Resuming Routine Radiology Care During COVID-19

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Strategies for providing inpatient and outpatient imaging under new and challenging conditions.

The persistence of the COVID-19 virus is requiring many imaging providers to adjust operations in order to resume routine radiology care as well as attend to patients infected with COVID-19.

Everything Rad asked several imaging providers around the world for their recommendations for resuming routine radiology exams while also caring for patients infected with COVID-19. Continue reading to learn insights on:

• How to provide infection control in inpatient and outpatient imaging
• How to safely diagnose COVID-infected patients
• How to safely image COVID-infected patients
• How to reassure the general population that the imaging center is safe
• How to weather the financial hit in diagnostic imaging
• The lasting impact of the coronavirus in radiology

“The biggest challenge for the whole world now is how to open up hospital services for people with other diseases and sickness,” emphasized Dr. Arnon Makori, Director of Imaging Informatics at Clalit Health Services in Israel. “We have to learn how to manage services knowing there is a potential COVID-positive patient. Our most important calling and challenge as radiology administrators, rad techs, and radiologists is how can we provide the same service now as we did before COVID? It is professionally wrong to delay other imaging exams. It is a very fine balance and it is not easy.”

How to provide infection control in inpatient and outpatient imaging

As the rate of infection ebbs in some regions, patients with health issues not related to COVID-19 are returning for imaging services in hospitals and outpatient facilities. The foremost concern for many of these patients and the healthcare staff is infection control. Today, it is common to see plexiglass partitions that provide a barrier between patients and registration and scheduling staff. Also, staff and patients alike wear masks. Those are the easy changes.

At Cedars-Sinai in Southern California, one of the biggest challenges in resuming routine radiology care has been accommodating physical distancing, which resulted in losing almost half of all waiting room capacity, said Dr. Barry Pressman, M.D., FACR; and Chair Academic Imaging. To make up for the loss, Cedars-Sinai created new waiting spaces in hallways and the hospital mezzanine. An outdoor seating area where healthcare staff used to have their meals is now a waiting area for families.

“The biggest problem has been where patients are sitting in the waiting room. And that has a cascading effect on when you can do cases and how many per hour, because there’s no more room for patients to sit,” explained Dr. Pressman.

Hours have been extended to accommodate the slower throughput caused by the physical spacing as well as the time required to clean rooms in between exams.

Golden Gate Radiology Medical Group, a small community-based imaging facility in the heart of San Francisco, has tightened access to the hospital and radiology department to patients only. “There was never a free flow of patients into private portions of the department before, but since COVID, everyone and everything is more highly regulated to protect both patients and staff from infection,” said Dr. Roger S. Eng, MD, MPH, FACR.

As part of resuming routine radiology care, Clalit Health Services developed a questionnaire to identify COVID-19 risk factors and integrated it into their RIS at 50 imaging centers throughout Israel. Every outpatient is asked the series of questions at the front desk.

“Having this process computerized is an important tool,” said Dr. Makori. “When a flag comes up in the system, the front desk staff is instructed to discuss the case with those of us in radiology.”

At Cedars-Sinai, all outpatients who are to undergo image-guided procedures (e.g. angiograms and biopsies) are tested for COVID-19 48 hours before their imaging appointment. “If anyone tests positive, we don’t image them unless they are urgent or emergent, which generally isn’t true with outpatients,” said Dr. Pressman.  

On the inpatient side, COVID-positive patients are imaged “only if they absolutely have to be done,” and only after discussions and approval by radiologists, explained Dr. Pressman. “Of course, if a patient is urgent or emergent, you have to do them. You just have to take all the necessary precautions.”

Studies like upper GIs, sniff tests, swallowing studies and esophagrams that require patients to remove their masks remain a challenge, whether or not the patient is infected. Typically, the procedure requires staff – whether a radiologic technologist, nurse, or physician – to be in the room and in close proximity during the procedure. In these cases, staff at Cedars-Sinai wear full PPE, including N95 masks. Patients are instructed to fill their mouths with contrast while staff stands a distance away. Then the patient is instructed to put their mask back on and swallow.

