Keywords
Health-care workers - COVID-19 - cancer
BACKGROUND
In early 2020, the world started to suffer from the sudden outbreak of the novel coronavirus
disease-2019 (COVID-19). Since then, there was an exponential growth in the number
of patients presenting with COVID-19 worldwide.[1]
Despite the current burden on health-care facilities imposed by the COVID-19 pandemic,
maintaining adequate care of cancer patients without compromising survival outcome
is an important goal and therapeutic challenge. Meanwhile, keeping safety of patients
and health-care professionals (HCPs) is of utmost importance.[2] However, providing the proper patient’s care in inpatient departments in oncology/hematology
services is especially challenging in the current era of the COVID-19 pandemic. Admitted
cancer patients can be immune compromised and debilitated which makes them at particular
risk for COVID-19-related complications.[3]
Nevertheless, certain modifications of medical and nursing management of admitted
patients in oncology/hematology inpatient facilities may be required to maintain adequate
patients’ care while maintaining the safety of HCPs. Therefore, during the COVID-19
pandemic, the risk/ benefit ratio of different treatment approaches of inpatient care
may need to be reconsidered.[4]
Several recommendations have been suggested by national and international medical
and nursing societies to provide guides for patients’ care during the COVID-19 pandemic.
However, specific recommendations dedicated for inpatient oncology/hematology service
are lacking. Different precautions related to nursing and physicians care in addition
to infection control measures are needed to minimize the risk of transmission of infection
among patients and HCPs.[4] In the current survey, we explored the views of different HCPs including oncologists,
hematologists, and nurses on suggestions of possible modifications of inpatient oncology/hematology
care during the current period of COVID-19 pandemic. These suggested modifications
included physician and nursing-related practice in addition to infection control precautions.
MATERIALS AND METHODS
Study design/procedures
We used nonprobability snowball sampling.[5] A web-based questionnaire submitted to licensed HCPs taking care of inpatient hematology/oncology
service including oncologists, hematologists, and inpatient nurses in Saudi Arabia.
We contacted HCPs who are members of established national oncology/hematology societies
in addition to nurses working in inpatient oncology/hematology services in Saudi Arabia,
to participate and distribute the survey. Fellows and trainees were excluded. The
survey was sent by WhatsApp to participants and reminders were sent weekly for three
times and then data was collected via SurveyMonkey.
Development of the instrument
We generated our survey instrument using rigorous survey development and testing methods.[6] Items were selected based on literature review, emails, and telephone correspondence.
Three experts in the field of oncology, hematology, and nursing from our institution
extensively discussed the topic and reviewed items until no further questions were
missed.
Items were nominated then ranked by expert HCPs to reach a consensus on selected items.
Further review was performed to eliminate redundant items using binary responses (exclude
and include).
During construction of the survey, items were grouped into domains we wanted to explore
and then refined the questions.[7] The self-administered survey consisted of 25 items that focused on five domains:
characteristics of HCPs, COVID-19 infection risk among admitted patients, possible
modifications related to physicians’ practice, possible modifications related to nursing
practice and suggested infection control measures. Structured responses formats used
in this survey included binary (yes/no), nominal and ordinal responses. Other options
were also allowed such as “I don’t know.”
Respondents received electronic links accompanied with concise instructions then a
cover letter stating the background, objectives of the survey, target population,
and request to participate voluntarily. Their answers were kept anonymously using
SurveyMonkey.
Testing of the instrument
During pretesting and pilot testing, questions were reviewed by three experts in oncology,
hematology, and nursing to check for the consistency and appropriateness of the questions
designed by investigators and then reviewed by a non-expert colleague to assess the
dynamics, flow, and accessibility. Five HCPs carried out pilot testing of the instrument.
We also conducted clinical sensibility assessment to evaluate the comprehensiveness,
clarity, and face validity of our instrument on a scale of 1–5.
We invited five colleagues with methodologic and oncology/hematology expertise. Results
of the clinical sensibility testing using mean scores on 5-point scale suggested that
the instrument had face validity (4.2), content validity (4.1), clarity (4.3), and
discriminability (4.4).
We sent an embedded link to the web-based survey on SurveyMonkey along with electronic
cover letter/instructions to complete the survey via WhatsApp after IRB approval to
licensed oncologists/hematologists and inpatient nurses in Saudi Arabia.
