Stepwise Strategic Mitigation Planning in a Pediatric Oncology Center During the COVID-19 Pandemic

Abstract

Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) first reached the United States in January 2020. Located in New York City (NYC), MSK Kids, at Memorial Sloan Kettering Cancer Center services, is one of the largest pediatric cancer centers in the U.S., caring for children, teenagers, and young adults with cancer, immune deficiencies, and blood disorders. Methods: Implementation for infection mitigation and ongoing care of patients included: (1) the creation of a strategic planning team of physicians, advanced practice providers, nurses, and administrators to develop guidance and workflows, (2) continuous reassessment of patients’ needs for hospital services and visit frequency, (3) the use of telemedicine to replace in-person visits, (4) the use of satellite regional centers to manage patients living outside NYC, (5) pre-screening of patients prior to visits for risks and symptoms of coronavirus disease 2019 (COVID-19) infection, (6) day-of-service screening for risks or symptoms of COVID-19 infection, (7) surveillance testing of children and their caregivers, and (8) creation of cohort plans for the management of COVID-19 positive and uninfected patients within the same institution, in both the outpatient and inpatient settings. Results: We describe the timeline for planning mitigation during the first weeks of the pandemic, and detail in a stepwise fashion the rationale and implementation of COVID-19 containment efforts in the context of a large pediatric oncology program. Discussion: Our experience offers a model on which to base strategic planning efforts at other pediatric oncology centers, for continued preparedness to combat the threat posed by SARS-CoV-2 worldwide.

Introduction

In December 2019, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) emerged as the cause of what would become a worldwide pandemic challenging our health-care system and rapidly affecting the delivery of care for pediatric oncology patients (Zhu et al., 2020). The first reported case in New York State occurred on March 1, 2020, and by March 13, 2020, the COVID-19 outbreak was declared a national emergency (Goldstein & McKinley, 2020). At the time, data relevant to pediatric patients were scarce. Reports from the site of the initial outbreak in Wuhan province, China, showed that <1% (416 cases) of 72,314 cases reported were in children younger than 10 years of age and 1% (549) of cases were aged 10-19 years (Liu et al., 2020; Wu & McGoogan, 2020).

MSK Kids, at Memorial Sloan Kettering Cancer Center (MSK) in New York City (NYC), is one of the largest pediatric cancer programs in the U.S., caring for children, teenagers, and young adults with cancer, immune deficiencies, and blood disorders. Most of its activity is in the outpatient setting, with an average of 120 visits daily (30,000 visits annually) and inpatient facilities comprising 33 beds and 5 pediatric critical care beds. Faced with the COVID-19 pandemic, there was an urgent need to address the challenges of screening pediatric patients and staff to limit the infectious spread and continuing to provide safe treatment to patients and families, all while simultaneously preparing for an anticipated shortage of resources during what was predicted to be a massive influx or “surge” of critically ill adult patients. In addition, preparation for potential workforce erosions due to infection was required.

On March 3, 2020, the Hospital Incident Command System (HICS) was activated in response to the COVID-19 crisis, holding twice daily meetings. On March 6, 2020, MSK Kids formed a departmental Pediatrics Incident Command System (PICS), a multidisciplinary COVID-19 task force in constant communication with the HICS, to plan and develop pediatric-specific mitigation strategies in response to the pandemic. We describe the pragmatic steps taken to screen, test, and manage pediatric patients over time during the initial stages of the pandemic (Figure 1). These operating principles will be carried forward as NYC approaches a tenuous equilibrium in COVID-19 infectious burden amongst children and our pediatric patients and caregivers (New York City Department of Health, 2020b).

Figure 1.

Timeline of the strategic mitigation planning for the management of patients during the COVID-19 pandemic, and data on the Cumulative incidence of COVID-19 positivity in MSK pediatric patients, MSK caregivers, and the pediatric population in NYC.

Note. COVID-19 = coronavirus disease 2019; NYC = New York City.

