In an article published in Annals of Oncology, members of the National University Cancer Institute of Singapore (NCIS) workflow team described a segregated-team workflow model that allowed continuation of cancer care at the comprehensive cancer center during the COVID-19 outbreak in Singapore. Principles of the model were developed in response to experience during a prior severe acute respiratory syndrome (SARS) epidemic in Singapore.
“We show that despite COVID-19 community transmission, the segregated team model allowed the continuation of cancer care and clinical trials and may be replicable in other similar centers globally.”— Ngoi et al
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Elements of the segregated-team model at NCIS and the resource allocation measures necessary for effective implementation of the model described by the workflow team are reproduced verbatim or summarized below.
Segregated-Team Workflow
Since minimizing loss of workforce is central to continuity of institutional function, all NCIS staff (clinical and nonclinical) were segregated into two teams to ensure that whole departments were not quarantined in the event of a COVID-19 infection. Physician leave was canceled to maximize manpower resources.
Physician subteams were geographically confined to specific ward, outpatient, and office areas to minimize exposure and cross-contamination. Each outpatient sector had its own registration counter, triage, venipuncture service, consultation rooms, isolation rooms, and lavatories, with this organization serving to facilitate contact tracing.
In the cancer pharmacy, one team performed dispensing of outpatient prescriptions and review of chemotherapy orders, while the other team compounded chemotherapy, managed investigational studies, and stored inventory. Each team at the radiotherapy treatment center comprised radiation oncologists, radiation therapists, physicists, nurses, and administrative staff.
A smaller team of physicians was dedicated to cover an NCIS satellite center located 8 km away. Cross-hospital transfer of staff was prohibited.
Community cancer services (eg, home chemotherapy and nursing) were discontinued to consolidate manpower. Face-to-face meetings were canceled, and all department meetings, including multidisciplinary tumor boards, were conducted on a secure video-conferencing platform.
Resource Conservation and Allocation
Reduction of patient volume was necessary to allow sustainability of the segregated-team approach. Thus, for outpatients, nonresident referrals were stopped and appointments for patients on cancer surveillance were deferred. Telemedicine consults, home delivery of medications, and online payment were encouraged. Volunteer groups coordinated delivery of maintenance chemotherapy to pediatric patients with leukemia residing outside of Singapore.
For patients undergoing radiation therapy, hypofractionated treatments were favored, whereas specialized procedures like stereotactic body radiotherapy, radiosurgery, and brachytherapy were limited. In the inpatient setting, cancer surgeries were allowed to proceed as planned. All noncancer surgeries were postponed by 3 months.
Hospital negative-pressure isolation rooms were reassigned to the pandemic team for suspected and confirmed COVID-19 cases. Given an anticipated shortage of these rooms hospital-wide and the nursing complexity for patients undergoing hematopoietic stem cell transplant (HSCT), low-risk patients suspected to have COVID-19 who were undergoing HSCT were kept in the HSCT unit HEPA-filtered single rooms with an antechamber. Non-HSCT hematology patients who were low-risk suspected COVID-19 cases were admitted to neutral-pressure isolation rooms rather than negative-pressure rooms, thereby preventing them from being exposed to other nosocomial infection sources.
Social distancing practices, cancellation of mobile blood drives, and stringent donor screening resulted in a nationwide blood product shortage. For patients with cancer, blood stocks were conserved for emergency surgeries, active bleeding, and semielective cancer surgeries. Red cell and platelet transfusion were limited per patient and lower hemoglobin thresholds were accepted for asymptomatic patients.
The authors stated, “We show that despite COVID-19 community transmission, the segregated team model allowed the continuation of cancer care and clinical trials and may be replicable in other similar centers globally. While the exact workflow will be center-specific, we hope that the principles of the segregated team approach described here may provide a modifiable framework for local strategy planners in cancer centers at high risk for COVID-19 transmission.”
Anand D. Jeyasekharan, MD, PhD, of the Department of Hematology-Oncology, NCIS, is the corresponding author for the Annals of Oncology article.
Disclosure: For full disclosures of the study authors, visit annalsofoncology.org.
