Covid-19 pandemic: Summary of current and emerging issues for radiographers

Imaging departments will play a vital role in managing patients during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Covid-19 pandemic.

Radiographers, in particular, are crucial patient-facing staff who will play a key role. Guidance and recommendations are fluid and rapidly changing as evidence emerges and evolves. It is essential that imaging departments, including radiographers, radiologists and support staff, are kept up to date.

This is a shared responsibility between management and individuals. Local policy should be adapted and consistent with national and international guidance. Infection control, especially hand hygiene, will be central to mitigation.

In order to protect themselves, colleagues and patients, it is critical that radiographers have access to, and training in, the safe use of personal protective equipment (PPE).

Updated PPE guidance has been issued in response to the increasing prevalence of Covid-19 cases. Public Health England (PHE) advice is for in all secondary care/acute hospital settings that do not involve non-aerosol generating contact, staff should wear a surgical mask, eye protection, disposable apron and disposable gloves.¹

Specific guidance on PPE for imaging departments has been provided,² reinforcing the key role that radiographers are playing, particularly with chest radiograph (CXR) acquisition forming a pivotal role in diagnosis. Surgical mask and eye protection should be worn for a ‘session’ (eg mobile ward round). This is consistent with World Health Organisation (WHO) guidance³ and supported by a recent single centre case report from Singapore⁴ and a meta-analysis.⁵

Trusts should have clear policies in place for imaging staff in relation to suspected or confirmed Covid-19 patients and systems in place to ensure these are regularly updated and as disease prevalence increases. Current PHE guidance indicates that all emergency/acute imaging referrals should be treated as potential Covid-19 cases.

Polices should include:

• Decontamination of imaging equipment (CT and MRI gantries, ultrasound probes) and any surface that may have come into contact with respiratory droplets
• Clean techniques for imaging, including dual working where possible
• Mobile imaging wherever possible, avoiding transfer of the patient
• Transfer of patients to imaging departments when mobile imaging is not appropriate

Radiographers should receive an update on the safe application and removed of PPE relevant to the level of potential exposure. Fit testing for FFP3/N95 masks should occur for key staff likely to be involved in aerosol generating procedures.

Recent research suggests SARS-CoV-2 (coronavirus causing Covid-19) can persist on steel and plastic surfaces for up to 72 hours, reinforcing the need for appropriate barrier precaution (for example detector covers) and decontamination of imaging equipment and rooms.⁶

Mobile imaging will play an important role in patient management, both for critically unwell patients and also to avoid increased contamination risk associated with patient transfer. Consideration for a dedicated mobile unit should be made, preferably a DR unit to reduce transit and to effectively manage radiographer workload.

Imaging departments should screen all outpatients that attend at first contact with the hospital for symptoms, such as fever or persistent cough, that could be consistent with unsuspected Covid-19.⁷ Consideration should be made by trusts to ensure sufficient staff are available and to reduce transmission risk. Possible mitigation strategies could include:^7,8

• Split teams to ensure continuity, with mirrored skill mix in each team as far as possible
• Reallocation of resource to facilitate dual working for imaging suspected or confirmed Covid-19 cases
• Delay of non-urgent imaging to increase capacity
• Phone rather than face to face consultations regarding imaging referrals
• Back-up/on-call systems to cover staff illness

The British Society of Thoracic Imaging (BSTI) have conducted a rapid evidence review and produced guidance to support departments when imaging suspected Covid-19 patients, a clinical decision support tool (in collaboration with clinical directors in NHS England) to guide appropriate referrals and characteristic findings on chest radiographs (CXR) and CT scans.

Effective and efficient use of imaging, both staff and equipment, will be essential to manage the predicted surge in demand; to do this, imaging must only be placed at a point in the clinical decision-making workflow where it will influence the patient’s location, management or prognosis. Referrals for imaging must include information on the Covid-19 risk of the patient (possible, suspected or confirmed case) so that appropriate precautions can be taken.⁷ The greatest transmission risk is within one metre of the patient and patients should wear a mask wherever possible during imaging.⁶

Radiographers are often the first healthcare professional to see a diagnostic image. Preliminary clinical evaluation and escalation to a reporting practitioner will play a role in rapid diagnosis and infection control. CXRs with features to suggest possible Covid infection (bilateral, lower zone and peripheral predominant [ground glass or airspace])should receive an immediate report by a radiologist or reporting radiographer wherever possible.

CT radiographers should review the lungs of all scans, including lung bases on abdominal scans, for characteristic appearances (peripheral or patchy ground glass opacification) and triage to a radiologist review while the patient is still on the scanner. Where CXR or CT findings are suspicious for an unsuspected Covid-19 infection, the patent should be fitted with a mask, the clinical team notified in line with urgent and unexpected findings policy, and a deep clean performed.

The proportion of patients with confirmed Covid-19 infection and abnormal CXR reportedly ranges from 60% (3 of 5)⁹ to 97.5% (40 of 41).¹⁰

Use of template report proformas for CXR and CT chest should be considered, especially for suspected cases of Covid-19. Immediate reporting of chest imaging (CXR and CT) could play a role in rapid diagnosis and assessment. Reporting radiographers are an additional resource available to rapidly increase diagnostic capacity, providing CXR reports and adding manpower to the consultant radiologist workforce.

Finally, please take care of yourselves, your colleagues and your patients. Be mindful of rest breaks, down time, and both your mental and physical health.

References

1. Public Health England. COVID-19 personal protective equipment (PPE). London: Public Health England, 2020.
2. Public Health England. Recommended PPE for healthcare workers by secondary care inpatient clinical setting, NHS and independent sector. London: Public Health England, 2020.
3. World Health Organisation. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19). Geneva: World Health Organisation, 2020.
4. Ng K, Poon BH, Kiat Puar TH, et al. COVID-19 and the Risk to Health Care Workers: A Case Report. Annals of internal medicine 2020 doi: 10.7326/l20-0175
5. Offeddu V, Yung CF, Low MSF, et al. Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis. Clin Infect Dis 2017;65(11):1934-42. doi: 10.1093/cid/cix681 [published Online First: 2017/11/16]
6. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. The New England Journal of Medicine 2020 doi: 10.1056/NEJMc2004973 [published Online First: 2020/03/18]
7. Mossa-Basha M, Meltzer CC, Kim DC, et al. Radiology Department Preparedness for COVID-19: Radiology Scientific Expert Panel. Radiology 2020 doi: 10.1148/radiol.2020200988
8. Kooraki S, Hosseiny M, Myers L, et al. Coronavirus (COVID-19) Outbreak: What the Department of Radiology Should Know. Journal of the American College of Radiology : JACR 2020 doi: 10.1016/j.jacr.2020.02.008 [published Online First: 2020/02/25]
9. Ng M-Y, Lee EYP, Yang J, et al. Imaging Profile of the COVID-19 Infection: Radiologic Findings and Literature Review. Radiology: Cardiothoracic Imaging 2020;2(1) doi: 10.1148/ryct.2020200034
10. Shi H, Han X, Jiang N, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis 2020 doi: 10.1016/S1473-3099(20)30086-4 [published Online First: 2020/02/28]

Authors

Dr Nick Woznitza, consultant radiographer, Homerton University Hospital
Clinical academic, Canterbury Christ Church University

Dr Samanjit S Hare, consultant chest radiologist, Royal Free Hospital

Dr Arjun Nair, consultant chest radiologist, University College London Hospitals
Disclosure: Arjun Nair reports, unrelated to the current submission, part funding from the UCL NIHR Biomedical Research Center, and a medical advisory role with Aidence  BV, an artificial intelligence company.