The outbreak of COVID-19 required an immediate reorganization of our workflow to minimize the risk of contamination. Before this emergency, there were no specific procedures to evaluate patients before admission for active treatment, nor were there any epidemiological checks with attention being paid only to signs and/or symptoms (such as fever or neutropenia) which could potentially contraindicate active therapy.
From February 24th, we choose to start a protocol based on a double-step triage strategy for cancer patients, already under treatment or newly diagnosed, consisting of:
- First step: a phone call the day before active therapy or admission
- Second step: a clinical evaluation before the admission to the outpatient and inpatient wards on the day of the treatment.
The phone call was done by an experienced clinician in order to evaluate the clinical conditions of the patient and all members of his/her family by asking about the presence of signs/symptoms as detailed in Table 1.
This assessment took account of signs and symptoms potentially related to the underlying disease or treatment toxicity.
Moreover, the clinician asked each patient if, within the previous 72 hours, he/she had been into known outbreak areas (for the first period of epidemic), or had had direct contact with people known to have been affected by COVID-19 or with people currently in quarantine. The same questions were addressed also to the patient’s relatives, to identify potentially infectious close contacts.
The questionnaire was modified according to relevant information on COVID-19 published in the medical literature (e.g. after the alert on anosmia and dysgeusia as consequence of COVID-19 (Lechien et al. 2020)) and to the local protocol management (Fondazione IRCCS Policlinico San Matteo 2020).
In the presence of symptoms potentially related to COVID-19 infection, the patient was invited to stay at home, and symptomatic treatment was suggested. Daily phone monitoring was implemented and, in cases of worsening of clinical status, the patient was reported to the general practitioner for clinical evaluation at home and eventually referred to the regional Emergency Medical System (EMS) for evaluation for hospital admission (Spina et al. 2020), according to standard protocols of outpatient management.
The second triage level was performed before the patient entered either the day hospital or the inpatient ward by the nurse case manager and a physician, both wearing personal protection equipment (PPE) as suggested by WHO guidelines (WHO 2020). This triage consisted of a new evaluation of clinical state by measuring body temperature and evaluating possible signs and symptoms of respiratory infections. This procedure was aimed at a more careful examination of patients to reinforce what emerged at the first triage level. Both in the triage area, as well as in the therapy rooms, a security distance of at least 120 cm was rigorously observed, and every patient was trained to wear surgical mask and shoe covers, and to disinfect, at least at admission and before discharge, the hands with an hydro-alcoholic gel. Patients who were hospital admitted, in case of fever or other suspicious symptoms, underwent a nasopharyngeal swab for SARS-CoV 2, an X-ray of the thorax and blood exams. In cases where the swab was negative, but X-ray was doubtful for a diagnosis of interstitial pneumonia, patients were not allowed to entry in the ward. With the aim of reducing social interaction, patient’s relatives were not allowed to enter the hospital area.
Healthcare workers at the second level triage position and involved in the direct care of patients used the WHO-suggested PPE: eye protection (goggles), liquid-repelling gowns, double gloves, a class-2 filtering face-piece respirator (FFP2). Workers inside the Day Hospital room were equipped with surgical mask, googles, not waterproof gowns and, obviously, gloves. The aim was to supply each worker with standard protective equipment for each work-shift.
Cleaning procedures have been also implemented and standardized; in particular, ward surfaces were cleaned every day with sodium hypochloride in terminal sanitation (Colaneri et al. 2020; European Centre for Disease Prevention and Control (ECDC) (2020)). Every day, a careful check of the procedure was made, with the aim of revealing any deviation from the protocol. Furthermore, the people wearing PPE followed refresher-training sessions on their use.