MSKCC Strategizes to Provide Safe Outpatient Cancer Care During the COVID-19 Crisis

Tiffany A. Traina, MD

Despite the threat the coronavirus disease 2019 (COVID-19) presents, it’s necessary that patients with cancer continue to receive care at outpatient facilities—a feat that has been made possible at Memorial Sloan Kettering Cancer Center through multidisciplinary efforts, innovative strategy, and technology, according to a presentation given during the 2021 AACR Virtual Meeting on COVID-19 and Cancer.¹

These operational methods were utilized to positive reception from patients and hospital staff alike, according to Tiffany A. Traina, MD, vice chair of oncology in the Department of Medicine; associate attending of Breast Medicine Services; and section head of the Triple-Negative Breast Cancer Clinical Research Program at Memorial Sloan Kettering Cancer Center (MSKCC). This success is of particular importance when considering the impact that COVID-19 has had on cancer screenings and treatment, and the potential future implications of these deviations.

Access to cancer screenings decreased over the course of the pandemic to prevent unnecessary exposure to the virus. Additionally, non-evidence–based treatment modifications and delays were implemented by institutions around the world. Results from 1 study showed that approximately 64% of patients who had a history of cancer deviated from their treatment.² While the future impact of these modifications and delays are not yet known, investigators theorize that there will be an excess of 10,000 deaths from colon cancer and breast cancer alone from 2020 to 2030.³

To provide safe conditions for treating patients with cancer during the COVID-19 pandemic, MSKCC established 4 guiding principles that would help to determine clinical priorities and optimize patient care.

“Early in the pandemic, our organization established guiding principles on how we were going to manage the care of our patient population in the setting of a pandemic,” said Traina, who is also an associate professor of medicine at Weill Cornel Medicine, said during the presentation. “We clearly needed to remain open and available for our patients, [and this] needed to be done in a safe way. We were going to need technology to support this effort. [In terms of] staffing, we needed to redeploy, innovate, be creative, and ensure we were caring for our caregivers.”

The “operational pearls” of the effort included multidisciplinary teams, outpatient operational levers, and technologic innovations that were used to establish an outpatient COVID-19 care strategy for patients with cancer.

Importance of Multidisciplinary Efforts and Innovation

Establishing multidisciplinary teams that represented all aspects of the organization was critical to ensure that all healthcare workers were able to have a voice in meeting patient needs. This not only helped to establish a degree of control over an uncertain situation, Traina said, but it also helped to minimize uncertainty and ambiguity.

From there, a COVID-19 surge plan was established to provide optimal safety for healthcare workers and patients alike. This plan called for measures such as universal personal protective equipment and masks, remote work options, lobby screenings and COVID-19 testing hubs, and communication enhanced by technology.

Pulling Clinical Levers

Among the many strategies implemented by MSKCC was the use of a COVID-19 screening questionnaire that would be assigned to any patients who scheduled an outpatient appointment. The questionnaire would be generated at 7:30 AM the day before the appointment and would expire at 11:59 PM the day before. This tool would collect important information, such as whether the patient had recently traveled or if experienced any symptoms associated with COVID-19. Additionally, this helped clinic coordinators to prepare for outpatient appointments electronically, according to Traina.

Moreover, patients and visitors were required to be screened for COVID-19 upon check in. Additional workflows were established for patients who were positive for the virus so that patients would still be able to safely receive their cancer care on site.

“Making outpatient clinical care possible really was a herculean effort; it required constant communication, reminders about social distancing, mask requirements, hand sanitizer, rearrangement of furniture, daily critical supplies, and environmental services with enhanced response for cleaning the ambulatory care setting,” said Traina. “[There were also] specific workflows for those patients who were COVID-19positive, but we knew needed care. We tried to cohort these patients in specific outpatient areas to minimize transmission across the ambulatory care sites.”

One of the earliest efforts made at the institution was to establish COVID-19 testing hubs, both in their main location and across all regional enterprises. This effort offered drive-through testing that COVID-19 screenings to both patients and healthcare staff.

