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Covid-19 HSE Clinical Guidance and Evidence

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NCCP guidance for Medical Professionals on the management of patients with head and neck cancer undergoing radiotherapy in response to the current COVID-19 pandemic

NCCP guidance for Medical Professionals on the management of patients with head and neck cancer undergoing radiotherapy in response to the current COVID-19 pandemic (CD 19-182/16.06.20)


  • 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.
     
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:

Purpose
  • To provide guidance for Medical Professionals on the management of patients with head and neck cancer undergoing radiotherapy in response to the current COVID-19 pandemic.
     
Multidisciplinary team meetings (MDT)
  • All patients should be discussed at an MDT as normal including discussion of routine staging (i.e. imaging and histology). 
  • Where radiotherapy does not provide equivalent outcomes such as definitive treatment of resectable oral cavity tumours, options of delays in surgery vs. inferior outcomes from radiotherapy/chemoradiotherapy should be carefully discussed on a case by case basis and decisions on management affected by COVID-19 should be carefully documented (Thomson et al., 2020).
  • The benefits and risks of adjuvant radiotherapy should be carefully considered especially in patients with intermediate risk factors for locoregional recurrence. 
  • Concomittant chemotherapy: Decisions on concomittant chemotherapy should be made in consultation with the patient taking into account patients comorbidities and risk of COVID-19 infection in potentially immunocompromised patients.
  • Please refer to ‘NCCP advice concerning Multidisciplinary Team Meetings (Cancer Case Conferences) in response to the current novel coronavirus (COVID-19) pandemic’ for more information.
     
Radiotherapy clinic assessments 
  • The number of staff members meeting a patient should be minimised. Guidance on PPE is detailed below in ‘Section 11: Radical radiotherapy treatment for head and neck during COVID-19 crisis: PPE guidance for staff’.
     
Nasoendoscopy
  • Nasendoscopy procedures should not be performed unless considered essential. Detailed discussion with surgeon in relation to prior EUA / surgical findings is strongly recommended to reduce need for nasoendoscopy. Guidance on PPE is detailed below in ‘Section 11: Radical radiotherapy treatment for head and neck during COVID-19 crisis: PPE guidance for staff’.
     
Dental Service
  • The Cork and Dublin Dental University Hospitals and other dental surgeries services are currently limited due to COVID-19. Patients should still be referred for dental assessment and treatment as per normal practice. Patients may be reviewed post radiotherapy as an alternative. Availability of customised dental stents may be limited. 
     
Allied Health Service
  • Virtual clinics should be conducted where possible in accordance with local policy. 
  • Please refer to ‘Guidelines for the use of Telecommunications within the Speech and Language Therapy clinical setting in the context of Covid-19 Pandemic’ for further guidance on Speech and Language Therapy.
     
Peer Review
  • Peer review such as planning quality assurance meeting should continue via videoconferencing.
     
Radiotherapy treatment and fractionation
  • Where patients are undergoing radical non-surgical treatment, consideration may be given to reducing treatment times (e.g. with hypofractionation), and/or withholding of chemotherapy in favour of radiotherapy alone, where appropriate. Examples of SIB IMRT hypofractionation schemes as alternative to 70/63/56 in 35 fractions include 65/60/54 Gy in 30 fractions, or, where volume is not large 60/50 Gy in 25 fractions as SIB. 
     
Radiotherapy treatment prioritisation and capacity 
  • Head and neck cancer patients are category 1 patients and treatment should be prioritized. Please refer to ‘NCCP advice on radiation therapy capacity escalation plan in response to the current COVID 19 pandemic’ for more information on stratifying appropriate adjustment of the clinical service dependent on the capacity level.
  • Treatment interruptions should be avoided as they are associated with reduced local control even for short interruptions. Patients who are suspected to have COVID-19 should have rapid for testing in order to minimize treatment interruptions.
  • Every institution should have a treatment protocol for calculation of compensation strategies to minimize the impact of treatment gaps.
     
