Splitting Healthcare Teams May Help to Reduce Disruption in Patient Care

In Singapore, a first confirmed case of COVID-19 was reported in late January and, since then, government measures to contain the first wave of infections have resulted to be effective. As part of a whole national plan to control the outbreak, a timely planning of strategies taken by medical oncologists at the National University Cancer Institute of Singapore (NCIS) has contributed to ensure the continuum of cancer care for patients in the city-state according to Dr Ross Andrew Soo sharing his direct experience. 

What are the workplace measures recommended for healthcare professionals by local authorities in Singapore in response to the DORSCON Orange situation?

DORSCON is defined as Disease Outbreak Response System Condition. It is a colour-coded framework for prevention and response taking into consideration the infectious disease situation overseas, the nature of the disease and its impact on daily life. At level Orange, the public health impact to Singapore local population is moderate to high, where there is evidence of local transmission and there is a risk of community spread. Given this situation, at NCIS the following measures have been taken since January: healthcare teams split into two with minimal contact between the two teams; all leaves from staff members frozen; departmental meetings/ teaching activities are cancelled and moved online; enhanced screening measures. It’s important to note our institution’s response is part of a coordinated national effort, otherwise the impact of our response would be minimal.

In some countries, specific actions such as postponing non-urgent visits have been taken to face the emergency so far. Are oncology teams adopting the same measures in Singapore? 

At NCIS, the strategies being adopted include a business continuity plan and containment whilst providing optimal patient care, maintaining staff safety and continuing research and educational activities. The main containment measure is triaging of suspected cases in the outpatient through the use of screening questions and temperature assessment. Patients meeting the criteria for a high-risk case — and the definition is changing frequently —, are placed in an isolation room, evaluated by dedicated medical and nursing staff in full personal protective equipment (PPE). An infectious diseases specialist is readily available through a hotline for consultation. Patients with cancer suspected of COVID-19 infection are admitted and managed initially by the pandemic ward team. If the patient is COVID negative, they are transferred to the care of the oncologist. Also, we are aiming to reduce the patient volume visiting the institute during the pandemic. Similarly to the approach taken by other countries, we have postponed non-urgent outpatient visits, increased use of telemedicine and home delivery of medications.

How has containment measures impacted on daily clinical routines?

Currently, the routine of clinical practice is similar to the pre-pandemic period and we aim to preserve the delivery of optimal patient care. We are still attending outpatient clinics, conduct ward rounds, attend research and educational meetings whilst adhering to the rules described above. Currently, we have not experienced any shortages of resources and essential services have not been disrupted. In unpublished analysis, we found that the utilisation of systemic therapy chairs and patient recruitment into clinical studies are in line with data reported in 2019.

In many countries, an increasing number of healthcare providers have tested positive to coronavirus, as they are highly exposed to hazards that may put them at risk of infection with COVID-19, including pathogen exposure. What strategies have been adopted in Singapore to address this issue beyond the use of PPE?

Having split teams would help minimize exposure and cross-contamination among healthcare professionals which in turn reduce disruption to patient care. There is minimal physical contact between the separate teams and only one team provides inpatient services. The inpatient team is further geographically confined within their ward areas of cover. The split team concept applies to other areas such as outpatient clinics, oncology nursing, pharmacy, patient service associates, administrative staff, and clinical research staff. Furthermore, work stations are separated by at least one meter, with only members from the same team sharing adjacent work spaces. In the outpatient setting, the clinic areas are also split with separate registration counters, triage, venepuncture service, consultation rooms, isolation rooms, lavatories and treatment areas. In addition, healthcare workers with acute respiratory infection or fever with possible COVID-19 exposure are initially assessed to determine the need for testing.

Split teams may not be feasible in hospital systems where resources are limited, but every effort should be made for healthcare professionals to be separated physically, much like “social distancing”, an approach that has been widely adopted in many countries.

What should medical oncologists do to monitor the impact of COVID-19 on cancer care?

With COVID-19 extending globally, we need to learn more about its impact on our patients with lung cancer. The characterisation of cancer patients with COVID-19 infection is required and I urge other oncology colleagues and the cancer community to collect information on patients who have been infected with COVID-19.  Some metrics that could be used to assess impact include: waiting times for diagnosis and treatment (surgery, radiotherapy, systemic therapy); utilisation of beds, treatment chairs, radiation and systemic therapies for curative intent; impact on the recruitment of patients into clinical trials; disruption of specialty training; measurement of economic impact.