Reviews and CommentaryFree Access

Radiology Department Preparedness for COVID-19: Radiology Scientific Expert Review Panel

Published Online:https://doi.org/10.1148/radiol.2020200988

The coronavirus disease 2019 (COVID-19) pandemic began in December 2019 in Wuhan, China. The outbreak is due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (1). Approximately 81 000 patients have been infected in China (2). Although infection rates are said to be controlled in China through severe public health measures, Italy (more than 10 000 cases) and Iran (more than 8000 cases) have seen exponential increases in the number of infected individuals.

Other than China, Italy, and Iran, most countries have had approximately 2 months to prepare their responses to the COVID-19 pandemic. These responses are led by public health authorities of national governments in coordination with local governments and hospitals. Because of the nature of the emergency in China, chest CT findings (eg, peripheral ground-glass infiltrates and/or organizing pneumonia) temporarily became part of official diagnostic criteria of COVID-19 as a surrogate for viral nucleic acid testing (1). With improved disease understanding, chest CT findings are no longer part of the diagnostic criteria for COVID-19. Instead, at present, the focus of most radiology departments outside of China has shifted from diagnostic capability to preparedness.

Radiology preparedness is a set of policies and procedures directly applicable to imaging departments designed to (a) achieve sufficient capacity for continued operation during a health care emergency of unprecedented proportions, (b) support the care of patients with COVID-19, and (c) maintain radiologic diagnostic and interventional support for the entirety of the hospital and health system (Tables 1, 2).

Table 1: Health Care Institution Response to COVID-19 Pandemic

Table 1:

Table 2: Radiology Preparedness for COVID-19 Pandemic

Table 2:

Because of varying infection control policies (both nationally and regionally), steps for radiology preparedness for COVID-19 will vary between institutions and clinics. The Radiology editorial board has assembled a team of radiologists who are active in the coordination, development, and implementation of radiology preparedness policies for COVID-19. Their policies have been developed in conjunction with top infection control experts at their respective world-class health care systems. In the sections below, each panel member describes their department’s top priorities for COVID-19 preparedness in their environment. The editorial board hopes that readers may find one or more of the highlighted health care systems to be similar to their own, providing impetus for action or confirmation of your current preparedness activities.

University of Washington Medicine

University of Washington is a major metropolitan medical system, with three major urban medical centers and many outpatient clinics and imaging centers spread across Western Washington, the epicenter of the COVID-19 outbreak in the United States. There have been more than 267 cases of COVID-19 and 24 deaths in Washington state, including approximately 18 patients with confirmed COVID-19 hospitalized at our institutions as of this writing. There is a substantial Asian population in Seattle, including many professionals and students who frequently travel to China and other regions with high infection rates. The largest risk remains in older patient populations, as 71% of patients infected in Washington state are older than 50 years and 57% are older than 60 years.

Radiology leadership has helped in the development of policies and guidelines relating to COVID-19 in areas of patient screening, spread precautions, and patient triage in coordination with the hospital leadership. Radiology leadership has worked with input from our department membership, especially operations leaders and chest imagers, to develop screening-specific guidelines.

Top Priorities in Our Environment for COVID-19 Preparedness

1. Early detection and limiting exposure of health care workers, employees, and patients, especially critically ill patients. The hospitals have implemented screeners at all hospital entrances to check those coming in for symptoms that could be related to SARS-CoV-2 infection or with risk factors related to travel or exposure. The radiology front desk serves as a screening site, with similar screening to that performed at the hospital front door. Patients who present with respiratory symptoms who are undergoing outpatient imaging or procedures have their studies canceled and are asked to follow up with their primary care physician. For inpatients with suspected or confirmed COVID-19, all nonemergent imaging and procedures are delayed until diagnosis is confirmed and they recover from their illness and are considered noncontagious.

