Since the initial peak of the pandemic, sonographers have carried on working in very difficult situations, writes Gill Harrison, SCoR Professional Officer for Ultrasound. There have been challenges throughout and these will likely continue for the rest of the year and into 2021.
What have they been doing?
Wherever possible, sonographers have kept obstetric screening services running. They have provided the two routinely offered screening scans, early pregnancy services and additional examinations for growth and fetal well-being.
Sonographers not only scan pregnancy but are involved in non-obstetric scanning including seriously ill in-patients with, for example, abdominal or gynaecological symptoms, or patients with advanced stages of cancer and elderly or vulnerable patients. Some patients delayed attendance to hospitals for fear of contracting Covid-19, which meant that sonographers were seeing complex pathologies and extremely unwell patients when it became safer for patients to attend.
Sonographers often work in confined spaces, and due to the nature of work are unable to physically distance from patients while undertaking the scanning investigation. Protective screens seen in the retail and hospitality industry cannot be accommodated due to the nature of the examination. It is usual for sonographers to spend from a minimum of 20 minutes up to 45 minutes on average with each patient.
Why has it been challenging?
Sonographers have had to deal with many difficulties and uncertainties particularly associated with PPE. There were the initial challenges of sourcing PPE and changing guidance. Some sonographers were told by their employer that they did not need PPE, others were told that they only required PPE for scanning Covid-19 positive patients because asymptomatic patients could not transmit the virus.
The SCoR team was working hard behind the scenes to keep up with the guidance and provide advice to members, continually updating the frequently asked questions to help provide timely advice. To date the guidance on ultrasound FAQs is version 9. This reflects the fact that coronavirus was an unknown, so everyone was learning and responding quickly to a changing situation.
We had some glorious weather during lockdown which was wonderful if you were outside, but wearing PPE in the often small, already hot, ultrasound rooms was a challenge for sonographers. Fans could not be used. Due to difficulties with donning and doffing PPE we heard that many staff were not drinking enough liquids during the day to keep well hydrated.
Examinations took longer to ensure adequate cleaning, not only of the transducer and machine, but also anything within the two-meter radius. Other high-touch surfaces had to be thoroughly cleaned between patients, along with chairs in the waiting room. In some departments the same numbers of patients were being booked, so staff were not getting adequate rest breaks.
Sonography is already facing a workforce crisis, but staff shielding, self-isolating when family members were ill and reports of 50% of staff being absent with virus symptoms in the early stages of the pandemic in some departments, added to the pressures. Now departments are facing staff self-isolating when they or family members have symptoms, and until test results are received the pressure is still on departments. Staff are often working extended days to meet demand which is only sustainable in the short term.
What changes were made to working practices?
The risk of spread of the virus impacted the service and restrictions, with many departments unable to support a partner or supportive person to accompany those attending for scans. This was and is particularly challenging for those attending for a scan with a suspected cancer diagnosis and those attending for pregnancy scans.
This created challenges for patients, their families and sonographers. Sonographers want to give the best care possible and knew how upsetting it could be for people having to attend an ultrasound examination alone. Risk assessments highlighted that for the safety of all staff, patients, relatives and the wider community this was essential. Guidance from the RCOG, the RCR and ISUOG informed decisions, as did local risk assessments.
Guidance has been changing at a rapid pace and sonography teams have had to balance risks. A sonographer might scan between 20 to 30 patients in one day, some of these patients may be extremely vulnerable to Covid-19, for example immunosuppressed patients undergoing cancer treatment. Reducing the number of people in attendance in waiting rooms, scan rooms and the hospital in general was a necessary change to help reduce spread. This has changed as restrictions began to ease and new guidance was published, and has helped to support patients in their journey.
Examination vetting became even more important and will continue, as many patients were and are still having remote consultations without clinical examination. Ultrasound is not always the most appropriate modality and referrals must often be discussed and prioritised with referring clinicians. It is time well spent as resources are stretched and services try to cope with current demands in addition to backlogs.
Some regional groups came together to develop collective policies. This helped to standardise practice across the region, but also provide ultrasound teams with a support network, to share best practice and advice.
What is needed going forward?
Sonographers have been contacting SCoR for advice on a whole range of issues. Most of the answers required and still do require addressing at the local level, taking account of the context and setting with a local risk assessment. National guidance can help direct local risk assessments but it is important for departments to have risk assessments that consider their working environment, individual staff needs, patient types attending the department.
Policy needs to be in place and all staff must be aware of and adhere to policies, to provide consistent services to patients. Justification for policies and changes made should be publicised, to ensure service users are fully informed about decisions and know what to expect when they attend the department. Policy should include potential situations that might arise, for example what happens if a patient cannot wear a face covering? What if they can, but refuse to? The same consideration is needed for anyone else in attendance at the examination.
Are there alternative ways of working that could be considered? Can vulnerable patients be seen in a different room to other patients? Would this give enough variety in workload to ensure that sonographers do not increase their risk of work-related musculoskeletal disorders? Can Perspex screens be used in waiting areas or scan rooms?
Staff support will be essential as sonographers continue to work under extremely difficult circumstances. Additional time is required for examinations to enable cleaning to be undertaken. Good leadership, inter-professional team working and communication is crucial to provide effective, safe working environments for patients, staff and the wider community.
What new skills were learnt?
Learning about the virus and ways to reduce contamination and spread has been a steep learning curve. We still do not have all the answers. How the virus can manifest in patients of different ages and co-morbidities has been another challenge. Sonographers scanning paediatric patients have seen appearances associated with multi-system inflammatory syndrome. Adult patients have been presenting with coagulation associated complications. Some sonographers have been brushing up on or learning lung ultrasound to help in detecting signs of Covid-19. Writing learning resources for lung ultrasound has helped give some guidance to the international ultrasound community, for example ISSRT.
Online conferences and webinars have been focusing on Covid-19 as well as providing, often free, resources for on-going CPD in other areas of practice.
We are not through this pandemic yet but what we do know is that sonographers are working extremely hard to ensure that high quality ultrasound examinations can be provided in as safe, effective and compassionate way possible for the protection of everyone in the community.
They are doing their upmost to provide patient centred care and values based practice. The SCoR is very grateful to the teams of dedicated sonographers for all their work and commitment and hope you enjoy celebrating some of the achievements made by sonographers during Medical Ultrasound Awareness Month (#MUAM #MUAM2020) and AHPs day (#AHPsDay).