Coronavirus (COVID-19): clinical guidelines for managing systemic anti-cancer therapy (SACT) and radiotherapy (RT) for COVID-19 positive cancer patients

Aim

This guidance is to support the development of local standard operating procedures (SOPs) for the safe delivery of systemic anti-cancer therapy (SACT) to patients who have tested positive for SARS-CoV-2 (COVID-19) within 14 days prior to attending SACT delivery clinical areas. It is recognised that some immuno-compromised patients may continue to test positive after the normal 14 day isolation period and evidence suggests that in some cases, there may be a risk of ongoing onward transmission of COVID-19.    

This guidance has been developed with reference to the National Infection Prevention and Control Manual – Standard Infection and Control Precautions (SICPs) and Scottish COVID-19 Infection Prevention and Control Addendum for Acute Settings.

The aim is to ensure that patients have access to the appropriate cancer treatment in a safe, effective and timely manner whilst also ensuring the safety of other patients and staff using and working in the department. This guidance will help ensure a standardised approach to the management of COVID-19 risk when developing local SOPs.

Key points applicable to patients who have tested positive for COVID-19

Patients who have been prescribed SACT and who test positive for COVID-19 should self-isolate as per national guidance i.e. 14 days from onset of symptoms or positive COVID-19 test. Should these patients require admission within the 14 days, they should be managed in line with the high risk pathway.

Patients who have been prescribed SACT and have completed the required 14 day self-isolation period and are considered recovered following a clinical review should commence or recommence SACT as soon as possible to ensure cancer treatment is not unnecessarily delayed. On admission for treatment, these patients should be managed as per the medium risk pathway.

Any patient who has previously tested positive for COVID-19 by Polymerase Chain Reaction (PCR) oral-pharyngeal nasal swab test should be exempt from being re-tested within a period of 90 days from their initial symptom onset, unless they develop new possible COVID-19 symptoms. Fragments of inactive virus can be persistently detected by PCR in respiratory tract samples for some time following infection. These patients should continue on the medium risk pathway unless they develop further symptoms in which case they should be transferred to the high risk pathway.

All asymptomatic and PCR negative patients attending a department should be considered as potentially incubating COVID-19 and managed as per the medium risk pathway.

Standard Operating Procedures (SOPs) should be developed in conjunction with local infection prevention and control teams.

Patients should never attend for an appointment or admission without having first had a pre-admission triage for COVID-19.

Patients undergoing SACT treatment continue to be at increased risk of acquiring other infections and potentially neutropenic sepsis therefore further consideration needs to be given to acute oncology pathways for these patients.

Consideration should be given to:

Patient information 

Written and verbal information should be available to patients and families prior to attendance in department that details:

• how and when to contact department if they become symptomatic, test positive, have been in contact with a possible COVID-19 positive case or have been asked to self-isolate by Test and Protect.
• travel considerations and advice when attending appointments - patients would be advised to drive themselves if they are able, be transported by someone/else in their household or bubble or by Ambulance Transport Service where physical distancing and cleaning can be facilitated.
• what they should expect when attending in relation to accessing and moving about department; face coverings; hand hygiene; Personal Protective Equipment (PPE); physical distancing; accompanying relatives/carers,  and importance of observing signage.

Prior to patient attendance at department

Once decision to treat the patient has been made by the patient’s medical team, key individuals of the multi-disciplinary team should be notified in advance of the patient’s attendance including Domestic Service Supervisor.

SOP should list key individuals.

Negative Pressure Isolation Rooms, if available, should be identified for the delivery of SACT treatment for those patients requiring placement on the high risk pathway.

Pre-assessment for treatment – limit the number of physical attendance within department by use of telephone assessment where possible; use of community hubs for pre- treatment bloods etc.

Appointment scheduling – patients who have previously tested positive in the last 90 days or considered high risk should be scheduled to have assessment, pre-treatment tests (bloods/ ECG) or treatment at a time where there are less opportunities for them to come in contact with other patients and when additional cleaning between patients can occur e.g. end of day; or dedicate side rooms for these patients if appropriate scheduling cannot be achieved.

Patient placement

Consideration should be given to how patients:

• access the department – e.g. designated entrances to be used; waiting in cars to be instructed to enter at designated times.
• are met at entrance-ways and escorted to department/ treatment room / chair. When accompanying the patients, staff should wear a Fluid Repellent Surgical Facemasks (FRSM) and advise the patient that they will aim to maintain 2 metre physical distancing. 
• are screened for COVID-19 symptoms and can access hand hygiene stations. 
• are given a FRSM and supported to put it on appropriately. Ensure patient asked to perform hand hygiene before donning FRSM.
• are encouraged to use identified one-way systems within departments to prevent close contact with others.
• are cared for in rooms/ treatment chairs separate from other patients within the department.
• are advised on how to alert staff should they require to without wandering around the clinical area – this should be discouraged.
• ensure signage within the department clearly alerts staff to areas belonging to the high risk pathway and areas belonging to the medium risk pathway.

Hand hygiene

Hand hygiene should be performed in line with section 1.2 of SICPs.

Respiratory and cough hygiene 

The principles of respiratory and cough hygiene can be found in section 1.3 of SICPs.

Personal protective equipment 

As per section 5.6 of Scottish COVID-19 Infection Prevention and Control Addendum for Acute Settings

High Risk Pathway - Aprons, gloves/ face visor/FRSM should be worn for all direct care within 2m of the patient.

Medium risk pathway – FRSM should be worn for all direct patient care however gloves, apron and eye protection should be risk assessed.

Safe management of care equipment

As per section 5.6 of Scottish COVID-19 Infection Prevention and Control Addendum for Acute Settings. Medium / High Risk Pathway.

Safe management of care environment 

As per section 5.8 of Scottish COVID-19 Infection Prevention and Control Addendum for Acute Settings. Medium / High Risk Pathway

Ensure local protocols are in place for alerting domestic services to rooms which require cleaning following departure of a patient on the medium or high risk pathway.

Safe management of linen 

All linen should be handled as per section 1.7 of SICPs – Safe Management of Linen.

Linen used on patients in the high and medium-risk pathway should be treated as infectious.

Safe management of blood and body fluid spillages

All blood and body fluid spillages across the three pathways should be managed as per section 1.8 of SICPs – Safe management of Blood and Body Fluid Spillages.

Safe disposal of waste 

Waste should be handled in accordance with Section 1.9 of SICPs. 

Waste generated in patient treatment areas within the High and Medium Risk pathway should be treated as infectious (category B).

Occupational safety: prevention and exposure management

Section 1.10 of SICPs remains applicable to COVID-19 patients.

View occupational risk assessment guidance specific to COVID-19.

PPE is provided for occupational safety and should be worn as per Tables 1 and 2.

Documentation

To mitigate against outbreaks it is essential to have a list of patients/ carers attending the department and timings of attendance for ease of contact tracing. This may be achieved through SACT scheduling and administration systems such as ChemoCare.