Medical Physics and Radiation Dosimetry During The COVID

AAMD Virtual 46th Annual Meeting 6/1/2021

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Medical Physics and Radiation Dosimetry During The COVID‐19 Crisis: Perspectives from New York

Adam C. Riegel, PhD DABR

Associate Chief PhysicistDepartment of Radiation MedicineNorthwell Health, Lake Success, NY

DirectorMedical Physics Graduate ProgramHofstra University, Hempstead, NY

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Outline

1. The end of “The Before Times”

2. COVID‐19 in New York

3. Pandemic Preparedness Plan

4. Impact in Clinical Operations

5. Discussion

6. Looking Beyond COVID

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The End of “The Before Times”•December 2019: Wuhan, China‐ A novel coronavirus, SARS‐CoV‐2, was identified in patients exhibiting flu‐like symptoms

‐ Disease associated with SARS‐CoV‐2 virus called “COVID‐19” (discovered in 2019)

‐ The virus, with characteristic “spike” proteins, spread through respiratory droplets

‐Within weeks, tens of thousands of people were sick with COVID‐19 in China

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https://www.apsf.org/article/an‐update‐on‐the‐perioperative‐considerations‐for‐covid‐19‐severe‐acute‐respiratory‐syndrome‐coronavirus‐2‐sars‐cov‐2/

Chine Nouvelle/Sipa/Shutterstock

The End of “The Before Times”•Cases began popping up in the United States but are contained

•January 2020: Seattle, Washington‐ The positive test case of COVID‐19 in the United States

‐ Later, scientists discovered the virus had been spreading silently for weeks1

‐ Nursing homes became the new battleground

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Jason Redmond/Reuters

1https://www.nytimes.com/2020/04/23/us/coronavirus‐early‐outbreaks‐cities.html?searchResultPosition=1

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The End of “The Before Times”•March 2020: New Rochelle, New York‐ Second documented case of COVID‐19 in New York State

‐ First patient in New York to get seriously ill

‐ Virus began to spread through downstate New York, including New York City

‐ The national outbreak truly began in earnest…

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Reuters

COVID‐19 in New York

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Tayfun Coskun/Anadolu Agency via Getty Images

https://www.usnews.com/news/health‐news/articles/2020‐03‐30/navy‐hospital‐ship‐comfort‐arrives‐in‐new‐york‐city

https://www.nytimes.com/2020/05/14/nyregion/coronavirus‐ny‐hospitals.html

https://www.nytimes.com/2020/04/02/nyregion/coronavirus‐new‐york‐bodies.html

REUTERS/Lucas Jackson

https://www.cntraveler.com/gallery/15‐photos‐of‐new‐york‐city‐during‐coronavirus‐from‐empty‐times‐square‐to‐a‐deserted‐subway

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COVID‐19 in New York•The virus began to spread exponentially in New York

•Schools began to close

•Recognition that significant disruption was probable‐ Illness among patients (particularly vulnerable)1,2

‐ Illness among staff

‐ Dependent care issues

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New Cases of COVID‐19 in New York State, March‐April 2020

1. Yu J, Ouyang W, Chua MLK, Xie C. SARS‐CoV‐2 Transmission in Patients with Cancer at a Tertiary Care Hospital in Wuhan, China. JAMA Oncol. Published online 2020:25‐27. doi:10.1001/jamaoncol.2020.0980

2. Liang W, Guan W, Chen R, et al. Cancer patients in SARS‐CoV‐2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21(3):335‐337. doi:10.1016/S1470‐2045(20)30096‐6

COVID‐19 in New York•In early March, we developed our Pandemic Preparedness Plan (PPP)

•On March 23rd, we activated it

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New Cases of COVID‐19 in New York State, March‐April 2020

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Month Day, Year 9

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Brooklyn

QueensNassau

Staten Island

Westchester

Connecticut

New Jersey

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Suffolk

Hudson River

NY Geography

Month Day, Year 10

Northern Westchester Hospital

Phelps Hospital

North Shore Medical Accelerator

Imbert Cancer Center

Center for Adv. Medicine

North Shore Univ. Hospital

Long Island Jewish Hospital

Maimonides Cancer Center

Staten Island Univ. Hospital

Lenox Hill Hospital

Radiation Medicine

Queens Radiation Center

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Northwell Radiation Medicine•11 full or affiliated sites

