Resource depletion to the extreme would be analogous to having a non-operational clinic as some experienced during the Hurricane María disaster. I would suggest reading the paper:

Lessons Learned From Hurricane Maria in Puerto Rico: Practical Measures to Mitigate the Impact of a Catastrophic Natural Disaster on Radiation Oncology Patients

The paper discusses considerations and actionable items when transferring patients from one clinic to another, and how to handle treatment gaps.

Now would be the time to negotiate with neighboring practices and insurance companies on how to seamlessly transfer patients from one clinic to a neighboring clinic in case there is a staff shortage at your clinic. Are the Linacs interchangeable? Is the immobilization the same? Can you easily transfer treatment plans even if just to understand what was being done? Does it mean a new sim and plan is required causing a longer delay or are the practices interchangeable? How will you compensate for the treatment gap?

Former competitors need to be ready to be collaborators and put any differences aside for the well-being of patients. This can be an incredible challenge in some practice environments.

If there is just one missing link: physician, physicist, dosimetist, therapist, nurse, front desk...the entire practice could be compromised. The more redundancy there is in the system, the better. Are there alternative sources of staffing? Retired staff who could help? Locums? Small practices are going to be more vulnerable than larger multi-site practices.

Hopefully no one will face these extreme situations, but we should be ready.

As per FAQ’s posted by ASTRO:

It is important to have clear protocols for COVID-19 and COVID-19-suspected (Patient Under Investigation (PUI) or screen positive patients) who are not undergoing aerosol-generating procedures (e.g., on a ventilator, receiving anesthesia that requires an airway, etc.). Work with your ID team to establish these protocols ASAP. Droplet precautions should be used for these patients and limiting the personal protection equipment (PPE) to only required clinical staff (e.g., medical students are being excused from seeing these patients). Separate protocols may be required for patients undergoing aerosol generating procedures in your department insofar as these are high risk (e.g., vent-dependent patients, anesthesia requiring intubation, etc.). In some cases, more resource intensive airborne precautions may be needed for these patients (e.g., CAPR or N95 with a face mask and eye protection, ideally in a negative pressure room, etc.).

Minimum staffing requirements for your department should be determined, scaled to your patient volume, for all of your patient-facing personnel (nurses, therapists, physicists, physicians, trainees). A “work from home” approach has been implemented in many practices where patient-facing personnel only come in when they have clinical activities that require on-site presence. Clinic staff may be asked to work from home when their presence on-site is not required. This will help minimize the risk to patients and may help preserve the workforce by limiting their risk of COVID-19 exposure at work from fellow colleagues. Once minimum staffing requirements are determined, the absolute minimum staffing required for safe patient care should be ascertained. Creation of minimum staffing requirements will also allow consideration of contingencies in the event of severe workforce depletion (e.g., threshold for referring patients elsewhere, etc.)

Work aggressively to minimize risk. Emphasize to staff and colleagues the importance of self-screening (unless you have an active screening program implemented) and self-isolation if they have respiratory symptoms (fever, cough, shortness of breath, etc). Most clinicians and staff try to “work through it” when ill due to their commitment to patient care and fellow colleagues, but this is not appropriate during this pandemic. Staying at home when clinic staff have respiratory symptoms is the best way to protect patients as well as colleagues. 

SOURCE: Institutional experience, multiple sites

For the full ASTRO guidelines see: https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/COVID-19-FAQs

As of March 24, 2020, there is a national and global supply shortage of both N95 and standard surgical masks. Standard surgical masks are currently recommended to be worn by therapists who are treating patients with any upper respiratory symptom at several radiation therapy centers. Resupply of masks are coming in at a trickle as all mask consumers are competing for the same resources globally.

I would suggest the following as a simple way of limiting resource use for a radiation therapy department so that you and your staff are protected and only need to replace a mask if soiled or broken. Additionally, this will minimize the drain on the existing mask supply for general medical use.

In a high risk setting and while standard surgical masks are in short supply, I would consider providing each therapist or other employee that must come in close contact with a patient, 3 to 5 masks with their name on it and perhaps the day of the week or day 1,2,3...The mask could be worn for an entire shift and placed in a brown bag at the end of the shift not to be used again for at least 72 hours. Having a mask for each day of the week would be easier to track if you have enough supplies.

The mask supply should be very secure. Reports have emerged of simple locks being broken to steal PPE.

Until the global demand for such supplies increases capacity or until there is a proven vaccine or treatment, we may be forced to use a simple plan such as this.