Description of Process

Creation of a PICS

With the first reported COVID-19 case in NYC, the Department of Pediatrics developed the PICS, a multidisciplinary team that included attending physicians, Advanced Practice Provider (APP), nurses, and administrators representing pediatric inpatient, outpatient, critical care, and the different oncology and bone marrow transplant services (Figure 2). Two task forces were generated from the PICS: an operations task force and an implementation task force. The operations task force, responsible for managing the pediatrics platform, included medical directors, APPs, nursing managers, and administrative managers. This task force met twice daily via video-web conferencing to develop the operational workflows and guidelines needed to address evolving COVID-19 pandemic updates. The second task force led by the pediatrics department chair included all operational task force members, as well as the service chiefs, clinical research leadership, and the pediatric hematology–oncology fellowship director to review the various aspects of the pandemic, application, and effects of newly instituted guidelines, and to identify emerging issues of concern. Together the task forces implemented processes to meet the needs unique to our pediatric patient population, streamlined communication, centralized and disseminated information and provided staff education.

Figure 2.

Organizational diagram of the hospital and departmental leadership during the coronavirus disease 2019 (COVID-19) pandemic in a New York City Cancer Center.

MSK leadership utilized informational resources established by health authorities, such as the Center for Disease Control (CDC) and the New York State Department of Health (NYS DOH) (Centers for Disease Control and Prevention, 2020; New York City Department of Health, 2020a) to direct and continuously update pediatric-specific institution-wide guidelines and processes. The PICS worked in conjunction with the HICS structure to develop pediatric-specific workflows through the lens of the hospital's directions and available resources. As an example, when the HICS team implemented the Department of Health's mandated “no visitor policy for inpatients,” the PICS developed a necessary exception (1) to allow one caregiver at the bedside for pediatric patients, ideally to be rotated every 7 days for prolonged patient admissions and (2) to have the ability to test the caregivers of patients admitted, for COVID-19.

COVID-19 information and policies were updated frequently as health authorities gained more knowledge of epidemiology and clinical presentation of COVID-19. The Department of Pediatrics was able to continuously adapt to rapidly changing information through the task force structure.

Communication

One very important aspect of the management of this crisis within the department was communication and effective propagation of information that was changing daily, and sometimes within the same day. The leadership provided on-site coverage and support 7 days a week and participated in daily morning huddles on all units. Two video-conferencing workflow huddles were scheduled daily: (1) a twice-daily operational huddle reviewed daily activities within the pediatric inpatient and outpatient platform including isolation activities, numbers of patients tested and results, the number of staff members tested and results and (2) a second huddle within the departmental services reviewing the summary of the first huddle, the activities of the different services, and the HICS recommendations. Pediatric-specific updated workflows created by PICS were communicated via regular email. An email contact group address was created as a conduit to update guidance. Pediatric staff was encouraged to review the hospital's internal COVID-19 hub on the institutional intranet, including a real-time dashboard of the total number of patients who tested positive and were hospitalized for COVID-19 within the MSK system.

Mitigation Measures

Patient Volume

Patient volume mitigation focused on reducing routine follow-ups and non-urgent main campus appointments while recognizing the need for clinically urgent testing, treatments, and clinician visits. Efforts were made to align with a reduced staffing model in anticipation of staff shortages due to illness, medical exemptions, childcare issues, and redeployment with the goal of reducing onsite visits by 50%. At the direction of the governor of the New York State, MSK HICS in conjunction with the Department of Surgery began postponing all elective surgeries in early March. Service teams, administration, and nursing have worked together to minimize the patient volume. Service chiefs worked closely with their team members to review patient schedules to determine whose treatments were safe to postpone and the feasibility of modifying chemotherapy regimens to decrease the patient visit frequency. Clinic visits of patients whose care would not suffer from delays of 2-3 months were postponed accordingly. In-person long-term follow-up, Clinical Genetics, and Integrative Therapy clinic visits were canceled and transitioned to telemedicine visits. Routine surveillance scans and laboratory work were also postponed. New patient consults were limited to patients needing urgent consultation with no alternative assistance; in-person second opinion consultations and international visits were suspended and transitioned to telemedicine visits. Patient populations were identified that could be scheduled for phone visits, telemedicine visits, and regional appointments. Figure 3 shows the impact of these strategies. Before March 2019, pediatrics averaged 119 outpatient visits at the main hospital (located in Manhattan) and 7 visits at regional sites in a day. From March 6, 2020 to April 12, 2020, this volume shifted to 65 outpatient visits at the main hospital and 21 regional visits per day. Phone and telehealth visits were introduced and quickly grew in volume to 27 visits a day.

Figure 3.

Patient volume mitigation: Comparison of March 2019 and March 2020 pediatric outpatient visits: (A) main campus visits, (B) regional satellite center visits, and (C) telephone and telehealth visits.

