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REVIEW ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 67-73

Corona virus outbreak and Radiology Department: Workplace preparedness, evidence based measures to limit transmission, and how radiologist can help reduce the spread


Department of Radiology, MGM IMS and Research institute, Aurangabad, Maharashtra, India

Date of Submission18-Apr-2020
Date of Decision02-Jul-2020
Date of Acceptance30-May-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. Amol M Lahoti
Endovascular Experts, Flat 15, 4th Floor, Sai Bhadra Residency, Venktesh Nagar, Near Ellora Diagnostics, MGM, Aurangabad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_57_20

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  Abstract 


As we are facing a country wide lockdown in view of international pandemic of Corona Virus-2019 (COVID-19) and deal with never seen before circumstances all over the world, healthcare personnel are often first one to get affected in view of direct exposure because of limited availability of knowledge and personal protection equipment (PPE). Planning and preparedness are essential to respond effectively to outbreaks and epidemic. Radiologists have greater risk of acquiring and transmitting infection due to its close contact with patients during ultrasound (USG) and other procedures related to invasive patient care the service needs to offer. High density, limited space, and working in air conditioned set up are needed for computed tomography, MRI, ultrasonography, X-ray machines; this makes it essential to set specific guidelines to limit transmission and utilize resources in the best possible way so as to minimize the transmission, and at the same time, implementation of a well-prepared plan as per the radiology department is required to prevent further transmission of the virus to department staff members and patients. A multitiered, updated scientific approach suited to us needs to be devised, followed, and monitored at the administrative and departmental level, taking into account the Radiology team that includes doctors, technicians, assistants, and patient contact-operating points. Here, is a systematic scientific review of infection control measures that cover the different dynamics of utmost patient care and staff protocols without hampering the patient treatment for the radiology department set up. We review precautions and safety measures for radiology department personnel to manage patients. It is not clear to what extent the COVID-19 epidemic would establish itself and how long it is going to continue in India. As case diagnosis may take anywhere from a minimum of 14 days to a few months to be visible, we need to enhance surveillance and prepare the community in a proportionate way. Radiology department and the overall health care system should be prepared, educated to continue the servicing emergency scans procedures and important elective procedures following the strict aseptic precautions so health care workers and patients safety are maintained. Each one of us should understand the disease dynamics, routes, and source of transmission and should take utmost precautions to prevent transmission to colleagues and patients by properly using PPE, as early detection and limiting exposure of healthcare workers, employees, and patients is of utmost importance.

Keywords: CORONA, Corona Preparedness and Radiology Department, COVID-19, prevention


How to cite this article:
Lahoti AM, Makasare K. Corona virus outbreak and Radiology Department: Workplace preparedness, evidence based measures to limit transmission, and how radiologist can help reduce the spread. J NTR Univ Health Sci 2020;9:67-73

How to cite this URL:
Lahoti AM, Makasare K. Corona virus outbreak and Radiology Department: Workplace preparedness, evidence based measures to limit transmission, and how radiologist can help reduce the spread. J NTR Univ Health Sci [serial online] 2020 [cited 2020 Dec 2];9:67-73. Available from: https://www.jdrntruhs.org/text.asp?2020/9/2/67/289893