•15 linear accelerators‐ 5 TrueBeams

‐ 1 Halcyon

‐ 1 Tomo

‐ 8 older Varian machines

•5 remote afterloaders

•2 GammaKnife

•5 kV therapy units

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Northwell Radiation Medicine•Velocity contouring/registration (Varian)

•Eclipse EBRT planning (Varian)

•Mixed Aria (Varian)/Mosaiq (Elekta) environment

•Brachytherapy/Special procedures

‐ GammaKnife

‐ IVBT

‐ Prostate seed implant

‐ Skin/Gyn HDR

‐ IORT (Zeiss/Xoft)

‐ Liver microspheres

‐ Radium injections

•18 Physicists

•2 Physics Residents

•15 Dosimetrists

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Northwell Radiation Medicine•Active research program

•Academic affiliations ‐Medical School @ Hofstra University (residency)

‐ Graduate School @ Hofstra University (MS in medical physics)

‐ Dosimetry Program @ University of Wisconsin LaCrosse

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Pandemic Preparedness Plan

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5 Priorities

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Reduce Patient Volume

Actively Manage Staff

Implement Telehealth

Encourage Multidisciplinary

Discussion

Maintain a Culture of Safety

5 Priorities

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Discussion


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Reducing Patient Volume

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Urgent need for radiationPriority I• Loss of life, progression of disease, or permanent loss of function possible

• Examples: Oncologic emergencies, advanced disease

4‐week delay unlikely to significantly impact prognosisPriority II• Examples: Lung cancer, lymphoma, benign brain conditions

>30 day delay unlikely to significantly impact prognosis Priority III• Examples: Prostate cancer, early stage breast cancer

Reducing Patient Volume•Hypofractionation

•Extending daily schedule to space out treatments throughout the day‐ Reduce crowding

‐ Allow time for cleaning/disinfection

•Ambulatory surgery closed‐ Reduction of special procedures and brachytherapy

‐ Consideration of EBRT alternative

•Priorities/treatment modifications reviewed in daily rounds

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https://geomarketing.com/as‐late‐beacon‐adopters‐healthcare‐and‐travel‐businesses‐slowly‐catch‐up‐to‐retail/thinkstockphotos‐78744520

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Reducing Patient Volume•COVID+ patients were scheduled at the end of the treatment day‐ PPE for all staff

‐ Brought into department through different entrance

‐ Room left vacant for 5 minutes after treatment

‐ Significant disinfection

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https://geomarketing.com/as‐late‐beacon‐adopters‐healthcare‐and‐travel‐businesses‐slowly‐catch‐up‐to‐retail/thinkstockphotos‐78744520

5 Priorities

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Discussion


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Actively Managing Staff

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Physics and Dosimetry Responsibilities

External Beam Planning

Special ProceduresHardware Quality

AssuranceTeaching/Research

Actively Managing Staff•Convert as many responsibilities as possible to remote work

•External Beam Treatment Planning‐ Velocity image registration, contouring

‐ Eclipse treatment planning

‐ Aria/Mosaiq R&V

‐ In‐house “whiteboard” to track treatment planning tasks

‐Most resources already available remotely via Citrix/VPN

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Actively Managing Staff•Convert as many responsibilities as possible to remote work

•External Beam Treatment Planning‐Work from home (WFH) was not common prior to COVID

‐ Prior to March 23rd: All physicists and dosimetrists surveyed for remote access needs

‐ After March 23rd: •One planner present at main clinical site

•All other planners began WFH

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Actively Managing Staff•Physics on‐call‐ Usually, at least one physicist per geographic site as “on‐call”

‐ During pandemic, reduced to single AM and single PM on call physicist at main site for entire department

‐ “Skeleton crew”

