COVID-19 Pandemic Rearranges Oncology Practice, Policies at Seattle Cancer Care Alliance

As the Coronavirus disease 2019 (COVID-19) pandemic evolves, healthcare providers in the oncology realm are faced with a number of unforeseen challenges requiring immediate attention and swift changes in policies. Experts at the Seattle Cancer Care Alliance (SCCA) shared their insights and advice with the public in a recent article to demonstrate how they have adapted to provide the most optimal care for patients with cancer in light of the COVID-19 outbreak.

Challenges institutions face now include staff shortages due to potential exposure of school closures, limitations of resources, and impact on treatment due to travel bans. Reduced access to international donors for allogeneic stem cell transplants (SCTs) may pose a challenge. Hospital beds, mechanical ventilation, and other equipment are among some of the resources that are becoming scarce.

To mitigate some of these concerns, the authors from SCCA, which included those from the Fred Hutchinson Cancer Research Center and the University of Washington, recommended several proactive measures:

• Patient information can be provided with handouts, signs, web-based communication, as well as phone calls for questions and triage.
• The number of team members who enter a patient’s room should be limited. A no-visitor policy should also be adopted with rare exceptions, such as end-of-life circumstances.
• Hours of general hospital operations can be increased to limit any unnecessary use of emergency department resources.
• The use of soap and water should be prioritized over hand gel.
• Physicians should also consider lower thresholds for blood transfusions.
• Well visits, as well as elective surgeries, can be rescheduled; second opinion consultations can also be deferred, particularly when care is already appropriately established. Some procedures should be moved from inpatient to outpatient.

The importance of self-care, both within and beyond the healthcare community, should be emphasized. The health and safety of frontline staff should be prioritized, according to the authors, to ensure a safe work environment. A strict “stay at home when ill” policy should be reinforced, while institutions should also ensure that staff have access to testing. Travel bans can be put in place, and work-from-home should be enabled wherever possible to limit the number of individuals on-site.

SCCA Practice Changes and Policies in Action

Early identification of patients with respiratory symptoms was among the first steps taken at the SCCA. These patients were triaged and masked in order to reduce exposure to other patients and healthcare providers. Additionally, symptoms screening was put into effect at all entry points throughout the system for all patients, visitors, and staff for outpatient clinics and hospitals.

Symptomatic patients were separated to a secondary screening area for consideration for testing.

“In Seattle, we are fortunate to have early access to COVID-19 testing, which was rapidly scaled up, allowing staff to perform nasopharyngeal swabs for symptomatic patients meeting COVID-19 testing criteria on entering the facility,” authors wrote.

Educational resources were developed quickly and implemented in the form of handouts, signs, and online to provide patients and family members information on infection prevention. A phone triage line was also developed to address questions for patients with mild symptoms in the community in an effort to minimize exposure in the clinic and emergency departments.

Staff operated under a strict “stay at home when ill” policy and receive access to testing when symptomatic. A comprehensive testing policy was put into effect regarding testing staff, tracking results, tracing exposures, and defining return to work. However, all policies and guidelines should be consolidated into a web format for quick access.

Other preventative measures for staff included travel bans and enabling work-from-home.

As many patients are seen in the outpatient setting from different regions, there is a growing concern of exposing non-local patients to COVID-19. Staff shortages are also among concern in the clinic. Establishing a multilayer coverage system should be of priority in the event that healthcare providers need to be quarantined on short notice.

Well visits were rescheduled or referred for telemedicine practice, as well, to minimize the risk of exposure. Telemedicine efforts have rapidly evolved with expedited physicians credentialing, training, and modification based on changing regulations. Second-opinion consultations were also deferred if an appropriate treatment plan was already in place for the patient.

The center also increased their hours of operations, as well as acute evaluation capabilities, so that the emergency departments and hospital resources are reserved for those requiring higher-level care.

