-
Awaiting decision to resume non-emergent care
General considerations - Continue to maximize telehealth, when possible
- Ensure sufficient resources: PPE, healthy workforce, facilities, medications, supplies, post-acute care, testing capacity sufficient not to jeopardize surge capacity in facility or community;1 per ACS, ensure supply adequate for possible 2nd wave2
- Evaluate incidence/trends of COVID-19; coordinate decision to resume in-person care w/ state/local public health dept;1,3 ACS recommends consideration of resuming elective surgery only after ≥14 days sustained ↓in COVID-19 cases in area, and all facilities in state hospitalizing pts w/o crisis standards of care2
- Triage based on clinical necessity of care: prioritize surgical/procedural care, high-complexity chronic disease mgmt, essential preventive measures;1 ACS recs forming facility committee to prioritize elective procedures;2 CDC recs balancing harm of deferral to pt w/ degree of community transmission3
- Consider HCW fatigue and stress before resuming elective surgery to ensure pt safety, per ACS2
- COVID-19 screening: consider separate screening location; check all pts, staff for COVID-19 sx, fever prior to entering facility; when lab testing capacity avail, implement lab testing as screening;1 consider timing of testing to provide useful info in pre-op pts, consider false negs;2 see epocrates COVID-19 Symptom Eval
- Develop plans for responding to COVID-19 positive and PUI staff, pts (identified before, during, after care)2
PPE recommendations1 - Wear surgical masks at all times: all health care providers and staff
- Use N95 and face shields during procedures on mucous membranes of respiratory tract
- Require cloth face covering for pts, surgical mask only if already in pt possession; conserve PPE supply at all costs
Facility recommendations1 - Segregate COVID-19 care from non-COVID-19 care by largest degree possible (eg, separate bldg, separate floor, separate entrance); staff working in non-COVID-19 care should not work in COVID-19 areas
- Facilitate social distancing: minimize time in waiting room, space chairs 6 ft apart, reduce pt volume
- Prohibit visitors/guests unless necessary for pt care; screen as w/ all others in facility
- Ensure thorough cleaning/disinfection of space prior to non-COVID-19 care
Footnotes 1 CMS 2020. Centers for Medicare & Medicaid Services (CMS) Recommendations. Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare. June 8, 2020. PDF • Certain preventive services may be highly necessary and can be resumed. Which specific services may qualify is not delineated by CMS.
• Follow CDC guidelines for decontaminating medical equipment, such as ventilators, which have been used on pts w/ COVID-19.
2 ACS 2020. Joint Statement: Roadmap for Resuming Elective Surgery After COVID-19 Pandemic. April 17, 2020. Accessed 4/30/20
• ACS recommends considering known evidence supporting health care worker fatigue and impact of stress when determining if staffing is sufficient and able to work w/o compromising pt safety.
• Infxn prevention techniques also include access control, workflow redesign, and social distancing.
3 CDC 2020. Framework for Healthcare Systems Providing Non-COVID-19 Care During the COVID-19 Pandemic. Accessed 5/13/20
-
General considerations for adult pts: - Maximize telehealth for screening and triage of pts before office visits
- Reopen incrementally, beginning w/ a few in-person visits per day
- Triage based on clinical necessity of care: prioritize surgical/procedural care, high-complexity chronic dz mgmt, essential preventive measures1
- COVID-19 screening: consider separate screening location; check all pts, staff for COVID-19 sx, fever prior to entering facility; when lab testing capacity avail, implement lab testing as screening
- Provide clear messaging w/ pts about changes in care, incl COVID-19 screening, facility safety procedures, PPE use, visitor restrictions, follow-up procedures
- Segregate well and sick care physically (separate entries, waiting room, exam rooms) and temporally (schedule well care in AM, sick care in PM)2
- Wear surgical masks at all times (all health care providers and staff); use N95 and face shields during procedures on mucous membranes of respiratory tract
- Require cloth face covering for pts, surgical mask only if already in pt possession; conserve PPE supply at all costs
- Facilitate social distancing: minimize time in waiting room, space chairs 6 ft apart, reduce pt volume/increase time btwn pts on schedule
- Prohibit visitors/guests unless necessary for pt care; screen as w/ all others in facility
Footnotes 1 CMS 2020.Centers for Medicare & Medicaid Services (CMS) Recommendations. Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare. June 8, 2020. PDF • Certain preventive services may be highly necessary and can be resumed. Which specific services may qualify is not delineated by CMS.