‐ Issues would be handled remotely if possible

‐ All other physicists WFH, assigned to local site

‐ If on‐site help needed, designated local physicists would travel, fix the problem, and leave

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Actively Managing Staff•Brachytherapy and Special Procedures‐Most were cancelled or postponed (lower priority)

‐ Some alternative treatment options were considered (EBRT boost)

‐ Physicists were scheduled on‐site for procedures that remained

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https://brownneurosurgery.com/portfolio/gammaknife‐radiosurgery‐system/

Actively Managing Staff•Quality Assurance‐ Patient‐specific, monthly, and annual QA was performed after‐hours or on weekends

‐Minimized contact with other staff members

‐ Non‐urgent machine service was consolidated to limit vendor visits

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Actively Managing Staff•Education‐ Classes shifted online via Zoom or Teams

‐ Clinical practica shut down

•Research‐ Some projects continued remotely

‐ A few COVID‐specific protocols initiated

‐ Student participation limited

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5 Priorities

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Discussion


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Communication•In‐person meetings suspended

•As office interaction decreased, critical to keep lines of communication open

•Email and phone were primary means of communication

•Increased utilization of Microsoft Teams‐ Text communication

‐ File sharing

‐ Video conferencing

‐ Troubleshooting via screen sharing

‐ Daily contouring rounds

‐ HIPAA compliant!

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5 Priorities

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Discussion


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Culture of Safety•PPE

•Temperature checks, questionnaire at entrances

•Northwell established testing for employees/family

•Most important, we wanted to maintain high quality of treatment‐ Checklist‐based “No Fly” System1,2

‐ Prevents last‐minute rushing, ensures all QA steps have been performed prior to beam on

‐ “No Fly” should remain in effect during pandemic

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1. Potters L, Kapur A. Implementation of a No Fly safety culture in a multicenter radiation medicine department. Pract Radiat Oncol. 2012;2(1):18‐26. doi:10.1016/j.prro.2011.04.010

2. Kapur A, Potters L. Six sigma tools for a patient safety‐oriented, quality‐checklist driven radiation medicine department. Pract Radiat Oncol. 2012;2(2):86‐96. doi:10.1016/j.prro.2011.06.010

Impact in Clinical Operations •So, how did it go?

•Collected data from Whiteboard and R&V

•Timeframe: March 23, 2020 to May 6, 2020

•Compared to similar timeframe in 2019

•1‐2 dosimetrists on site every day

•6‐7 physicists on site every day (on call + procedures)

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Impact in Clinical Operations •2 dosimetrists were quarantined‐ 1 confirmed case of COVID

‐ 1 symptomatic unconfirmed case

•6 physicists were quarantined‐ COVID symptoms

‐ Prolonged contact with COVID+ person

‐ Travel

•Team members quarantined without symptoms (or significant caretaking responsibilities) were asked to work from home

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Impact in Clinical Operations

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Metric Quantity Hypothesis

EBRT Planning EfficiencyCalculated hours between EBRT tasks using electronic “Whiteboard”

Tasks in 2020 would take longer than 2019

Chart Check Efficiency

1st day check Tasks in 2020 would take longer than 2019

Weekly check

Final physics check

Frequency of ROILS Entries Assess safety ROILS entries would increase

Survey to Assess Employee Satisfaction

Covered working arrangements, responsibilities, stress level, etc.

Employees would generally be less satisfied and more stressed

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EBRT Efficiency

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25% decrease in cases

EBRT Efficiency

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Median

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EBRT Efficiency

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First Day Weekly Final

Number of Patients

Chart Checks in Mar‐May Timeframe in Successive Years

2019 2020

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Median Time to Completion for Chart Checks

2019 2020

ROILS•Physics/Dosimetry ROILS entries dropped by 68%

•Overall entries dropped by 50%

•Why?‐Majority of ROILS entries by therapists

‐Most likely consumed with additional responsibilities (disinfecting, etc)

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Survey – Work at Home vs. Office

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Motivation

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Focus

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Efficiency

Survey

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Additional Responsibilities at Home

Caring for children Caring for elders

Caring for sick family members No additional responsibilities

Other

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How would you prefer to work in the future?

