There have been delays in planned cancer care during the COVID-19 pandemic resulting in a backlog of diagnostic and elective surgical work. Additional Infection Protection and Control (IPC) measures to protect clinically vulnerable patients and to reduce the risk of nosocomial infection have added to these delays by mandating a 14 day isolation period and a negative SARS-CoV-2 swab prior to admission. Modelling studies suggest delays in elective cancer treatments could result in additional cancer related mortality (1). Amongst other risk factors, patients with cancer and those undergoing major surgery have an increased risk of COVID-19 related mortality (2).
Recently, ’NICE COVID-19 rapid guidance: arranging planned care in hospitals and diagnostic services’ (NG179) was reviewed by an expert working group. In particular, the group reviewed guidance related to minimising the risks associated with COVID-19 and adopted a risk stratified approach to isolation prior to planned care.
- Sud A, Jones ME, Broggio J et al. Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic. Annals of oncology. 2020;31(8): 1065-1074
- COVIDSUrg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV2 infection: an international cohort study. The Lancet. 2020;396(10243): 27-38
Authors: Nadia Yousef, William Allum, Susanna Walker, Pascale Gruber, Eleanor Bateman
Aims and objectives
The COVID-19 pandemic has significantly affected the ability of the NHS to deliver planned cancer care. As a tertiary cancer centre, the Royal Marsden Hospital has continued to deliver as much planned cancer care as possible during the COVID-19 pandemic, however a ‘one size fits all’ strict IPC approach has made this challenging at times. Falling infection rates and the recent NICE guidance (NG179) provided the opportunity to implement a risk stratified approach to minimising the risks associated with COVID-19 for planned cancer care (diagnostics, surgery, chemotherapy and clinical trials).
Reasons for implementing your project
The Royal Marden Hospital Foundation Trust is a tertiary cancer centre across two sites (Chelsea and Sutton). Predominantly the Trust’s workload is from within the South West and West London Cancer Networks but, as a specialist cancer centre, the Trust has a high out-of-area referral rate for rare cancers, recurrent disease, treatment-related problems and clinical trials. We provide cancer diagnostics and treatments including surgery (inclusive of critical care), day case and inpatient systemic anticancer therapies and radiotherapy. In addition, we have a large clinical trials portfolio including a Drug Development Unit focusing on phase 1 trials.
On 14 May 2020, NHS England and NHS Improvement published an operating framework for urgent and planned services in hospital settings during COVID-19. The operating framework stipulated 14 days of self isolation for patients prior to admission. In addition, pan-London guidance extended 7-14 days of self isolation, including the household, to day cases and required a negative SARS-CoV2 swab as close as possible to admission. When these guidancedocuments were published, the 7 day average for the number of reported cases of COVID-19 in the UK was between 4000-5000. Despite a significant increase in testing since May, the 7 day average number of cases has fallen significantly to just over 800 cases on the 1 August (PHE dashboard).
The need for patients and whole households to self isolate has become increasingly challenging with the easing of lockdown restrictions, advice to return to work where possible and the imminent re-opening of schools. The self isolation rules are particularly intrusive for groups of patients who are admitted as day cases and for those frequently admitted for chemotherapy or treatment within clinical trials. Additionally, theatre and diagnostic capacity has been lost due to an inability to fill empty slots due to last minute cancellations. Despite this and due to the nature of our work, we treat a large number of clinically vulnerable patients.Therefore excellence in IPC, especially in an inpatient environment, is central to keeping our patients safe.
At the end of July, NICE published COVID-19 rapid guidance NG179: arranging planned care in hospitals and diagnostic services. This guidance allowed for some flexibility, advising that patients at greater risk of getting COVID-19 or having poorer outcomes may want to self isolate. However other groups of patients could follow comprehensive social distancing and hand hygiene measures.
This guidance provided us with the opportunity to review the planned care pathway for our patient group.
How did you implement the project
We formed a multi-disciplinary working group which consisted of IPC team, microbiologists, anaesthetics, surgeons, oncologists and managers. We also took into account feedback from groups of patients who found 14 days of self and household isolation challenging. All members of the working group reviewed the NICE guidance and the evidence related to COVID-19 related mortality and morbidity in patients with cancer. The working group was also familiar with the hospital infrastructure. As a result, we changed the 14 day planned care isolation guidance to a risk stratified approach described below:
All patients should follow comprehensive social distancing and hand hygiene measures for at least 14 days before admission.
- All day case procedures including endoscopy and planned admissions to the drug development unit: a negative SARS-CoV2 swab <72 hours prior to admission. Following SARS-CoV2 swab, patient to self-isolate until admission.
- Non-major surgery requiring admission and inpatient chemotherapy: patient must self-isolate for 7 days and a negativeSARS-CoV2 swab <72 hours prior to admission.
- High risk patient group and those undergoing major surgery (e.g. requirement for critical care, haemato-oncology patient): patient to self-isolate for 14 days prior to admission and a negative SARS-CoV2 swab <72 hours prior to admission. The patient’s household are encouraged to self-isolate with the patient where possible.
In addition, over the course of the previous few months we have implemented both symptomatic staff and patient testing programmes and regular asymptomatic staff and patients SARS-CoV2 screening programmes which have given us the ability to carefully monitor the incidence of infection amongst our staff and patient populations.
The need to be agile based on the community and hospital prevalence of COVID-19 was also agreed. Therefore, a review point was decided: 2 positive SARS-CoV2 swabs over a 7 day period within the screened Royal Marsden patient/staff population.
The change in guidance was communicated widely with staff throughout the Trust via multiple routes; a Trust-Wide COVID-19 instant messaging group, team meetings, via the site management team and Trust wide internal email. In addition, in order to communicate the changes in guidance with patients and in order to ensure a mutual understanding of jargon such as ‘self-isolation’ and ‘social distancing’ we produced a patient information leaflet.
This new approach has only recently been adopted and therefore a full formal evaluation has not yet been conducted but there are a number of key findings detailed below.
This risk stratified approach has not, as yet, adversely impacted the incidence of nosocomial infection.
We have been able to safely manage patients on clinical trials who are not able to self isolate for 14 days due to planned trial related procedures and frequent planned admissions.
We are also better able to utilise day case diagnostic and surgical capacity as patients can be offered empty slots at relatively short notice. Additionally, we have not had to cancel or delay any planned care due to insufficient isolation since the implementation of the new guidance.
Informal feedback from some patients prior to the change in guidance was that they found the 14-day period of social isolation difficult to adhere to with impact on their work, finances, partners and child care. This was particularly onerous for those patients having day surgical procedures, non-major surgical patients and frequent admissions for treatment. Since implementing the new guidance and the patient information leaflet we have had anecdotally better patient compliance with recommendations and improved patient satisfaction.
Key learning points
The key learning points were the benefits of a multi-disciplinary approach to implementation and adoption of the new guidance. Taking into account patient feedback with regards to the practical adoption of processes outlined was also important to help rationalise the approach. We took into account the risks of COVID-19 transmission in different environments i.e. inpatient environments where patients may share open wards for days vs. outpatient departments.
Closely monitor infection rates in our local population though an asymptomatic staff and patient testing programme will help us remain agile and tighten restrictions should the incidence of infection start to rise.
Due to the complex nature of hospitals and planned care pathways involving multiple teams and departments, an iterative approach to informing staff of changes was necessary using multiple modalities of communication over a sustained period of time.
Following patients feedback we also took on board the need for better clarity on isolation procedures and with the help of the Trust’s Communications Team created a patient information leaflet to help improve understanding and compliance.