2. Use of radiography and chest CT. Despite reports from China (3) and initial concerns from the U.S. Centers for Disease Control and Prevention (CDC) regarding unreliable test performance (4), our current reverse-transcription polymerase chain reaction (RT-PCR) assay for SARS-CoV-2 viral nucleic acid is estimated to have a sensitivity of 95%–97%. Our laboratory also has a turnaround time of less than 1 day, making RT-PCR an easy, accurate, and less resource-intensive examination. Our laboratory has been performing more than 500 tests per day, covering our system but also other regional systems, with approximately 10% positive results. Inconclusive results are seen in a small subset, which are then sent for confirmation to Washington state laboratories.

Sensitivity and specificity of chest CT for COVID-19 are reported to be 80%–90% and 60%–70%, respectively (3,5). Thus, imaging is reserved for those cases where it will impact patient management and is clinically indicated or to evaluate for unrelated urgent and/or emergent indications. This typically occurs in cases where an alternative diagnosis is being ruled out or being considered for acute symptom worsening. In our current workflow and with the accuracy and rapidity of RT-PCR testing, there is no need for immediate CT imaging. In addition, if symptom worsening is thought to be secondary to COVID-19, imaging would not change management, as current treatment consists of oxygen and supportive care.

When possible, imaging is performed at sites with less foot traffic and with fewer critically ill patients in that area to avoid secondary patient and staff exposure. Considerations are also being made to implement containment zipper (a room isolation tarp barrier with a zipper for room access) to separate the control area from the CT scanner room. Imaging is performed in the imaging center nearest to the patient and, if possible, at the ambulatory clinic. This approach limits the transit of contagious patients and potential exposure of others. When possible, portable imaging is performed (both portable radiography and portable CT in patient rooms) to limit equipment, room, and hallway decontamination requirements.

3. Imaging in patients who are suspected of being COVID-19 positive or who have positive results at RT-PCR testing. For these patients, droplet precaution is employed. Patients are masked during imaging and procedures. Deep cleaning of the room is performed after each patient. Air exchange processes are not employed due to patient masking. After imaging, the room downtime typically ranges from 30 minutes to 1 hour for room decontamination and passive air exchange. Airborne precautions are reserved for those patients who are critically ill or who are undergoing aerosol-generating procedures (bronchoscopy, intubation, nebulization, or open suction). Airborne precautions are not necessary with patients receiving mechanical ventilation as the system is considered a closed system. The decision to remove patients from isolation is determined by hospital infection control staff. Those staff members consider RT-PCR results, imaging findings, clinical characteristics, potential exposures, and risk factors and comorbidities into their decision-making.

4. Staff protection. Our hospital systems, in coordination with the state, have worked to reduce the need to bring patients to major hospitals and clinics. This will help protect our vulnerable patient population and university employees. Harborview Medical Center, Seattle, instituted a team of physicians and nurses that go out to the homes of patients suspected of having SARS-CoV-2 to perform testing and evaluation. In coordination with the Seattle Flu Study and Gates Foundation, University of Washington has begun issuing SARS-CoV-2 testing kits for home use. University of Washington Medical Center Northwest Hospital, Seattle, has implemented drive-through testing for university employees who are symptomatic. The university has placed a moratorium on travel for all employees for 1 month.

5. Maintenance of radiology department operations. In radiology, we have focused on providing the ability for radiology faculty to work from home if needed for isolation. For those who are not suspected of having been exposed or infected but are concerned about potential exposures, we have created radiology outposts and isolated reading rooms across our enterprise, including single-station reading rooms in our hospitals as well as in our outpatient imaging centers. Staff that do not need to be on-site and who can work remotely (eg, including coders, billers, and schedulers) are directed to work from home. The majority of hospital staff–related meetings now use videoconferencing rather than having in-person attendance. For those meetings that cannot be virtual, a determination of the necessity of the meeting is made by department leadership and those determined as nonessential are cancelled.

Emory University School of Medicine

Emory is a large urban, academic, research-oriented health care system with 10 affiliated hospitals and extensive outpatient facilities covering an urban sprawl of more than 6.5 million persons in the greater Atlanta area. Atlanta is also home to the world’s busiest airport and the CDC.