Outcome assessment
We assessed the percentage of response of HCPs regarding to the suggested modifications
in oncology/hematology inpatient practice. Descriptive statistics were used to summarize
data and report views of participants.
RESULTS
The survey was distributed to 215 participants in Saudi Arabia. Of those, 195 responded
and completed the survey. Of the respondents, 30.4% were medical oncologists, whereas
hematologists and nurses constituted 6.7% and 62.9% of the participants, respectively.
The majority of respondents (87.6%) work in governmental hospitals, 8.2% in academic
institute, whereas only 2% works in private hospitals. Less than half, 46.2% of the
participants have more than 10- year-work experience, 40% have 5–10 year-experience
and 13.8% have less than 5-year-work experience [Figure 1]. 82% of the participants reported that they have COVID-19 diagnosed patients in
their hospital, whereas 85% have HCPs diagnosed with COVID-19 infection.
Figure 1: Participant’s characteristics
The great majority agreed/strongly agreed that cancer patients are at increased risk
of COVID-19 related complications and that the risk of these complications is different
among cancer patients. About 70% of patients viewed that HCPs working in oncology/hematology
inpatients departments are at increased risk of COVID-19 infection compared to those
working in outpatient clinics [Figure 2]. Noteworthy, the great majority (95%) supported modifications in inpatient practice
during COVID -19 pandemic [Table 1]. Similarly, the majority (83.5%) endorsed replacing intravenous (IV) with oral medications,
whereas the respondents were split regarding the use of once daily compared to multi-dosed
antibiotics in those without febrile neutropenia. The great majority (93%) promoted
enhanced use of home health-care service for palliative care patients. More than three
fourths (77%), preferred phone calls to admitted stable patients by physicians, instead
of physical interview. In addition, two-thirds supported doing urgent procedures in
negative pressure-rooms [Table 2].
Figure 2: Participant’s responses when asked about the modifications and risks of COVID-19
Table 1
Risk of infection during COVID-19 pandemic
|
Are cancer patients at increased COVID-19 infection- related complications such as
respiratory failure?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
109 (56.48%)
|
71 (36.79%)
|
12 (6.22%)
|
1 (0.52%)
|
0 (0.00%)
|
|
Is the risk of serious complications of COVID-19 infection such as respiratory failure
is different among cancer patients?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
71 (36.60%)
|
97 (50.00%)
|
22 (11.34%)
|
3 (1.55%)
|
1 (0.52%)
|
|
Are health-care professionals working in inpatient oncology/hematology departments
at higher risk of COVID-19 infection compared to outpatient service?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
65 (33.33%)
|
74 (37.95%)
|
37 (18.97%)
|
19 (9.74%)
|
0 (0.00%)
|
|
Are practice modifications of inpatient practice required during COVID -19 pandemic?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
92 (47.42%)
|
92 (47.42%)
|
9 (4.64%)
|
1 (0.52%)
|
0 (0.00%)
|
Table 2
Suggested modifications of inpatient physicians practice
|
Can once daily replace multi-dosed antibiotics for patients without febrile neutropenia
when convenient ?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
38 (19.79%)
|
65 (33.85%)
|
55 (28.65%)
|
29 (15.10%)
|
5 (2.60%)
|
|
Can interview with patients by phone calls replace physician physical visits to patient’s
room in stable patients?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
77 (39.69%)
|
73 (37.63%)
|
18 (9.28%)
|
21 (10.82%)
|
5 (2.58%)
|
|
Replacing IV medications with oral formulations as much as possible
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
81 (41.75%)
|
81 (41.75%)
|
25 (12.89%)
|
4 (2.06%)
|
3 (1.55%)
|
|
Urgent procedures such as endoscopy for GI bleeding should be performed in negative
pressure rooms?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
70 (36.08%)
|
61 (31.44%)
|
39 (20.10%)
|
20 (10.31%)
|
4 (2.06%)
|
|
Should we encourage use of home health-care service for palliative care patients instead
of hospital admission?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
107 (54.87%)
|
75 (38.46%)
|
13 (6.67% )
|
0 (0.00%)
|
0 (0.00%)
|
Regarding nursing practice, the majority of respondents supported several modifications
during COVID-19 pandemic such as synchronizing medication administration with vital
signs assessment to decrease exposure with patients (84%), decreasing frequency of
vital signs assessment in stable patients (91%), decreasing the duration of stay in
patients rooms (89%), using peripheral instead of central lines (76%), checking patients
by nurses using phone calls instead of nurses hourly round (73%), using video-based
educational materials to patients through hospital TV network (91%), and electronic
instead of physical handover (84%) [Table 3].
