On 23 March 2020 the UK was placed in lockdown to try and counter the rising number of cases of COVID-19. Even before this date, hospitals were preparing for the pandemic with significant changes to practice.
As an oncology hospital, we were faced with difficult decisions surrounding maintaining a service and not compromising patients’ cancer management without unduly increasing patients’ risk of mortality or morbidity from COVID-19.
Four months later our service has dramatically changed on a number of occasions in line with the course of the pandemic to this point. In this example we will highlight some of our escalation strategies that have been successful in the hope these may prove useful or prompt discussion in the face of a potential second wave of cases over the winter period.
Practice in this example draws from NICE’s rapid Covid-19 guideline NG161: delivery of systemic anticancer treatments and describes how recommendations in section 1 and 3 can be implemented in practice.
In February 2021, NICE updated a number of recommendations in this guideline. The example has been reviewed and continues to align to the updated guidance (NG161) which should be referred to if replicating any aspect of this example
Authors: Dr Thomas Wilson & Dr Stephen Falk
Example
Aims and objectives
Bristol oncology team aimed to continue to run an effective cancer service during the COVID-19 pandemic without exposing patients to unnecessary increased risk of infection or serious outcomes from COVID-19.
For each patient, the risk from COVID-19 exposure had to be weighed against the risk of not receiving cancer treatments. We aimed to limit visits to secondary care. Where visits were unavoidable, we aimed to create the safest possible environment for both patients and staff in our inpatient and outpatient environments.
We accepted that some patients would have treatments, imaging and follow up delayed but success would be gauged if the vast majority of patients received standard of care management on schedule without seeing large numbers of patients diagnosed with serious COVID-19 infections.
Reasons for implementing your project
On 31 December 2019, China reported a cluster of cases of a new viral illness causing respiratory complications. It was later reported the earliest symptoms in these patients occurred back on 8 December 2019.
The first confirmed case of COVID-19 in the United Kingdom occurred on 31 January 2020 (1). From the beginning of March 2020 it was clear the UK was likely to face a significant outbreak of COVID-19 that would impact all hospitals.
Many specialties were able to safely reduce their patient workload in preparation to allow for staff, ward beds and outpatient areas to be reassigned to manage COVID-19 positive patients. However, we were in agreement that oncology services should not be stopped and treatments, assessments and admissions would continue with new procedures in place to increase safety for patients and staff. At the time of publication (3 August 2020) there have been over 305,000 confirmed cases of COVID-19 in the UK causing over 46,000 deaths (2).
There is limited data on cancer patients’ morbidity and mortality after exposure to COVID-19, although, reassuringly, some studies are now emerging suggesting that mortality is driven more by advancing age and non-cancer co-morbidities (3). However, it is reasonable to consider patients on active anti-cancer treatments to be at increased risk of exposure to COVID-19 due to the number of visits to hospital environments and at a potentially higher risk of death due to the immunosuppression from treatments such as chemotherapy and potentially increased immune mediated inflammatory response leading to excessive tissue damage which might be stimulated by immunotherapy treatments.
Practice in Bristol prior to the pandemic was for patients to be reviewed face to face in outpatient clinics as new patients, prior to each cycle of anti-systemic treatment and as part of routine surveillance. The majority of anti-cancer treatments were given in our dedicated chemotherapy unit within the same building.
Patients had pre-treatment blood tests performed at either their GP practice or in the oncology hospital within 48 hours of treatment. Radiotherapy also takes place elsewhere within the oncology hospital. Post-treatment, all patients are provided with a 24-hour emergency hotline number to speak to an oncology nurse. Patients are assessed in a dedicated acute oncology unit which provides a significant proportion of admissions to our inpatient ward.
Our hospital has a six-bed teenage and young adult unit which is separate from our main oncology ward. We determined that continuing with our current practice posed a significant risk of a rapid spread of COVID-19 between patients.
1) - https://www.bbc.co.uk/news/health-52935644
2) - Google UK coronavirus case tracker
3) – Lee L, Cazier J, Starkey T, Turnbull C et al. COVID-19 mortality in cancer patients with cancer on chemotherapy or other anticancer treatments: a prospective cohort study. The Lancet. June 2020. 395 (10241): 1919-1926
How did you implement the project
In March, we switched from face to face outpatient clinic appointments to an almost entirely telephone-based outpatient service, initially, working in the same teams although later registrars were removed to cover an increasing inpatient workload. We are now seeing new patients face to face and we have set up the option of video consultations.
