Strategic care assignments: patients with known/​presumptive COVID-19 and immunosuppressed patients

Evidence: Due to evolving knowl­edge of COVID-19 and standards regarding PPE usage, and the risk of severe outcomes that immuno­sup­pressed persons face, it is not recom­mended that health­care providers care for both COVID-19 patients and immuno­sup­pressed patients at the same time during their shift.

COVID-19 is a new (novel) coron­avirus, in the same family as SARS, MERS, and the common cold. Currently, it is thought to be spread through airborne or droplet contact. There are no treat­ments or vaccines for COVID-19. COVID-19 is thought to be more severe in the elderly, those with under­lying health condi­tions, and those who are immunosuppressed.

Immuno­sup­pres­sion is the inten­tional or idiopathic preven­tion or inter­fer­ence of the immune response. Persons who are immuno­sup­pressed (immuno­com­pro­mised) can include those with congen­ital immunity deficien­cies, HIV, cancer, solid-organ or stem cell trans­plant, autoim­mune disor­ders, or who are under­going radia­tion or chemotherapy.

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The Oncology Nursing Society states that Based on the limited data from COVID-19 and other related coron­aviruses, older adults and those with under­lying medical condi­tions that make them immuno­com­pro­mised may be at greatest risk for severe outcomes.” 

Fred Hutchison Cancer Research Center in Seattle released a state­ment for cancer patients and their caregivers. In it, they note that patients currently under­going chemotherapy, immunotherapy, radia­tion therapy and those with blood cancers or post-stem cell trans­plant are at highest risk for contracting a severe case of COVID-19. Even those who have had cancer in the past but are not currently under­going treat­ment are at some risk, because the after-effects of cancer can be long-term. 

A small study from China, recently published in the Lancet, confirms this. A prospec­tive cohort was estab­lished to monitor COVID-19 among cancer patients. Out of 575 hospi­tals, 18 patients met criteria for inclu­sion in the study. Although the study was limited in size, demographics, and type of cancer, analysis showed that patients with cancer were observed to have a higher risk of severe events, including ICU admis­sion, invasive venti­la­tion, and death. 

The updated CDC recom­men­da­tions encourage clustering patients with COVID-19 together in the same unit (or same area) in order to preserve PPE and decrease poten­tial trans­mis­sion of the virus. Patients with confirmed COVID-19 may be housed in the same room (cohorted). These recom­men­da­tions also state that dedicated staff should care for these patients — and only these patients – during their shift.

Of note, evidence does not support the use of protec­tive isola­tion’ or other reverse isola­tion’ measures when caring for non-stem cell trans­plant immuno­sup­pressed patients. Staff should continue to utilize good hand hygiene and isolate immuno­sup­pressed patients appro­pri­ately for trans­mis­sion-based organisms.

References: #

COVID-19 Fact Sheet and Impli­ca­tions for Patients With Cancer from the Oncology Nursing Society (March 4, 2020)

Interim Infec­tion Preven­tion and Control Recom­men­da­tions for Patients with Suspected or Confirmed Coron­avirus Disease 2019 (COVID-19) in Health­care Settings
from the Center for Disease Control and Preven­tion (CDC)

Coron­avirus: what cancer patients need to know from Fred Hutchison Cancer Research Center (March 6, 2020)

Liang, W., Guan, W., Chen, R., Wang, W., Li, J., Xu, K., … He, J. (2020). Cancer patients in SARS-CoV‑2 infec­tion: a nation­wide analysis in China. The Lancet Oncology, 21(3), 335 – 337. doi: 10.1016/s1470-2045(20)30096 – 6