A pediatric COVID hematology/oncology ward to guarantee adequate medical and nursing assistance.

The coronavirus disease 2019 (COVID‐19) pandemic has caused an interruption to several health services and the significant slowdown of many others. In Italy, a recent national survey concluded that there have been no major problems in ensuring care for the pediatric oncohematology population. At Bambino Gesù Children Hospital, about 250 new cancer patients are admitted every year. The hematology/oncology department has 77 ward beds, 150 outpatients every day and about 100 home care services every week. In addition, about 150–160 hematopoietic stem cell transplants are performed every year, 120–140 of which are allogeneic. The COVID‐19 situation began to spiral out of control from phase 2, with the end of the lockdown and the gradual return to normality. In the first phase, due to the national guidelines and lockdown, the hematology/oncology Department managed to work without downturns and clinical issues for patients or health care personnel. In the second phase, the situation worsened. In fact, despite attentive care, we recorded a substantial increase in the number of department staff infected with the virus, and the virus also spread among patients. Only patients with negative swabs were hospitalized, as for their carergivers. Telephone and on‐site screenings were performed on patients who were treated in the hospital or at home. Swabs were taken and tested in case of symptoms or suspicion of COVID.

Despite these measures, from May to December of 2020, the number of COVID‐positive individuals in our department increased dramatically. In December, the number with positive COVID tests was 31: 24 nurses, four doctors, two carergivers, and one non‐health personnel. In regard to patients, there were only seven COVID‐positive cases recorded until October. Four asymptomatic patients were monitored in home care for medical and nursing procedures (e.g., dressing of venous accesses, wounds, infusion antibiotic therapy, blood control, etc.). The remaining three patients were undergoing chemo‐ or immune‐therapy treatment, which could not be interrupted. They were immunosuppressed and therefore hospitalized in the infectious disease department that was set up by the hospital for the management of COVID‐positive pediatric patients. Considering that we are a pediatric hospital, the patients were managed by pediatricians on the advice of the oncologist or hematologist with fragmented assistance and frequent intervention of the nursing staff of the hematology/oncology department for the administration of chemo‐immunotherapy. With the start of phase 2 and the reopening, the number of positive patients increased. Until December, we recorded 39 oncohematology patients (mean age = 10.3 years [range 2–25]) positive for COVID and monitored by our department. Although central Italy has been less affected by the pandemic, the number of COVID‐19 infections among children with oncohematological diagnoses has been similar to the regions most affected by the epidemic. , , Even though we do not have updated information for phase 2 and the following phases, our study describes the prevalence of COVID‐positive patients and their characteristics.

For this reason, at the end of October, one of our hematology/oncology wards was converted into a COVID hematology/oncology ward. The main purpose for opening this dedicated ward was to guarantee adequate medical and nursing assistance, as well as to continue treatment of the COVID‐positive pediatric oncohematology patients. The COVID hematology/oncology ward had a total of six beds and a staff that included two nurses, two doctors, and one caregiver. The ward was operational until December 2020. There were no free beds for 2 months. Nineteen children (mean age = 11.3 years [2-25]) affected by various oncological and hematological pathologies and SARS‐CoV‐2 infections were hospitalized, accompanied by their parents (Table 1).

TABLE 1

Characteristics of children and COVID‐19 managed in Bambino Gesù Children Hospital (from March to December 2020)

Age group (n = 39)
	n	%		n	%		n	%
0–3	3	7.7	8–11	12	31	16–19	2	5.13
4–7	10	26	12–15	8	21	>20	4	10.26
Days of hospitalization (n = 19)
	n	%		n	%		n	%
1–4	4	21	10–14	2	11	20–24	2	10.53
5–9	7	37	15–19	3	16	>25	1	5.26
Characteristics of children from March to October (n = 7) (before the opening of COVID ward)
Diagnosis	n	%	Treatments a	n	%	Symptoms a	n	%
ALL/AML	4	57	Chemo or immunotherapy	3	43	Headache	6	85.71
						Fever	6	85.71
						No smell and taste	5	71.43
HL/NHL	2	29	Post therapy	4	57	Diarrhea	5	71.43
						Cough	3	42.86
						Skin rashes	1	14.29
Other solid tumors	1	14	Infections	2	29	Moderate RF	1	14.29
						Severe RF	1	14.29
						Conjunctivitis	1	14.29
Characteristics of children from November to December (n = 32) (before the opening of COVID ward, only 19 were hospitalized)
Diagnosis	n	%	Treatments a	n	%	Symptoms a	n	%
ALL/AML	15	47	Chemo or immunotherapy	22	69	Fever	8	25.00
Other solid tumors	10	31				No smell and taste	5	15.62
						Cough	5	15.62
HL/NHL	3	9.4	Infections	7	22	Headache	5	15.62
Sickle cell disease	2	6.3				Diarrhea	4	12.50
						Skin rashes	3	9.37
Histiocytosis	2	6.3	Post therapy	4	13	Moderate RF	2	6.25
						Severe RF	2	6.25
						Conjunctivitis	1	3.12

Abbreviations: ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; HL, Hodgkin's lymphoma; NHL, non‐Hodgkin's lymphoma; RF, respiratory failure.

