Cochin Hospital is an academic hospital in Paris which receives patients from all Ile-de-France region, much impacted by COVID-19 (5). During “Covid month”, we recorded 80 hematology patients infected by COVID-19 (Table 1). Patients were predominantly men, more than 65 years old.
Table 1
Patients’ characteristics
| | N = 50 |
| Age, median (range) | 68 (43–91) |
| Sex ratio (M/F) | 1.82 |
| Pathology, N (%) Plasma cell disorder Indolent lymphoma/CLL Hodgkin lymphoma/large B cell lymphoma Acute myeloblastic leukemia or MDS MPN Acute lymphoblastic leukemia | 17 (34%) 13 (26%) 5 (10%) 9 (18%) 5 (10%) 1 |
| Under hematologic treatment, N (%) | 25 (50%) |
| Neutropenia < 1000/mm3, N (%) | 7 (14%) |
| Intensive care, N(%) | 7 (14%) |
| Death | 10 (20%) |
Patients were mostly followed for an haematological malignancy (70%), the most frequent was multiple myeloma (34%). Half of them were currently under treatment but not neutropenic at the time of infection (14%). Half of them were still on chemotherapy treatment, 30% were on survey after treatment and 20% were on a “watch and wait” strategy
Three patients were already hospitalized at the time of diagnosis. Sixteen others patients were hospitalized for covid-19, including nine patients in intensive care unit. Sixteen patients (30%) evolved to an acute respiratory syndrome with a fatal outcome in ten cases. (20%). Among patients who died from COVID-19 infection, the median age was older: 80 years-old (range: 64–90).
Our past experience of flu, and the severity of some cases prompted us to insist on non-pharmaceutical intervention to prevent spread of COVID-19 (6). The organization of haematological ward, consultations and outpatient’s clinic were transformed (Fig. 1), according to recommendation(7).
Regarding the consultations, we performed tele-appointment for the large majority of patients in accordance with social distancing measures (8).
In the inpatients sector, six autologous transplants for multiple myeloma (MM) were postponed and only one was maintained for plasmablastic MM. We maintained all other hospitalizations, but visitors were not alloawed to come in hospital.
In the outpatient clinic, we largely modified our organization. In a covid-free period, the outpatient clinic receives about 370 patients a month for immunotherapy or chemotherapy treatment (85%), transfusion ( 12%) or diagnostic procedure (3%).
Firstly, we postponed bone marrow biopsies and treatment initiations when possible, mainly for low-grade B-cell lymphoma and non-symptomatic MM. We reduced our activity by about 10% in this period.
Secondly, the patients’ journey was adapted to limit the spread of COVID-19 inside the clinic and the risk of nosocomial infection. Patients were not allowed to be accompanied and staff member wore protective equipment (8). Every patient was called two days before by a nurse to document any history of fever, cough or contact with subject affected by COVID-19. Patients were checked again for symptoms and temperature when they arrived and directed straight to their room.
Thirdly, we assessed the risk-benefit of each treatment for each patient. Haematological patients are considered high-risk in this pandemic because of the immunosuppression due to their disease and treatment (9). Specific algorithms have been implemented by cooperative groups to adapt treatment (10). In accordance with these recommendations, we created a weekly staff including doctors, a nurse and a secretary to decide if each treatment should be cancelled or done. If treatment was maintained, we have chosen to treat in the outpatient clinic only patients requiring long parenteral treatment or with a complex decision, which needed a clinical examination. Other patients received treatment outside our outpatient clinic (“beyond the walls”), e.g at home or in another hospital.
Among the 36 patients cancelled for IV/SC treatment, cancellation was related to COVID-19 in 13 patients: 7 were infected, 1 was in contact with a suspected case, and 5 were stranded abroad. In 23 patients, cancellation was planned to avoid immunosuppression. This concerned mainly maintenance treatment for patients in good response: Multiple Myeloma (n = 15) and small B-cell lymphoma (n = 7), acute lymphoblastic leukaemia (n = 1) In 19/36 patients with cancellation, oral treatment was maintained (Imids n = 15, Venetoclax n = 2, Purinethol/Methotrexate n = 1, Ibrutinib n = 1). These medications were sent by the hospital pharmacy to their community pharmacy after a tele-appointment.
Fifty-six patients received their IV/SC treatment “beyond the walls”. The Hospital at Home programme (HAH) usually dispense parental chemotherapy in our patients from the second injection per cycle for subcutaneous or short intravenous treatment. In this period, treatment was done at home from the first injection for 42 patients: 25 patients received subcutaneous 5-Azacitidine for myelodysplasia or acute leukaemia, 14 were treated for MM (subcutaneous Bortezomib n = 8, intravenous Daratumumab n = 2, intravenous Carfilzomib n = 4), 1 received intravenous Brentuximab. Moreover, 2 patients received palliative care at home to avoid hospitalization (11) – which implicates to separate families. The HAH managed to ramp up its activity in this troubled period.
Eleven patients living outside the Ile-de-France region, where HAH was not present, were treated at their local general hospital.
Finally, three COVID-19 positive patients were treated in a COVID-ward.
During “Covid-free month”, we received 386 patients (mean 19.3 patients/day). During “Covid month”, we received 249 patients (12.5/day) but managed 92 additional patients with tele-health: cancellation n = 36, “beyond the walls” n = 56. This resulted in a total of 341 patients (mean 17/day). Every patient with a change in the treatment administration had a tele-appointment with the doctor to check for symptoms, signs of relapse and results of their blood test. The associated oral treatment was prescribed, and the next visit was re-scheduled. Overall, tele-health represented 25% of our outpatient clinic activity. Every staff member had to be mobilized for the continuum of care of the patients.