Table 3
Suggested nursing practice modifications
|
Can medication administration be synchronized with vital signs assessment to decrease
exposure with patients?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
83 (42.78%)
|
81 (41.75%)
|
24 (12.37%)
|
6 (3.09%)
|
0 (0.00%)
|
|
Can peripheral lines be used if feasible instead of central lines?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
56 (28.72%)
|
93 (47.69%)
|
22 (11.28%)
|
21 (10.77%)
|
3 (1.54%)
|
|
Decreasing the frequency of vital signs assessment in stable patients
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
104 (53.33%)
|
75 (38.46%)
|
6 (3.08%)
|
9 (4.62%)
|
1 (0.51%)
|
|
Decreasing Time of each entry to patient’s room to < 10 min is preferred
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
87 (44.62%)
|
88 (45.13%)
|
14 (7.18%)
|
3 (1.54%)
|
3 (1.54%)
|
|
Can checking patients by nurses using phone calls replace nursing hourly round ?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
64 (32.82%)
|
80 (41.03%)
|
23 (11.79%)
|
25 (12.82%)
|
3 (1.54%)
|
|
Video educational materials to patients provided through hospital TV channels can
replace direct face to face education by medical team
|
|
|
|
|
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
91 (46.91%)
|
87 (44.85%)
|
6 (3.09%)
|
10 (5.15%)
|
0 (0.00%)
|
|
Can handover by electronic media replace face to face handover?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
83 (42.78%)
|
81 (41.75%)
|
17 (8.76%)
|
12 (6.19%)
|
1 (0.52%)
|
Furthermore, the majority of respondents supported infection control measures such
as wearing surgical masks by patients during physicians’ visits and nursing care (96%),
testing for COVID-19 before scheduled radiology imaging and procedures (74%) and doing
routine nasopharyngeal swab for cleaners (73%), whereas doing routine nasopharyngeal
swab for HCPs was supported by (67%) of the respondents [Table 4].
Table 4
Suggested infection control modifications
|
All admitted patients must wear surgical mask during physicians /nurses care
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
131 (67.53%)
|
56 (28.87%)
|
4 (2.06%)
|
2 (1.03%)
|
1 (0.52%)
|
|
Testing for COVID-19 before scheduled radiology imaging and procedures should be considered
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
56 (28.87%)
|
88 (45.36%)
|
22 (11.34%)
|
26 (13.40%)
|
2 (1.03%)
|
|
Do you recommend nasopharyngeal swab for cleaners regularly?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
66 (34.02%)
|
77 (39.69%)
|
31 (15.98%)
|
18 (9.28%)
|
2 (1.03%)
|
|
Do you recommend nasopharyngeal swab for health-care professionals regularly?
|
|
Strongly agree
|
Agree
|
Neither agree nor disagree
|
Disagree
|
Strongly disagree
|
|
26 (13.47%)
|
104 (53.89%)
|
31 (16.06%)
|
26 (13.47%)
|
6 (3.11%)
|
DISCUSSION
This survey was conducted among HCPs in Saudi Arabia and explored the views of HCPs
through possible modifications in three dimensions including general infection control
measures in addition to physician and nursing practice. Admitted patients to wards
with advanced solid tumors and hematological malignancies who are on active anti-cancer
treatments or symptomatic are more likely to suffer from COVID-19 serious sequelae.[8] Close contact between patients and HCPs is required in many inpatient assessments
and procedures, which increases the risk of transmission of COVID-19 infection.[9] This highlights the importance of the above-mentioned suggested modifications in
inpatient practice.