Multiresponse items.

In accordance with the provisions of international recommendations, the COVID oncology staff has always attempted to keep health professional teams (doctors, nurses, carergivers) at the COVID hematology/oncology ward separate from those in the rest of the department. , , This has been done in order to ensure adequate continuity of care as well as maximum containment of infection transmission among patients, visitors, and health care personnel. The creation of a dedicated COVID ward was not easy, from both the structural and assistance point of view. Cooperation from hospital management was required in order to make the identified space suitable and operational. An unstructured questionnaire was submitted to 10 nurses and one nurse coordinator in order to identify strengths and weaknesses perceived during this experience (Table 2).

TABLE 2

Strengths and weaknesses of COVID oncohematology ward (n = 12)

Respondents	n	%
PedRN	7	58
RN	4	33
RN coordinator	1	8.3
Strengths a
Increase of nurse autonomy, as doctor and head nurse were not always present within the ward	12	100
Clinical risk reduction, due to the maximum ratio of 1:3 nurse/patient	11	92
Time available to develop your theoretical skills	10	83
Being able to satisfy patient needs, even from a psychological point of view	10	83
Greater collaboration between social and health staff	9	75
More knowledge about COVID in the oncohematological patient	9	75
Increase of theoretical and practical skills regarding the management of patients with respiratory symptoms	8	67
Weaknesses a
Psycho‐physical difficulties in remaining for a long duration in the various PPEs	12	100
Communication difficulties due to PPE	12	100
Teamwork is not always possible	11	92
Communication between nurses and doctors is not always effective	11	92
Difficulty managing the emotions of caregivers who have been hospitalized for a long period	9	75
Difficulty in creating a relationship between nurse, parent, and patient due to the required distance from the COVID‐positive patients	9	75
Difficulty in traveling for diagnostic and therapeutic procedures or investigations	7	58
Fear of having contracted COVID once the shift is over and infecting loved ones	6	50
Difficulty in managing and maintaining, where necessary, sterility during procedures due to mandatory PPE	6	50
Increase timing in case of emergency	6	50

Abbreviations: PPE, personal protective equipment; RN, registered nurse.

Multiresponse items.

The COVID‐dedicated staff was a part of the hematology/oncology department staff, and 55% of these personnel had previously contracted the virus. Most patients infected with the SARS‐CoV‐2 virus were asymptomatic and few needed respiratory support, so care complexity was minimal. This made the entire COVID situation easier to deal with despite the fear of infection for the health care workers. The experience has allowed all nursing staff to acquire theoretical and practical skills for the management of patients with respiratory symptoms, as all patients were monitored for oxygen saturation and respiratory rate, which was necessary to observe patient's respiratory dynamics. This experience also made it possible to acquire knowledge relating to the management of the oncohematology patients affected by SARS‐CoV‐2, and the less experienced nurses have become more independent. A negative aspect was the difficulty of managing patients due to the physical distances and the personal protective equipment. The main difficulties were due to communication among various professionals, transport of patients within the hospital for diagnostic/therapeutic procedures, and dealing with emergencies. For the organization, the coordinator nurse dedicated a large amount of time to ensure that every activity was carried out in the best way and shortest time possible. From an emotional point of view, it was sometimes difficult to manage the concerns and emotional crises of patients and parents, who were forced to remain in the ward for weeks. In conclusion, despite the fear, inexperience, and complications, the work within the COVID ward has been a path of professional growth for all health care personnel.

It is predictable that a “delicate” patient population such as the oncological one would be particularly affected by COVID‐19, especially in light of the case studies communicated by some northern hospitals where the percentages were close to 20% of adult oncology patients. Implementing most of the described and recommended precautions has allowed us to contain the spread of the virus. Oncohematology activities at our institute have progressed without suffering particular slowdowns. The ward is now open again to non‐COVID oncohematology patients, and the staff has been downsized. We hope that this experience will be able to help others in similar situations in the future.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.