Emory Healthcare rapidly assembled as central coordination team for COVID-19 preparedness, including daily leadership teleconferences, maintenance of a central stockpile of N-95 masks and other personal protective equipment (PPE), and policy alignment with CDC, employee health, and infection control personnel. In the radiology department, we are holding regular meetings with the departmental leadership, including division directors and health care staff to plan for workforce integrity and the health of our staff. We also work closely with the Emory Office of Critical Event Preparedness and Response to ensure communication between our emergency department and the radiology department’s Division of Emergency and Trauma Imaging. E-mail notifications, leader calls, and redistribution of the department’s disaster preparedness escalation policy are the main modes of communication.

Top Priorities in Our Environment for COVID-19 Preparedness

1. Ensuring the health of our workforce so that we can best care for our patients.

2. Planning for sufficient staffing to cover our clinical needs. Quarantine of clinical radiologists, staff, and trainees following travel to level 3 countries and/or after exposure to patients proved to have or suspected of having COVID-19 have the potential to quickly overburden our ability to adequately staff critical services. We are working to rapidly obtain and deploy additional home workstations so that asymptomatic radiologists can work from home. Although this approach does not help procedural services, it can decompress diagnostic interpretations and provide back-up for surge capacity.

3. Arranging for surge potential should the health care system be taxed by increased volume of patients and associated imaging needs.

4. Contamination of CT scanners is major concern. CT equipment may be out of commission for several hours for cleaning. Should a patient presenting with atypical symptoms and/or not triggering suspicion for COVID-19 be scanned, the potential for additional patient and radiology staff exposure is heightened.

Other Workforce Considerations

The many spring radiology meetings are important venues for professional satisfaction, networking, and sharing meaningful scientific and educational material. With the prospect of major conferences being canceled, we are finding opportunities for faculty and trainees to present their work locally to colleagues. During this period, our colleagues have substantial concerns about the safety of their families and school and daycare closings can impact their ability to get to the hospital.

New York University Langone Health

New York University is a large academic health care center in New York City. The catchment area includes the tri-state region of New York, New Jersey, and Connecticut. With three large airports serving the area, there is a large volume of domestic and international people traffic. Currently, New York has the second greatest number of COVID-19 cases in the United States. On March 7, 2020, the governor of New York, Andrew Cuomo, declared a state of emergency for New York State.

At our institution, guidelines are distributed from the institutional leadership and then implemented by individual departments, including radiology.

Top Priorities in Our Environment for COVID-19 Preparedness

1. Establishment of a COVID-19 crisis management team. A dedicated team from radiology leadership was charged with overseeing the departmental preparedness for COVID-19. A vertical communication network was established to coordinate the activities of four hospitals and multiple ambulatory care offices that comprise our department. Department directors and site managers participated in regular conference calls to standardize the protocols for patient care and operational workflow. The crisis management team shares institutional news and sources of information to inform the department leaders. The crisis management team serves as a centralized resource to answer questions and address concerns from individual sites and department members.

2. Implementation of protocols for patients known to have or suspected of having COVID-19 exposure. Institutional directives for patient care protocols were adapted to the radiology environment. For outpatients, patients who schedule imaging examinations are screened for pertinent symptoms, travel history, and exposure to individuals with known COVID-19. On the basis of these answers, patients are scheduled for their imaging examinations or directed to the virtual urgent care program or the emergency department. At radiology reception areas, patients are screened for symptoms of fever and cough. Initially, patients with travel history to countries with widespread transmission or contact with individuals with known COVID-19 were identified and consult calls were placed to the institution’s infection prevention and control team to determine the need for patient testing and whether the patient will be transferred to the emergency department or discharged home. Subsequently, as evidence of community spread of COVID-19 appeared in our geographic area, the threshold for calling the infection prevention and control team has been lowered, with increased emphasis on patient symptoms. For these high-risk patients, the need to perform the scheduled imaging examination was determined by the relative urgency of the examination for patient care management.

In the hospital and emergency department setting, patients have usually already been identified as known to have or suspected of having COVID-19, and imaging examinations are provided as clinically warranted.