Shifts in outpatient care pose another logistical challenge in the clinic, but the authors said these decisions are relatively straightforward. For patients who are currently receiving chemotherapy or about to initiate this therapy, clinicians are faced with the challenge of deciding if treatment should be delayed. In patients with solid tumors, adjuvant therapy with curative intent should move forward despite the risk of infection. In addition, performance status  may worsen in patients with metastatic disease or the window to treat may be lost if their treatment be delayed.

A 2-week ban has been put into effect on elective surgery due to the limited availability of equipment, staffing, and other necessary resources. Overall, surgical intervention needs to be prioritized at this time, and although cancer surgery is not elective, a delay in surgery may be appropriate in some patients, such as those with early-stage hormone receptor-positive breast cancer. The decision-making process in these cases can be optimized with a surgeon-to-patient phone call.

There is similar or greater urgency for life-saving treatment in patients with aggressive hematologic malignancies. SCT, as well as cellular immunotherapies, may be curative treatments that cannot be delayed for those with aggressive cancers. However, travel bans are limiting the availability of donors for allogeneic SCT. Cryopreservation of donor products is recommended.

Providers are tasked with determining what treatments can be selected in an effort to lessen the immunosuppression, which can be moved from the inpatient to outpatient clinic, and which therapies can be delayed.

Clinical trial enrollment should be limited to those who are most likely to benefit from the therapy.A remaining challenge in the field is understanding to what extent therapies can be given to reduce the burden on the system that is now under stress.

“Cancer centers should make it their mission to do all possible to continue to keep their doors open to provide care, unless there comes a time when staff and patient safety are no longer tenable,” authors wrote.

More Hurdles to Overcome inTime

The authors expect that there will come a point in time in which channeling a large amount of resources for 1 individual patient may cause conflict with the greater social good. It is imperative that proactive end-of-life and palliative care discussions are made with patients who may become infected with COVID-19; the prognosis is likely too dismal in patients, for example, with late-stage disease or comorbid health conditions like heart or lung dysfunction, should they acquire COVID-19 and require mechanical ventilation.

While resources on COVID-19 are limited, healthcare providers are tasked to consider treatment considerations that are most likely to be successful, symptom-relieving, or lifesaving for their patients. Multidisciplinary teams should share in these discussions to help in the challenging decisions physicians are faced with.

Inpatient oncology units should prepare for potential shortages of beds and resources as COVID-19 continues to spread and cause the necessity of acute care and ICU beds for infected patients. Reallocation of units, hospital wards, and potential entire systems may be required during the pandemic. Blood shortages are also expected due to declines in blood drives. Stricter adherence to and consideration of lower thresholds for transfusions are also important at this time.

Creative solutions can be developedtocombat upcoming shortages. This includes encouragement of using soap and water over hand gel, limiting the number of healthcare providers that can enter a patient’s room, and reducing nursing procedures that require personal protective equipment (PPE).

Training regarding PPE should be updated and made available to all staff members on a daily and hourly basis. A no-visitor policy has been put in place for inpatient units, although there are rare exceptions such as end of life circumstances. While these decisions are difficult on both patients and families, as well as the medical staff, they are necessary in protecting the health and safety of the public.

Provider burnout is inevitable as the pandemic advances, and so the emotional and physical wellbeing of staff and faculty members should receive proactive attention. Priority should be given to frontline staff to assure a safe work environment. A conscious effort has been made at SCCA to reassign roles for staff who are immunocompromised or have significant comorbidities that put them at higher risk and to stress the importance of selfcare.

The future trajectory of the pandemic remains unknown, and so the healthcare community must prepare for any impact. Policies may change at any time, emphasizing the unique challenges providers must overcome at this time. The overarching goal is to continue providing safe and compassionate care for all patients with cancer.

“To many of us, this has become the health care challenge of our generation, one that modern cancer therapy has never had to face,” the authors concluded. “We will prevail, and when the pandemic ends, we will all be proud of what we did for our patients and each other in this critical moment for humanity.”

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Reference:

Ueda M, Martins R, Hendrie PC, et al. Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal [Published Online March 16, 2020]. Seattle, WA:JNCCN. doi: 10.6004/jnccn.2020.7560.