May 14, 2020

The Role of Advanced Practitioners in Radiation Oncology During the COVID-19 Pandemic

By Kaitlyn Coucoules, MS, PA-C

Winston Churchill said, “Never let a good crisis go to waste.” What about the COVID-19 crisis could possibly be good?

The good thing about a crisis is that it naturally instills a sense of urgency. Suddenly, it is easier to discern what it is important. Things considered optional at one time become critical. Barriers resisting change are overcome in less time. Most importantly, crisis can create camaraderie. Many people diligently working toward one mission has changed and will continue to change the world.

Over half of patients with cancer require radiation therapy (RT). Sometimes it is the only treatment necessary and sometimes it is used in combination with surgery and systemic therapy. RT often requires patients to present to the treatment facility for daily sessions for weeks. While delivering larger doses of radiation per fraction to reduce the total number of treatment sessions (hypofractionation) and other advances in technology can help reduce possible COVID-19 exposure, little wiggle room exists for modifying established curative treatment regimens.

During the COVID-19 crisis at Moffitt Cancer Center, advanced practitioners (APs) in radiation oncology are offering help wherever and whenever it is needed. They are wearing many hats, but the overarching goal is the same: reduce the risk of COVID-19 transmission and allow radiation to continue for those most likely to benefit.

Screening

The frequency of visits for patients undergoing RT is unavoidable. Screening the particularly vulnerable patients before entering the department is of utmost importance. APs have volunteered to administer staff and patient screening questions before entrance to the department. In addition, regular COVID-19 testing ensures the safety of patients and staff. APs are entering COVID-19 testing orders on all patients prior to simulation. Patients receiving 3 or more weeks of therapy are being tested weekly on the day of on treatment visits (OTV).

Super Functional Unit

Moffitt’s Radiation Oncology Program consists of 25 board-certified radiation oncologists and 11 APs divided into teams by disease site. The Super Functional Unit (SFU) was created to reduce the number of staff on-site without sacrificing patient care. Disease sites, along with the corresponding physicians and APs, were grouped together (e.g., Breast/Gynecology). One physician per SFU staffs the department on a given day, with AP support. Physician responsibility grew beyond routine demand and APs did what they do best: force multiplication. Together, the SFU team covers patients on treatment, inpatient consults, and impromptu clinic needs.

Team Telemedicine

Safer-At-Home initiatives, inability to interpret masked facial expressions, and a greater reliance on video technology have changed the way we connect with individuals. Telemedicine at Moffitt Cancer Center increased over 5,000% between the beginning of March and the end of April 2020. There is no arguing telemedicine is here to stay. APs in radiation oncology are well-suited to identify candidates for conversion from an in-person visit to a virtual visit. Their training and relationship with physicians also allow APs to assist with patient prioritization based upon established guidelines.

Quickly implementing virtual technology into any telemedicine-naïve practice has been no easy task. APs are involved in most of the radiation-related telemedicine visits and have experienced similar frustrations. Patients unfamiliar with the technology have difficulty operating aspects of the virtual visit. Visits have been abandoned in the virtual setting in favor of a phone call or rescheduled to an in-person visit later. In addition, APs frequently find themselves acting as an IT specialist at the beginning of telemedicine visits while attempting to troubleshoot communication delays on the patient end. Larger institutions have the resources to deploy a robust infrastructure, including the necessary support services to alleviate patient and provider burden associated with telemedicine. On the other hand, smaller practices may not be so lucky. One solution to eliminate learning-curve frustration would be dedicating a qualified individual to conduct a practice run with patients prior to their appointment with the physician or AP.

On Treatment Visits

Weekly OTVs are in-person and represent standard of care in radiation oncology. Radiation oncologists, nurses, and APs use OTVs to regularly monitor patient progress during active treatment. It is a time to evaluate any side effects and recommend appropriate treatment(s). OTVs also help determine if any changes need to be made to the schedule or treatment plan. Some APs adapted to COVID-19 concerns by conducting a majority of the OTV via telemedicine. Direct contact was limited by virtually collecting information and answering questions and performing a portion of the physical assessment prior to the physician entering the room for a focused exam.

Visitor Restrictions

Some visits cannot be virtualized. A nurse practitioner specialized in prostate cancer expressed difficulty in evaluating a gentleman before prostate brachytherapy, an operating room procedure. A restricted visitor policy prevented his wife from being present during the encounter. The nurse practitioner recounted how this patient, as with many of her patients, relied heavily on his spouse/significant other to manage his health history, medications, and note-taking. The challenge can be mitigated by using phone or video capabilities from the room when feasible.

Difficult RT discussions in the inpatient setting are tougher in the era of COVID-19. An AP described the emotional toll she experienced when delivering a terminal diagnosis to a patient who was physically alone in a hospital room. This AP would never choose to deliver a poor prognosis or disclose a lack of available treatment options to a patient who is alone, but she recognizes the current situation is unique. She attempts to engage family members on speaker phone or via secure video applications whenever possible.

Risky Procedures

A physician assistant specialized in head and neck cancer described the halt on performing nasopharyngolaryngoscopy (NPL; since there is a droplet risk associated with this procedure) as a challenge unique to her specialty. Prior to in-house COVID-19 testing capabilities, any patient with urgent issues or significant concerns was scoped with PPE. In non-urgent cases, the treatment team was forced to rely on patient history and imaging. Any new patients had their scope deferred until widespread testing became available. An AP is currently screening schedules in advance to identify new patients and follow-ups that will require NPL. Virus testing is ordered prior to the visit, and the procedure can be performed during the appointment if the test is negative.

Facts Over Fear

It is difficult to deny the heightened level of patient and provider anxiety as a result of the COVID-19 pandemic. The AP group is involved in daily radiation oncology department updates. It is a time for leadership, physicians, and APs to discuss COVID-19 updates and effects on proceedings. Relevant information from these meetings is escalated to the institutional level and used to guide senior leadership. An AP is involved with the publishing of the radiation oncology semi-weekly update, The Beam. The newsletter includes relevant viral statistics, governmental orders, news, and PPE status updates. APs also participate in COVID-positive patient drills to ensure proper preparation and adherence to established standards when the time comes to treat one of these individuals.

Radiation oncology APs are less involved in the technicalities of treatment delivery, which enables them to spend extra time with patients and caregivers when necessary. Uncertainty demands all available time and then some. They recognize the extra empathy, compassion, and level-headedness required to navigate individuals through unknown situations.

AP First Touch

The institution is anticipating an influx of new patients as the shock of COVID-19 lessens and restrictions are lifted. One result will be widespread adoption of AP First Touch across more disease sites. AP First Touch is a novel program designed to reduce new patient delays in being evaluated. It offers patients the opportunity to meet sooner with an AP only, if it is agreeable to them. The AP ensures all aspects of the workup are available when the patient subsequently meets with a physician and that the patient meets with the appropriate specialist. It serves as an excellent moment to educate patients on their disease and common treatments.

Conclusion

The persistent threat of COVID-19 makes caring for our cancer patients difficult. On the other hand, it forces us to conceptualize problems differently and approach them in innovative ways. APs in radiation oncology demonstrate unwavering flexibility, teachability, and creativity daily. According to Radiation Oncology department leadership, “Our APs have been indispensable to the department’s mission achievement during this crisis. They did not miss a beat during the shift to virtual visits and have been critical to the continuing care of patients under treatment and in clinic. We, and our patients, would be far worse off had they not been so engaged.”

The ideas and processes that emerge from thinking outside the box during difficult times can be reformed to improve cancer care in the future. Take advantage of the good that will emerge from this crisis.

Read more from the  APSHO Advance: Special COVID-19 Series