COVID-19 FAQ Updates

Updated - June 2020

Since posting the original set of ASTRO FAQs and Clinical Recommendations for COVID-19 on March 17, hospitals, clinicians and radiation oncology practices have learned how to efficiently function in the face of a pandemic and to adapt to rapidly changing circumstances. Although much of the initial guidance is essentially unchanged, other areas have evolved with time and should be updated. Likewise, new scenarios have emerged that deserve further elucidation. The ASTRO COVID-19 Work Group has reviewed the relevant online sources, as well as reaching out to select academic institutions for this update. Portions of the original Summary, as well as FAQs #5 and #12, have been updated to reflect current practice. As always, it is important to understand that one size does not fit all. Our intent is to guide, not to dictate; to counsel broadly; and to aid our colleagues across all practice environments, from academic to free-standing facilities. Please continue to send questions and suggestions, including links to COVID-19-related publications and helpful websites.

Safety in the Clinic

1. Examining head and neck patients: This challenging patient population requires close-in, hands-on exams, sometimes more frequently than the usual weekly OTV for most other patients. Coughing, sneezing, nasal wiping, and forced expectoration are common symptomatic behaviors which must be monitored to determine the extent of room cleaning necessary following the patient’s exit. Appropriate PPE is critically important for the examining clinician. Exams may fall into one of two broad categories: non-aerosol-generating procedures (less risky) and aerosol-generating procedures (more risky). Routine head and neck exams are considered non-aerosol-generating, in which case a mask, a face shield covering from the forehead and extending down below the chin, and gloves should be worn. Strong consideration should also be given to wearing a disposable gown for all patients and certainly if a patient has a known history of coronavirus infection. In some practices, digital palpation of the deep oropharynx is a standard part of head and neck examination; since this typically produces vigorous gagging it should be considered an aerosol-generating procedure and be managed similar to nasopharyngolaryngoscopy (NPL). These scenarios both require more stringent precautions. Full PPE should be employed, including N95 mask, face shields, gowns and gloves. It is recommended that deep digital examination and NPL be performed only when absolutely necessary and with minimum staff presence in the exam room. The scope should be handled and disinfected in accordance with established infection control guidelines. Practitioners are encouraged to confer with colleagues in Otolaryngology and/or with their Infection Control team to pursue uniform local precautions.
2. Safety for radiation therapy technicians (RTTs): Of clinic staff, RTTs have the most contact with patients and are unable to practice social distancing. The recommendations for their safety remain largely unchanged: scrubs instead of street clothes, face shields, masks and gloves with use of hand sanitizer upon entering and exiting the treatment vault. Patients with trach collars, CPAP/BIPAP or highflow O2 should be considered high risk for aerosol generation, in which case N95 masks, full face shields, gowns and gloves should be worn during treatment. These precautions are also recommended when treating patients undergoing external beam radiation therapy while under anesthesia. New masks and clean scrubs should be issued daily. Where feasible, continue social distancing of 6 feet.
3. Masks and hand hygiene for patients and staff: All patients and staff should wear an appropriate face covering while in the clinic for any reason (treatment, consultation, etc.). All patients and staff should wash or sanitize their hands upon entering and exiting both the clinic and the treatment vault.
   *Note: Our original recommendations have been updated from questions 5 and 12 below.
4. Screening and/or testing of patients and staff: Staff should be screened at the beginning of each shift. Patients under treatment should wear a mask and, likewise, be screened daily prior to treatment[RR3] . Patients who “screen-positive” should self-isolate and monitor their conditions, and follow up as per local recommendations (e.g., nasal swab if appropriate with PPE precautions if in clinic, separate waiting room, follow up with their PCP if at home). New patients, simulations, new starts and follow-up patients should be screened by phone the day prior to their appointment, and if appropriate, their appointment may be deferred or changed to a remote assessment (telemedicine). Although there are no standard guidelines for testing patients prior to initiating a course of radiation therapy, there is a growing consensus that COVID-19 NAT (Nucleic Acid Amplification Technique) testing of all patients prior to therapeutic procedures, including radiation therapy, is both prudent and reasonable. In lieu of universal testing pre-treatment, COVID-19 NAT testing should be performed on any symptomatic patient and on all patients coming from long term care facilities, senior residences, group homes and shelters. In addition, patients who are undergoing in-department brachytherapy procedures or receiving external beam radiation therapy while under anesthesia should be considered for testing.
5. Patient scheduling: As restrictions loosen, cancer screenings and elective surgeries will resume rapidly with an expected increase in the number of patients diagnosed with cancer who will require radiotherapy as part of their treatment regimen. Delays in treatment may result in an increase in tumor stage and more urgency in initiating treatment. This may put considerable stress on providers and clinic capacity to safely and expeditiously schedule new patients, as well as backlogged follow-ups, while maintaining appropriate social distancing in waiting rooms. Telemedicine may offer a safe way to initially interact with a new patient and selected follow-up patients. New patients who require radiation therapy may then be examined by the physician at the time of simulation. Follow-up patients who can safely be evaluated without a detailed physical exam should be seen via telemedicine with appropriate CPT coding. Insofar as all clinic waiting areas are different, the only specific recommendation is to maintain the standard 6’ distance between patients; family members should wait elsewhere (e.g., another part of the hospital/clinic, auto, etc.). Patients with cell phones may be asked to wait in their autos until receiving a text from the RTT that they may enter the clinic for treatment.

View the original FAQs