Clinical Trials

MSK Kids’ specific clinical research guidelines were aligned with our institutional policies and staffing models. New potential registrations to phase 1/2 trials were reviewed and evaluated based on the potential for benefit to the patient and the workforce resource requirements. Enrollment to non-therapeutic protocols was suspended. Enrollment required approval by leadership. Careful consideration was made for enrollment on clinical trials that required planned hospitalizations and standard treatment options were encouraged when available.

Several steps were taken to support the continuation of patients on trials while maintaining continuity of care and study integrity. The schedule for all upcoming clinical research visits was reviewed by the primary physician and the clinical trials nurse to determine whether alternate plans could be made to minimize on-site treatment visits, labs, and imaging. All non-clinically indicated visits, procedures, imaging, or laboratory tests were postponed.

Pediatric Staff

As the on-site patient volume was reduced by 50%, a formal operational response to staffing was required to ensure staff preservation and personnel resource sharing throughout the institution. Staffing plans identified the minimum staffing needs and prioritized critical versus non-essential services based on direct patient care roles. The objectives of the staffing model were guided by the principles of physical distancing for mitigation of spread of the virus, protection of the workforce, and right sizing of staffing to areas of need. Surge capacity plans were also identified to ensure staff availability for redeployment to direct patient care, if necessary.

All disciplines were tasked to reassess team structures and create workflows that limited onsite staff members. Remote roles were developed and promptly implemented to support the new team structures. Faculty was required to work offsite when not assigned to inpatient or outpatient service. New workflows were introduced, including telephone and video telemedicine visits allowing remote providers to continue to engage in inpatient care. Remote staff supported the clinic by following up on patient inquiries via the patient portal and telephone, entering routine and follow-up orders for upcoming visits, and writing chemotherapy orders. In addition, the staff was deployed to satellite regional centers to assist in the increase of regional pediatric patient volumes. Service chiefs organized rotation schedules for the attending staff, to include one single attending physician per service in the clinic on weekly basis instead of the 3-5 attendings who normally work on different days of the week.

Shared workspaces with multiple computer stations were adapted to minimize the number of staff members by turning off every other computer. Clinic exam rooms were designated for each service to avoid cross-contamination.

Graduate Medical Staff

Pediatric hematology–oncology (PHO) fellows were transitioned to remote work except for those fellows covering the inpatient services. Rotating pediatric residents remained on their inpatient clinical rotations. In the event of loss of resident coverage, a contingency plan for PHO fellows to provide in-house overnight coverage was developed; redeployment plans for fellows to assist on adult units were also developed. Educational activities including daily didactic conferences were transitioned to online learning platforms.

Pediatric COVID-19 Triage Team

On March 9, 2020, the task force established the COVID-19 Pediatric Triage Team, a group composed of APPs and hospitalist physicians who provided daytime care 7 days a week. The COVID-19 Triage APPs and physicians were trained on triage procedure, the clinical presentation of COVID-19, and donning and doffing of appropriate personal protective equipment (PPE) use. The APPs were required to review all COVID-19 updates daily and to implement pediatric-specific procedural changes. Daily hand-off occurred between day and night coverage clinicians to follow-up on COVID-19 testing results. The APP triage team participated in the twice-daily huddles to maintain communication with the COVID-19 task force and primary services.

Patients and caregivers had a primary telephone screening performed at two different time points, 72 and 24 h before each visit and upon arrival to the clinic by the administrative support team. Screening questions included (1) travel history (before community spread in NYC was established), (2) known contact with a COVID-19 positive individual, and/or (3) presence of signs or symptoms of COVID-19 infection. Patients and/or caregivers positive for any of the screening questions were immediately masked and placed in an isolation room. Once isolated, a more in-depth symptomatic screening of the patient and/or caregiver was performed. The COVID 19 triage APPs assessed and ordered laboratory testing. Patients with mild illness were managed at home under the remote supervision of their primary oncology team.

Isolation and cohorting

Patients seen in the outpatient clinics were placed in isolation when screening positive or symptomatic; they were seen by dedicated staff, treated as needed, and discharged home, or admitted. Initially, pediatric patients were admitted to a COVID-19 dedicated adult unit and cared for by assigned pediatric staff. Four beds on the pediatric inpatient unit were dedicated to COVID-19 patients for the management of symptoms or of their primary disease. The beds chosen were spatially separate from the rest of the unit, and staff cohorting policies were simultaneously established to avoid cross-coverage of COVID-19 negative patients. Because of the paucity of airborne isolation rooms, the majority of patients suspected or known positive for COVID-19 were seen in regular positive pressure rooms with high-efficiency particulate air filters.