100% office Mostly office, 1‐2 days remote

50% office, 50% remote Mostly remote, 1‐2 days office

100% remote

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Discussion•For many of us, preparation for such an event was new experience

•For some, it was not

•Gay et al., “Lessons Learned from Hurricane Maria in Puerto Rico”1

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repare

ommunicate

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ompensate

1. Gay HA, Santiago R, Gil B, et al. Lessons Learned From Hurricane Maria in Puerto Rico: Practical Measures to Mitigate the Impact of a Catastrophic Natural Disaster on Radiation Oncology Patients. PractRadiat Oncol. 2019;9(5):305‐321. doi:10.1016/j.prro.2019.03.007

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Discussion

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Prepare

• Establish/verify remote connectivity

• Generate alternate staffing models

• Acquiring PPE/cleaning supplies

Communicate

• Frequent and transparent communication from administration

• Precise communication to patients about care

Operate

• In Gay et al, referring to loss of power, water, etc.

• Transportation issues

• Quarantine enforcement

• Flexibility!

Compensate

• Altered fractionations

• Alternate modalities

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Discussion•Publications were rapidly published in beginning of pandemic

•Zaorsky et al., “Prostate Cancer Radiation Therapy Recommendations in Response to COVID‐19”1

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emote visits

void Radiation

efer Radiation

horten Radiation

1. Zaorsky NG, Yu JB, McBride SM, et al. Prostate Cancer Radiation Therapy Recommendations in Response to COVID‐19. Adv Radiat Oncol. 2020;M:1‐7. doi:10.1016/j.adro.2020.03.010

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Discussion•Common approaches for physics and dosimetry‐ Remote access to planning/checking via technology

‐ Virtual meetings/education

‐ Reduction of on‐site presence

‐ Push non‐essential QA and maintenance

•Other ideas we did not consider‐ Split physics/dosimetry into rotating teams1

‐ Testing of asymptomatic staff2

‐ Increased focus on infection control3

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1. Khan R, Darafsheh A, Goharian M, Cilla S, Villarreal‐Barajas JE. Evolution of clinical radiotherapy physics practice under COVID‐19 constraints. Radiother Oncol. 2020 Jul;148:274‐278. doi: 10.1016/j.radonc.2020.05.034. Epub 2020 May 29. PMID: 32474126; PMCID: PMC7256544.

2. https://w3.aapm.org/covid19/documents/UCSD_RadOncCovidPolicies.pdf3. Li D, Liu R, Wei S, Li T, Cai J, Ge H. Infection prevention and control measures during COVID‐19 from medical

physics perspective: A single institution experience from China. J Appl Clin Med Phys. 2020;(April):acm2.12889. doi:10.1002/acm2.12889

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Discussion•Once we gained our footing, we started to figure out how we could help‐ Discussions about using radiation to sterilize masks1,2

‐ CT could identify COVID in negative RT‐PCR test3

‐ CBCT could incidentally pick up disease4

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1. Pirker L, Krajnc AP, Malec J, Radulović V, Gradišek A, Jelen A, Remškar M, Mekjavić IB, Kovač J, MozetičM, Snoj L. Memb Sci. 2021 Feb 1;619:118756. doi: 10.1016/j.memsci.2020.118756. Epub 2020 Oct 1. PMID: 33024349; PMCID: PMC7528844.

2. DeAngelis HE, Grillet AM, Nemer MB, Wasiolek MA, Hanson DJ, Omana MA, Sanchez AL, Vehar DW, ThelenPM. PLoS One. 2021 Apr 8;16(4):e0248859. doi: 10.1371/journal.pone.0248859. PMID: 33831014; PMCID: PMC8031388.

3. Xu J, Wu R, Huang H, Zheng W, Ren X, Wu N, Ji B, Lv Y, Liu Y, Mi R. Clin Infect Dis. 2020 Jul 28;71(15):850‐852. doi: 10.1093/cid/ciaa207. PMID: 32232429; PMCID: PMC7184489.

