Optimizing Cancer Hospital Services in the Era of COVID-19 Pandemic

Abstract

The public sector cancer hospitals in Pakistan adopted a resource constrained approach to optimize cancer care delivery to their patients owing to the challenges imposed by COVID-19 pandemic. The cancer patients are immune-deficient, with lymphopenia and neutropenia, either due to the disease process or treatment induced (chemotherapy or radiotherapy). This makes them more vulnerable to all sorts of infections including COVID-19. The smart lockdown approach and transport restrictions enforced by the government remained very effective in controlling the spread of COVID-19, however these brought numerous logistic hurdles both to the cancer patients as well as to the cancer care providers. To prevent overcrowding at the workplace and maintain social distancing, the entire hospital staff was put on staggered duties and patients’ appointments were limited and curtailed.  A triage was set at hospital entry point where COVID-19 risk scoring was carried out to filter out patients as well as hospital staff suspected of COVID-19. A pass “COVID-19 risk score” of less than 3 was set to allow entry into the hospital. Awareness posters were displayed at hospital entry point, reception, registration, and waiting areas to guide patients and public about COVID-19 and the importance of adopting the preventive measures such as wearing of facemasks, hand sanitation and social distancing. The education and training of hospital staff regarding COVID-19 prevention, infection control, sanitization and disinfection of hospital building and equipment, donning and doffing of personnel protective equipment (PPEs) was carried out side by side. The cancer care services in nuclear medicine department were curtailed. All non-urgent nuclear medicine scans and aerosol generating procedures such as lung ventilation scan, cardiac stress testing and I-131 nuclear medicine therapy were cancelled or delayed. Alternate testing measures and other supportive therapies were prescribed, and patients were counseled to remain in contact with the hospital through teleconsultation.  In oncology department all indoor admissions were closed and patients were put on faster “day-care metronomic chemotherapy regimens” or oral maintenance therapies. In radiotherapy department radiotherapy start (RT-Start) prioritization was adopted, after a detailed peer review of each individual patient keeping in mind the urgent or emergent clinical state of the patient without compromising the treatment outcome.  During the COVID-19 pandemic, out of the 2091 cancer patients who underwent radiation treatment 27.6% were treated under priority-1 (RT-start within a week), 29.3% were treated under priority-2 (RT-start between 1-4 weeks) and 43.1% were treated under priority-3 (RT-start after 4 weeks). The radiotherapy workload volume was reduced by changing the standard of care radiation treatment protocols to quicker “hypofractionantion protocols” with similar treatment outcome, approved for pandemic situations by national and international radiation oncology societies. We found that this multifaceted optimization applied at various levels in our hospital helped in mitigating COVID-19 spread to the cancer patients along with continued and uninterrupted delivery of services by the hospital, during the era of COVID-19 pandemic.