Coronavirus outbreak: Reorganising the breast unit during a pandemic.

Introduction

After seeing the COVID-19 pandemic ravage Italy [1,2] it became apparent that the United Kingdom had to prepare for a similar surge of patients. The intercollegiate guidance from the Royal College of Surgeons suggests that two groups of patients should continue to receive surgical care – acute patients requiring emergency surgery, and those requiring urgent planned surgery (for example, patients with cancer) [3]. In this article we describe the rapid adaptations we have made as a breast cancer service at a district general hospital in London in response to the pandemic.

Workspace and work practices

The clinic area was measured to ensure that there is a two-metre distance between the seated patient and doctor and also between two patients in the waiting room. A thirty-minute interval is kept between patient consultations to allow time for cleaning of surfaces and ensure that there are as few patients in the waiting room as possible. All appointments for patients referred from nursing homes or aged over 70 are deferred. Our service is now being run only with consultants, registrars and breast cancer care nurses.

One stop clinic

In the one stop clinic the patients are triaged using the COVID 19 North Central London Alliance Breast Unit protocols. The protocols are the result of a collaboration between the Breast Unit Leads of North Middlesex Hospital, University College London Hospital, Royal Free Hospital and Whittington Hospital. The guidelines were created incorporating the Association of Breast Surgery (ABS) guidelines [4].

An urgent two week wait appointment is only offered for patients age >25yrs with:

a breast or axillary lump;

blood-stained nipple discharge;

skin changes suspicious for cancer

symptoms on a background of strong family history (2 or more first degree relatives affected)

previous history of breast cancer treatment

Routine follow-up clinic

All routine follow-up appointments are performed by telephone. The telephonic consultation allows the breast surgeon to review the patients notes, review relevant imaging, request future imaging and include patients in the decision-making process. To allow for limited physical examination, patients can submit photos either via hospital e-mail or to smart phones. Facilities for a video consultation also exist.

Imaging

Diagnostic imaging in the one stop clinic with ultrasound and mammogram continues as per established clinical protocols. All routine surveillance imaging has been deferred for three months.

Multi disciplinary meeting (MDT)

Only one member per discipline attends the MDT in person. Provisions are made for colleagues to join in via telephonic or video link using Zoom and Facetime.

Surgery

As part of a pan-London initiative, our hospital trust has an agreement with a “cold” private hospital at a different site to allow access to theatres for day case surgery. The host hospital does not have any acute COVID 19 patients.

To ensure safe surgery patients continue to have their imaging and clinical appointments at their base hospital. On the day of surgery the surgeon, breast care nurse, radiologist and anaesthetist travel to the host private hospital for the operation. This is to ensure continuity of care and reduce potential litigation.

Conclusion

This pandemic has unleashed a major crisis within the healthcare systems across the world. It has forced healthcare providers to change the way services are delivered. For our breast surgery unit in a district general hospital this has led to multiple changes to our work practices. These include physical re-organisation of the breast consultations spaces; changes to staffing; stricter criteria for one stop clinic referrals; embracing telemedicine for routine follow-up; identifying essential imaging; virtual MDTs; a straight-to-surgery policy in operable tumours; and creation of a “clean” hospital site for breast cancer surgery. Time will tell which of these changes are here to stay.

Declaration of competing interest

None.