3. Reduction of potential transmission from patients known to have or suspected of having COVID-19. The guiding principle to reduce potential transmission from patients known to have or suspected of having COVID-19 is source control. In the ambulatory care setting, a patient presenting with fever and cough is immediately given a mask and directed to an isolation room for further screening and consultation with the infection prevention and control team. Health care providers who perform this additional screening wear PPE, including gloves, mask, and eye shield. If the scheduled imaging examination is ultimately performed, the health care providers, such as the technologist and nurse, wear the same PPE and may wear a gown if there is the potential for close or direct contact with the patient. A census of the other patients and staff in the practice at the time of the patient visit is logged so that they may be contacted should the patient test positive for COVID-19.

In the hospital and emergency department setting, patients have usually already been identified as known to have or suspected of having COVID-19. A dedicated portable radiography machine was assigned to image only these patients. If additional advanced imaging examinations are required, the radiology staff wears the necessary PPE and the room is cleaned and disinfected according to hospital protocols.

4. Reduction of potential exposure for department members. To minimize risk and potential for exposure, travel restrictions were instituted for all employees of our organization. All domestic and international work-related travel and business and/or academic attendance at meetings, conferences, and similar events were banned for a temporary time period. Large group gatherings were discouraged.

In our department, a substantial number of the clinical faculty already have home workstations as part of our clinical wellness program. Before the travel ban, radiologists returning from high-risk areas were asked to self-quarantine and interpret cases from home. With the possibility of increasing COVID-19–related quarantines involving the clinical faculty, additional home workstations have been ordered to provide quarantined clinical faculty the ability to work from home to meet the clinical demand.

With the increased use of PPE and the concern for shortages, our institution implemented conservation measures to ensure that supplies are available for radiology staff and patients who require them. In addition, allocation of PPE has been centralized within our hospital. PPE is distributed to areas of our department on the basis of clinical need.

University of Wisconsin Hospital

The University of Wisconsin Hospital is a 675-bed academic hospital in Madison, Wis. Our catchment area is a population of approximately 600 000 people. The main risk factor in our area is the international nature of our university and area businesses. There are 44 000 students at the University of Wisconsin–Madison, and many do a semester abroad; the university research programs thrive on international outreach. Madison is home to Epic Systems; under normal conditions, 4000 employees travel weekly to work in hospitals throughout the United States and internationally.

At the time of writing, the University of Wisconsin Hospital has had one patient diagnosed with COVID-19. None of the hospital personnel in contact with the patient developed symptoms or had a positive RT-PCR test for viral nucleic acid.

Our radiology department response is closely coordinated with our hospital infection control team. Hospital infection control personnel have had in-person meetings with our radiography technologists and have given tutorials on infection control procedures for respiratory infections. The hospital infection response workgroup sends out daily e-mails to all employees. Our department’s senior director attends daily hospital COVID-19 command center briefings and meets daily with the radiology vice chair of operations. Department modality managers have policies and procedures developed several years ago to deal with patients who might have the Ebola virus; existing policies were reviewed and staff were updated.

For the faculty radiologists, our hospital infection response workgroup had our department create a back-up call schedule. The purpose is to cover faculty who become ill or are quarantined. Each radiology section has responsibility for sick coverage for their daily clinical services and on-call staffing; individual radiology specialty areas have created back-up call schedules. Almost all radiologists have home picture archiving and communications system workstations; use of remote interpretation has been incorporated into our department’s response plan.

Top Priorities in Our Environment for COVID-19 Preparedness

1. Ensure all department employees are aware of and are performing recommended infection control protocols. This applies not only to interacting with patients but also with fellow employees and to working on shared workstations.

2. Arrange infection control tutorials led by hospital infection control experts. Time has been allocated for hospital infection control experts to provide in-person tutorials and supply information on required protocols for interaction with patients who may have COVID-19. Seminars by our infection control personnel have also been arranged with our CT, US, and interventional technologists. These individuals are anticipated to be on the front lines in interaction with patients suspected of having COVID-19 infection.

3. Develop a detailed operational plan for a new, separate, urgent care site for COVID-19. In the case of a severe community outbreak, hospital infection control staff may take steps to provide care for patients with COVID-19 in a separate facility away from our main hospital. We have developed a plan to equip and staff the site with a portable radiography machine using strict infection control procedures.

