By Louis Potters, MD, FASTRO

Three weeks feels like years when on any given day things change hour to hour. The transformation of our lives and jobs in caring for cancer patients has completely and utterly been remade in ways many of us never imagined. And the situation remains fluid and continuing to change further. It just happens that this is the first time in three weeks I have had time to reflect, even a little, on what has transpired.

As of March 26, Northwell Health has diagnosed 4,399 positive COVID-19 patients which is about 20% of NY State and 1.2% of all cases in the world. All cancer surgery was discontinued as of March 20 and all of our 23 hospitals are seeing COVID-19 admissions and ICU care became the primary focus of the entire system. As of today, we have reserved one floor in two hospitals for non-COVID care such as trauma. That’s it.

Radiation Medicine at Northwell consists of eight separate locations treating on average 280 EBRT cases a day, not including SBRT/SRS and brachy cases. That of course was three weeks ago.

During this crisis we have maintained two guiding principles: Do everything to keep the staff well and safe and maintain access to cancer patients needing our services.

To achieve these goals we have summarized five key takeaways:

1. Actively manage your staff
2. Decrease treatment volume
3. Implement telehealth
4. Multidisciplinary discussions are critical
5. Do not compromise on treatment safety

Actively Manage Staff

It is important to recognize that linacs do not treat our patients, people treat our patients. And without a workforce that is present and engaged we are dead in the water. Our techs are at the front line of COVID-19 potentially exposed to each other and to patients. Some will convert to positive and that will then domino through the staff. One needs to actively manage their anxiety and fears before and when that happens. We have done the following:

1. Decrease treatment volume
2. Spaced out, rather than bunch up treatments to decrease foot traffic through the department
3. Assigned two techs to treat patients only
   1. Either create manageable shifts for the techs or provide rotating breaks
   2. One facility has created treatment teams working every other day
4. Have a back-up plan ready
   1. We will have residents and attendings work with a tech to keep treating, if it gets to that.
5. Work from home
   1. Outside the obvious such as a rotating secretarial staff and billing staff working from home, we have instituted physics and dosimetry working from home
   2. Plan to need extra laptops and VPN access, especially for treatment planning off site
6. Daily Huddles
   1. The staff want to understand what is going on. They have many questions. As leaders we are provided with access to a lot of information that the staff do not have. It is vital to share as much with them as possible.
7. Be Flexible (and admit to that flexibility)
   1. Things change rapidly and we have written more policies in the past two weeks than collectively in the past several years. Be sure to communicate these changes effectively.
   2. Watch for ad hoc rule making. The staff will feel like they need to be proactive and may institute some ad hoc changes. Sometimes these are helpful and sometime, not.

Decrease Treatment Volume

It is important to decrease treatment volume. And it is critical to recognize that it will take up to two weeks to meaningfully lower volumes. You cannot start planning too soon.  We developed prioritization criteria and had an extended faculty case review of all pending treatment starts. On a first pass, we were able to re-prioritize with consensus 50% of our patients to delayed starts. As things are changing, that will not be enough and we continue to work on the list based on resources and volume at a local site.

Communication with patients is critical. They are anxious and scared. Documentation is also important. Once we achieve a satisfactory decrease in volume at our sites, we will develop a new start triage list to pre-plan the order in which these furloughed patients start treatment.

Prioritization Criteria

Priority I
These are cases where a delay of treatment may result in a loss of life, progression of disease or a permanent loss of neurological or other function. These patients are to be assessed and managed accordingly.

Priority II
Priority II patients may defer treatment for up to four weeks where such delay in treatment is unlikely to result in a loss of life or (significantly) negatively impact a patient’s prognosis.

Priority II patients may be seen in consult or contacted (by phone or telehealth) to ascertain their clinical condition and will be informed that their care is not urgent.

The majority of patients requiring radiation treatment will be considered as priority II.

Priority III
Priority III patients are those that may be delayed for greater than 30 days, where such delay in radiation treatment is unlikely to result in a loss of life or negatively impact a patient’s prognosis.

Examples of priority III patients include but are not limited to breast cancer and prostate cancer, but may also include any of our patients on a case-by-case basis.

Implementing Telehealth

If there is any one bright spot in this crisis is that the future has been thrust upon us. I doubt we will go back from telehealth. You will need to work with your hospital and health system to implement a telehealth strategy. A physician and administrative super-user will help with implementation. We have decided to install the systems in the examination rooms so that a consult can be performed along with the advanced care provider (or resident) and the attending. Another bright spot of telehealth is that it improves wait times as patients expect these interactions to start on time.

We did not wait for our telehealth system to be installed. We started two weeks ago with good old “Ma Bell” – calling follow ups and documenting. We also did not wait for billing codes but at present there are codes.

Multidisciplinary Care

As noted, all cancer surgery in our system has been cancelled. As a result there is a new found respect for organ preservation treatments. The irony is that we also have to prioritize care. It is important to continue with tumor boards and have the discussion about best options for patients and to actively manage patient lists together in order to develop the best path forward. An observation is that the culture of these discussions will evolve from denial to acceptance as the overall crisis takes hold. This is a good opportunity to strengthen our relationships across disciplines in the effort of doing the best we can for our patients.

Maintain the Culture of Safety

It is critical in a crisis to maintain the rules and policies you put into place regarding patient safety. This is not the time to relax them or allow for work arounds, but rather to assess and view these rules as the foundation of providing safe care. Opportunities to explore modifications of these rules given the COVID-19 crisis provides fresh perspective. We have refrained from making those changes at this time and rather, are cataloguing them for future discussion and potential changes later.