key: cord-1028280-mus6ul14 authors: Suárez, Vladimir; Moreno-Olmedo, Elena; Pérez, María; González, Esq. José; Rivas, Daniel; Fusco, Juan; Kechagioglou, Penny; Lopez, Escarlata title: Spanish risk management framework across 17 radiation oncology centers during COVID-19 pandemic date: 2020-05-29 journal: Radiother Oncol DOI: 10.1016/j.radonc.2020.05.041 sha: 09157268cd2e4809bae0814fd001be258fe130bc doc_id: 1028280 cord_uid: mus6ul14 The COVID-19 pandemic has impacted our healthcare systems and the rapid introduction of new protocols that have been required to keep patients and workforce safe. In order to maintain activity with radiotherapy clinical assistance, we have implemented different measures in our centers from a patient and staff safety perspective. 2 Summary: The COVID-19 pandemic has impacted our healthcare systems and the rapid introduction of new protocols that have been required to keep patients and workforce safe. In order to maintain activity with radiotherapy clinical assistance, we have implemented different measures in our centers from a patient and staff safety perspective. Keywords: COVID -19, SARS-CoV-2, radiotherapy, MDT, safety 3 The current SARS-CoV-2 pandemic situation has significantly affected the normal activity of healthcare systems. Measures for controlling the spread of the virus include keeping patients and workforce safety procedures in radiotherapy (RT) centers where there generally a close contact during treatment delivery (1-4). Patients with cancer are particularly fragile in this COVID-19 crisis. On the one hand, their survival will depend most frequently on tumor aggressiveness and appropriate treatment for it; on the other hand, continuous visits to the hospital will expose them to an increased risk of becoming infected (5), so they are "swimming against the tide" and are in real need for medical advice and special care (6) . Radiation treatment is part of the integral cancer treatment and about 50% of all patients who are diagnosed with cancer require radiotherapy at some point in their treatment (7) . Our experience during the crisis has focused on four different aspects: patient and staff safety, implementation of alternative radiotherapy schedules, psychological approaches, and establishment of a COVID-19 multidisciplinary team (MDT). Since the beginning of the outbreak, Spain could not do massive testing due to the lack of Polymerase-Chain-Reaction (PCR) tests. Therefore, COVID-19 MDT was created to handle positive or suspected positive patients and workforce, individualizing case assessment and collecting all the incident report form. Hypofractionated-based schemes minimize the time that the patient stays at the center (8). Furthermore, RT can be used as a temporal bridge to avoid chemotherapy immunosuppression. Psychological care may help patients to overcome the fear of infection and keep patients on treatment (6). From our point of view, the workforce could also be extremely impacted. Our psychooncology team and an external online coaching assistance has been implemented to support our patients and staff. Procedures were implemented even before the state of alarm in Spain was declared on the 13 th of March, when the incidence of COVID-19 began to rise in our country. Standard protective measures have been implemented across all national units; staff are being instructed to use face masks, hand washing with soap, and hydroalcoholic solutions, 4 also, to avoid close contact with patients and maintain appropriated distances. Daily cleaning and disinfection of the areas is reinforced. Moreover, patients are instructed to call in case of suspicious symptoms and they pass through a robust triage process when arriving to clinic in order to rule out fever or respiratory problems. These steps maintain a clean circuit for patients in avoiding the risk of viral spread. A patient´s treatment priority needs to be established on a patient-by-patient basis according to different factors; tumor type and staging, intention-to-treat, general patient status and potential RT schedule approach. Tumor categorization protocols have been established to determine priority for RT delivery. Five categories have been determined, mainly based on tumor histology: rapid access (<14 hours or in the same day), A category (<5days), B (>5 and <10 days), C (<4-6 weeks), D (>6 weeks). With this, patients with high priority, i.e. lung cancer, will start treatment in a period no longer than 5 days, while lower-priority patients may have their treatment delayed for more than 6 weeks or even wait for the pandemic to resolve in particular cases. In order to guarantee the operation of our centers and the continuity of patient treatments, several back-up teams have been created. These support teams are made up by at least one Radiation Oncologist, a receptionist, a nurse and two radiotherapists. These staff members work from home by making patient review consultations over the phone. Staff members have remote access to our electronic medical reports, as well as to patient history and treatment planning software. As volume delineation can be performed remotely, planners and physicists are working from home. In addition, these teams are ready to go to any center that requires help or to replace usual equipment. Moreover, the staff on quarantine can work from home doing patient remote follow-up, data entry, or telephone and/or video consultations. In this COVID-19 era, oncologists have adapted to these new ways of communicating and working, which will probably stay until the end of this crisis. Safety measures have been implemented from the 2 nd of March across the 17 national centers, six of them located within different hospitals, and across 224 staff members, including physicians, nurses, physicists, radiotherapists and administrative personnel. Among the staff, only 18 (8%) developed a confirmed or suspicious COVID-19 infection and had to quarantine. Diagnosis was confirmed in seven members by PCR. Since the implementation of COVID -19 MDT back on March 7 th , 36 suspected cases were discussed and 21 out of those 36 were diagnosed with COVID-19 by the PCR test. In addition, 7 out of the 21 corresponded to workforce and the 14 remaining were patients under treatment. Unfortunately, 15 out of the initial 36 suspected cases could not be tested due to the lack of available tests in Spain, 11 were staff members and four were patients. These cases were directly isolated in quarantine due to high clinical suspicion. To sum up, the rapid implementation of these safety measures in our units has allowed us to continue treating cancer patients successfully. Introduction of priority staging systems, patient-by-patient case discussion and staff safety measures are mandatory. With a fast 7 evolving landscape, where governmental indications may vary from day-to-day, management operations have also been implemented consistently; by the implementation of MDTs, with expertise not only in the Radiation Oncology field, but also from the legal, epidemiological, human resources, and economical perspective to improve workflow models and make decisions to protect both healthcare providers and patients. Priority stage systems, patient-by patient case discussion and centers providing clean circuits are mandatory in this situation. However, isolation will end soon in our country and we expect a rebound of patients during the following months to come, due to delayed diagnosis. Therefore, we are anticipating strategies to set our departments up for this short-term future, in terms of avoiding collapse and growing waiting lists. Data collection The official French guidelines to protect patients with cancer against SARS-CoV-2 infection First statement on preparation for theCOVID-19 pandemic in large German Speaking University-based radiation oncology departments Radiation therapy during the coronavirus disease 2019 (covid-19) pandemic in Italy: A view of the nation's young oncologists Cancer guidelines during the COVID-19 pandemic Cancer patients in covid-19 era: Swimming against the tide cancer patients in SARS-CoV-2 infection: a nationalwide analysis in China COVID-19: Global radiation oncology's targeted response for pandemic preparedness How decision makers can use quantitative approaches to guide outbreak responses