So this is the basic structure of the hospital incident command system. So one of the priorities during the pandemic was protection. As we say in emergency medicine safety first. So with the leadership of the administration hospital administration and the hospital infection control unit risks were primarily managed through engineering and administrative controls as well as the use appropriate personal protective equipment. So the first word we converted to a COVID word is actually the temporary emergency department and we were used to at that time the trauma word. Had to immediately convert this through the help of architects, engineers and of course our medical specialists convert this to a COVID emergency department. And so we were able to provide an area to manage not just the COVID cases but also the suspects and the different critical patients. And for the administrative this included different policies for patient care which especially during this pandemic would constantly change almost every day we would need to revise and adapt according to information that this means and to us. And it also included developing duty schedules and rotations so that there would be appropriate breaks and recipes for the staff and reassigning different units of the hospitals, different areas of the hospital, different means according to what is appropriate. So we would need sometimes to convert and COVID words to COVID words especially during surges then during downtime we would convert back now the COVID word to the two non COVID words in school. And of course personal protective equipment which became big issue at the start but now more or less we have stable supply personal protective equipment what is needed is to constantly remind our healthcare workers to don them properly. So this is the focus of all our activities now that we have considered this a protract emergency response this will be with the help of the administration the emergency department as early as last year we develop programs to address the emotional mental and physical well-being for staff. So first we have prepared counseling through the psych serve of UP Diliman and of course our partner the Department of Psychiatry and Medicine in addressing some of the patients of our staff and we also develop programs such as our painting class as an outlet for the staff so this is open to all including medical students. Then support from each other support from the staff and support from family friends is critical in keeping us motivated to continue our work even during challenging clients such as surges during surges. So just to show you what we did in terms of patient flow or patient services so at the start of the pandemic we had to incorporate into our patient flow management of suspected cases so during regular time at the emergency department we're just using a simple triad system to direct them and categorize patients into critical emergent, critical and non-urgent so that's the general classification but for the COVID you have to decimate more categories so that we'll be able to provide appropriate services and consequently provide our staff to the appropriate PPE. So just to give you an overview so kung dati simple na yung categories nan min or emergent, urgent, non-urgent na yung meron kanang category na critical percent to with non-respiratory symptoms critical percent to with respiratory symptoms and then yung in-between the mild, the moderate cases and so on and then separate pa yung COVID confirmed cases so all of this had to be managed properly and directed to the proper services or areas of the emergency department and the emergency department the patient flow need to be coordinated as well with the overall patient movement within the hospital so this is just an example of our layout na this was at the start of the pandemic na we set up a screening area this is at the parking lot in front of the main building it is just adding so we had to set up a screening area direct the patients we opened an entrance on the side and closed the main gate na so that we can check the flow of the patients so we have a screening area at the front and then patients are directed for the COVID confirmed directed to the COVID-19 six table and they also have a flow going to the emergency department for the critical cases so as I mentioned before at the start of the pandemic this was constantly changing na misa aro-aro na diiba yung information na diiba dinyo kailangan na re-ditions to the flow so that was the challenge report often at the hospital service at the critical even during the pre-pandemic then regular in the operations but more so during the pandemic because you now have to deal with a special set of patients which would necessitate creating sometimes more complex but the goal is to simplify patient flow so that we can properly efficiently deal or manage our different sense of patients so in some ordination with community resources na at the start of the pandemic the philipinder hospital set up what we call the transfer command center so the main goal then being a COVID refer center was to facilitate reference non-movement of COVID-19 patients from the different hospitals and isolation units or LGUs to PGH and also downgrading patients or those who are have been managed and can be transferred back now to their LGUs or to other hospitals so that was the main task of the transfer command center so they were aided by the critical care services or EMS and also our medical social service they play a big role this is still operational but now when we have more non-COVID cases then we now also cater to non-COVID cases so the transfer command center coordinates with different government and the COVID units now such as OHCC the one hospital command of the department where the others other with the LGUs particularly we have a close coordination with the Manila city local government and sometimes when we have a lot of calls or a lot of patients that need to be transferred to other hospitals then we also seek the help of our partners at the Bureau of Fire Protection as well as from the Pilpian Red Cross so this operation has started in April and it's still ongoing and the services are needed and we are very grateful for these two hospital university programs that made a big impact on our services in the emergency department the Bayanihan operation center of the UP Manila and the Teligabay program of the PGH so these two programs helped us in redirect giving proper advice to callers who may need may not need emergency services but would still need to be advised and directed to the proper service that can't provide their needs so we get as well as of course to our partners in the outpatient department so well coordinated response is very helpful hospital response rather is very helpful emergency department correct that's all thank you very much for your attention thank you so much Doctor April medyo lumabulang po yung audio niyo ma'am April maybe because of your your headphones ah baka niyan sorry sorry yan okay di na kababa di na kababa ha ha ha okay lang po pero later on and the Q&A we hope it'll be a lot louder po in terms of the volume but thank you po for giving us a glimpse of how the Philippine General Hospital made preparations and in terms of adjustments and setting up really it was impressive especially because you were able to marshal aluhu lot of resources po no and made different adjustments with regards to the engineering part ah and all other nonclinical aspects po the administrative and very very helpful po ang cooperation by the PGH management thank you so much and we look forward to the Q&A po later on Doctor April thank you for our next presenter we will be hearing naman po from the current chair of the East Avenue Medical Center the Department of Emergency Medicine first time po na join po sa at and please welcome to your screens Doctor Maria Veronica Dating guno po Doctor Vera Hi, good afternoon thank you for giving me the chance to present our East Avenue Medical Center adaptation to how can we cope up with the surge next so East Avenue Medical Center is a tertiary level DOH General Hospital with a current 600 bed capacity the hospital was recently upgraded to 1000 bed capacity through Republic Act 11561 which was approved last June 24, 2021 East Avenue Medical Center is a specialty unit center in East Avenue Medical Center so we have burn unit endoscopy unit UHI Center renal retotip seat center toxicology center maxillofacial aesthetic center sleep center TB dots DOH skin center and rehabilitation medicine so center for emerging reemerging infectious disease or the serid building so the serid building or the center for emerging and reemerging infectious disease building is a six story building that caters to severe and critical cases of COVID-19 so it was inaugurated last August 17, 2020 with the presence of NTF Secretary Carlito G. Galvez Jr. and DOH Asec P. P. J. Vega so this building has its own emergency room burning center operating room radiology area for X-ray ultrasound CT scan MRI laboratory intensive care unit and quarantine facility for health care workers so for the EAM-CCOVID dashboard last January 19, 2022 next slide I will present the EAM-C situation so we are at 600 bed capacity so we're still functioning as a non-COVID hospital as well as COVID hospital so from