CDC guidance was followed for PPE recommendations. Direct patient care of COVID-19 patients required an N-95 mask, which could be re-used with an additional surgical mask as a preservation strategy, eye shields, gowns, and gloves. MSK's PPE guidelines were made available and updated to all staff via the MSK intranet. Physicians and APPs used a “buddy” system to monitor each other donning and doffing PPE.

Screening and Testing

The PICS developed specific screening and testing guidelines to protect our unique patient population and decrease the risk of transmitting COVID-19. These guidelines are outlined in Table 1. Early on, the testing ability was limited to patients who screened positive or were symptomatic and their caregivers. Later, with the increase in the testing kits, we tested: (1) children with positive screen or symptoms, (2) children seen for urgent care, (3) children before high-dose chemotherapy, (4) children before procedures or surgery requiring anesthesia, and (5) children (and their caregivers) scheduled for admission.

Table 1.

COVID-19 Screening and Swabbing of Pediatric Patients.

Screen negative and asymptomatic
Patient/caregiver	Indication	Timing of COVID swab
Patient	High dose chemotherapy Anti-GD2 antibody	24-72 hr
	Pre-procedure Pre-anesthesia	24-48 hr
Patient and caregiver	Pre-admission	24-72 hr

Note. COVID-19 = coronavirus disease 2019; PICU = pediatric intensive care unit

As reported separately (Boulad et al., 2020), the rate of SARS-CoV-2 positivity was 29.3% in symptomatic patients and only 2.5% in asymptomatic patients (Figure 1). Because pediatric patients were allowed to be accompanied by a single caregiver, on March 30, 2020, screening of the caregiver of patients requiring admission and patients requiring consecutive day outpatient chemotherapy was initiated. As reported, 14.7% of asymptomatic caregivers were found to be SARS-CoV-2 positive (Boulad et al., 2020) underscoring an important infection control consideration for pediatric health-care facilities.

Caregivers of admitted patients who tested positive were asked to return home, self-quarantine, and follow-up with their primary care physician. Whenever possible, an alternative caregiver was swabbed, and, if confirmed COVID-19 negative, could remain as the bedside patient’s caregiver. Patients whose caregivers tested positive for COVID-19 were isolated and placed on COVID-19 exposure precautions for 14 days. Weekly post-exposure testing was conducted. If the patient became symptomatic during the 14 days, the patient was immediately tested. These guidelines were updated to include routine 72-hour surveillance testing of all hospitalized pediatric patients and caregivers for SARS-CoV-2. Patient and caregiver testings are tracked on a dashboard accessible to all clinical staff detailing the reasons for testing and results.

Testing of employees included symptomatic employees on a case-by-case basis. Before March 16, 2020, employees who were symptomatic were asked to remain at home and notify employee health. On March 16, 2020, employees who self-reported symptoms were tested by the COVID-19 employee response team. A daily electronic symptom check tool (Health Check) was implemented to screen and instruct employees with COVID-like symptoms to stay home.

Discussion

As the COVID-19 pandemic spread from Asia to Europe and then to the U.S., our oncology institution and pediatric oncology department anticipated the need to develop plans for the screening, testing, and treating of patients, as well as specific mitigation plans (Griffin et al., 2020; Gupta & Federman, 2020). We developed a stepwise strategic planning effort for infection containment and ongoing cancer management (Stenger 2020; Ueda et al., 2020). Our first step was to build centralized leadership in the form of a Pediatrics Incident Command team that could function on a 24/7 basis, develop recommendations, and communicate regularly with the department staff. It is noteworthy that the PICS team began planning more than a week before the first COVID positive patient entered our unit. A second task force inclusive of the PICS team, together with the different chiefs of service, director of education, and director of clinical research, was critical to guide implementation and provide feedback. It was important that both task forces include multidisciplinary individuals representing attending physicians, graduate staff physicians, APPs, nursing, infection control, and administration to ensure broad stakeholder input, and dissemination of information.

