Frontline work during a major incident is part of the role of a radiographer. Personal events that come to mind are working on the west coast of New Zealand when a viewing platform collapsed, resulting in the death of over 20 students and leaving just six survivors. Also being on duty at Glasgow’s Royal Hospital for Sick Children at the time of the Dunblane massacre.
As a general medical sonographer and professional lead, coronavirus has not hit the sonographer workforce with the same ferocity as it has many radiographers. Nevertheless, it has turned out to be a most difficult period professionally. This pandemic is not a short, sharp shock; it is a marathon.
Reports coming out of Wuhan and mainland Europe were bleak but informative. Guidance around PPE was shifting rapidly but it was obvious to most that sonographers were at high risk due to prolonged patient contact. Remaining in communication with Gill Harrison, Professional Officer for Ultrasound at SCoR, enabled advice on the changing situation to be received.
Evidence from Wuhan showed that ultrasound doctors were 50% more likely to contract the virus (1) compared to medics as a whole and that around 30% of the asymptomatic population had the virus (2). The International Society of Obstetrics & Gynaecology (ISUOG) webinars were informative and helpful.
In late March and early April, almost a quarter of our sonographers were self-isolating with presumed coronavirus in our department. A much loved Health Care Support Worker colleague was ventilated and extremely unwell with the virus (they have since returned home and continue to recuperate) . Staff anxiety was understandably high and, after what seemed an age, getting approval to use PPE for all cases was an enormous relief. Our management team used regular teleconferencing and virtual meetings to communicate, which worked surprisingly well.
Practicalities and prioritisation
Although point-of-care ultrasound was used to evaluate pulmonary fibrosis by critical care doctors, this was not part of the general medical sonographers’ role with the health board. Routine examinations were cancelled and we only responded to urgent cases.
Patient safety was paramount. NHS Greater Glasgow & Clyde’s ten radiology departments had to be transformed hastily. Specific red and green rooms, routes and waiting areas were identified. In some older sites, waiting areas could not accommodate patients. Ultrasound units were moved into clinics in order to maintain essential services.
All requests were re-vetted and prioritised. Most were put on hold. As time stood still, risk mitigation became a concern and urgent suspicion of cancer and medically planned cases were prioritised. As services now re-start, there is a huge backlog of patients.
The art of the possible
While the backlog is a significant clinical risk, the challenges of social distancing and PPE availability, staff shielding, limited access to equipment and waiting areas, patient anxiety and staff morale are now important considerations as we move into the next phase.
When re-vetting thousands of requests, it became apparent that a significant proportion were duplicates or had no appropriate clinical question. Liaising with clinical colleagues, a brief audit showed 17% of requests could be returned. Specialist vetting groups were set up and there is now a proposal to introduce specific teaching for vetting, and the allocation of vetting time.
The volume of requests received is returning to near that of pre-pandemic levels and shows no signs of abating. This is in part due to virtual clinics that do not allow for physical examination, resulting in a heavier reliance on diagnostic tests. As waiting times are longer, some referrers are upgrading requests to urgent in order to push through scans more quickly but this practice results in longer waits for other patients.
How to deal with the volume of requests coupled with limited access is a conundrum.
An ultrasound Special Interest Group (SIG) in Scotland has proved invaluable in these times. Lead sonographers from each health board work collaboratively and all boards report similar concerns: loss of capacity by at least 30%; staff burn-out; waiting-time pressures. Most report they can facilitate scanning inpatients and urgent or semi-urgent cases but there is little capacity to clear the backlog in the near future.
SIG members have been in contact with Scottish Government around ways to alleviate the burden. A national sonographer bank has been advocated by the SIG which may help with the backlog, allow for cross-boundary working and reduce the governance issues that can come with the use of locums. It is at present unclear if this idea will come to fruition.
Some staff have expressed an interest in more flexible working patterns and are keen to extend the day slightly (8am - 6pm model). This model would be cost effective as there is no need for enhanced payment and enables increased throughput while allowing for social distancing. A cautious approach is required in order to reduce risk of repetitive strain injury.
As the coronavirus crisis continues there is no quick fix. We all speak of a ‘new normal’ but how will that look?
More virtual meetings are anticipated as opposed to sitting in traffic before heading to a conference room en masse. This will allow more time to clinically respond to the backlog.
Perhaps patients and referrers will appreciate the value of the NHS and utilise it more appropriately moving forward?
For weeks we stood on our doorsteps and ‘Clapped for Carers’. We were deemed heroes. Government and the NHS boards must commit to investing in diagnostics rather than deal with the consequences of delayed diagnoses or treatment. How do we best invest in the NHS? Appropriate financing is imperative. Nonetheless, vitally, we need a pledge to respect and enable its biggest resource: its staff.
1. Wang J, Zhang W, Chen QC, You MJ, Yang YL, Lü Q, Zhang L, Xie MX. [Ultrasound Staff infections in Wuhan during the COVID-19 epidemic. Chinese Journal of Ultrasonography [accepted for publication 2020;29].
2. Nishiura H, Jung SM, Linton NM, Kinoshita R, Yang Y, Hayashi K, et al. The extent of transmission of novel coronavirus in Wuhan, China. J Clin Med 2020a;9(2), 330.