2 AMA 2020. COVID-19: A Physician Practice Guide to Reopening. May 1, 2020. Accessed 5/12/20
-
Pre-operative assessment1 - Pt readiness can by coordinated by anesthesiology-led pre-op assessment service; H&P w/in 30 days needed for all pts, per CMS regulations
- Consider telemed, APPs for components of pre-op eval
- Face-to-face components can wait for day of surgery in healthy pts
- Special attn and re-eval needed in pt w/ hx of COVID-19
- Avoid labs and imaging w/o indication; may need to repeat previous studies, if done before surgery delayed by COVID-19
- COVID-19 screening: consider telemed pre-screening; consider separate screening location; check all pts, staff for COVID-19 sx, fever prior to entering facility; when lab testing capacity avail, implement lab testing as screening;2 consider timing of testing to provide useful info in pre-op pts ( w/in 48-72h of surgery, per IDSA),3 consider false negs;1 see epocrates COVID-19 Symptom Eval
- Develop plans for responding to COVID-19 positive and PUI staff, pts (identified before, during, after care)
Other considerations - Wear surgical masks at all times: all health care providers and staff1,2
- Require cloth face covering for pts:1,2 surgical mask only if already in pt possession2
- Provide clear messaging w/ pts about changes in care, incl COVID-19 screening, facility safety procedures, PPS use, visitor restrictions, follow-up procedures1
- Consider review of advance directive, esp if pt frail, elderly, or post-COVID-191
- Eval and discuss potential need for rehab/SNF post-op, given known outbreaks in PAC facilities1
Footnotes 1 ACS 2020. Joint Statement: Roadmap for Resuming Elective Surgery After COVID-19 Pandemic. April 17, 2020. Accessed 4/30/20
• Infxn prevention techniques also include access control, workflow redesign, and social distancing.
2 CMS 2020.Centers for Medicare & Medicaid Services (CMS) Recommendations. Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare. June 8, 2020. PDF
• Certain preventive services may be highly necessary and can be resumed. Which specific services may qualify is not delineated by CMS.
• Follow CDC guidelines for decontaminating medical equipment, such as ventilators, which have been used on pts w/ COVID-19.
3 IDSA 2020. Hanson KE, et al. Infectious Diseases Society of America Guidelines on the Diagnosis of COVID-19. May 6, 2020. Accessed 5/7/20
Inter-op considerations - Mask pt before/after intubation, if using general anesthesia1
- Consider inclusion of COVID-19 risk/results and PPE use in time-outs2
- Limit personnel present during intubation/extubation; consider waiting air circulation cycling time before starting operation3
- Consider limiting nonessential personnel in OR, incl students2
- Drape equipment to reduce contamination1
- Review specimen pick-up protocol2
- No recommendation from ASA re: site of extubation, recovery in elective cases, but OR is preferred in pts w/ known/suspected COVID-191
Footnotes 1 ASA 2020. COVID-10 Information for Health Care Professionals. March 20, 2020. Accessed 4/30/20
2 ACS 2020. Joint Statement: Roadmap for Resuming Elective Surgery After COVID-19 Pandemic. April 17, 2020. Accessed 4/30/20
3 ACS 2020. Local Resumption of Elective Surgery Guidance. April 17, 2020. Accessed 4/30/20
Post-op considerations - Adhere to standardized care protocols when possible1
- Discharge home when possible; PAC setting such as nursing homes may have higher rate of COVID-191
- Follow plans for responding to COVID-19 positive and PUI staff, pts (identified post-op)1
- Continue to monitor COVID-19 incidence, supply inventory, staff availability2
- Continue infxn control measures at post-op visits: provider and staff in surgical masks; pts mandated to wear face coverings; social distancing; ↓volume; ↓time in waiting room; segregation of COVID-19 pts from non-COVID care; limiting guests3
Footnotes 1 ACS 2020. Joint Statement: Roadmap for Resuming Elective Surgery After COVID-19 Pandemic. April 17, 2020. Accessed 4/30/2020
2 ACS 2020. Local Resumption of Elective Surgery Guidance. April 17, 2020. Accessed 4/30/2020
3 CMS 2020.Centers for Medicare & Medicaid Services (CMS) Recommendations. Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare. June 8, 2020. PDF
-
General considerations - Continue to maximize telehealth when community circumstances require limiting in-person care1-3
- Triage based on clinical necessity of care: Prioritize surgical/procedural care, high-complexity chronic dz mgmt, essential preventive measures,2 esp newborn care, WCC/vaccines ≤24 mo3