In our survey, we showed that most of the respondents recommended modifications in
inpatient practice in hematology/oncology wards to match the current limitations related
to COVID-19 infection while maintaining the safety of both patients and HCPs. Several
reports displayed that longer exposure to infected persons is correlated with increased
risk of COVID-19 infection.[10] The results of our study showed that decreasing frequency and duration of contact
between patients and HCPs was recommended by the majority which can be achieved through
contacting patients by phone calls and using video-based educational materials. Noteworthy
and consistent with our results, an International Collaborative Group reported that
during COVID-19 telehealth can be used to decrease the frequency of hospital visits
for stable patients, on follow up or those on oral treatment.[11] Expanding this approach in some inpatient scenarios such as COVID-19 suspected/confirmed
stable oncology patients, may be considered. Furthermore, decreasing the frequency
of vital signs assessment in stable patients, using long acting and /or oral medications
when appropriate can be a good strategy to decrease risk of infection transmission
in the current era. In addition, avoiding procedures that need long and close contact
with patients such as central line insertion that needs repeated prolonged care with
close contact among patients and HCPs.
According to WHO recommendations, patients visiting health-care settings should not
wear a medical mask when isolated in a single room, but should instead follow proper
hygienic measures.[12] However, in many health facilities, patients are admitted in shared rooms (mostly
2 patients per room). Furthermore, the immune-compromised nature of oncology patients’
needs to be considered carefully which may justify wearing a surgical mask by admitted
oncology/hematology patients during interactions with HCPs.
In our survey, the majority of respondents endorsed doing routine COVID-19 testing
among HCPs, admitted patients, cleaners, and among patients before doing radiological
imaging/procedures, this is in keeping with CDC guidelines, testing of asymptomatic
HCPs without known or suspected exposure to COVID-19 infection can be considered in
special situations.[13] Subsequently, this may improve the outcomes of admitted patients to hematology and
oncology wards. This practice can be a valid approach especially in services hosting
highly immune-compromised patients such as those with acute leukemia and bone marrow
transplant units.[14] Furthermore, cleaners in some health institutes live in shared residency places.[15] This may highlight the importance of extra-precautionary measures when appropriate
such as regular COVID-19 testing in addition to housing spacing and rigorous measures
for proper health and hand hygiene.
In keeping with the American College of Surgeons endorsed precautionary measures for
infected or suspected patients while doing aerosol-generating procedures including
intubation/extubation, bronchoscopy, and laparoscopy/endoscopy, our survey showed
that the majority of respondents supported doing urgent procedures in negative pressure-rooms
and doing COVID-19 testing before doing imaging or invasive procedures. These measures
include wearing full personal protective equipment, including an N95 mask or powered,
air-purifying respirator (PAPR) designed for the operating room.[16]
Our survey has several strengths such as it was conducted using rigorous methodology
and explored views of HCPs dealing with vulnerable patients. We also have several
limitations that include, the nature of the web-based survey, small sample size, as
we did not know the total number of this population however we tried to invite more
participants using snowball sampling. In addition, it was conducted in Saudi Arabia
only, which may not reflect current practice in different countries. Lastly, some
of the suggested modifications need infrastructure that may not be available in all
health facilities such as video-based educational materials and local hospital TV
networks.
Our study adds to the previous knowledge that from HCPs views, admitted patients with
cancer need to be managed with some modifications that are consistent with the evolving
literature and implement new effective strategies such as videoconference tools, rigorous
precautionary measures such as testing for COVID-19 and treatment modifications such
as changing the route to oral treatment. This would help with the reduction of COVID-19
transmission among patients and HCPs and ensure continuity of cancer care with better
quality.
Many questions remain to be addressed concerning these modifications. Advocating for
such modifications is subject to local health-care policies, prevalence of infection
in the community, and heath-care facilities and ultimately provided that these resources
and logistics are available and feasible. Another unanswered question remains is the
implications of cost and the presence of adequate infrastructures as it is clearly
not similar in all institutions. Finally, an important unanswered question is how
to adopt specific guidelines in the midst of pandemic as the recommendations can continuously
change such as the mode of COVID-19 transmission, need to wear mask all times, re-infection,
vaccination and so on. These are possible avenues for future research to understand
how these modifications translate into a better quality of care for admitted patients
with cancer
Finally, these suggestions need to be discussed on local basis and ensure the quality
of inpatient service frequently monitored during COVID-19 pandemic to maintain the
desired level of care to oncology/hematology patients without compromising the safety
of HCPs
CONCLUSION
Several modifications in inpatient oncology/hematology practice were supported by
the survey participants which could be applied during infectious outbreaks. These
suggestions need to be discussed on local basis considering local infrastructure,
available resources, and level of required care to ensure continuity of delivering
high quality of care to patients with cancer.