January 19 we have 265 sensors for main building and for COVID are the serid buildings 190 so a total of 455 admitted patients so with a 600 bed capacity where all the 75.83% occupied us creating us to a high risk by the Department of Health so our situation by average daily occupancy rate from December 19, 2021 to January 15, 2022 so you can see there's an increase set of patients during December 19 to 25 with a 300 bed allocation we are 196% average so from the serid building or the COVID building medyo mababa but when it reaches from January 2 to January 8 we have 192% for main building or the non-COVID building and with the serid building we had 194% for ICU utilization and for isolation we have 44.40% which is 252 bed capacity so with the help of the management we allocated two more wards or rooms for the serid building or for admissions of COVID patients so we open up more rooms for them next so cumulative confirmed COVID-19 cases as of February 20 to January 18, 2022 we have a total number of 6,434 cases so we can see the date range from December 19 to 25 we only have two confirmed cases tested but during December 26 to January 1 we have 45 and then 2 to January 8, 1034 and January 9, 2015 we have 964 for a total of 2,045 so we have an increased number of positivity during that time which you can see by the graph that we also were able to surpass the Delta surge with this Omicron surge next so for COVID confirmed cases NCRF so we can see that the number of deaths are also low so December 19 to 25 we'll have only one COVID-19 related and then December 26 to January 1 2 then January 2 to January 8, 7 January 9 to 15, 12 so a total of 22 COVID-related deaths during that time next so for admitted COVID-19 cases in East Avenue Medical Center from December 29 to January 19 so it's a four-week average four weeks data so you can see we have an increased number of suspect and probable so only 141 during the start of the end of the year and then we have an increasing number so why is this so? so because we have incidental positives for our OB patients who delivered and then apparently when they tested they become positive no? so during the January 19, 2022 there is a decreased number catered or admitted in our hospital because of the because of the ER consultations now we are limited because of the limited workforce as high as 51 healthcare workers of the emergency department were affected so we have to trim down our admissions next so for our utilization for oxygen and high flow high flow machines we have 62 units of high flow but only four were used so we have 6.45% also in mechanical ventilator 93 were units available but only 37 were used or 40% so with this data we have only low risk of utilization for our mechanical ventilators and high flow oxygen next so for the COVID testing there is a decreased number prior to the surgery so December 19, 2025 we only have 166 samples but during December 26 to January 1 medyo nag-i-increase ng contes so 376 but during January 2 to January 8 we had 2258 number of samples tested as well as on January 9 to 15, 2,195 so all in all for that four week we have 4,995 samples tested so for the positivity rate only national cumulative positivity rate is 14.1 but the cumulative samples tested were 74,492 and the results tested were 7,294 making us 9.79% but the two week samples tested January 9 to 15 only 2,258 and the positive were 1034 making it 45.79% next slide so the reason why because we are the catchment area for Kesson City so as you will able to see in the news that Kesson City still remains the highest district so all in all from 1 to 9 we have Kesson City next so for our healthcare workers next slide so you can see during that time so we have an increased number of in the green line it is the number of patients handled but during the start of the vaccination of our healthcare workers the the positivity rate of our healthcare workers decreased that was on week 18 which is may 2 to 8 2021 but during the December 19 to 25 we have an increased number of positivity as well as with our with our patients too next so for our healthcare workers as of January 18, 2022 no new cases for our healthcare workers for 34 days so on December 27 the start of the new cases so we have more cases as reported so we have an accumulated number of healthcare workers positivity during that time so from from that number we have 440 which is an active case and we have a recovered recovered healthcare workers of 334 we have no expired healthcare worker so kind of go back to the previous sir okay, next slide sir ready next slide sir, okay so for our confirmed COVID-19 cases which is 454 so majority of our infected personnel were the nursing service and the medical which are the residents and the consultants so we also receive the following vaccine Sinovac AstraZeneca and with booster mong fully vaccinated were 197 next so for the places of isolation during that time of the 454 infected healthcare workers we're able to sleep through the health of one hospital command 31 healthcare workers but majority of our healthcare workers stayed at home so where they were regularly monitored by our employees clinic and our department regarding their well-being next so with increasing number of positive healthcare workers during that time to adopt the department memo of the department of health with the following adjustments only so we ask them if the patient is asymptomatic or mild we ask them to go back to their area after 7 days provided they are asymptomatic or mild and then for COVID confirmed and severe so we follow the protocol of 10 days and for severe 21 days also for asymptomatic and close contact we ask them to report on duty without any signs and symptoms next so as you can see in my chart so during January 2 and January 3 we have an increased number of ER consultations during that time so the admission rate is very low but the overstaying patients also is very low so with this we augment we saw the problem because majority of our consultations were mild patients so with that we recommended to the management that we open the isolation clinic for mild and moderate for mild and flu-like symptoms in the outpatient department so next so what are the actions taken during that time so with the current problem of what can we do if our healthcare workers are down so all the areas are also affected during that time we have so many patients admitted during that time so what will we do so adhere to basic minimum public health standards so wash hands wear face masks face shields at all areas enforcement of safety officers in each department section and unit so we ask the safety officers to monitor the co-health workers our co-employees the following signs symptoms if they are already infected so once na identify nila yung mga co-health workers nila they ask them to do the swab and then if ever to have the tele-consult right away so we also increase the utilization of tele-consultation for symptomatic healthcare workers so it was man by the family physicians at the OPD so to the employees head IAC doctor so with the family medicine residents so they able to to check the well-being of the different healthcare workers under home quarantine so we also increase the OPD tele-consultation from other clinical departments now since we are shortened our face-to-face check up or face-to-face consultation with our outpatient department from 8 to 12 noon so the tele-consultation extended up to 5 o'clock pm so this is also we also open the isolation clinic catering to patients with flu-like symptoms and mild COVID at 19 cases from 8 to 3 o'clock at 8 to Friday so that's our primary goal to decongest the emergency room also we ask the augmentation of consultants from different specialty services for dispossession discharges of admitted patients so kesa po ay ano pa nila referred to consultant and all we ask the consultants not to do their rounds early morning para we can dispose of discharge patients right away para we can ask the admitted patients to emergency room we can facilitate their transfers also we were able to ask the department of health for augmentation for uniform personnel like AFP so they are able to share us five personnel from the AFP next so we also close several units to pull down to pull down other manpower or other nurses and other staff to man the areas that greatly affected by the non-COVID and the COVID areas so these are the specialty centers that were able to augment during that time next so conversion of regular wards six west and three east to COVID wards in order to increase the bed capacity between firm and suspect since majority of our incidentals were pregnant or those who were currently delivered or yung maobigani patient so we are able to transfer them to six west and three east so we are able to upgrade our molecular laboratory to increase the number of samples analyzed in efficient turnover of results so we are able to hold transfers to other hospitals too so with limited consult and admissions of patients in the emergency department for unstable traumas so quite a tap then get toxicology cases imminent deliveries, all obstetrical emergencies and stable pediatric patients severe and critical COVID patients we are also catered during that time even though we are undermanned pero we were able to pull down our nurses and