- COVID-19 screening: Consider separate screening location; check all pts, parents, staff for COVID-19 sx, fever prior to entering facility2
- Discourage extra parents, siblings from attending office visits4
PPE recommendations2 - Wear surgical masks at all times: all health care providers and staff
- Use N95 and face shields during procedures on mucous membranes of respiratory tract
- Require cloth face covering for parents, pts >2 yo; surgical masks only if in pt possession, preserve PPE
Facility recommendations - Segregate sick and well care: strategies include separate waiting/exam rooms; using back door for sick pts; scheduling well care in AM, sick care in PM; separate clinic/facility for well care2-4
- Facilitate social distancing: Minimize or eliminate time in waiting room, space chairs 6 ft apart, reduce pt volume2,4
- Remove tables, toys, books from waiting room
- Shut down exam room x2h after aerosolized procedure4
Footnotes 1 CDC 2020. Coronavirus Disease 2019: Information for Pediatric Healthcare Providers. Updated May 3, 2020. Accessed 5/5/20
2 CMS 2020.Centers for Medicare & Medicaid Services (CMS) Recommendations. Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare. June 8, 2020. PDF
3 AAP 2020. Guidance on Providing Pediatric Ambulatory Services via Telehealth During COVID-19. Last updated: April 15, 2020. Accessed 5/5/20
4 AAP 2020. Pediatric Practice Management Tips During the COVID-19 Pandemic. Last updated: May 4, 2020. Accessed 5/5/20
-
Resume care using tiered approach, balancing risk of exposure w/ harm of delaying radiology care; safety measures include:1 - Defer screening, time-insensitive care until ≥2wk post-peak locally
- Continue telehealth, work from home, when possible
- COVID-19 screening: screen pts for sx upon scheduling, all pts/staff/visitors upon facility entry; develop plan for those who screen positive
- Restrict sick or extra visitors from accompanying pts
- Universal masking of all health care providers, staff, pts and visitors (N95 and face shields for aerosolizing care); ensure sufficient current & future supply
- Flag pts w/ recent, current, suspected COVID-19: Treat in separate designated area
- Facilitate social distancing: Minimize or eliminate time in waiting room, space chairs 6 ft apart, reduce pt volume, direct pt flow one-way through corridors
- Breast pts may need to be prioritized: imaging for pts w/ delayed surgery, delayed percutaneous bx, pts recalled from screening or needed short-term f/u, screening of high-risk pts2
Footnotes 1 ACR 2020. Davenport MS, et al. ACR Statement on Safe Resumption of Routine Radiology Care During the COVID-19 Pandemic. J Am Coll Radiol. 2020. Journal Pre-Proof:doi.org/10.10106/j.jacr.2020.05.001. Accessed 5/8/20
2 SBI 2020. SBI Recommendations for a Thoughtful Return to Caring for Patients. Society of Breast Imaging. Updated May 5, 2020. Accessed 5/8/20
-
Coordinate level of care w/ public health officials Level 2 (Resume some services): - STEMI: Use PPE as directed by local authorities; PCI for most pts; pharmaco-invasive tx per region practice; if mod/high prob of COVID-19, consider alt investigations (TTE and/or CCT) prior to cath lab activation or pharmaco-invasive tx
- NSTEMI/UA: Invasive strategy if high risk NSTEMI; selective invasive strategy if med risk; medical tx if low risk or UA1
- Elective cath cases: out-pt w/ sx and non-invasive testing showing high risk for event in short-term
Level 1 (Resume most services): - STEMI: Use PPE as directed by local authorities; PCCI for most pts; pharmaco-invasive tx per region practice; if mod/high prob of COVID-19, consider alt investigations (TTE and/or CCT) prior to cath lab activation or pharmaco-invasive tx
- NSTEMI/UA: invasive strategy if high or mod risk NSTEMI; med tx if low risk or UA1
- Elective cath cases: out-pt w/ high or mod risk for event in short-term; stable cases may still be deferred
Level 0 (Resume all services): - STEMI: Use PPE as directed by local authorities; PCCI for most pts; pharmaco-invasive tx per region practice; if mod/high prob of COVID-19, consider alt investigations (TTE and/or CCT) prior to cath lab activation or pharmaco-invasive tx
- NSTEMI/UA and elective cases: routine service for all pts
Footnotes 1 JACC 2020. Wood DA, et al. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: Guidance From North American Society Leadership. J Am Coll Cardiol. April 29, 2020. Accessed 5/7/20
High risk NSTEMI criteria: Refractory sx, hemodynamic instability, significant LV dysfxn, suspected LM or significant proximal epicardial dz, GRACE risk score >140.