  Introduction Top


Transmissibility and severity are most important factors that determine the effect of an infectious epidemic [1] The ongoing Corona Virus-2019 (COVID-19) outbreak caused by a novel Corona virus known as SARS-CoV-2 has become a global pandemic with more than 17,50,000 cases reported worldwide at the time of this article, with number of deaths more than 1, 17, 000. Many aspects of the organism and manifestations related to short- and long-term consequences are still unknown even after lot of studies and articles published and getting published. Since the epidemic it has been recognized that health care workers (HCWs) managing this potentially lethal airborne disease are a high-risk group. There are reports that front line HCWs, doctors, nurses, and health assistants who got infected from their patients, were treating and several have succumbed to it. In the index outbreak in Wuhan, 1300 HCWs became infected; their likelihood of infection was more than three times as high as the general population.[2],[3] Secondary transmission of any air and fomite borne infection, including COVID-19, occurs more in the hospital setting. This is true for COVID-19 as well because it is transmitted via air and fomite of infected person, general population. Similarly in India, as on April 15, more than 100 HCWs were affected due to exposure while handling corona virus patients. The primary consideration in preparing radiology services for COVID-19 is prevention of intra- and interhospital transmission so as to protect patients and HCWs from getting infected, while providing safe radiology service to patients. Recent studies and knowledge suggest that person who is asymptomatic can spread COVID-19 with high efficiency, and conventional measures of protection, such as face masks, provide insufficient protection. A COVID-19 infected boy aged 10 years who had no symptoms but had visible changes in lung imaging and blood markers of disease on examination.[2],[4],[5] So apart from just clinical symptoms, travel and contacts history is equally important so as not to miss subclinical infections, which might infect lot of people and HCWs before they are diagnosed. The SARS epidemic taught us that the protection of healthcare workers is crucial for optimal patient management.[6],[7],[8]


  COVID-19 Suspect Case Definitions Top


A person is suspected of COVID-19 if the person has acute respiratory infection, shortness of breath (ARI), and travel history to regions affected by COVID-19 within 14 days of onset of symptoms or the person has been in close contact with a known COVID-19 patient. All patients with fever, lethargy, and respiratory symptoms like shortness of breath may have to be considered as suspected COVID-19 cases unless proved otherwise.


  Screening and Prioritization Top


The hospitals are screening at the high-flow main hospital entrances to check those coming in for symptoms that could be related to coronavirus infection or with risk factors related to travel or exposure. The risk of transmission is directly related to the degree of contact between the patient and HCWs. Therefore, radiologists are predisposed to a risk of acquiring infection while performing ultrasound scanning in a closed room space with distance less than 1 m. The first step in limiting the propagation of the disease is proper screening of the requested scans and postponement of the elective scans till the current situation is brought under control and following government guidelines and protocols. The radiologist should limit acceptance of routine cases to only urgent that needs immediate treatment surgery; disease course of which will change by proper diagnosis and appointing semi-urgent elective ones for a later date when heard immunity vaccine is developed. All patients coming for OPD and procedures should be screened by general physicians to rule out active or subclinical COVID-19 infection. Apart from this, diagnostic radiology reception desk should ask patient about basic travel contacts history apart from clinical complaints. Those having active clinical complaints should be managed first before any radiology investigation.[5],[9],[10]


  Control of Patient and Staff Movement in the Hospital Top


  1. Limiting traffic through the healthcare facility is very important. The entry point of all confirmed or suspected cases should be limited to one section isolated only.
  2. Signs and posters are recommended at these points detailing instructions on hand hygiene using sanitizer and cough etiquette, appropriate use and disposal of masks, and other protective apparels.
  3. Patients who come in with respiratory symptoms are asked to follow up with their primary care physician unless there is an emergency scan.
  4. Only one visitor should be allowed to accompany the patient.
  5. Good ventilation and clean working area needs to be ensured at all times to prevent air and contact transmission of virus.
  6. Where possible sufficient physical barriers should be installed to limit contact and transmission.



  Radiology Department Top


Radiology department policies and procedures are designed to have enough capacity for continued operation during a health care emergency of unprecedented proportions and to support the care of patients with COVID-19 while serving the hospital and health system. For patients requiring urgent diagnosis and treatment for complaints like acute pain in abdomen, acute limb ischemia, deep vein thrombosis, stroke, acute gastro-intestinal bleeding, etc.[11],[12] Patients presenting with acute complaints for noncovid pathologies should be screened, enquired for corona virus-related complaints, contacts, and history. The requesting clinical team must be instructed to assess the patients for fever, myalgia, and shortness of breath or respiratory symptoms and to follow preventive measures like making the patient wear a facemask and to sanitize the contact surfaces as much as possible.