our doctors so hindi po nagsalangan in emergency room so elective admissions and surgeries like private and service were suspended for two weeks and opening of the six serid isolation facility a total of 32 bed capacity for our healthcare workers na hindi po kaya mag self isolate sa bahay so with the help of the DPWH under asek asadain and with our director Dr. Alfonso Nunez and our CMPS Dr. Alan Foyback here they able to next slide please they able to donate us 32 rooms next slide that can be utilized by our healthcare workers who cannot self isolate in their homes so ito po ay binuksan po namin para sa kanila next so other medical resources were updated stockpile of malnupiravir, tocilisoma rendin severe and varsity need so we also updated our stockpile of oxygen tanks oxygen cylinders since we have a great number of difficulty during the delta surge so sinegurado na po namin na we have enough stockpile and then for PPE and COVID related medicines and flowweeds so we also dedicated 20 mechanical ventilators and 6 high flow oxygen in our emergency department para hindi na po na tatagalan once the patient needs it so we can directly access to the following machines na so we also have 2 dedicated portable X-ray machines next so we also have mandatory swab and routine swab for employees especially for critical areas so we have electronic monitoring for healthcare workers, daily department staff, reporting processes to return to work protocols and transfer for mild COVID confirmed healthcare worker to quarantine facility we also noted that the continued vaccination program for healthcare workers every Monday to Thursday from 8 o'clock to 12 noon kasi alam namin po now they still need to continually give the vaccine even though we are under-man it caters approximate 200 patients per day coming from different government institutions like DPWH, DSWD, PDEA and DOTR so we never stop giving the vaccine even though we are under-man so you utilize augmentation for personnel from AFP so there are one doctor and four nurses so kahit na po limited na yung time but we never stop vaccinating our healthcare workers and other government agencies so yung lam po from the east avenue medical side of how we come up with our strategies in coming up with the COVID surge thank you very much thank you very much maraming salamat doctor vero dating gino'o my goodness what a wonderful presentation na makikita nyo yung detaliya yung pagihirap ng ating hospital po, alam lang ng taong bayang yung dinadaan ng emergency room managers and leaders natin ano you could really see how detailed your presentation was na pahusay congratulations i thought it was a really good presentation and i think in the future because what will happen here ang magiging surveillance, ay ilipat yan mula sa tiniting na yung numero sa population, papunta doon sa ilan ang na hospital at ilan ang malubha so yung tinataw na ating sentinel testing para yung sentinel surveillance i mean to try to understand the disease yung na ginagawa natin sa HIV AIDS parang di mo tiniting na yung bong population pero tiniting na yung mga nagpukuntas hospital ay Dr. Bero acyan April din kami na these are examples of what we need to prepare for because that's where the pandemic is going papunta doon nyo na ang kailangan natin ditalia na nang gagaling ngayon sa hospital so thank you very much Dr. Bero and i think later for those of you who have any questions please go ahead and put your questions in the chat box at minabating center. All right now we go now to a private hospital and it is my pleasure to introduce Dr. Lourdes Jimenez who is the chair of the department of emergency medicine of the medical city. Des, welcome to the webinar and please go ahead with your presentation. Dr. Doon, thank you for the invite. I'll share my screen. Yes, go ahead. I hope you can hear me well. A little louder, doc. Yes, a little louder. All right. Thank you. I hope you can hear me well. Are we good? Can you speak louder? We're good on your voice, Dr. Lourdes but if you could go to slide show. All right. To the declaration of the pandemic of March 11, 2020 we were already experiencing an increasing number of cases respiratory infections across all triad straight areas. Our journey begins by narrating the dilemmas we have encountered over the last surges including this one and the measures we have implemented to enable us to operate on the 24-7th scale despite the circumstances. I am Des Jimenez and emergency medicine and the current director of emergency department of the medical city and it's my pleasure to share our experience. Emergency department have become the nucleus of the hospitals we serve. Likewise, we have as shown eight people since half of the hospital admission comes through the ED hence it's important to preserve the function of the emergency department since it directly affects the hospital operations. The pandemic completely changed the conventional landscape on how we run and decide the emergency department based on staffing, structure system and supplies and this is exemplified by separating the respiratory cases for COVID and non-COVID which introduced us to the concept of two in one hospital catering to both COVID and non-COVID cases. We created two emergency departments for adult and pediatric with the same triage capabilities catering to all case severities for both COVID and non-COVID and by doing this we maintained the main PD as the COVID area on its base instructional design and converted our PD active PD to an adult non-COVID PD. As rock liners we are also assured that we are protected to sustain our function hence the inventories of our PPEs were monitored and with concomitant advice at least. Our supplies then were amended by the donation received from the different NGOs and private institutions we were confronted with trained resources. In collaboration with schools and religious institution provision of accommodation and transportations were arranged for our staff. Responding to surge happens in a cyclical manner but the behavior of each surge is different. Like our current surge now it seems to have a shorter span lesser ICU utilization The next three slides will illustrate the impact of COVID-19 particularly in our hospital because these are excerpts from my study regarding the ED utilization. As you can see here there was a big drop of our volume in terms of our census pre-pandemically compared to the pandemic we're experiencing now and this is more relevant during the lockdowns the ECQ and ECQ. I think what is important to remember here is that there's an inverse proportion of COVID-19 during the surge. So when you have high COVID cases there's a concomitant decrease in the non-COVID cases. The next slide is also very wide because in this study there was a big drop of PD applications and we were literally not seeing kids or pediatric cases in the ED in the year 2020. And the last slide is also significant because our age group now is shifting to the older population and as a private institution most of our patients are HNO subscribers if we are catered to younger professionals that are more or less connected to corporations. Now in health economics we are this is a red flag for us because an increasing out-of-pocket payment scheme is more or less connected to financial poverty. We're getting a lot of sicker patient and they stay longer and they're critical. This is a 2020 data. So I guess the most important as a director of emergency department in a private institution is basically how to balance the clinical and the financial aspects in terms of service. Of course we are expected to render clinical service but also need to be aligned with the business aspects of the hospital to remain operational. So what prevents us from shutting down? Early on in January 2020 the epidemic rapid response team was formulated by our CMO our chief medical officer and infectious director and this is basically the objective is to plan ahead on what will be the possible effects of COVID-19. So what I want to re-day regarding or what I wanted to remember will be for these teams the meetings and please don't send representatives because at that time during the initial phase everything was so fluid and decisions is needed when you're in a meeting so don't send representatives because they will just relate to their supervisors so then send a decision maker so we make a decision at that point in time to address the needs and of course the segregation is also important why is it important? First and foremost we need to protect our patient and second we also need to protect our staff so the advent of antigen testing in the virtually department was very helpful because we can easily triage patient but for cases wherein they turn out as negative but remain symptomatic we have an intermediate section and I guess this is one of the most important things that we formulated the COVID pathways COVID per se is something that you need to imagine repetitively so what we did here was to convene all the key specialties to the infectious the pulmonary, the nephro the EM, the CCM and agree to the clinical management of COVID so this is very helpful for us because it addresses both the clinical and operational aspects in handling COVID and a lot of these projects actually came from the over congestion or overcrowding of COVID as mentioned