We ensured there was a constant direct communication between the hospital leadership and the departmental leadership to reconcile our measures to those of the center. In the context of a cancer hospital, certain directives required specific adaptation to our pediatric patient population. For example, the NYS DOH recommendations to restrict hospital visitation and bedside companions were not appropriate for minor patients. Following discussion with hospital leadership, allowances were made such that all pediatric patients could have one caregiver at the bedside. In the face of limited testing, we also argued that the patient–caregiver dyad should be considered as one unit, particularly during hospital admission. As a result, we were granted permission to test caregivers for COVID-19 on an as-needed basis.

While it is understood that MSK Kids cares for a select group of patients in the context of a free-standing cancer center and that our experiences may not be universally applicable, the processes implemented here may serve as a model to help guide other centers during these unprecedented times (Saini et al., 2020). The pediatric-specific workflows, processes, and procedures described were the product of continuous and iterative, interdisciplinary collaboration and may be applicable to some extent to the care of hospitalized children outside of oncology during the pandemic (Pathak et al., 2020).

We found that the communication with the hospital's COVID19 response team and regular dissemination of updated information and protocols were vital to maintain morale and provide staff accurate information and the tools needed to manage this challenging time. Preemptive patient volume mitigation, decreasing patient numbers by half, allowed for increased patient safety and right sizing of on-site staffing needs, protecting and preserving personnel resources. Finally, prioritizing and optimizing of patient–caregiver screening, case isolation, and ultimately COVID-19 surveillance testing have paved the way towards a “new beginning,” where the active management of COVID positive patient flow using centrally accessible testing dashboards, segregated treatment areas, and dedicated personnel can be realized, allowing for a much needed and highly anticipated shift in focus from pandemic mitigation to the restoration of full cancer care activities.

Implications for Pediatric Hematology/Oncology Nursing

Despite evidence that children with cancer may not be more vulnerable than other children, the threat posed by this pandemic requires significant changes to our nursing practice and cooperation and coordination with our colleagues across disciplines and hospital administrations.

Pediatric hematology/oncology nurses are in a key position to ensure successful infection mitigation, coordinate patient care workflows, and assess additional needs. As such, pediatric hematology/oncology nurses and advanced practice providers were critical leaders and participants in our efforts to develop guidance and workflows, continuously assess patients’ needs for hospital services and implement solutions, increase utilization of telemedicine to replace in-person visits, use satellite regional centers to manage patients living outside NYC, implement a patient and caregiver screening/surveillance program for both pre-screening and day-of-service screening for risks, or symptoms of infection, and implement plans for the management of COVID-19 positive patients.

Our objective in sharing this work is to provide an example of substantive and effective measures implemented in our response to the current pandemic in a pediatric department located within a large comprehensive cancer center.

The planning described can inform strategic planning efforts at other pediatric oncology centers, as different states face a surge of COVID-19 cases and for continued preparedness to combat the threat posed by SARS-CoV-2 worldwide, or other potential future pandemics.

Author Biographies

Victoria Szenes, MS RN CPNP, is the nurse leader for clinical trials for the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Rachel Bright, RN BSN CPHON®, is the nurse leader for the Pediatric Ambulatory Care Center in the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Deborah Diotallevi, MS RN CPNP, is the Manager for the Advanced Practice Provider of the Pediatric Ambulatory Care Center in the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Giselle Melendez, EdD RN NE-BC, is the nurse leader for inpatient and critical care in the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Cassie Martinez, MS RN CPNP CCRN, is the Advanced Practice Provider Manager for inpatient and critical care in the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Nicole Zakak, MS RN CPNP, is the Associate Director for Advanced Practice Provider Quality & Professional Development, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

James Killinger, MD, is a critical care physician and the medical director of the Pediatric Intensive Care Unit in the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Stephen Gilheeney, MD, is a pediatric hematologist–oncologist and Inpatient Medical Director of the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Stephen S. Roberts, MD, is a pediatric hematologist–oncologist and the director of the Pediatric Fellowship program in the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Mini Kamboj, MD, is an infectious disease specialist and chief of the Medical Epidemiology Service in the Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Julia Glade Bender, MD, is a pediatric hematologist–oncologist and the vice-chair for clinical research in the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Andrew L. Kung, MD PhD, is a pediatric hematologist–oncologist and chair of the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Farid Boulad, MD, a pediatric hematologist/oncologist, vice chair of clinical operations, and medical director of the pediatric ambulatory care center in the Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.