For suspected or confirmed COVID-19 cases, interdepartmental and ground-level communication is needed. Radiology department is highly trafficked with in-patient, outpatient; febrile and nonfebrile patients coming across HCWs from other departments. Hence, radiology department infection prevention and control policies have far-reaching consequences. The radiology front desk should serve as an additional screening site, with similar screening to that performed at the hospital front door. A rotational shift system that keep specific people in one department working on the same team, limiting number of staff at one time with different timings if possible even within one group. This allows radiology services to continue uninterrupted in the event any group need to be quarantined. Depending on the air exchange rates, rooms should not be used for approximately 1 h after imaging of the infected patient. Other basic precautions include minimizing conversation with the patient to avoid aerial spread of droplets, covering probes with gloves or condoms before scanning, using disposable plastic sheets on the couch for each patient, and to wipe probes and cables of USG with Cidex—savlon. On entering your home, keep car keys, purse, pens, etc., in a plastic box with formalin balls or wipe it with cotton dipped in a sanitizer.

  1. Radiology preparedness: resource management is a set of policies and procedures designed for continued operation in sufficient capacity during a health care emergency to support the care of patients with COVID-19 and to maintain radiology service for hospital and health system.
  2. The American College of Radiology is urging physicians to use computed tomography (CT) in very specific circumstances to assess coronavirus patients, and CT not as screening or first line investigation to diagnose—the virus.
  3. Use CT scan for hospitalized, symptomatic patients with specific clinical indications for CT.
  4. Where resources are available and possible, one CT/MRI/USG and X-ray machines should be reserved—separated for suspected or confirmed COVID-19 patients.
  5. Encourage using portable radiography in ambulatory care facilities. Surfaces on such machines are easily cleaned and their use helps keep radiography rooms open for other patients.
  6. Radiologists must also familiarize themselves with the CT appearance of the coronavirus infection “to be able to identify findings consistent with infection in patients imaged for other reasons.” People and HCWs are the most valuable resource during a crisis, and it takes the collective effort of every staff member to meet the challenges of an infection outbreak.
  7. Frequent cleaning of surface, bed, probe, and handle of the USG room is required. Decontamination of the surfaces of the imaging room is then required, with appropriate solutions and cleaning materials as recommended. Dilute bleach can be used; it should be prepared fresh and left on the surfaces with a contact time of at least 10 min. On surfaces where the use of bleach is not suitable (e.g., metal surfaces), alcohol impregnated wipes may be used, with a contact time of at least 15 min.
  8. Training and education of staff for COVID-19, preventive measures, care.


The clinical referring physicians should be clearly instructed to inform radiology reception team when scan is being requested for a confirmed COVID-19 patient, so all precautions are taken care of. Also whenever possible, such case should be taken at the end of the day so that fumigation and sanitation of the place and department can be carried without hampering department work. Depending on the burden of cases and resources of the institution, a dedicated COVID-19 room with isolated floor space, bathrooms, and designated HCW should be established. Suspected, unconfirmed patients should not be kept in the same unit or room as a confirmed case. The patients should be instructed to wear facemasks at all times to reduce source transmission.

In COVID-19 infected patients, scan procedure must be performed by the patient's bedside in the isolation room if the procedure can be done solely under ultrasound guidance as instituted in guidelines by CDC, and OSHA recommends the use of protective eyewear, facemask, full gowns, and shoe covers. Maximum barrier precautions (cap, mask, sterile gown, sterile gloves, double glove use, and large sterile drape) are advised during the insertion of central venous catheters.[13],[14],[15]


  How to Perform Safe Diagnostic Scans Top


It should be noted that the technologist or the registration clerk should try to avoid contact with the patients; the patients must wear a face mask and engage in minimum conversation, and the distance between the technician and patients must be more than 2 m. Only urgent relevant scans with detailed clinical history with clinical suspicion should be written on investigation page so scan can be focussed and finished sooner.Unnecessary, suspected scans, routine check-up and follow up scans, should be avoided.