Radical radiotherapy treatment for head and neck during COVID-19 crisis: PPE guidance for staff
  • ‘NCCP guidance on the use of PPE by medical professionals when managing patients requiring radiotherapy in response to the current novel coronavirus (COVID-19) pandemic’ details five broad groups of patients receiving radiotherapy during the COVID 19 pandemic requiring different levels of PPE. Group 1, 2 and 5 below are also relevant to healthcare workers treating head and neck cancer patients.
  • In addition ‘Group 6 Patients having a nasogastric tube/ scope inserted’ and ‘Group 7 Patients having an oral cavity examination’ are detailed below.
  • This is guidance only; there may be individual patients who require PPE over and above the group they would normally fall into.
Group PPE requirement

Group 1

Suspected or COVID-19 positive patients

Procedures that require high contact patient care and increased risk for transfer of virus to the hands and clothing of HCWs require:
  • Hand Hygiene
  • Long sleeved gown (single use/disposable)
  • FFP mask
  • Eye protection (visor or goggles) 
  • Surgical long sleeve gloves 

Group 2

Patients with tracheostomy (considered aerosol generating)

Procedures that require high contact patient care and increased risk for transfer of virus to the hands and clothing of HCWs require:
  • Hand Hygiene
  • Long sleeved gown (single use/disposable)*
  • FFP mask or surgical mask
  • Eye protection (visor or goggles) 
  • Surgical long sleeve gloves

* Where there is reduced availability of long sleeved gowns they can be replaced by another option such as a plastic apron in patients not suspected of COVID-19.

Group 5

All other patients.

All other patients. Procedures that require high contact patient care and increased risk for transfer of virus to the hands and clothing of HCWs require:
  • Hand Hygiene
  • Plastic apron (single use/disposable)
  • Surgical mask 
  • Gloves (disposable single use Nitrile Standard blue)

Group 6

Patients having a nasogastric tube/ scope inserted

Patients having a
nasogastric tube/ scope inserted Procedures that require high contact patient care and increased risk for transfer of virus to the hands and clothing of HCWs require:
  • Hand Hygiene
  • Long sleeved gown (single use/disposable)
  • FFP2/3 mask 
  • Eye protection (visor or goggles) 
  • Surgical long sleeve gloves

Group 7

Patients having an oral cavity examination

Patients having an oral cavity examination Procedures that require high contact patient care and increased risk for transfer of virus to the hands and clothing of HCWs require:
  • Hand Hygiene
  • Plastic apron
  • Surgical mask
  • Eye protection (visor or goggles) 
  • Gloves (disposable single use Nitrile Standard blue)
Admission of patients
  • Head and neck cancer patients with a tracheostomy, laryngectomy and other high risk patients being admitted should be placed in a single room.
     
BD treatment
  • Out-patients who are high risk for aerosol generation (e.g. tracheostomy) and patients with suspected COVID-19 or proven COVID-19 should not wait for prolonged periods between BD treatments in the department. Therefore BD treatment should not be done if an outpatient cannot be safely isolated between treatments. In-patients may be treated BD if locally feasible. This should be reviewed on a case by case basis.
     
Guideline Development Group
  • Dr Sinead Brennan, Consultant Radiation Oncologist, SLRON
  • Dr Orla McArdle, Consultant Radiation Oncologist, SLRON
  • Dr Kathy Rock, Consultant Radiation Oncologist, CUH
  • Dr Eve O’Toole, Guideline Lead, NCCP
  • Ms Ruth Ryan, Programme Manager, NCCP
  • Ms Louise Murphy, Research Officer, NCCP
     
References
  • Thomson, D.J., Palma, D., Guckenberger, M., Balermpas, P., Beitler, J.J., Blanchard, P., Brizel, D., Budach, W., Caudell, J., Corry, J. and Corvo, R., 2020. Practice recommendations for risk-adapted head and neck cancer radiotherapy during the COVID-19 pandemic: an ASTRO-ESTRO consensus statement. International Journal of Radiation Oncology* Biology* Physics.

 

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