4. Kinj R, Bennassi A, Romano E, Scher N, Bourhis J, Ozsahin M. Radiother Oncol. 2021 Mar;156:199‐200. doi: 10.1016/j.radonc.2020.12.030. Epub 2021 Jan 2. PMID: 33400940; PMCID: PMC7776124.

From Xu et al., 2020

Looking Beyond COVID

•Over 33 million cases and almost 600,000 deaths in US

•Virus continues to mutate and cause outbreaks all over the world

•Fortunately, US new case numbers continue to drop

•Over 50% of all Americans have received at least 1 dose of vaccine

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Looking Beyond COVID•At Northwell, we are currently operating at normal capacity‐ Normal number of patients treated

‐ No restrictions

‐ PPE still required

‐ Physicists on‐site 3‐4 days per week (1‐2 days WFH)

‐ Dosimetrists on‐site 1‐2 days per week (3‐4 days WFH)

•Good time to pause and reflect

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Looking Beyond COVID… to Remote Work?•Our survey showed staff felt same or more motivated, focused, and efficient working from home

•Appetite for some degree of WFH

•Efficiency did not suffer as anticipated

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Getty Images

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Looking Beyond COVID… to Remote Work?•Hoffman et al. studied burnout among radiation oncology remote workers during COVID1

‐MD Anderson radiation oncology, radiation physics, experimental radiation oncology

‐ 89% reported WFH some or all the time

‐ 74% reported working from home was positive or somewhat positive

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Job Number Respondents % Reporting Burnout

All 505 31.9%

Physics faculty 30 38.7%

Physics staff 23 21.7%

Dosimetrist 42 31.0%

1. Hoffman KE, Garner D, Koong AC, Woodward WA. Understanding the Intersection of Working from Home and Burnout to Optimize Post‐COVID19 Work Arrangements in Radiation Oncology. Int J Radiat Oncol Biol Phys. 2020 Oct 1;108(2):370‐373. doi: 10.1016/j.ijrobp.2020.06.062. PMID: 32890515; PMCID: PMC7462773.

Looking Beyond COVID… to Remote Work?•I think remote work will have a place in how we do our jobs …

•… BUT don’t pack your office up yet!

•Scalability is an issue1

•Team cohesion, interpersonal relationships are important

•Remote work is controversial2

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Shutterstock

1. Whitaker M, Kron T, Sobolewski M, Dove R. Phys Eng Sci Med. 2020 Jun;43(2):473‐480. doi: 10.1007/s13246‐020‐00869‐0. Epub 2020 Apr 13. PMID: 32524449; PMCID: PMC7153354.

2. Lincoln H, Khan R, Cai J. Med Phys. 2020 Jun;47(5):2045‐2048. doi: 10.1002/mp.14203. PMID: 32335929; PMCID: PMC7267135.

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Looking Beyond COVID… to Remote Work?•More likely to see remote work in dosimetry than clinical physics‐ “Remote dosimetrist” job description?

‐ Opens search to national talent

‐ Take advantage of time zone differerences

‐ Oncology as a Service (OaaS)?

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Shutterstock

Summary•COVID‐19 has significantly impacted radiation oncology physics and dosimetry in New York and beyond

•Pandemic Preparedness Plan successfully mitigated potential issues related to COVID‐19‐ Reduce number of people in department

‐ Prioritize patient treatment

‐ Reduce on‐site coverage to skeleton crew

‐ On‐site service should be performed with infection precautions in place

‐ Utilize remote access to clinical software whenever possible

‐ Prepare backup coverage if staff must quarantine

‐ Establish and maintain clear lines of communication

•Interest in remote work long‐term, but is it viable?

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Thank You!Adam C. Riegel, PhD DABRAssociate Chief PhysicistDepartment of Radiation MedicineNorthwell Health, Lake Success, NY

DirectorMedical Physics Graduate ProgramHofstra University, Hempstead, NY

Email: [email protected]: @HofMedPhys

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Medical Physics and Radiation Dosimetry During The COVID