in the study that I presented there was a drop in terms of the EB but during the surge of the cases are respiratory so marami parang so in collaboration with the laboratory and collaboration with the marketing the purpose is basically to stratify your patients you cannot cater to everyone in the EU and what we did here was basically to create different problems where we can direct them so we have the drive-thru services on laboratory and bills and they can get the letter of authorization if you're familiar with patient books then you usually require an OO before any procedure and then we formulated some sort of an arm swapping which is do the RTPC so it's a more expedited process teleconsultation became a mainstream and if you notice the time frame it was adapted based on the behavior of our EB patients because our EB patients particularly the non-urgent ones level 4, level 5 they come in based on their convenience because they have work so what we did was when we decide the teleconsultation it was it has extended parts plus it covers from Monday to Sunday so making it more feasible for everyone available and I guess lastly one of the innovations we did of course no our concept of healthcare is still hospital centered but if you see a lot of models na especially in different countries it's shifting towards the community based practice so for the patients that we cannot afford because we operate on a 30% ceiling there is the COVID co-care pack program which is collaborated with the company so we refer to them so this is their second year in traversing this journey and the mentioned programs are all important but as mentioned by the other speakers the mental health is also important it's equally important so we have to be assured we have to make sure that our staff is healthy our staff are healthy so in the GS or in the national just to answer the question first and foremost in terms of the structure I feel the structure to a one concept will be we still need to take it to both COVID and non-COVID cases and second in terms of structure it is important to take the eight other avenues so that the volume of the evening will be more or less redirected to other avenues just like through your home care from tele-consultation to admission and of course to RTDC RTDC are interesting the system once it changes structure also there will be restrictions in terms of the system what I think was really renovated was the creation of a path because it is an agreement of the different key specialties in terms of managing COVID the staff is primarily the logistics we need to have a steady supply of our logistics and I think the most difficult to manage is the staff because the 24-7 alone combined with search is really challenging as in the studies that you see that around 10 to 20% of the staff will be affected by COVID-19 so if you go by that direction there should be some sort of preparation on how to address this in our setting most recently one-third of our nurse staff were actually affected by COVID-19 we deployment was an option tried to redeploy the nurses from the non-COVID to COVID but we find it non-sustainable kung sanyong way or newly available nurses because the set skills are good right? what we actually did here this is a collaboration to the nurse management we contracted the group of PDN to at least assist our nursing nurses in terms of the bedside management for a superior level at one mile so that has been very helpful to us another thing is we also contracted a group of practitioners to man the 24-7 transport system because we cater also to not only to the PD but the hospital first aid and of course one group also to man the non-urgent non-urgent section we PD and this is really helpful because it addresses one of your problems in terms of the schedule and in the ED in any 24-7 operations once you address the schedule I guess 50% of your problems will be resolved so that's it for Medical City thank you for the invite and I hope you learn something from this presentation Arami salamat Arami salamat din po Doctor Raddes we really were impressed with regards to the preparations done by the Medical City at maraming-maraming salamat for sharing your experience in your hospital finally as part of our webinar we have a reactor who's really not a stranger to all of you one of the persons behind the stop COVID-19 webinar series institution na po siya sa emergency medicine dito po sa Pilipinas please welcome again to the webinar the current chair of the UPPGH department of emergency medicine Doctor Teddy Herbosa sir Ted maraming salamat Raymond for that kind introduction and actually I'm really elated now because all three presenters were my former chief residents and were trained in Philippine General Hospital in emergency medicine when I was starting emergency medicine before I got comments like try to solve the problems of the health system of the country I just wanted the emergency department is the crossroads between public health the health system and the hospital system this is where I call these men and women that actually work there are the Marines if you compare them to the battle in the military they're the Marines that confront the problem as they come because of a weak health system the need for a better hospital care and you saw from the presentations of all the three how important emergency departments are including the presentation of Rich our president at the Philippine College of Emergency Medicine and let me give a shout out to all the emergency physicians out there of PSM either in training or not you know the field of emergency medicine is still very young we only started it in the Philippines in 1988 I started the one at the Philippine General Hospital in 97 so we're celebrating our 2050 and thank you to TVUP for hosting this webinar in behalf of our doctors in the emergency department right now you saw how dynamic the emergency department is many things happen and change and let me just give you a run through of how we did it at the Philippine General Hospital it's a national university hospital it's a COVID referral one of four actually one of three because East Avenue PGH and Lang Center are COVID referral meaning they were also catering to non-COVID while Jose and Rodriguez actually is a pure COVID hospital that means you can't get in there unless you have COVID but you can give birth there if you are COVID you can get operated there if you have COVID so we have actually four COVID hospitals designated by our government because of COVID you heard the descriptions of all three speakers we had to do engineering designs for infection control so PGH was functioning at 1333 but because we have to increase the distances between beds we decreased to 863 beds capacity so that's almost half of what it used to be and of course residency training was present at the input here Raymond and Susie is that if we had these doctors and all the emergency departments of the Philippines had an emergency doctor like them I don't think we need the IATF because everything will be solved by them so I honestly think it's a specialty that needs to be looked into by our health system so that we can really operate between the realms of public health and the health system we show you some of the interesting stats PGH being a referral hospital has a higher mortality than the general population mortality and that's because we get the cohort of the sickest and the worst COVID patient so our mortality rates are unusually high number two of course that's because of the severity the other thing is we've been testing our healthcare workers and we've done over 23,000 tests since March of 2020 and our test positivity rate is about 12% so it's still an acceptable number I think it's not very different from those presented by the others also we notice that the infection of our healthcare workers didn't happen in the hospital they were suited up, they were well protected they knew this patient was high risk and they don't get infected in the hospital they get infected in the community now in January 5 when Omicron started to surge we actually technically did what was called an ED diversion so you've learned terms like emergency department emergency physician now I'm introducing another term which is really emergency department diversion so when a hospital cannot cope with a number you can't close the ED but you divert patients so we divert the less severe to other hospitals and we will only accept these cases which are life or limb threatening and this is basically basically like you can't close but it's basically similarly to closing so our statistics at that time showed you that we had a lot of very acute patients at the emergency department and many of them in this current Omicron surge were actually emergency cases the usual but when you test them they tested positive for Omicron because they have influenza like illness so I've been asked to return back I started in 25 years ago I started the program of emergency medicine and I didn't realize I really enjoy being in the emergency department when GAP asked me to be the head again to follow the footsteps of April so we have got a modern ER and it's got a 1,700 square meter area and this is the flow it's very designed modern but it's still fall short in terms of addressing the issues of the pandemic and COVID-19 