Coordinate level of care w/ public health officials Level 2 (Resume some services): - TAVR or MitraClip: in-pt and out-pt w/ severe, symptomatic valve dz
- Other cases (ASD/PFO, LACC, etc): selective cases
Level 1 (Resume most services): - Majority of cases, but stable cases may be deferred
Level 0 (Resume all services): - Routine service for all pts
Footnotes JACC 2020. Wood DA, et al. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: Guidance From North American Society Leadership. J Am Coll Cardiol. April 29, 2020. Accessed 5/7/20
Coordinate level of care w/ public health officials Level 2 (Resume some services): - Coronary: in-pts awaiting surgery; out-pts with progressive sx or LV dysfxn
- Valves: in-pts awaiting surgery; out-pts w/ severe, symptomatic valve dz or LV dysfxn
- Others: acute aortic dissection; valvular endocarditis; heart transplant/VAD; high-risk cardiac tumors; severe, symptomatic congenital heart dz
Level 1 (Resume most services): - Coronary, valves: in-pts awaiting surgery; majority of out-pts, but stable cases may be deferred
- Others: majority of cases, but stable cases may be deferred
Level 0 (Resume all services): - Routine service for all pts
Footnotes JACC 2020. Wood DA, et al. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: Guidance From North American Society Leadership. J Am Coll Cardiol. April 29, 2020. Accessed 5/7/20
Coordinate level of care w/ public health officials Level 2 (Resume some services): - Ablation: Pre-excited AF, AF w/ recurrent admits +/-CHF, drig-refractory VT
- Devices: PPM for all in-pts & high risk out-pts; secondary prevention and select primary prevention ICD; generator elective replacement indicator activated
- Selective other cases: lead replace/revise/extract w/ infxn or inappropriate shocks; ILR for syncope; ambulatory monitor; cardioversion
Level 1 (Resume most services): - Majority of cases, but stable cases may be deferred
Level 0 (Resume all services): - Routine service for all pts
Footnotes JACC 2020. Wood DA, et al. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: Guidance From North American Society Leadership. J Am Coll Cardiol. April 29, 2020. Accessed 5/7/20
Coordinate level of care w/ public health officials Level 2 (Resume some services): - TTE: all in-pts; out-pts in which TTE alters short-term mgmt
- TEE: all pts in which TEE alters short-term mgmt; consider aerosol precautions for all
- Stress echo: select cases where testing alters short-term mgmt; pharm testing preferred over exercise testing
Level 1 (Resume most services): - Majority of cases, but stable cases may be deferred
Level 0 (Resume all services): - Routine service for all pts
Footnotes JACC 2020. Wood DA, et al. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: Guidance From North American Society Leadership. J Am Coll Cardiol. April 29, 2020. Accessed 5/7/20
Coordinate level of care w/ public health officials Level 2 (Resume some services): - CT coronary angio: all in-pts; select symptomatic out-pts
- Structural heart dz: procedural planning for all in-pts, select out-pts
- Other: select cases (PV assessment for AF ablation planning, masses, congenital heart dz)
Level 1 (Resume most services): - Majority of cases, but stable cases may be deferred
Level 0 (Resume all services): - Routine service for all pts
Footnotes JACC 2020. Wood DA, et al. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: Guidance From North American Society Leadership. J Am Coll Cardiol. April 29, 2020. Accessed 5/7/20
Coordinate level of care w/ public health officials Level 2 (Resume some services): - LV/RV assessment: all in-pts, select out-pts (consider alt imaging modality)
- Infiltrative/inflammatory dz: all in-pts, select out-pts
- Myocardial viability: all in-pts, select out-pts
- Stress CMR: all in-pts, select out-pts (consider alt imaging modality)
- Other: select cases (congenital heart dz, masses, vascular)
