COVID-19 is testing the medical community in unprecedented ways, and every specialty is grappling with its own issues and complications. How do you continue to deliver the highest standard of care to the greatest number of patients while preserving the health of providers? For many, it means continuing carefully constructed treatment plans despite the heightened risk.
To discuss these issues, UCHealth, Aurora, CO, recently participated in a webinar, Infusion Center Management During the COVID-19 Crisis, to share the challenges and best practices our oncology teams are employing. UCHealth has already been managing suspected and confirmed COVID-19 cases across the health system.
It is worth reiterating that this is an evolutionary process—practices are constantly changing as we learn more about the disease, and the volume of COVID-19–positive cases increase. Many questions remain in the planning of and daily execution of policies. However, to assist other organizations in establishing or adjusting their operations, it is essential that health systems around the world aggressively and regularly share strategies and lessons learned.
This article provides details on how we have approached, or plan to approach, specific issues related to resource allocation, patient care, operations, and staffing.
Resource Allocation
Many people have questions regarding the use of masks, including which types are suitable for which tasks, how long they should be worn, and when they should be replaced. The current UCHealth Cancer Care’s practice is to provide all patient-facing staff and providers with a regular surgical mask. N95 masks are reserved for those performing procedures that require more protection. In such cases, teams use appropriate personal protective equipment (PPE), such as gloves, gowns, masks, respirators, and eye protection.
UCHealth has taken a very serious and proactive approach to PPE conservation. We have implemented a central distribution model to safeguard our supply of PPE. At the start of each shift, practice leaders get their allocation for the day. Staff are each allotted one mask for the entire shift, unless it becomes visibly soiled or broken.
This process allows us to better control where PPE goes, and provides greater visibility to run rates at each campus and across our health system. This centralized system enables everyone to get what they need, but no more than they need. However, there are exceptions. When staff perform tasks such as accessing ports or setting up lines, they are using gloves, gowns, and masks. Protective eyewear is also available when appropriate. We are also beginning to deliver certain medications without a gown to conserve resources. UCHealth is not presently utilizing fabric or homemade masks because our PPE supplies are adequate to protect our patients and staff.
To create appropriate social distancing in our treatment areas, we have reduced the number of infusion chairs available. Deciding how to do so depends on the size of the area, the geographic layout, and volume levels at each site. We have ensured that each infusion chair used is ≥6 feet apart. In some areas, we seat patients in every other chair; in other areas, we have removed some chairs.
After recalibrating our chair count in each center, we worked with LeanTaaS to create optimized and level-loaded templates to provide a safe environment for patients and staff. We were able to implement this across 5 UCHealth sites right away. We factored in constraints (eg, pharmacists, nurses) using sophisticated logic so that the scheduling decisions we were making in real time were appropriate.
Patient Care
Who receives what type of care in the present environment is one of the most difficult areas to define. This is further complicated when a patient is experiencing COVID-19 symptoms yet is due for chemotherapy or immunotherapy.
The first step we made was to postpone elective surgeries. We then deferred or converted all routine follow-up with providers to virtual visits, first for high-risk patients and then for all patients. We are working with our clinical pharmacists to convert from intravenous to oral therapy where possible and clinically appropriate. We are also evaluating home care options so that patients can remain safe in their living room and out of the hospital.
To determine whether to treat patients who have already tested positive for COVID-19, UCHealth broadly relies on 2 pieces of guidance. First, the American Society of Clinical Oncology recommends weighing the benefits of therapy against the risks for being exposed to, or having side effects from, being positive with COVID-19.1 This requires using our best clinical judgment to make a determination. Second, and what has perhaps been more helpful, comes from the Centers for Disease Control and Prevention.2 Its recommendation is that patients can continue with therapy once their fever has broken for 3 days or the onset of symptoms is >7 days, which we have seen already. Ultimately, however, the treatment decision is unique for each patient and provider.
For suspected or confirmed COVID-19 outpatients, we are caring for them in private rooms within a cohort unit. Rooms are thoroughly cleaned between patients. Currently, UCHealth’s model is a combination of dedicated staff, advanced practice providers, and a rotation of a physician who routinely cares for patients.