Additionally, the hospital is doing as many imaging exams as possible from a remote-controlled room rather than in-room flouroscopy. “These changes are not easy, but we need to make adjustments,” emphasized Dr. Pressman.

Another strategy to limit infection is the “capsule method of operating” – keeping the same staff members working together as a unit. Clalit Health Services used this staffing approach so that the possibility of infection would be limited primarily to those team members should someone on the team become infected. “COVID is here to stay. We have to find ways to do both COVID work and general imaging together,” stressed Dr. Makori.

Before resuming routine radiology care, Columbus Regional Health put in place adequate social distancing, plexiglass partitions and routine disinfecting. Also, the hospital has a designated Workforce Safety Officer who scrutinizes various areas of the hospital and notes opportunities to improve infection control, said Bill Algee, Director of Imaging Services.

How to safely diagnose COVID-infected patients

One of the most important strategies for infection control is to identify and isolate COVID-infected patients quickly. At Witham Health Services, all potential COVID patients go through a Respiratory Fast Track (RFT). A physician checks for symptoms and chest X-rays are taken with a portable imaging unit.

“We did single-view portable chest exams down in the COVID unit. The attending staff wore appropriate PPE. We were pretty much covered from head to toe, including eye shields, hair and shoe covers. The single view X-ray was always the baseline,” explained Jason Scott, MBA CRA FAHRA CPXP RT(R)(MR), Chief Patient Experience Officer Director, and Imaging/Respiratory/Neurodiagnostics/Wound Care at Witham Health Services.

If patients needed further testing or a CT exam, they were brought down to CT. However, CT exams were discouraged. “To get to the CT room, you are taking a COVID patient through hallways where exposure can occur. And if they were on any kind of aerosol, we had to clean the entire CT room afterward. Luckily, we have a UV light that can totally clean the room,” explained Mr. Scott.

Cedars-Sinai also discouraged the use of CT as a diagnostic tool early on. “Initially, there was a lot of talk about COVID being quite specific in its appearance on a CT scan. But now most data suggests that is not true. It took some discussion to clarify (to physicians) that CT was inappropriate and it could possibly harm other patients because we would have to clean the CT room afterward and delay care for other people. And the CT wouldn’t make the diagnosis,” recalled Dr. Pressman.

Golden Gate Radiology, which is associated with Chinese Hospital, initially planned to do CT scans when other testing options were not available. Hospital staff and referring clinicians worked together to develop policies for when a patient suspected of having COVID-19 should get CT imaging, and the process for transferring that patient to the imaging area and back. “We had to determine when there was enough benefit to imaging to initiate the process. It was a new factor of risk/reward to add to the imaging equation,” said Dr. Eng.

How to safely image COVID-infected patients

To help limit the possibility of infection spreading to patients who come in for routine radiology care, Clalit Health designated a self-contained, isolated unit for all COVID patients. Point-of-care imaging was captured with dedicated DR units, including the Carestream DRX-Revolution Mobile Imaging System that did not leave the area.

“We relied on chest X-rays for follow up – not for diagnosis – and for classifying disease severity. We combined the results with other medical parameters, such as ventilator settings and blood result tests, to get an overall predicting algorithm to see and identify patients who would deteriorate,” said Dr. Makori. “We believe the chest X-ray is the most important and most effective imaging tool for triage and follow up.” 

Having a dedicated unit that did not leave the area made cleaning easier. Exams were taken at the end of the day, and then the unit was disinfected in preparation for the next day.

Columbus Regional also relied on the DRX-Revolution for monitoring COVID-19 patients. Infected patients were restricted to ICU rooms. The mobile unit travelled from room to room within the ICU after having a thorough cleaning following each exam. In preparation for an increase in COVID-infected patients, the hospital leased an analog portable that it could upgrade to DR using its DRX-Transportable System from Carestream.

“This option kept us from trying to find other portable units which were in short supply. Also, it was less expensive. We were pinching pennies like crazy,” recalled Mr. Algee.

How to reassure the general population that the imaging center is safe

Imaging centers are implementing safety procedures and are ready to resume routine radiology care. But how can you reassure patients? Be visible in your efforts, stressed Dr. Pressman.

