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Covid-19 HSE Clinical Guidance and Evidence

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Cancer Care - Radiation Oncology

NCCP advice on radiation therapy capacity escalation plan in response to the current COVID-19 pandemic (CD 19-096-005/07.02.22)


  • This document relates to patients who do not have COVID-19 or are not suspected of having COVID-19.
  • Current events surrounding the COVID-19 pandemic are challenging and all public health bodies are placing the safety of patients, staff and communities first in all decisions.
  • This is an evolving situation. This advice is based on current information, it is additional to the advice of the NPHET, the HSE and the DoH, and will be updated as necessary.
  • The NCCP acknowledges that each hospital is working under individual constraints, including staff and infrastructure, and as a result will implement this advice based on their own unique circumstances.
  • The purpose of this advice is to maximise the safety of patients and make the best use of HSE resources, while protecting staff from infection. It will also enable services to match the capacity for cancer care to patient needs if services become limited due to the COVID-19 pandemic.
  • Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment.
  • COVID-19 vaccination is now available and is being rolled out to priority groups as agreed nationally. More information on the vaccine and its roll-out is available online from the HSE here: https://www2.hse.ie/screening-and-vaccinations/covid-19-vaccine/getting-covid-19-vaccine.html
  • Information for cancer healthcare professionals on vaccinations is available on the NCCP website at https://www.hse.ie/eng/services/list/5/cancer/profinfo/covid-19.html
  • Receipt of the vaccine (by either healthcare workers or their patients) does not eliminate the need to use appropriate PPE and to adhere to public health advice in relation to COVID-19.
     
NPHET, HSE and DoH advice

Hospitals will operate under the overarching advice of the National Public Health Emergency Team (NPHET), the HSE and the DoH. Information is available at:

The NCCP has defined a number of principles to underpin the delivery of cancer care, where this needs to be delivered outside of cancer centres or the usual designated place of care. These are outlined on the NCCP website at: https://www.hse.ie/eng/services/list/5/cancer/profinfo/covid-19.html

Purpose

This radiation therapy capacity escalation plan seeks to stratify appropriate adjustment of the clinical service dependent on the staffing level. This plan was developed based on the following principles:

  • Where possible those treatments that provide a chance of long-term cancer control or ‘cure’ will be provided and prioritised.
  • Treatments aimed at palliation alone or a minimal extension of life may have to be temporarily suspended during the peak of a COVID outbreak.
  • Those treatments which in which deferral for a 1-3 month period will have a minimum clinical impact (e.g. treatment of a basal cell carcinoma), should be deferred.
  • Patients who have commenced a course of radiotherapy or chemotherapy should be prioritised and supported in completing their treatments.

Please see ‘Children’s Cancer and Leukaemia Radiotherapy Group, Prioritisation of Paediatric and TYA Patients (with paediatric-type tumours) for Radiotherapy during the COVID-19 Pandemic.’ for guidance on paediatric cancers. Available at https://www.rcr.ac.uk/sites/default/files/paediatric-tya-patients-radiotherapy-covid19.pdf

General recommendations
  • To reduce transmission between staff or between staff and patients consult the most up to date information for health care professionals on the HPSC website and link with your local infection prevention and control team.
  • For radiation oncology guidance on PPE please refer to ‘NCCP guidance on the use of PPE by medical professionals when managing patients requiring radiotherapy in response to the current novel coronavirus (COVID-19) outbreak’.
     
Projected impact levels
  • For each of the clinical departments, the following are suggested impact levels as measured against normal roster staffing levels (1):

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Radiation Oncology Clinical response plan
  • Radiation therapists (RTs) are the largest single group within radiation oncology and are responsible for treatment planning and treatment delivery. However, the numbers of all staff involved in radiotherapy planning, delivery and maintenance should be considered when determining what radiotherapy level the service is functioning at.
  • Redeployment of staff may be necessary to maintain the service. During the COVID-19 response, it may be necessary to redeploy staff currently based within pre-treatment and treatment planning onto the treatment machines to complete treatments of patients already commenced.
  • During the COVID-19 pandemic, priority will be given to complete those treatment courses already commenced.
  • The response plan below describes the proposed plan for patients who have not yet started treatment.

oncology march 0921
 

Prioritisation of patients during COVID-19 pandemic
  • Cancer patients are considered a high risk group with a poorer outcome if they develop COVID-19 infection (2,3,4).
  • For this reason we need to strive to keep our radiotherapy departments COVID-19 free.
  • During the COVID-19 pandemic, the capacity of public centres is expected to remain at or below 80% because of the need for social distancing and rigorous infection control procedures.
  • Careful scheduling of patients is necessary.
  • As surgical activity increases, referrals for radiotherapy are expected to rise so clinical prioritisation will be extremely important to enable us to safely deliver radiotherapy.
  • The following table can be used as a guide for Radiation Oncologists in order to prioritise patients for outpatient, new patient assessment clinics and radiation treatment.
  • Utilisation of the private sector should be considered where available for the treatment of patients whose treatment is being deferred. Please refer to Principles underpinning the delivery of cancer care outside of cancer centres (or usual designated place of care) during the current novel coronavirus (COVID-19) pandemic for the principles of treating patients in the private sector. An SOP with the private sector is recommended.
  • ** Please note there are times when operating at Level 1 (80% capacity or above) when impacts on staffing capacity necessitates implementing some of the prioritisation as laid out in Level 2 without moving fully to Level 2. 

prioritylevel 096


Guidance Development Group
  • Dr Aileen Flavin - Consultant Radiation Oncologist,
  • Dr Cormac Small - Consultant Radiation Oncologist,
  • Dr Clare Faul – Consultant Radiation Oncologist,
  • Dr Caitríona McCarthy - Consultant in Public Health Medicine, NCCP,
  • Dr Eve O’Toole - Guideline Lead, NCCP,
  • Ms Ruth Ryan – Programme Manager, NCCP,
  • Ms Louise Murphy - Research Officer, NCCP

Bibliography
  1. Peter MacCullum Cancer Centre (2020), COVID-19 - DRO Clinical Response Plan V3 (Accessed 25/03/2020)
  2. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020; 21: 335-337.
  3. Onder G, Rezza G, Brusaferro et al. Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy. JAMA 2020. 323(18) 1775-1776
  4. Jordan RE, Adab P, and Cheng KK. COVID-19: risk factors for severe disease and death. BMJ 2020. 368.
  5. NICE guideline. COVID-19 rapid guideline: delivery of radiotherapy March 2020
  6. Children’s Cancer and Leukemia Radiotherapy Group, Prioritisation of Paediatric and TYA Patients (with paediatric-type tumours) for Radiotherapy during the COVID-19 Pandemic. Available at: https://www.rcr.ac.uk/sites/default/files/paediatric-tya-patients-radiotherapy-covid19.pdf

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