Level 1 (Resume most services): - Majority of cases, but stable cases may be deferred
Level 0 (Resume all services): - Routine service for all pts
Footnotes JACC 2020. Wood DA, et al. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: Guidance From North American Society Leadership. J Am Coll Cardiol. April 29, 2020. Accessed 5/7/20
Coordinate level of care w/ public health officials Level 2 (Resume some services): - Nuclear stress test: all in-pts, select out-pts; vasodilator preferred over exercise
- Myocardial viability: all in-pts, select out-pts
- Other: select cases (LV assessment, pre-op organ transplant eval, infiltrative dz)
Level 1 (Resume most services): - Majority of cases, but stable cases may be deferred
Level 0 (Resume all services): - Routine service for all pts
Footnotes JACC 2020. Wood DA, et al. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: Guidance From North American Society Leadership. J Am Coll Cardiol. April 29, 2020. Accessed 5/7/20
Coordinate level of care w/ public health officials Level 2 (Resume some services): - Cardiopulmonary testing: all in-pts, select out-pts
- Endomyocardial bx: select cases (transplant surveillance if high risk for rejection, tx guidance in myocarditis)
- Right heart cath: select cases (facilitate transplant listing or candidacy for mech circ support; tailored hemodynamic tx in cardiogenic shock)
Level 1 (Resume most services): - Majority of cases, but stable cases may be deferred
Level 0 (Resume all services): - Routine service for all pts
Footnotes JACC 2020. Wood DA, et al. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: Guidance From North American Society Leadership. J Am Coll Cardiol. April 29, 2020. Accessed 5/7/20
Coordinate level of care w/ public health officials Level 2 (Resume some services): - Critical limb ischemia: all in-pts, select out-pts
- TEVAR/EVAR: all in-pts, select out-pts
- Other: select cases (mesenteric ischemia, symptomatic DVT)
Level 1 (Resume most services): - Majority of cases, but stable cases may be deferred
Level 0 (Resume all services): - Routine service for all pts
Footnotes JACC 2020. Wood DA, et al. Safe Reintroduction of Cardiovascular Services During the COVID-19 Pandemic: Guidance From North American Society Leadership. J Am Coll Cardiol. April 29, 2020. Accessed 5/7/20
-
Resume routine care only when cleared by public health department; considerations for in-person care: - Screen for COVID-19 sx and exposure prior to appt1
- Facilitate social distancing: minimize or eliminate time in waiting room, seat pts ≥6ft apart, reduce pt volume (esp vulnerable groups)
- Wear mask & eye protection for all procedures or exams in close proximity to pt (N95 for any aerosolizing procedure); pts should also wear mask or cloth face cover
- Install slit-lamp barriers or breath shields; ask pt to remain silent, speak as little as possible to pt during slit-lamp exam
- Retest pts w/ history of COVID-19 in past 6wk before routine care; if positive, pt to wear surgical mask, provider to wear N95/eye protection/gown
- Disinfect visual field analyzer per manufacturer recs between pts, wearing mask and eye protection
- Use single-use, disposable tonometer tips; if not available, 5%-10% bleach solution or 70% alcohol are options (alcohol will work for SARS-CoV-2, but not adenoviruses)
- Multi-dose eye drops OK, avoid contact w/ lashes or conjunctiva, as usual
- Cataract surgery is semi-urgent (not elective) when: pt cannot drive, work or see to take medications properly; pt w/ ↑ risk of falling; pt w/ phacomorphic glaucoma or intolerable anisometropia
Footnotes 1 AAO 2020. Chodosh J, et al. Important Coronavirus Updates for Ophthalmologists. May 11, 2020. Accessed 5/10/20.
Recommended questions for screening pt before appt:
• Does pt have sore throat, fever, fatigue, loss of smell or respiratory sx?
• Has pt been in the presence of someone w/ known COVID-19 in the last 2 to 14 days?