When it comes to prechemotherapy clearance visits, we are using several creative combinations, including virtual, to decouple the infusion visit from the provider visit. For example, a patient might be in the building but not in front of the provider, or the patient is in his or her vehicle and the provider is in the clinic. Fortunately, our providers and patients have been flexible regarding how care is administered in the interest of everyone’s safety.
Operations
There has been some debate in the industry about whether to prescreen patients. We have found that prescreening, in addition to screening patients when they enter the facility, works best to help us manage patient flow. Prescreening approximately 12 hours in advance helps us to plan for people who may need to be fast-tracked when they arrive. It can also prevent people from traveling far distances when ill-advised. For last-minute cancellations or no-show patients, we use that time to do different work, such as outbound calls or communicating via the patient portal.
Prescreening criteria have and will continue to adapt to the changing crisis. In the first days of our response, we implemented travel screenings for patients who had recently visited international hotspots. As the pandemic spread, we added questions about any known contact with anyone who had recently traveled to these locations or was suspected to have the virus. Eventually, we moved to symptom-based screenings. Currently, the symptoms we are screening for are fever, cough, and other respiratory symptoms. If an organization must choose between prescreening and screening at the door, our experience so far suggests it is probably more important to do screening at the front entrance.
We have had to impose strict rules regarding visitors. Initially, we discouraged them. Then we limited the number of visitors per day, and now we are prohibiting inpatient visitors with extremely limited exceptions. We understand this is a difficult decision that a lot of our colleagues are facing right now. We have made exceptions for outpatient caregivers when the patient has significant physical, cognitive, or emotional support needs. All caregivers are screened and provided masks.
Physical dependencies, such as those who need help from the car to the door, and cognitive support, such as difficulty understanding what is happening, are more straightforward. Emotional support gets trickier. As with emotional support animals, people may be inclined to take liberties with the definition.
We are also encouraging patients to have their lab work done externally. This enables them to get in and out faster and decreases the volume and touch points in the laboratory itself. We have a centralized lab draw area, which geographically is a difficult area for distancing because of its size, so we are actively trying to decentralize it as much as possible.
Staffing
There are several concerns regarding the best way to leverage staff members to preserve their health and avoid overtaxing our personnel. We are using an aggressive work-from-home approach complemented by a shift to working behind the scenes. After moving any staff members to work-from-home who could do their job that way, we redeployed other staff members to off-stage locations and duties. This may entail taking clinicians or administrative staff who work at the front desk and spreading them out into spaces vacated by people working from home.
We have created a jeopardy plan and multiple backups for that plan. This was done on a disease team–based level. Each team created independent plans for staff and providers. We are also developing plans across teams. For example, if our breast cancer team members need support, members of the genitourinary team can be their cover. Currently, each plan goes 2 weeks into the future. We want our staff to be prepared to leap into action.
It is essential that personnel stay safe and fresh in this very stressful situation, so we are insisting they rotate off. Our staff members are volunteering for the most part, but we are in the early stages of a medical crisis that we anticipate lasting for a while.
Responding to this crisis means that we are forced to live in some gray areas. We have an organization wide hotline with nurses managing a triage phone line to help employees get checked. We are testing providers and staff who have been in contact with positive or high-risk patients if they exhibit symptoms. For those who do test positive or with pending results, we are discussing redeployment of those who are asymptomatic and working in isolation from home.
There is always risk involved, but we also have an urgent need to match a shrinking healthcare workforce with growing patient numbers. Again, this is certainly not an exhaustive discussion of all the issues and questions that arise, but we hope it will generate more knowledge-sharing as we work together to get through the pandemic.
Ultimately, our immunocompromised patients are demonstrating an inspiring commitment to continuing their care. These folks are already facing life-altering situations on their cancer journey. We are deeply humbled by their trust during an uncertain time for everyone.
References
- American Society of Clinical Oncology. COVID-19 patient care information. www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19. Accessed March 27, 2020.
- Centers for Disease Control and Prevention. Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance). www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html. Accessed March 27, 2020.
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