publication date: May. 1, 2020

Guest Editorial

Under the onslaughts of COVID-19, Montefiore deployed a PPE strategy for patients—PREVENT/PROTECT/ENABLE

Balazs Halmos
Balazs Halmos, MD
Montefiore/Einstein NCORP co-principal investigator;
Professor of Oncology, Department of Medicine,
Albert Einstein College of Medicine
Roman Perez-Soler
Roman Perez-Soler, MD, PhD Chairman, Department of Oncology,
Montefiore Medical Center;
Deputy director,
Albert Einstein Cancer Center
Stuart Packer
Stuart Packer, MD
Medical director, Department of Oncology,
Montefiore Medical Center;
Assistant professor of medicine, Department of Medicine, Albert Einstein College of Medicine
IMG_2020-05-01_10-48-34
Mary G. LaRocca
Administrative manager, Research Operations, Oncology Services,
Montefiore Medical Center
Bruce Rapkin
Bruce Rapkin, PhD Montefiore/Einstein NCORP program co-principal investigator;
Professor, Department of Epidemiology & Population Health;
Professor, Department of Family and Social Medicine, Albert Einstein College of Medicine
Shalom Kalnicki
Shalom Kalnicki, MD
Chair, Department of Radiation Oncology;
Professor, Department of Radiation Oncology,
Albert Einstein College of Medicine
Joseph Sparano_1
Joseph Sparano, MD
Montefiore/Einstein NCORP program co-principal investigator; Associate director of Clinical Research, Albert Einstein Cancer Center;
Professor of Oncology, Department of Medicine;
Professor, Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine

This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.

March 1, 2020, started as a good day at the Montefiore Einstein Center for Cancer Care in New York.

As an NCI-designated cancer center based at the Albert Einstein College of Medicine, our accrual to cancer clinical trials reached its highest level in the last decade, and our faculty was leading innovative work at the local and national levels.

The number of cancer patients referred to our system and patients accrued to cancer clinical trials was steadily rising. We were providing state-of-the art cancer care, collaborating in translational research with scientists at the NCI-designated Einstein Cancer Center, supporting a robust education and training program, and serving our community.

Although these attributes were not unique to our center, a distinguishing feature was that 80% of our patients and trial participants were African-American or Hispanic, and about 25% were living below the federal poverty rate, contributing to successful efforts to secure NCI funding as a minority underserved NCORP. 

However, that very day the first documented case of COVID-19 was reported in New York City. Every day since then has brought new challenges and multiple COVID-19 teleconferences.

Fast forward just four-to-six weeks, and our institution was challenged in ways one could not imagine. The census of COVID-19 patients in our three Bronx hospitals swelled to a peak of 1,148, including 241 vented patients in multiple newly constructed ICUs with our EDs seeing more than 500-plus new COVID cases per day.

With up to 1,200 sick calls per day, some of our staff were also becoming ill, some seriously. On Monday, March 30, our community was devastated upon learning of the deaths of our first two associates: a 29-year old clerk and a 73-year old physician—a pediatric neurosurgeon who was world renowned for successfully separating conjoined twins.

Many of our trainees and support staff were deployed to cover these new units, and our medical oncology faculty staffed a new COVID-positive inpatient unit while supporting our usual set of inpatient oncology units. All cancer surgeries and most other procedures were cancelled, creating major challenges in developing bridging strategies to surgery.

All research labs were shut down, with the brightest minds on campus locked into endless Zoom meetings for the foreseeable future. While the COVID deluge flooded the entire city of New York, the Bronx was even more seriously impacted, with a higher-than-anticipated proportion of cases and deaths impacting our minority communities.

As bad as it was at the time, our leadership was preparing for the worst that was yet to come—a period of unimaginable losses. The five stages of loss are classically listed as denial, anger, bargaining, depression, and acceptance.

No question that most of us have faced many of these stages ourselves over these dizzying times. However, the last stage we seem to have successfully converted into an ongoing phase of “adaptation.” Below we will describe the key steps we have taken in order to keep our patients the safest possible, allow reasonable ongoing clinical care and research while keeping our staff engaged and sane during these most trying times.

Learning from the first major epicenters of COVID-19 in China and Italy, we realized early on that we have to go out of our way to “cocoon” our cancer patients from the epidemic, and one key element of this had to be protecting them from cross-contamination through infected health care workers—ourselves (more than 10% of all infected cases in Italy occurred in HCWs).

Our center therefore very quickly established a core leadership group to implement rapid changes to optimize safety in both the outpatient and inpatient settings. The implemented changes reviewed below could be broken down along the easy and familiar mnemonic put to new use—PPE- PREVENT, PROTECT, ENABLE—establishing the best “PPE” we could offer to our patients.


PREVENT

As many centers, we recognized the first obvious step that we could take is minimize exposure of patients to the health care environment. For example, all non-urgent visits/procedures were deferred and visits that did not demand actual physical encounters were converted into telemedicine visits.

Within six weeks, this led to the point that currently approximately 75% of the encounters take place via telemedicine tools. In addition, early assessment of the first wave of COVID-positive cancer patients revealed that elderly, frail patients, and especially those living in residential facilities or being inpatients, were particularly vulnerable resulting in special attention to minimize risk of exposure to such patient groups.

Early steps included the establishment of a completely closed COVID-negative inpatient/transplant unit with admission only following testing and deferral of visits from nursing home patients to our facilities.