The standard prescription length for some oral medications was increased to reduce appointments. Medications including oral anti-chemotherapy are now sent to patients’ home addresses to avoid needing to break shielding. Patients established on immunotherapy have been switched to longer regimens. These service changes underpin how recommendations in section 1 and 4 of NICE NG161 on communicating with patients and modifications to usual service, can be introduced in practice for staff and patients.
Patients were assessed using the prioritising systemic anticancer treatment score (an updated version of which) is set out in recommendation 3.3 of NICE NG161 to facilitate frank discussions with patients about the appropriateness of receiving treatments during the pandemic. In each tumour site, management was evaluated and some standard practice altered to reduce fractions of radiotherapy, delay chemotherapy and proceed with surgical managements rather than neo-adjuvant chemotherapy where appropriate without compromising patient care.
One of our key objectives was to limit entry to our cancer hospital. All intravenous anti-cancer treatments were moved off site. This unit allowed social distancing to be maintained and increased capacity to avoid the need for satellite units. This unit had registrar and pharmacy cover onsite. The majority of pre-treatment blood tests have been performed by primary care or taken in a dedicated pod outside the hospital.
Our hospital has an oncology and haematology ward on separate levels. These were repurposed into a clean ward for patients who had tested negative and a second ward for patients awaiting test results. We had a separate unit for patients with COVID-19 symptoms. This unit was expanded at the peak of the pandemic to include the entire second ward. Separate acute assessment units were used for potential positive patients and those deemed unlikely to have COVID-19.
Single point entry to the hospital was instated, where all patients and visitors were screened. Visitation has been limited, although exceptions were made for patients at the end of life. Separate staffing was implemented for clean, potential positive and confirmed positive areas. Junior doctors provided cover for all inpatient areas onsite 24 hours a day. A shadow rota was implemented to cover sickness or self-isolation. Separate consultants provided inpatient cover to clean and positive areas.
Clinical trial investigators were to discuss ongoing treatments and follow up for patients with arrangements made to avoid unnecessary trips into hospital. We are planning to reopen trial recruitment which was paused due to staff reassignment during the pandemic.
To facilitate rapid decisions and communication, task groups were set up between registrars, consultants, senior nursing staff and management. At the peak of the pandemic these groups were meeting daily. Weekly meetings via zoom were set up between registrars and training programme directors to facilitate discussion about patient management, service provision and training. A weekly teaching programme via Zoom, provided by consultants was created and has been ongoing to ensure ongoing training.
Key findings
During this challenging time period every specialty has been forced to rapidly adapt services to help hospitals cope with the COVID-19 pandemic. Our principle aims during this time period were to keep patients and staff safe and continue to provide an oncology service that would not compromise patient outcomes.
So far we have been largely successful due to the hard work, flexibility and dedication of staff. Anti-systemic cancer treatments have been delivered throughout this period and our capacity to treat patients safely in a dedicated outpatient environment has actually increased. By managing oncology patients potentially positive for COVID-19 within our own unit we have reduced the pressure on acute medical services.
A large proportion of patients reviewed in acute oncology have symptoms in-keeping with COVID-19, the majority of whom were found not to be positive. By managing our own patients, we’ve been able to balance treating potential COVID-19 and side effects from anti-systemic treatment or symptoms from the underlying cancer diagnosis. To date, 292 haematology and oncology patients have been reviewed through our COVID-19 assessment unit, of these there were 6 deaths in patients who had tested positive for COVID-19.
During the pandemic a dedicated palliative care team has been located with the oncology hospital. All patients had escalation and resuscitation discussions at admission including management if they were to become COVID-19 positive. Appropriate patients were transferred to high dependency care beds and we are extremely grateful to our colleagues in these areas for their advice and assistance in treating cancer patients very unwell from COVID-19.
We have cautiously returned much of our practice to a new normal, although with a significant reduction in patient attendance for outpatient clinics.
We feel we have a successful blueprint ready should a second wave of cases occur during the winter period.
Key learning points
Our blueprint for providing an oncology service during the COVID-19 outbreak was constructed throughout the five-month period since the virus arrived in the UK.
It has been fluid and has heavily relied on the dedication and goodwill of staff who have sacrificed holidays, time with their families and put themselves on the frontline to not only treat patients with coronavirus but also to ensure oncology services have been able to continue.
At each point during the pandemic we were proactive in escalating our COVID-19 services in anticipation of rising patient numbers rather waiting for current plans to be overwhelmed. Increased communication, particularly between junior doctors, consultants, nursing staff and management has rapidly highlighted problem areas and facilitated early changes in practice.
By limiting visits to the hospital, moving our chemotherapy delivery to a separate unit and changing to delivering medications to home addresses we have been able to keep our patients as safe as possible during this time period.