(1) The nursing staff shall wear protective equipment according to the tasks performed, such as wearing third-level protective equipment if taken venous access for enhanced CT examination in the contaminated area designated for COVID-19 and wearing second-level protection while guiding others to wear protective clothing in the clean area. Personal protective equipments needed as per the level of protection [Table 1].
Table 1: Personal Protective Equipments Needed as Per the Level of Protection

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(2) Routine CT technologists at medium risk shall take secondary protection standard.

(3) CT technologists who are in physical contact with the patient should perform personal protection in strict accordance with the third-level protection standards, and at the same time, do well in wearing and removing protective equipment. Also, they should ideally take a shower and wash hair in the clean area sooner.

(4) Since the diagnostic CT-MRI physician does not need to contact the patient directly, personal protection according to the first- or second-level protection standards is sufficient.

Donning of PPE sequence

: 1. Hand wash with soap and running water. 2. Cap. 3. Shoe Cover. 4. Inner gloves. 5. Disposable body gown/dress. 6. Mask (N95). 7. Goggle. 8. Outer gloves.

Doffing of PPE sequence: 1. Outer gloves. 2. Hood. 3. Shoe cover. 4. Hand wash (gloved hand). 5. Goggle. 6. Mask. 7. Cap. 8. Inner glove. 9. Hand wash.

Priorities for handling COVID-19 cases and suggests strategies that radiology departments can implement to contain further infection spread and protect hospital staff and patients.

STAFF: All nonessential leaves are put on hold so that there is sufficient manpower available for rotation and all extra preventive measures to be taken care of. This is necessary as infection prevention measures need more staff, and there is the possibility staff quarantine that can reduce manpower. Many departments have some staff who provide services at multiple locations or departments. These cross-covering staff members who have been in contact with a COVID-19 patient risk exposing other healthcare teams to the contagion. It is very important to create a separate clinical team that includes the treating physician and an entire unit of nurse, technician, as well as other support staff, who are necessary for complete patient care at one particular center.[13]


  Disinfecting the Surface Equipment Decontamination Top


An independent control room is set for special fever (suspected COVID-19 patients) CT examination, which is isolated from the normal working environment of the radiology department, and if possible a separate way is to set up between the CT room, the fever clinic, and the isolation area. In order to reduce the spread of virus, a disposable bedspread (one person one change, no reuse) is used to for the examination table. The flat detector of special mobile X-ray equipment is wrapped with disposable sheet or clothing. Every time after the completion of imaging, equipment are disinfected (wiped with 75% alcohol solution or a sanitizer)[16]

Similarly, in CT and MR gantry machines, surfaces should be disinfected every time after use. This might be little time and energy consuming but need of the hour. Patient movement outside designated units should be limited and portable imaging and lab work should be performed in the room when feasible, and post use, cleaning and sanitation of the surface should be strictly performed using disposable disinfectant wipes containing 75% ethanol, at least 3 times a day. The used cleaning wipes and other materials shall be uniformly incinerated. It is forbidden to disinfect the medical equipment or the room with a spray. Wherever possible, frequent appropriate fumigation–sterilization of equipment surface should be carried out


  Interventional Radiology Top


Requested procedures are to be assessed for the infection risks and the urgency. For patients suspected or confirmed of COVID-19, the procedure is deferred if it can wait. Clinically, urgent life and limb saving and elective oncology procedures will continue, but other nonurgent elective cases are postponed. Movement of patients with or suspected of COVID-19 are minimized. Procedures that can be performed under ultrasound guidance (e.g., ascitic and pleural drains, peripherally inserted central catheter, central venous lines, etc.) are performed at the patient's bedside in the isolation ward with all precautions. If fluoroscopy or angiography is required, the next preference is to transfer the patient to the hospital's designated COVID-19 operating theatre and perform the procedure using portable C-arm systems whenever possible, or the procedure is kept at the end of the day so post procedure fumigation–decontamination can be carried out without hampering department work. Tissue or fluid specimens are considered infectious and are transported in leak-proof specimen container preferably plastic one.[14],[17]