Maintaining Supportive Care and Communication Through Technology

Healthcare workers utilized dashboards to schedule and consolidate appointments, track COVID-19–positive patients going through ambulatory care, and allow for effective communication.

“We can track all aspects of outpatient care,” said Traina. “[One dashboard] is a heatmap that [includes] the building, floor, and time of day. Within a given hour, you could see where those patients are. Is there a backup in chemotherapy? Are many patients seeing 1 particular physician at a particular clinic location? We could, by using operation engineering, smooth out [clinic appointments].”

Telemedicine was 1 of the many technological advances adopted by MSKCC during the pandemic; this enabled continued care in a virtual setting. In the beginning of the pandemic, challenges existed pertaining to patient privacy and licensure, Traina explained. However, through the development and implementation of a centralized outpatient follow-up system for patients who had tested positive for COVID-19, they were able to provide safe, patient-centric care. They leveraged existing technology to provide support for patients who required a direct response.

“What we saw through our experience was a 3000% increase in telemedicine utilization from February 2020 through the peak of the pandemic, which was in June 2020 for us,” Traina explained. “Just to give a magnitude of scale, in a given month, we were seeing about 230,000 outpatient visits…It really is an enormous undertaking to continue providing quality care.”

Additionally, the institution created a COVID-19 Cohort Management Program team (CCMT), which allowed for outpatient follow-up for patients confirmed to have COVID-19 so that they could ensure continued recovery following discharge. The program utilized existing technology such as pulse oximeters to monitor patients and intervene when an immediate response was needed. Moreover, this technology also helps clinical healthcare teams determine when it’s safe for patients to leave isolation and resume their cancer treatments.

“Patients would enter with a COVID-19 test upon discharge from the hospital or by physician [recommendation],” Traina said. “The nurse would call the patient and officially onboard them, have a problem list established, and [patients] would receive questionnaires daily through their patient portal or from a call from a CCMT member. If the questionnaire sent a red or yellow alert, then a member of the CCMT would call the patient, instruct them on patient care or management or escalate as [needed].”

The questionnaires were met with a positive response from patients, with 763 having filled out 10,044 surveys. The daily response rate was 53%, with 47% of patients receiving their assessment via telephone. Morever, 13% of survey results triggered a red alert, which resulted in intervention by CCMT members. Of the 2816 phone calls that were made, 3% of patients were referred to an acute care setting to be assessed further.

Among the 239 patients who answered the patient satisfaction survey, 92% said they would recommend the program to similar patients, 92% felt the time and effort to report symptoms was worth it, and 93% felt more comfortable being at home with a pulse oximeter. Moreover, 90% felt safe and comfortable with their remote interactions with the CCMT and 89% felt more connected with MSKCC, having participated in the program.

Finally, MSKCC launched a Virtual Integrative Medicine at Home program, which delivered weekly physical activity classes in addition to medicine programming. Of the 8116 participants who attended from April 1, 2020 through June 30, 2020, 96% reported being extremely satisfied with the experience and 84% experienced a notable reduction in stress and anxiety after taking classes. The classes helped to encourage psychological coping, promote positive health behaviors, and foster social engagement.

“Ongoing cancer care is essential concurrent with the COVID-19 pandemic. That was made possible by multidisciplinary teams that contributed to the shared goals and guiding principles that we established very early on that were synonymous with our identity,” concluded Traina. “There was operational innovation, collaboration, and really nimble experimentation as to what could work.”

References

1. Traina TA. Caring for patients with cancer during COVID-19: outpatient operations. Presented at: AACR meeting: COVID-19 and Cancer; February 3-5, 2021; virtual. Accessed February 4, 2021.
2. Wu JTY, Kwon DH, Glover MJ, et al. Changes in cancer management due to COVID-19 illness in patients with cancer in Northern California. JCO Oncol Prac. Published online December 17, 2020. doi:10.1200/OP.20.00790
3. Sharpless NE. COVID-19 and cancer. Science. 2020;368(6497):1290. doi:10.1126/science.abd3377.