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Covid-19 HSE Clinical Guidance and Evidence

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NCCP advice on the management of patients undergoing radiation oncology treatment, in response to the current novel coronavirus COVID 19 pandemic

NCCP advice on the management of patients undergoing radiation oncology treatment, in response to the current novel coronavirus COVID-19 pandemic (CD19-100-008 / 06.12.21)


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 as agreed nationally. More information on the vaccine and its roll-out is available online from the HSE

Information for cancer healthcare professionals on vaccinations is available on the NCCP website

Receipt of the vaccine (by either healthcare workers or their patients) does not eliminate the need to use appropriate PPE and 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


Knowledge of patient’s COVID-19 exposure risk prior to attending

Consider contacting patients to ascertain their COVID-19 exposure status and vaccination status 24-48 hours prior to their planned attendance for treatment. This will also act to reassure those without exposure that their treatment will continue as planned. 

Patients should be re-assessed on a daily basis for any symptoms or history of contact, throughout their course of radiotherapy. 


Radiotherapy may be given as follows:
  • As per standard protocols.
  • A hypo-fractioned schedule should be considered (Please see ‘NCCP advice for medical professionals on acceptable dose fractionation during the novel coronavirus (COVID-19) pandemic’ for more information.)
  • Treatment deferred or stopped as per local recommendation.
  • Aim to prioritise curative category 1 cases and emergency radiation therapy.

Any change in fractionation should be approved by the local planning meeting or be based on a pre- agreed fractionation schedule.

Any changes to treatment protocol including deferral/ interruption should be discussed with patient. 

Planning meetings are essential during the COVID-19 pandemic.

If a planning meeting is not possible sign-off of the management plan should be in consultation with another consultant.
 

Communication with radiation oncology patients
  1. Communicate with patients and support their mental wellbeing, signposting to charities and support groups where available, to help alleviate any anxiety and fear they may have about COVID-19.
  2. Communication with the patient should be documented in the patient’s notes
  3. Patients should have the opportunity to discuss and consider the following when suggested by their Consultant:
    • Proposal for a treatment deferral or treatment break.
    • Modifications to their treatment to reduce the risk of COVID-19 infection.
  4. Patients who continue to attend for treatment should be:
    • Triaged prior to commencing treatment.
    • Advised to follow the relevant parts of the guidance of the NPHET, the HSE and the DoH on reducing your risk of exposure to COVID-19 including the benefits of vaccination.
    • Visitor Allowance - where possible, patients should have a relative or significant other with them at time of diagnoses, when bad news is being given or at the end of life, if this can be accommodated.
    • Advised to attend appointments without family members or carers unless approved by the Radiation Oncology centre.
    • Informed as to the steps being taken in the hospital to reduce the risk of infection by:

i. Minimising face to face contact by offering virtual consultations.

ii. Minimising the number of patients and time spent in waiting rooms.


Principles underlying treatment decisions

Underlying principles are:

a. Emergency radiotherapy will at all times be prioritised (Please refer to ‘NCCP advice on radiation therapy capacity escalation plan in response to the current COVID 19 pandemic’ for more information)

b. Effectiveness of radiation treatment can be significantly impacted by interrupting the schedule.

c. Delay in commencement of treatment is reasonable and is preferable to an interruption during the course.

d. All decisions to treat or defer will be based on clinical judgement and an individual risk assessment. 

e. Decisions on deferral or interruption of treatment are made on an individual basis taking into account risks and benefits.

f. Up-to-date infection prevention and control guidance will be followed at all times, with the support of local IPC teams. 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’ for more detail. 


Patient and COVID-19 exposure

In terms of COVID-19 exposure patients may:

a. Have confirmed COVID-19 disease

Where possible, defer treatment until the patient is clinically recovered and no longer infectious (defined as 10 days since onset of first symptoms and 5 days fever free, for hospitalised patients and those in residential care, the infectious period is 14 days with no fever for the last five days of that period), unless based on clinical judgement and risk assessment you consider treatment to be essential (e.g. radiotherapy emergency or radical definitive treatment). If proceeding with treatment, closely follow the specific infection prevention and control recommendations, within the unit and regarding travel to the unit.

b. Have been defined as a ‘close contact’ as per the HPSC definition but have no symptoms.

Ensure that these patients are triaged clinically each day, prior to treatment.

Household close contacts are considered higher risk of COVID-19 infection and PCR testing may be considered (e.g. Day 0, 5 and 10).

Certain close contacts of a confirmed case are advised to “restrict their movements” up to 14 days since last close contact, even where testing of the contact shows no virus detected. This includes patients who have not been fully vaccinated (defined as at least 14 days after an additional dose, where indicated due to immunocompromise) or patients who have been fully vaccinated but are significantly immunocompromised due to a previous solid organ, bone marrow or stem cell transplant.  

If they haven’t started their treatment, delay treatment until the 14 days has passed if possible. If they have already started or if you judge treatment to be essential, closely follow infection prevention and control guidance.  

Where COVID-19 testing of asymptomatic close contacts is not recommended at a population level, it can be carried out on those patients who are close contacts and undergoing radiotherapy where the information will inform a decision regarding treatment or where the information will impact service delivery. 


Infection Prevention and Control Considerations

Consult the most up-to-day information for health care professionals on the HPSC website and link with your local infection prevention and control team for specific advice. 

Review practices within the unit now, to reduce the risk from a patient with unknown COVID-19. 

This may include such measures as requesting all patients use the available hand sanitiser on arrival, asking patients to turn up no more than 15 minutes before their appointment, spacing within the waiting area, not to be accompanied within the unit. Review the treatment room set up to identify changes that can be made to aid cleaning and minimise risk of cross-infection, e.g. moving surplus supplies or equipment to storage areas. 

For COVID-19 patients, those with suspected COVID -19 and those who are close contacts, consider: 

a. How the patient will be transported to/from hospital and the treatment area

COVID-19 patients, those with suspected COVID-19 and those who are household close contacts should not be using shared transport.  A risk assessment should be made with the support of your IPC team, and specific advice sought as to appropriate precautions during travel to and entrance to the unit. 

b. IPC precautions during treatment

If a unit needs to treat a patient with known or probable COVID-19, follow the guidance on the HPSC website.

This includes advice on correct use of personal protective equipment (PPE); standard, contact and droplet precautions; waste and environmental cleaning/disinfection; including specific advice in relation to treatment rooms and equipment. 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’ for more detail.


Guidance Development Group
  • Dr Aileen Flavin - Consultant Radiation Oncologist (until Sept 2021)
  • Dr Caitríona McCarthy - Consultant in Public Health Medicine, NCCP
  • Dr Carol McGibney - Consultant Radiation Oncologist (until Oct 2021)
  • Dr Ciara Lyons, Consultant in Radiation Oncology, CUH (from Nov 2021)
  • Dr Clare Faul - Consultant Radiation Oncologist 
  • Dr Cormac Small - Consultant Radiation Oncologist 
  • Dr Eve O’Toole – Head of Evidence and Quality Hub, NCCP
  • Ms Ruth Ryan - Programme Manager, Radiation Oncology, NCCP 
  • Ms Louise Murphy - Research Officer, NCCP

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