so you can see our isolation is just two rooms and this is supposed to have been well thought of well it was well thought of prior to COVID-19 and we have an area called the transition area which is well of course you enter you get triaged based on the severity ratings that April described and then depending on where you go you can be either in the trauma room or in a transition area if you're critical or if you're in an ambulatory care and the medicine will look at you and then we have a pediatric area so it's kind of unique because everybody is in that battlefield and unlike what was nice about the presentation of Vero they were able to operationalize a building and transferred all the COVID cases to that building which is a better engineering design but we couldn't make that engineering design redesign at PGDH so all emergency patients get tested using the gene expert which is also a PCR test but it only takes 45 minutes but the whole turnaround time from the time you swap the ED patient to the time you get the result is about two hours at the very least and that's how we actually are able to classify whether COVID or non-COVID so if you're negative you immediately go to the non-COVID area and eventually if you're COVID you go to the COVID area so very important also is our pre-hospital care so when Omicron came I really implemented the stuff that they were talking about I was scared that we would have ED overcrowding because of what we also term access block so when the hospital gets full patients accumulate in an emergency department and that's called access block so I created a daily crisis which is really all about the systems that you put in place communications, coordination collaboration and cooperation and then I talked to medicine luckily the chair of medicine is a good friend of mine and we had twice weekly huddle I was able to push all the intubated patients and all the COVID negative patients into a specific area and a specific ward and because of that before we knew it Omicron cases were already declining and today as we speak the number of non-COVID have now outnumbered my COVID cases in the emergency department so this was already discussed when we changed the healthcare worker my only comment on this is it was a good idea because at that time we had 900 of our personnel that were positive or in quarantine they were mostly vaccinated but one of my ER doctors who was positive told me the UP Health Service is telling her to come back already to work to report following the DOH 5 day rule and she was still coughing I said no we followed so it has to be also a case to case basis because sometimes the guidelines don't fit the actual situation but it actually helped us a lot to prepare and if actually we had a higher number we would be able we would be losing health professional so this was an important part of being able to do this so for April you saw that April talked about the hikes the hospital emergency incident command system and the very important the very importance of having a system of command a structure also and she also talked about how human resources and how important they are East Abinus engineering design was unique because it had a building that was ready to become COVID-19 so they just rushed that and by August it was eventually used and that helped them because the main hospital continued to function and had non-COVID cases as well so I think that's the hospital for for desks my comment is very clear to her that as a private hospital there are economics involved in being able to make sure that your hospital will function will continue to function unlike government hospitals public hospitals earn a subsidy from the government that means the salaries of the personnel and the nurses there continue to flow even without profit however in private hospitals there is a cash flow and you saw her comment at the risk they were facing when they were having elderly patients and longer patients so that type of prediction also involves the importance of being able to understand the economics of the healthcare system and of a response to the pandemic another thing she mentioned and all three actually mentioned this is their telemedicine program I think telemedicine has had the resistance prior to this pandemic that suddenly became and I think that's really the most important part that we were able to decongest the emergency department by making sure that people who don't need to be in the emergency department don't go to the emergency department and clog the people working there I think her last comment about the four SS are very important the structure the systems the staff and the staff two most important things I will say in any crisis that all these emergency doctors did is take care of their people they made sure they took care of the patients all acute patients were taken care of and you saw the systems they put in place but it's very important they all took care of their personnel from mental wellness to physical fitness to protective equipment and also you saw them accumulate and stockpile medicines trained emergency physicians in emergency preparedness and making sure we were looking at the worst-case scenario to be able to respond in times of greater need so with that maraming salamat to all these emergency physicians and to all the nurses, PR nurses watching this afternoon na ko maraming-maraming salamat sa inyo thank you TV UP and stop COVID deaths for giving them this webinar episode only for emergency medicine okay, thank you very much that's Dr. Tedder Wosa kailalang kailalan yun na na we always enjoy his presentations kasi kasi hindi siya very very broad view of the situation and I think when he said na kung sana yung mga emergency yung doctors natin re-involved in the pandemic response I agree with that because it's actually an emergency on a large on a very large scale so I think there are lessons we can learn from this and we do have time for questions and answers but first of all I think let me see Raymond you have we have a public service announcement we're going to ask our panel please open your video so Dr. Richard Dr. Vero Dr. Radez Ted please open your videos and let me turn over to Raymond for the public service announcement TV way can you play the video thank you oh ako mukhang malalib niyang hindi isimong ha wala ka magpasuk ngayon wala ko may disinfection ba siya sa grocery a gan ba pwede ba wala rin kayong pasukahabong patinong isang ako sana makabalik na ako sa tabahong oh siya siya di na muna kitay store buyan at mukhang malalim niyang hindi isig mo look magpabakuna na kayo tayo wala problema po ang mga ang mula na ako e talaga dahil mahal ko kayo magpapabakuna ako imanda sang ka na go yes thank you thank you so much at TV UP that was our COVID communication public service announcement which is one of the many outputs of the UP research and titled communicating COVID-19 in post quarantine Philippines it's headed by UP vice president for public affairs Dr. Elena Perna and funded by the DOSTPHRD and the Department of Health through the AHEAD HSPR project Dr. Susie okay so I think Raymond like what we did last time questions from the audience kasi marami ako nakikitang mga questions dito na interesting puntahan na natin ang mga tanon nila siya ikaw mo na Raymond ang upvoted mo dyan or meron tayong from the audience we have someone from the audience yes we have one we have one Dr. Susie our most upvoted question will be asked live by Ruperto Angel Navarro may we have you open your screen and ask your question Bob yes good morning everyone and like to thank everyone who's a panel member of this meeting because all of you have unmatched dedication and expertise in terms of handling emergency cases I don't think the emergency room will shut down because of your lack of dedication or expertise ang problem ako really is yung resources I just want to ask kung kumusta na yung mga fill health payables that are all in the headlines what's their status as far as the emergency room department is concerned and in terms of percentage magkano na ba ang binayad ng fill health sa ER ninyo para malaman natin okay that's all thank you very much para pinatama anyata si Tedo na thank you for the question I will answer that that's a very interesting question and I agree with the question because if you're going to mount a national response to a pandemic it's very important to support the hospitals which are in the front lines of taking care of your fill health members who are the citizens so if you're unable to pay for two years honestly that's criminal right so what's happened is that of course the government hospitals which had ample subsidy and supply from other things from the budget and because they have what we call the PS personal services and the MOE were able to cope unfortunately the comment is really a representation of the difficulties of the private sector yung medical city na kausap ko siya na dyan over a billion yung utang ng fill health sa kanila that's terrible if you are a hospital that does not have a deep pocket or does not have a credit line from the bank you'll have to fire personnel like nurses and maintenance personnel of course the lowest personnel and that's not right so to me I agree now a known solution na binigay what I know is that there is a solution that was put forth to the private