“We tell our techs that they need to become salespeople. We tell them to make sure that patients see what they are doing to protect them. We tell them to clean the chairs when the people who will sit there will see it. Tell them about your mask and be sure to wear your mask. Put markers all over the floor for where to stand. And put markers on chairs that indicate– ‘don’t sit here’, ‘sit here’. Do everything you can do to make patients understand that you are taking action,” he said.

Additionally, the hospital instructs staff to, “tell non-COVID patients that they are being imaged in rooms that we don’t believe have had COVID patients. Tell them that the machines were cleaned before they came in. Don’t assume patients know what you are doing. Tell them everything that is being done. We gave our doctors the same information so they can share this with their patients (who need imaging) and give them piece of mind,” Dr. Pressman added.

Mr. Algee agrees that facilities cannot communicate enough to patients who need routine radiology during this time. “We need to continue to pound home to patients that we are creating a safe environment. There is not a doubt in my mind that anybody coming to the hospital is safer here than anywhere else in the community, other than their own house.”

The hospital also reminds staff that they are role models when they are out in the community and to wear masks as needed.

Anish R. Kadakia, MD, Professor of Orthopedic Surgery at Northwestern University/Northwestern Memorial Hospital, has found that patients have less anxiety when they can see their physician and have their imaging done in one place, in one visit. “We anticipate that patients will want to minimize visits to hospitals for some time. The pandemic made the general public more safety cautious about the spread of infectious diseases. Although patients need to come to our hospital setting, they are reassured that we can do imaging and share results in one office visit. If you have imaging in house, that is a huge benefit.”

How to weather the financial hit in diagnostic imaging

In addition to meeting their mission of providing quality healthcare, imaging providers also need to maintain their revenue stream. Many imaging services experienced a massive decline in exams as patients stayed home due to fears of being infected by COVID. Additionally, some governments, like the US federal government, urged a widespread halt of elective procedures in hopes of slowing the viral spread.

Golden Gate Radiology and the Chinese Hospital never had high numbers of COVID-19 cases. Nonetheless, they felt the financial impact as strongly as anyone. “We had to prepare, so we canceled all outpatient procedures and outpatient imaging exams. For a small hospital like us without big endowments, that’s a major issue,” said Dr. Eng, adding that at one point, imaging appointments were down 80 percent.

“A lot of patients say they are still concerned about coming back, even to an outpatient setting. We are reaching out to them and giving them facts. We tell them no staff members have tested positive in the entire hospital; and we tell them about our safety procedures to keep them safe during their brief encounter here,” Dr. Eng explained.

Like other facilities, Columbus Regional Health initially shut down its outpatient imaging but quickly did a reversal after two weeks. “During that two-week period, very, very few patients – other than those with COVID – visited the hospital’s emergency department. Early on, we realized that other people who needed care were not coming in,” said Mr. Algee.

The facility reopened its outpatient imaging center for three days a week, eventually expanding to five days a week as demand for imaging services steadily increased as the number of COVID-19 cases in the area declined.

What is the lasting impact of the coronavirus in radiology?

Although there is hope that an effective vaccine will be found, those interviewed expect the impact of the coronavirus to be long lasting.

“I wouldn’t be surprised if the staff who work with aerosols and anesthesia cases wear face shields forever,” predicted Dr. Pressman. “For a long time there will be fear of ‘what else can I get?’ And the fear of COVID will probably last well beyond when a vaccine is available.”

If there is a second wave, some imaging departments will do their best to continue providing routine radiology care so they can serve the needs of all their patients. Their future might depend on it.

“We’re all here to take care of patients, but radiology is also a service line,” said Mr. Scott. “We will try as hard as we can not to shut it down. That’s why we’re wearing masks with every single patient all the time now. We are screening staff before and after shifts – all employees, whether radiology or nursing, or anyone else. We’re more confident now than in the first wave because we have been through it and we know what it is. We’re more prepared now.”

Katie Kilfoyle Remis is the editor of Everything Rad and the global digital media manager for Carestream Health. Contact her at Katie.Remis@Carestream.com

Editors note: Arnon Makori, Roger Eng, and Barry Pressman are members of the Carestream Advisory Board.

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