How we should prepare for the coming explosion of COVID-positive patients

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REUTERS

By Jose Xavier ‘Eckie’ Gonzales

WE ARE ALREADY in the middle of a stealth contagion. We just do not have enough testing capacity to show it.

South Korea, at its peak, was doing 10,000 tests a day. We did 11,000 tests last month, for just 2,000 individuals (with retests et. al.), and 800 were positive. Half our COVID-19 patients got their test results on the day they died or after.

The Medical City (TMC), along with other hospitals, will soon run COVID-19 tests to help the heroic and overworked staff at the Research Institute for Tropical Medicine (RITM). This will result in a big jump in COVID-positives, as 10 labs will produce at least 1,200 results daily. And it is still not going to be enough.

US Coronavirus Health Czar Dr. Anthony Fauci warns that “this outbreak… putters along and you think you’re okay. Then it starts to go up a little and then bingo, it goes up in an exponential way.”

Let’s stop thinking we are okay. We’re not. We need to implement the five key action points below to combat COVID-19. If, instead of doing these steps now, we again say “pasensiya na” (please be forgiving) for one reason or another, we will all soon be “pasyente na” (already patients).

1. INCREASE THE NUMBER OF TEST KITS
We need more test kits. The UP-invented test kit is still in field testing, but foreign-made kits are automatically accepted at their “local” Food and Drug Administration (FDA) face value. However, the Department of Health (DoH) has started discarding some of the donated Chinese test kits as they were shown to be only 40% accurate.

Results of the local field test will be out April 1. But test kit design is not rocket science — the genetic footprint of the virus was decoded on Jan. 10, 2020, a week after the Wuhan lockdown, and released globally by Chinese scientists. In February, our scientists already had the testing solution (the one that is now being field tested).

Once approved, the local kit will be made in a facility with the highest levels of international biosafety, the only one of its kind here. The local kits are also open-source, meaning they can be run on all Polymerase Chain Reaction (PCR machines) that are available here and now. But, in the meantime, we are all waiting for FDA approval.

2. INCREASE TESTING CAPACITY
Getting more test kits is not enough. We have to get more labs. The good news is that we actually have them. We have 1,436 hospitals divided into 476 public and 960 private. The most sophisticated, around 10%, are Level 3, which are medical centers and teaching hospitals. Following the model of South Korea, we should harness the laboratory power, with the right biosafety protection, of these estimated 140 hospitals.

Because South Korea trusted its scientists, early on, to find the reagent mix to get ahead of the testing curve, it can now screen up to 20,000 people per day. That is the number we should aim for.

An increase in testing means an increase in COVID-19 positives. Can our healthcare system handle an increase, including the tracing and quarantining of Persons Under Investigation (PUIs) and (Persons Under Monitoring) PUMs?

3. REPURPOSE FOR BED TRIAGE
There are now three nationally run hospitals in Metro Manila for COVID-19. Not enough. A distraught family reports that, because of the long lines, it took 11 hours for their father to be admitted to the Lung Center — only for their father to die alone a day later.

We need to triage beds by repurposing what exists. We need to create community hospitals for the mild to moderately symptomatic and use Level 3 hospitals for severe cases needing advanced breathing support. More capacity is available with our LGUs. For example, on March 20, TMC’s President, Dr. Gene Ramos, met with Mayor Vico Sotto of Pasig to discuss converting the 100-bed Pasig City Children’s Hospital for COVID-19.

Let’s use ULTRA in Pasig, Rizal Memorial in Manila, for PUMs. Gymnasiums. Churches that can also feed with community support. Hotels lent to the LGUs. Schools, like De La Salle University, that open their doors to the homeless. We all need space to recover in densely populated urban areas, to quarantine PUMs, PUIs, and the mildly symptomatic and their families living in close quarters. A surprising 75-80% of the patients in China were from families and workers that infected each other.

4. INCREASE THE POOL OF HEALTHCARE WORKERS (HCWS)
The biggest constraint to managing patients descending on already crowded hospitals is the HCW resource. A few days ago, both St. Luke’s Hospitals announced 592 HCWs under quarantine. The University of Santo Tomas hospital declared 530. On March 27, TMC reported 122.

COVID-19 ICU patients need one nurse each, while coverage for regular COVID-19 patients/PUIs is one nurse to two patients. ER coverage is a bit of a stretch at four patients, non-COVID-19 patients/PUIs at four. TMC can convert more rooms in its 520-bed hospital for COVID-19 use, but if there are not enough doctors and nurses, then both patient and HCW safety are compromised.

There are 500,000 registered nurses in the Philippines, but only 200,000 are active. We average 38,000 nursing graduates annually, with about half passing their boards. Around 18,000 migrate yearly. Those who stayed transferred to the growing BPO market for insurance claims processing and online healthcare support where pay is higher. As for doctors, there are 130,000 registered, but only 70,000 practicing.

The Philippine Regulatory Commission should relax its three-year relicensing (CME) provision for doctors and nurses so that those who left for the BPO industry, or OFWs who returned to retire here, can be pulled in to help. Maybe nursing graduate Board takers in the last five years can be given special passes to man the gyms and churches. Maybe we can stretch the definition of HCW to those LGU community workers manning the public spaces.

We will also need to train these HCW assistants quickly. The National Institute of Health, UP Manila, is offering free Online Biosafety Training for Laboratorians handling COVID-19. We need to have a similar course for LGUs, community leaders, and volunteers. We can then mobilize more COVID-19 warriors quickly.

5. STOCKPILE PPES AND CRITICAL SUPPLIES
Our doctor mortality rate is at 20%. Spain, with 90 times our number of COVID-19 patients, has 14%. The lack of PPEs, coupled with the impending explosion of COVID-19 cases, shows the need to stockpile right now. We also need more ventilators so we do not have to face the situation in Spain and Italy where the lack of ventilators forced them to let the elderly die.

Look at the math. Italy had over 60,000 cases cycling through COVID-19 on March 28. If we emulated Italy, in one month, 20% (12,000) would need hospitalization. Of these, 4,000 need intensive care. For 24-hour intensive care, that’s two visits per shift per nurse, plus two from doctors. One full PPE (personal protective equipment) set — cap, goggles, face shield or N95 mask, disposable gown, booties — is P500, with 80% of the cost the mask and gown. PPE monthly cost for ICU cases alone is P480 million.

The private sector has already stepped up. Volunteers are making face shields while the garment industry is making laundry-washable head-to-toe bio-containment suits. New methods of sterilizing N95 masks to make it reusable are being deployed. All these can help bring per use PPE costs down by up to 90%.

The latest Philippine ventilator survey showed 1,572 for all regions, a quarter in NCR. We need at least 600 more mechanical ventilators to cover half the national ICU beds. That will cost around P1 billion — less if we can manufacture these locally.

We also need to prepare ICU tents to augment hospital capacity. Ideally, these tents should have negative pressure, and be equipped with ventilators to handle the patient load. Our estimates are that it will cost around P20 million for a 10-bed tent.

While stockpiling PPEs and medical equipment may seem expensive, running in the billions of pesos, we are foregoing an estimated P1 trillion of GDP production monthly because of COVID-19. There are trade-offs in time and money that we simply have to make right now.

 

Jose Xavier ‘Eckie’ Gonzales is the Chairman of The Medical City, the largest hospital and clinic network in the Philippines.





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