hospital it's called the debit credit payment mechanism you sign it but if there is any fraud so that's the debit credit payment they will pay 90% of what you're filing and then the fill health will review it and if they find something wrong with it you upcased or you duplicated claims cases will be fired against your director now many private hospitals didn't sign it all the DOH government hospitals are signing this and they got money they got money out of it so I think it's really a conversation that has to continue between the health finance institution and the private hospitals and I think that's continuous I'm really glad there was omicron because the fill health holiday was going to decrease but I'm sad because what it will affect is not the pandemic because if the private hospitals disengage then how the hell are we going to implement universal health care in the Philippines but that's another topic altogether thank you Susie thank you very much it's a good question people want to know it's a problem I saw a question here about turning people away from the ER and this has happened even before the pandemic so what do you do how do you report tertiary hospitals that decline patients who need emergency care being referred by a primary hospital so what do we do about this meron ba talaga niyan meron talaga niyan dapat wala pero meron so what is the solution to this so I'll throw this to all our ER department anyone can answer I can start okay go ahead we operate based on our structural and manpower capacity so at a certain point we reach the scene and we cannot really accommodate patients it's a time that we limit our patients to live pregnant and high risk patients and I hope you understand that to continue to accommodate patients we cannot take care of them also and of course we have to preserve the remaining staff we have so I think that's one one answer to the question second is we try to provide different avenues where they can avail as mentioned in the presentation where they can avail services majority of our cases are still non-urgent cases technically by rule non-urgent non-urgent cases in order for you to accommodate there's a way to accommodate so we create different avenues where they can avail for those who we can grab admittedly this has happened because there's a certain point based on our capacity we try to prefer them to COVID-19 but the limitation there is it's not covered by the card na may mga kung it's not covered by the card your patients are each to provide or subscribe may tendency that they would not yeah thank you Des I mean let me I'm going to ask the others to answer this question as well but in other countries I know that in the UK for example you just don't go to an ER without knowing that that ER will accept you ang iyari kasi sa atin ang word na sinuso-good sa hospital sinuso-good sa hospital pagdating na ninyi di kayang kuni na ER na yung tindihan natin yun pero malayo ba tayo magkura ng systeman na bago sumugod mayro ng tatanggap sayo kasi yung problem ay yung lumalagari yung lumalagari from one hospital to another because there is no way if you're going to be accepted or not accepted actually if you know that you're not going to be accepted in a certain hospital hindi ka na pupunta doon di ba pero walang way na malaman kung sino ang tatanggap so yun Ted nakaraysang yun no I just wanted to raise what April presented April presented the transfer command center which is something set up by PEJs to solve this problem but the other thing she mentioned is the one hospital command which is also being managed by an emergency physician Dr. Bernadette Belasco and what the government did was first it's called one hospital command because it was trying to coordinate exactly this problem that patients with COVID will be accepted by the hospital that they're going to be brought to today it's no longer called well it's still called the one hospital command but the idea is to institutionalize it and its new name is the national patient navigation and referral system national patient navigation and referral system which addresses this one so interestingly COVID-19 gave us something that we now can answer the problem of this guy who was asking a question why are hospitals because now primary hospitals can coordinate through this national patient navigation and referral system na nga nakit na, mayro na tayong system so that's the big answer maybe Rich can talk more about it Sige Rich, sige gina saka uma-underbayan In addition just to figure out what Dr. Deter Boss has mentioned the one hospital command center has evolved into the national patient referral in navigation center so it tries to take away the burden of letting the patient or their relatives of looking for appropriate facility for their patients to be admitted and siguro in relation to that I would also like to emphasize in relation to emergency care as much as possible but even if the hospital mayro mga announcement that they are closed the emergency department in reality never co-sets we still cater and manage patients who are who needs urgent care category 1 and 2 and kaya punap kay importante ng triaging of patients at the minimum the patient should be triaged by a trained healthcare provider before he or she is transferred or turned away for another institution so it may pinaka-important the patient should be triaged at the very least okay, sige na lalaman ng intern ka kung ano ang practice mga referral tayo sa PGH ano nalagay na sa referral form to hospital of choice ang joke kung asayo pag mayaman ako magtatayo ako ng hospital ipapangalang ko sa kanya hospital of choice kasi that's what I call that's now what we call in the ED world an uncoordinated transfer hinayaan mo yung paciente sabi emergency ka maghanob ka na emergency puno kami di ka namin tatanggapin dito bahala ka sa buhay mo and these are the horror stories we hear of six, seven, eight hospitals ang pinantahanila and then died on the last hospital so we shun this we don't like this in fact pinipilit ko talaga yung residents ko na and to actually see all these patients when they go to the emergency room you have to see them and that's right which is correct at least you triage the severity of this particular patient before you turn them away and I remember kasi in the UK di ba yung St. John's ambulance system nakag-GIS lahat ang ambulans siya tapos yung mag-transport although not everybody uses an ambulance but given the use of apps and mobile phones these days it should be possible to see na pagdininan mo yung hospital itong ER na ito, ito, ito, ito ito, ito, ito, ito meron pang dalawang lugar di ba tas po ay di mong tawagan so anyway I think as you were saying April was describing that but of course we are thinking about the whole country right, we are thinking about so many hospitals okay, pero sigay kaw pero gusto magsabi something Yes ma'am, thank you for the chance ma'am kasi in East Avenue Medical Center ma'am we usually receive patients pang 12 na all the way from other nearby provinces na ma'am so I asked the triage officer with the second year resident to assess first the patient usually pag malalayo na po yan kahit na hindi pa sila unstable so we usually ask them and their relatives na we can accommodate you but may waiting times in the emergency room so usually they stay in the emergency room and then we prioritize pero yung tanong ma'am kanina if any case na they want to file a complaint there is a citizens complaint hotline yung 888 in L government hospital so they can address their complaints to that hotline so we usually receive them na ma'am so yung lang ma'am kasi pag malalayo na talaga na sobrang dumis na ng ambulance we usually accommodate them kahit na medyo benayin pang tingin nila pero since the kailami terse ninsan wala na silang oxygens turning around pero we usually receive them na ma'am so yung mga hindi lang namin we receive yung mga mag-to-moderate but they have to be accessed as seen by the emergency medicine residents pero kung talaga malalayo yung pinuntahan nila usually cater them ma'am and then we ask them to have patience in staying in the emergency room because we cannot accommodate them sa floors immediately because punong-punong yung bong hospital and then they willing to wait sila mam lahat so yung yung ano nila na kahit kasi naman sa bahay lang and then they don't know what to do and then the LGU doesn't yung coordination misan kasi hindi na sila nakakatawag sa one hospital kuman mam so misan yung din ang pobleman nila wala sin lang load and all so yun mamang mga burden don't pero at the end of the day mam we all we accept them without ok, thank you very much for the role we're approaching the top of the iron ako sayang I think there's a lot to talk about but we will have to now start winding down and Raymond you wanna answer our questions in the fun quiz and while we're let's answer that first thank you doctor Susie may we have that flash on the screen po there we go and also in mente if that's possible for our two questions the first question reads what are the signs that you need emergency management so mayang po limang options dito elderly with comorbidity generalized weakness difficulty of breathing confusion and behavior change so alin po ba dito ang mga tamang sagot maybe we called as doctora des ok, you know in terms of in terms of emergency