  Standard and Contact Precautions Top


If entry into the patients ward is needed, facemask should be used. Respirators and facemasks must be immediately thrown discarded immediately after leaving the patient's area, closing the door, and hand hygiene should be carried out. Blood, body fluids, secretions, and excretions may contain transmissible infectious agents via the nonintact skin and mucous membranes. Standard precautions and disposal criteria as per the nature of the interaction and the extent of anticipated blood, body fluids, and pathogen exposure must be followed. Detection of SARS CoV 2 in the saliva, gastrointestinal tract, and urine suggest other potential portals of transmission other than routine respiratory droplet mode (18). If splashes, sprays, coughs, contact with nonintact skin, mucous membranes are expected, facemask, gloves, and eye-body protection should be worn and discarded or sterilized regularly. Hand hygiene should be performed with alcohol-based sanitizer containing 70%–95% alcohol or by washing hands with soap and water for at least 20 s. It should be done before and after patient interaction or contact with potentially infectious material and before putting on and after removing PPE.[13]

Temperature checking and condition of staff

Many reports have shown that people of certain demographic parameters and those with comorbidities are at higher risk of acute respiratory distress syndrome if infected. Staff should be excluded with parameters like age above 60, smokers, diabetics, hypertensives, those with previous lung damage, chronic heart disease, cancer, Hepatitis B, chronic kidney disease. Although fever, dry cough, breathing difficulty, myalgia, and fatigue are the most common symptoms, there have been documented instances of isolated symptoms of sore throat, sneezing, and nasal discharge with a far less occurrence of headache, sputum production, hemoptysis, and diarrhea. To prevent further spread, onset of fever and respiratory symptoms should be closely monitored among HCWs. When available, testing of respiratory specimens should be done immediately once a diagnosis is suspected. Serum antibodies, faecal, and urine samples should also be tested among HCWs before and after their exposure to SARS-CoV-2 for identification of asymptomatic infections.[19]

Emotional support: HCWs are under constant extreme physical, mental stress. They are physically overworked beyond conceivable limits and suffer from pain of losing patients and colleagues in spite of the best possible treatment and care. This is in addition to worrying about their own health and the constant anxiety of passing infection on to their families and loved ones.[20]


  Managerial and Leadership Control Top


Regular and centrally directed communications of the daily, evolving situation is important to ensure that all staff are updated with the most current information and operations guidelines from the hospital. Staff morale and confidence boost up is needed in a climate of fear and uncertainty of COVID-19 infection and outcome.[17]


  Conclusion Top


At present, it is not clear to what extent the COVID-19 epidemic would establish itself and how long it is going to continue in India. As the introduction of cases may take anywhere from a minimum of 14 days to a few months to be visible, we need to enhance surveillance and prepare the community in a proportionate way.[21] The radiology department should be prepared to continue the servicing emergency procedures and important elective procedures following the strict aseptic precautions so HCWs and patients safety is maintained. The team members should understand the disease dynamics, routes, and source of transmission and should take utmost precautions to prevent transmission to colleagues and patients by properly using PPE. Anticipating that constant updates will be necessary in this volatile situation, the above recommendations may be used as basic guidelines, which may vary from department to department management decisions and strategize in order to optimize resources while minimizing risk to staff and delivering quality emergency patient care. Knowledge of this new condition is rapidly evolving, and not all of the published and publicly available information is complete or up-to-date. We should culture a habit of preparedness in future for such and other health-related pandemics.[22]


  Summary Top


  1. Radiology preparedness, resource management, CT and MR gantry machine surfaces are to be disinfected every time after use
  2. To limit the propagation of the disease, proper screening of the requested scans and postponement of the elective scans till the current situation is brought under control are required.
  3. Infection prevention and control mechanisms in the radiology department have far-reaching consequences. The radiology front desk should serve as an additional screening site, with similar screening to that performed at the hospital front door and at referring clinician.
  4. Preparedness in future for such and other health-related pandemics is required.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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[PUBMED]  [Full text]  
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