-
Pt and staff safety is top priority; considerations for pt care: - COVID-19 screening: screen pts upon scheduling, w/in 72h of procedure via telehealth, update upon arrival;1 per AGA, consider pre-test 48-72h before, depending on dz prevalence;2 check pt temp on arrival; develop plan for removing those who screen positive, incl notifying public health authority; screen staff similarly
- Survey pts 1-2wk post-procedure for development of sx, or positive COVID-19 testing; initiate contact tracing if pt or staff test positive or develop sx in interim
- Enforce physical distancing for pts and staff, except when close contact req to perform procedure or exam; install plexi barriers where distancing not possible; rework scheduling, check-in, check-out processes to minimize or eliminate contact; limit time and space seating in waiting room
- Mask pts, visitors and staff at all times; use N95, face shield and other appropriate PPE during endoscopy;2 consider N95 for staff w/ close contact perioperatively; ensure staff trained in proper donning/doffing of PPE
- Limit visitors to one per pt, ask them to wait in car during procedure
- Keep pts w/ coughing or needing nebulizer tx in procedure room until risk of aerosolization subsides
Footnotes 1 ASGE 2020. Hennessy B, et al. Guidance for Resuming GI Endoscopy and Practice Operations After the COVID-19 Pandemic. April 28, 2020. Accessed 5/7/20
Suggested screening questionnaire (refer to PCP if “yes” to any of 1-4; test if “yes” to any of 5-8):
1. Have you had testing for COVID-19? Clarify if this was a direct viral test (eg, swab, saliva) or serologic (blood antibody) test. Was your test positive or negative?
2. Do you have any of the following? (yes or no): fever to 100.4 degrees (38C) or higher; cough; shortness of breath, difficulty breathing, chest pain; sore throat; loss of sense of smell or taste; new onset of fatigue or lack of energy
3. Do you have nausea w/ or w/o vomiting?
4. Do you have diarrhea?
5. Have you recently traveled to any current COVID-19 hot spot? If so, where?
6. In the past 14 days, have you come into close contact (w/in 6ft/2m) w/ someone who has a laboratory-confirmed COVID-19 dx?
7. Are you a first responder, health care worker, or do you work or volunteer at a hospital or health care facility?
8. Are you an employee of a daycare facility, senior living location, adult daycare or extended care or rehabilitation care facility?
2 AGA 2020. Sultan S et al, on behalf of the AGA. AGA Institute Rapid Review and Recommendations on the Role of Pre-Procedure SARS-CoV2 Testing and Endoscopy, Gastroenterology (2020). Journal pre-proof
Don’t use serology (antibody) testing; consider RT-PCR pretesting 48-72h before endoscopy if prevalence of asymptomatic SARS-CoV2 is between 0.5% and 2%.
• If pt tests negative, endoscopists and staff should use surgical masks for all upper and lower endoscopies.
• Endoscopists and staff who are unwilling to accept the potential small risk of infxn (from false negatives) may use N95/N99 respirator or PAPRs for upper and/or lower endoscopies.
In settings where prevalence of asymptomatic SARS-CoV2 is <0.5%, pretesting may be less valuable due to ↑false postives, leading to cancellation of cases. Risk aversion may drive decision re: level of PPE used.
If prevalence of asymptomatic SARS-CoV2 is >2%, pretesting may be less safe due to ↑false negatives.
• If available, N95/N99 respirators or PAPRs may be used for all upper and lower endoscopies
• If cases surge and hospital resources burdened, endoscopy may be reserved for emergency/time-sensitive procedures w/ use of N95/N99 respirators or PAPRs for all procedures
-
Considerations for pts w/ breast CA on XRT:1 - Omit XRT if pt ≥65 yo w/ invasive dz <30 mm, clear margins, grade 1-2, ER+, HER2-, LN- and endocrine tx planned
- Consider omitting XRT for DCIS, depending on individual risk/benefit
- Deliver XRT in 5 fractions for all pts w/ LN- tumors that do not require boost
- Omit boost XRT in most pts, unless ≤40 yo or high risk for relapse
- Omit nodal XRT in post-menopausal women requiring whole breast XRT after primary surgery/sentinel node bx if T1, ER+, HER2-, grade 1-2 tumor w/ 1-2 macromets
- Use moderate hypofractionation on all breast, chest wall, nodal XRT
Footnotes 1 CO 2020. Coles CE, et al. International Guidelines on Radiation Therapy for Breast Cancer During the COVID-19 Pandemic. Clin Oncol (R Coll Radiol). 2020. May;32(5):279-281. Access 5/4/2020
|