management and according to the the WHO recommendation because we're trying to do some sort of a public service that we're trying not to alagang umunta sa ED kung mayang nakay mga singtomas and according to them it includes actually your behavioral change of confusion can be categorized as one under other level status say the explanation there probably will be there is lack of proportion atlaskan ng other type of status second would be of course your difficulty breathing part of the pathotysiology or pathogenesis of COVID-19 is still hypobshattin difficulty breathing so I think those are the two questions those are the three answers na poede in elderly with comorbidity especially if you have some sort of an exacerbation of the comorbidity so that can be a signal where in the EDP big emergency management and in terms of the generalized weakness na how progressive is the generalized weakness sa akin baka nahat anyway, it's not because I'm the only one but most likely baka nahat and thank you ok thank you so much doctora des for our second question nang mampo will pose it to the president of PCEM si doc rich what precautions are necessary before transporting a patient to the emergency room without an ambulance correct answer sir for this question I think there are more than one correct answer for this question first is you should treat everyone as COVID-19 suspects not the same way that we treat our patients at the emergency department kasi nga di ba we receive both COVID-19 and COVID-19 cases but since we don't know yet their COVID status we treat everyone else as COVID-19 suspects so that's one of the possible answer for this question and then another possible answer is it's free to open the car windows because in recent studies they are able to show how important ventilation is in terms of the spread of the disease so it is very important that when you are mula ka ng ibang option but to transfer your patient or your relative by yourself it's important that for example if you're using a car the patient could sit in the back and then you open windows to improve ventilation of your vehicle okay thank you doc rich before we go on po with our evaluation po we understand that everyone is very busy po so that in light of this and recognizing this that to stop COVID-19 webinar series team have come up with what we fondly call our SED shorts so ito po yung mga very very short clips that we have right now if you go to the TV UP YouTube channel you'll be able to see snippets po of the different webinars that we have had just to be able to refresh you of the different topics that we have discussed for all of our 84 webinars and for our evaluation po naman po as habang nag-i-isip na kailang final messages to our audience po ang ating panel of experts we have 5 questions here it's a 4-point Likert scale we hope yan parin po ang kailang problem at we hope may mga sasagot parin po ng ating evaluation po will continue to launch it angkat may sasagot po the questions are as follows the panelists demonstrated thorough knowledge of the topic the panelists were well prepared and organized the panelists spoke clearly and audibly the panelists used appropriate sorry, tumatalon help write language with medical medical jargots adequately explained and finally the panelists contributed to new perspectives and knowledge on managing key COVID-19 health issues Doctor Susie? Okay, thank you very much so I hope we can bangloto panel at ito evaluation po That's really it anyway so let's go to our parting words this is always a very nice part of our webinar we ask our speakers to share their final words of wisdom for our audience who are mainly frontliners so we're going to start with Dr. Ted Herbosa Wow, I'll start first okay all I ask is for those listening now you met the people who are running the big emergency departments of the ones that were holding the line these were the people who were holding the line during our previous waves every time you go to the ER and you tell me the ER doctor is masungit or doesn't smile please think of whether they've gotten their sleep they've gotten their last meal have they taken a shower because these are the people who will continue to serve you 24-7 whether you're dying or you're last short of breath thank you very much thank you very much as Dr. Ted Herbosa let's go to um... this Dr. Des okay ito lang yung gusto iparating nga sa lahat ng emergency decisions in terms of responding to search please remember that we are not and we di tayo nag-iisa at hindi natin kailang akoin lahat ng problema sa ER because now the crowding issue is also a hospital problem and when we try to disseminate information to public it's also a shared responsibility in the community so I think that's that's a message that I want to hear from you thank you okay thank you very much Dr. Veronica please so ang quarantine words ko lang ko get vaccinated get boosted it helps a lot so even though we have 845 healthcare workers being infected no deaths were recorded so get your booster and your vaccine thank you po thank you very much April alright um... sa sa first of all salamat sa lahat ng kapa ko frontliner sa lahat ng healthcare workers po at sa public na sumusupport and very important po in this difficult times yung support ng lahat from leadership down to our of course our families and our colleagues at malaking bagay for us to be continuously motivated to continue serving thank you okay Dr. Rich go ahead siguro po yung final message ko as the Omicon variant spreads outside Metro Manila the emergency department should be prepared a big portion of their staff ay makakasakit and at the same time message ko to the public because of that hindi lang naman mga pasyente na kakasakit but also our healthcare workers sabi nga nila the world is under staff so be kind to those who are able to report to work so yung main final message ko thank you very much Dr. Richard okay so we have a summary and closing remarks from the chancellor of UP Manila so I'd like to call on Dr. Menchit Padiria lang nga happen po sa yung lahat okay well today's webinar was opened by Dr. Rich Santas the president of the Philippine Emergency Medicine College of Emergency Medicine and he actually informed us of the new terminology and the preferred terms are not emergency room but emergency department, emergency unit or accident and emergency Dr. Rich presented the emergency care system framework which covers the scene, the transport and facility or emphasized importance of close coordination with partners in emergency response let us be reminded that the pandemic emergency response includes the safety for both patients and health providers our first presenter is Dr. April Yanetta the immediate past chair of the department of emergency medicine of PGH where she shared the PGH experience and the flow the patient flow during the pandemic allow me just to highlight the challenges that she mentioned for the emergency department protection of staff and patients to the management of undifferentiated COVID and non-COVID patients three coordination with the rest of the hospital services and fourth and very important will be the coordination with the communities the emergency management system of PGH adopted the hospital incident command system which has a wide network of services that is being handled by the hospital I want to take note of the priority that was mentioned by Dr. April which said the priority was given to staff protection and as she said safety first and this was managed by managing the risk and I urge you to go back to how she detailed on how the risks were managed at PGH now two programs that redirected the patients out of the ER that she mentioned where the call center the Bayanihana operation center we have a call center at PGH 155200 and the PGH now in closing she mentioned that in addition to the physical health of our health workers they did actually attend to the mental health the mental health of the workers by supporting our classes and also supporting them with psychosocial support through the UP Dilliman site serve in the department of psychiatry so thank you to the PGH emergency department our next speaker Dr. Viro Dating you know I hope I got that right and who shared the emergency medicine experience at the East Avenue Medical Center it was interesting to see the statistics at the hospital and her announcement that they recently opened the center for emerging and re-emerging re-emerging infectious diseases catering to COVID so you know probably East Avenue is the most is the most prepared because they had one big building dedicated to COVID and in addition to the adherence to the basic minimum public health standards she actually mentioned some key action points and I'll just mention some of them well number one will be the reinforcement of safety officers the increase of the utilization of teleconsultation which probably was that popular one prior to the pandemic shortened OPD services only until lunchtime the augmentation of the consultants for the disposition and these charges of admitted patients and maybe one thing that we do not have the augmentation from the uniform personnel from the AFP of course they had a closure of specific services and I think this happened in all of the hospitals the burn, endoscopy and so on and you can see here that she has a lot of programs