COVID19 Prep: Remote Reading, Admissions Screening, Dedicated Machines, and More

Amid calls from the Centers for Disease Control & Prevention that Americans limit social gatherings to less than 10 people, avoid restaurants and bars, and travel as little as possible, radiology experts are also releasing their own guidance.

In an article published Monday, March 16, in Radiology, departmental leaders from across the country, at the request of the journal’s Editorial Board, shared the policies and procedures currently in place at their own institutions to treat patients with suspected COVID-19 infection and control further contamination as much as possible. These actions go beyond social-distancing, providing personal protective equipment, and canceling travel.

“The Editorial Board hopes that readers may find similarity of the highlighted healthcare systems to their own environment, providing impetus for action or confirmation of their current preparedness activities,” said David A. Bluemke, M.D., Ph.D., Radiology editor and radiology professor at the University of Wisconsin School of Medicine and Public Health.

Remote Reading

To limit the interaction between radiologists and patients with potential infection, several institutions have moved image reading either off-site or to less crowded areas. According to Mahmud Mossa-Basha, M.D., associate professor and vice chair of operations at the major-metropolitan University of Washington Medicine, the department is maximizing providers’ ability to be mobile.

“We have focused on providing the ability for radiology faculty to work from home if needed for isolation,” he said. “For those that are not suspected of having been exposed or infected, but are concerned about potential exposures, we have created radiology outposts and isolated reading rooms across our enterprise, including single-state reading rooms in our hospitals, as well as in our outpatient imaging centers.”

Large, urban academic medical centers Emory University School of Medicine and New York University (NYU) Langone Health are also actively working to deploy more home workstations that would allow asymptomatic radiologists to continue to work from home.

“In our department, a significant number of the clinical faculty already have home workstations as part of our clinical wellness program,” said Danny C. Kim, M.D., associate professor and associate chair of quality and safety at NYU Langone Health. “Prior to the travel ban, radiologists returning from high-risk areas were asked to self-quarantine and interpret cases from home.”

Now, the facility has ordered additional workstations, as well, to enable at-home work as the specter of more COVID-19 quarantines continues to grow.

Admissions Screening

Identifying patients with respiratory symptoms is critical to separating them from a healthier population. To do so, most institutions have implemented screening protocols upon patient arrival.

For example, Washington screens patients for symptoms that could be related to SARS-Cov-2 infection, recent travel, or any potential exposures when they arrive at the hospital. The radiology department is the second line-of-defense, canceling procedures for outpatients with symptoms and asking them to follow-up with their primary care providers. Non-emergent imaging for inpatients has been postponed.

Outpatients at NYU who have traveled to countries with widespread transmission or who have had contact with infected individuals are referred to the hospital’s Infection Prevention and Control team to determine the need for testing. Given the pervasiveness of the virus, the threshold for calling the team continues to drop, Kim said.

Dedicated Machines

Even though the American College of Radiology recommended against using CT scanners for screening or diagnostics because the virus presents closely to several other respiratory infections, the machines are still being used guide patient management. Consequently, there’s a need to limit modality exposure.

According to Michael J. Tuite, M.D., vice chair of clinical operations at the internationally-populated University of Wisconsin Hospital, a plan exists, in the event a severe local outbreak, to image all patients with suspected COVID-19 infection in a separate facility with a portable X-ray machine.

Washington is also relying on portable X-ray and CT scanners whenever feasible to limit contamination of equipment, rooms, and hallways. Overall, Mossa-Basha said, steps are being taken to sequester imaging as much as possible.

“When possible, imaging is performed at sites with less foot traffic and with fewer critically ill patients in that area to avoid secondary patient and staff exposure,” he said. “Considerations are also being made to implement a containment zipper – a room isolation tarp barrier with a zipper for room access – to separate the control area from the CT scanner room.”

In addition, tertiary-quaternary, 1,000-bed University of California at San Francisco is also working on protocols to image patient safely.

“Standard operating procedures for safely imaging patients with portable X-ray units and for imaging patients with CT when necessary have been development,” said K. Pallav Kolli, M.D., UCSF’s associate chair of quality of safety, adding there’s an ongoing effort by a multi-disciplinary team, including thoracic radiologists, to develop guidelines for using CT with patients with suspected infection.

De-commissioning machines exposed to the virus for cleaning is critical, as well. Emory takes its machines off-line for several hours to be thoroughly sanitized, said Carolyn C. Meltzer, M.D., executive associate dean of faculty academic advancement, leadership, and inclusion. Additionally, said Wisconsin’s Tuite, facilities should plan for an hour of downtime for passive air exchange.

Information Exchange & Education Efforts

Perhaps the most significant tool in the toolbox to combatting the spread of COVID-19 is the free flow of information, and many department representatives shared how their facilities are keeping key decision-makers and leaders in the loop.

Regular conference calls help NYU department directors and site managers standardize patient care protocols and operational workflows, Kim said. The infection control experts at Wisconsin offer in-person tutorials and other information on how providers can best interact with patients who have suspected COVID-19 infections, as well as seminars for CT, ultrasound, and interventional technologists.

Ultimately, these changes in procedure are likely to represent a paradigm shift in radiology that will remain even after the worst of the crisis has passed. According to Bien Soo Tan, M.D., chair of the division of radiological sciences at Singapore General Hospital, treating and trying to contain the virus has created new norms.

“Our goal is to inculcate an ongoing culture of infection control practice embraced by all staff members,” he said. “We are re-thinking how radiology can deliver optimal imaging and treatment while reducing unnecessary movement and congregation of patients within our hospital environment. Teleconsultation and electronic smart appointment applications and counselling are being fast-tracked for implementation and will have far reaching impact on our future practice.”