PROTECT

Clearly, while telemedicine could be sufficient for some time in certain disciplines, in oncology we had to face balancing the competing risks of potential exposure to COVID-19 versus the risk of delaying needed procedures/treatments. In order to be able to offer critical therapies to our patients, we needed to convert our practices where we could feel secure of minimizing risk while allowing access.

For this, we made an early decision to consolidate our outpatient practices into a single performance site. Through a herculean effort by staff, we set up a free-standing outpatient facility that provided complete control of access in/out of the building serving as a “fort.” This permitted a screening station to be set up at the entrance supported by the establishment of an urgent care area with rapid COVID testing availability.

Exceeding attention was given to safe practices with full personal protective equipment for staff, limited patient density, physical distancing, and regular terminal cleaning runs. These procedures provided the assurances needed to allow our active oncology practice to continue despite the onslaught of the pandemic. Lastly, protecting our patients from potentially infected but asymptomatic staff was felt to be key as well. For this reason, we established the rule that staff who had worked on inpatient floors could not enter outpatient spaces until after a week of quarantine.


ENABLE

Last but not least, major efforts had to be undertaken then to enable reasonable ongoing clinical care and research. Regular review of appropriate treatment principles in the face of the pandemic has been an important element—converting regimens to require fewer infusional visits, oral regimens, regimens with less immune suppressive side effects, if such could be reasonable chosen, adopting hypo-fractionated radiation courses, etc.

While oncology clinical research clearly had to slow down, it did not stop with continued cautious enrollment of patients into studies offering needed options to our patients. In addition, we shifted our focus to support COVID-related research for this transitional time with active participation of novel treatment studies, coordinator support of key studies run by our ID and Critical Care Divisions, participation in national and international registries to ensure that we as a team contribute to the emerging knowledge gained as to the interface of COVID-19 and cancer.

Ongoing surveys of the financial burden of cancer treatment have continued to accrue in order to capture how patients and their family support systems are coping with additional impacts of the pandemic. Some of the most accomplished scientists at Einstein have also applied their expertise to development of antiviral and immune approaches directed against SARS-CoV2, the virus causing COVID-19.

Examples include development by the Gavathiotis lab of highly selective drugs against the SARS-CoV-2 protease required for viral replication,  generation of CD8 T dubbed “synTacs” (Synapse for T-cell Activation) pioneered by the Almo laboratory that are engineered to destroy SARS-CoV-2, and generation of pathogen-specific B cells from convalescent donors targeting the SARS-CoV2 spike protein by the Chandran, Lia, and Daily labs.

These efforts include collaboration with other basic scientists at Einstein whose work is not cancer-focused and is supported by the center’s shared resources that continue to function and sustain other vital scientific activities at Einstein addressing the Covid-19 pandemic.

 

Where are we eight weeks later?

After peaking at 2,200 COVID-19 patients in our health system’s nine hospitals serving the Bronx and beyond in mid-April, including over 1,000 at our Bronx hospitals, the trend is reversing now with 1,300 or so COVID-19 patients still admitted.

Although many have succumbed, more than 4,000 patients have been discharged as of April 25. We are now turning our attention to a fourth component of adaptation:


ENACT

We are setting up a new life recognizing that COVID-19 is certainly here to stay for the coming months. While possibly as many as 20% of the 1.5 million Bronx residents have been exposed, that still leaves 80% still vulnerable for an extended plateau or further waves. Our institution weathered this dramatic storm well—strong leadership and amazing demonstration of the selflessness of our health care workers across the board have shone through this crisis.

Furthermore, we cannot forget another key element of cancer care in this new COVID era:


EMBRACE

In particular, our vulnerable patient population in the Bronx, the poorest county in New York State, is facing unique challenges. In addition to facing a cancer diagnosis and now the fear of the pandemic, many of our patients are further burdened with financial challenges, lack of resources and a social support system, emotional burden, loneliness, etc. The unique aspects of the COVID crisis amplify all of these issues leading to a potential erosion of the patient/health care interface and added alienation.

We as a team are now back full steam, embracing this special challenge and addressing these key issues head-on via providing expanded services ranging from virtual supportive care services to telephonic counseling, bilingual peer support programs and food delivery through our renowned BOLD program and dedicated social workers.

Now, we need to be able to dig in and focus on this next phase as our staff/trainees/researchers will slowly be returning to home base, and cancer patients will re-emerge in large numbers after an extended period of delaying/deferring care.

 

What will be the new normal?

Many questions have yet to be answered. Currently, we are establishing new practices as to routine COVID testing for our cancer patients for all new patients before their first visit and monthly for patients on active therapy.

We are setting up a separate infusion unit solely for COVID-positive patients and we have already established separate inpatient areas. When can we resume ancillary services including all diagnostic and surgical procedures so needed to be able to provide comprehensive cancer care?

When can we feel comfortable resuming a full set of research activities? How can we help fellows to get back on track after months-long disruption of their research and training activities? What additional steps will be needed to support our staff who have been so deeply impacted by this crisis, both professionally and personally?

We will find answers to these questions, and we look forward to sharing our experience with others and learning greatly from other centers’ experience as well. 

One thing that is for sure—we are fully resolved to continue to focus on adaptation and not acceptance.

Our patients deserve nothing less.

Copyright (c) 2020 The Cancer Letter Inc.