that were similar to the others that were presented in prior webinars conversion of regular wards of COVID wards upgrading of the molecular laboratory so that they can actually analyze more samples desalation transfers from other hospitals limited consultation and so on so indeed you can see that a lot of our hospitals actually do share certain practices to be able to continue the services within their hospital network and maybe the most important that I heard actually from Dr. Herperot is the opening of the 6 the serid isolation facility for the health workers and I think this is really one of saying that you care you have prepared for them for their isolation our third speaker is is Dr. Desimenez who highlighted the challenge of a private hospital where she said the balancing act has to happen much as they want to deliver the care they have to make sure that the business is sustainable so just allow me to mention some of their strategies similar well some of them are similar to the other hospitals but just to show that emergency departments think the same hospital share practices and I think that's the beauty of getting to know the other hospitals so that they can actually share best practices well for one they separated at the emergency department they separated the COVID and the non-COVID patients just like the other hospitals they have an inventory of their PPE they partnered with the private sectors for the accommodation and travel of the health workers so but for a private hospital what is important is the impact this COVID in terms of numbers for the hospital because of course having to operate not having any substitute from the government they have to make sure that the business goes on and they're able to pay for their personnel the nurses and everything else well the first impact will be the drop of census during the lockdowns number two the inverse relationship of admissions at the time that COVID is high there was a decrease on non-COVID for the year 2020 they hardly had any pediatric patients and the last one is that they cater to a lot of HMO patients and they were sicker and they actually stayed longer so once again Dr. Des said as a private hospital we must balance the financial aspect to remain operational and here are some of the strategies that the medical city actually implemented to remain open well one just like the other hospitals they had epidemic rapid response and I take note of her advice she said that the decision maker has to attend the meeting because decisions have to be made immediately and that's why you have the decision maker in the table number two is cohorting the segregation of patients and the use of antigen testing so that decisions can be made at emergency room just like the other hospitals they had their COVID pathways wherein they brought all the key specialties on board so that they agreed on the clinical management and then and maybe the programs that are really interesting here is that they had the laboratory on wheels they had the drive-through services they had TMC online they had tele-consultation they had the home care program they were one of the first hospitals who actually offered the COVID home care program she summarized her talk by saying that there are many things that are important to remain open structure system stuff the needs as well as the staff the people our reactor is Dr. Herbosa who is now the chair of the the department of emergency medicine and BGH and she actually called our emergency personnel as the Marines of the healthcare because they confront the problems up front she introduced another word to us again she said, you know in the recent surge BGH had an emergency department diversion you can't close the emergency room but just he said that in the time of the recent surge they had to limit the admissions to life-limp threatening emergency conditions trauma stroke and heart attack well Dr. Herbosa gave us a glimpse of the newly opened emergency department of BGH which is more than a thousand square meters and well of course you know as always the the numbers never go down a major strategy that he shared was a daily crisis huddle which covered communications coordination collaboration and cooperation with all the departments that were actually important for the operations of the of the of the department he made comment of the the presentation of Dr. Viro because indeed the East Avenue Medical Center has a unique building with a proper engineering and as I said as we as we've heard today they were able to continue the operation of the main hospital as they actually operated the COVID hospital and the reaction of Dr. Herbosa on the presentation of Medical City we had an appreciation on the economics of healthcare because we do have a lot of private hospitals who actually need to work on the balancing act as I said of delivery of healthcare and at the same time making sure that you're able to pay for the services that you are providing in the hospital so in closing let me state that for the past two years we've been talking about patients genomics the variants epidemiology then it is really time to give the spotlight on the silent heroes of our COVID pandemic the people at the emergency room we are indeed the Marines the dedicated team that works 24-7 pandemic or no pandemic magantang hapon po sa inyong lahat and back to you Susie and Raymond well thank you very much Chancellor Manchik Padilla always a very inspiring and what should I say an excellent summary of that two hours that we had pulling out the main lessons and we really appreciate all of our speakers for today maraming salamat pusein nyo we'd also like to thank our audience who talaga magpupurusig silang maglagay dito ng strongly agree sa evaluation this is very important for our speakers and for us because we want to make sure that you feel that we are giving you the best speakers and indeed our speakers today we're all really very very good so maraming salamat pusein yong lahat next week we have a very interesting topic again I'm always excited about the topic so sorry na kayo but you know maraming pang lugar sa ating bansa na hindi panaharagko for dun sa Odette so pag-usapan natin COVID sa kuna COVID and disasters and we will include here the destruction of health facilities yung mga health workers natin na na sa lanta di ba nagbabakuna si lahat tapos na sa lanta yung mga bahay nila na sa lanta pati hospital pati health center napanpo natin na lahat we're going to have Dr. Johnny Nanyagas former undersecretary of health and former director of PGH to open and then one of your favorites Dr. Abdullah Dumama our undersecretary for field implementation and coordination Department of Health for Besides and Minnanavya Pusee Sidok Okang and us sa field palagay alam niya ko anong nangyayari we have a specialist Municef Mariala Castillo who will talk about the situation of children who are still in evacuation centers up to now and what are the COVID risks and also to talk about public health policy we have Dr. Carlos Romero Gundran from the UP College of Public Health so abangan niyo po lalo na yung mga na sa Minnanavya na sa Visays na kikinig sa atin paganda po yung ating yaya ay nyo yung mga kasamahan niyo to be part of the webinar next week over to you Raymond Thank you Dr. Suzie and thank you to Chancellor Padilla for cruising remarks and the synthesis of our webinar for today before we conclude our program we'd like to acknowledge the very hardworking team behind the Stop COVID Deaths Webinar Series so without each and every one of you we will not be able to churn out our quality content week in and week out and finally all of our 84 and after this webinar we'll be getting 85 na po Stop COVID Deaths Webinars are archived for viewing you could view it sa TV UP channel sa YouTube you'd be able to see all of them from webinar one up to webinar 85 over the weekend maraming-maraming sa lahat po ulit we hope is to see you again next week Friday from 12 noon to 2 pm this formally closes our webinar for the week makita-kita po tayo ulit it's a date together we will stop COVID Deaths so keep safe keep healthy and see you online I'll keep your hand in mind let's say a prayer one more time I know you long for home but I am here you're not alone we'll stay with you until the coast expire the other's pain before my fears the other's laughter before my tears but right behind the mask I look into myself and ask do I have strength to carry on my God our Lord what's this going on and leave you here to keep me strong I'm here to hold the line I'll keep my hand until my his name to realize it's fine to be afraid just hold on to the word he gave this time we'll come to pass because this salvation makes the last you'll carry you to see the break of day the other's pain before my fears the other's laughter before my tears but right behind the mask I look into myself and ask do I have strength to carry on my God our Lord what's this going on and leave you here to keep me strong I'm here to hold the line I'll keep my hand until my his name to realize it's fine to be afraid just hold on to the word he gave this time we'll come to pass because this salvation makes the last you'll carry you to see the break of day the other's laughter before my tears the other's laughter before my tears but right behind the mask break through another day