4. Review and practice protocols for decontaminating imaging rooms after caring for a patient with COVID-19. This includes a 1-hour downtime for passive air exchange.

5. Work to better define the role of CT and two-view chest radiography in patients with COVID-19. Although multiple publications in Radiology and other major journals have described COVID-19 findings on chest CT scans, the vast majority of patients have been from China. In that environment, lack of RT-PCR test kits and remarkable influxes of patients necessitated detection and staging of COVID-19 disease patterns with chest CT. The applicability of those results to our environment is not yet known.

6. Continue sharing information with all department employees, including open discussions on ramp-up of stricter infection-control procedures if needed. This includes having faculty work from their home picture archiving and communications system workstation or having sections split their faculty and fellows into separate reading sites, having residents attend conferences remotely from their reading rooms so they do not gather in one location, and having technologists work from one location and not rotate between health care facilities.

University of California, San Francisco

University of California, San Francisco, is a tertiary-quaternary 1000-bed urban referral academic center. San Francisco is an international crossroads and one of the earlier sites of disease in the United States.

The prevalence of COVID-19 cases in our institution’s catchment area has increased rapidly during the past 2 weeks. University of California, San Francisco, has instituted a Hospital Incident Command System structure to guide decisions and practice. The institution has shifted its strategy from containment to risk mitigation in view of the size of the outbreak and the documented community spread of infection. Until internal laboratory testing had been developed, confirmatory RT-PCR testing represented a significant bottleneck in patient triage.

The response of our radiology department is coordinated with health system leadership, including radiology planning and strategy at the health system level. Policies are developed at the health system level, including stay-at-home and return-to-work plans, faculty travel, and procedures for safe transport, respiratory isolation, and treatment of patients suspected of having or confirmed to have COVID-19. We have developed radiology-specific guidelines for safe imaging of patients under investigation with CT and radiography, contingency staffing planning, and reducing risk of nosocomial spread.

Top Priorities in Our Environment for COVID-19 Preparedness

1. Identification of patients at risk for having COVID-19. Patient screening is now undertaken at the time of radiologic examination scheduling and in all outpatient imaging settings. In addition, all patients and visitors are screened at the entrance to clinic buildings and hospitals. Respiratory clinics equipped with portable radiography units have been established at each of our three main hospital sites. Ambulatory patients who screen positive for possible COVID-19 illness are redirected to one of these respiratory clinics for further evaluation.

2. Development of standard operating procedures for safe imaging of patients suspected of having or known to have COVID-19 (Figs 1, 2). At University of California, San Francisco, CT is not considered a screening examination for COVID-19. A multidisciplinary team of experts, including thoracic radiologists, is developing a guideline for the use of CT imaging in patients known to have or suspected of having COVID-19. Standard operating procedures for safely imaging patients with portable radiography units and for imaging patients with CT when necessary have been developed, ensuring that all team members are aware of patients’ isolation status and that clinical and imaging teams provide coordinated high-level care in a safe and efficient manner.

Tip sheet posted at the radiology front desk at University of                         California, San Francisco. All front desk locations have been equipped with                         isolation packets containing instructions for staff roles, N95 masks, and                         gowns. ARDS = acute respiratory distress syndrome, CDC = Centers                         for Disease Control and Prevention, ED = emergency department,                         SARS-CoV-2 = severe acute respiratory syndrome coronavirus                         2.

Figure 1: Tip sheet posted at the radiology front desk at University of California, San Francisco. All front desk locations have been equipped with isolation packets containing instructions for staff roles, N95 masks, and gowns. ARDS = acute respiratory distress syndrome, CDC = Centers for Disease Control and Prevention, ED = emergency department, SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.

All radiology sites with rooms that can be used as isolation rooms are                         identified with appropriate signage. PAPR = powered air purifying                         respirator.

Figure 2: All radiology sites with rooms that can be used as isolation rooms are identified with appropriate signage. PAPR = powered air purifying respirator.

3. Staff education regarding COVID-19 prevention. Education of radiology staff regarding stay-at-home policies and infection prevention techniques, such as handwashing and regular cleaning of fomites, was an early focus in our department.

4. PPE availability and education for health-care workers. Our department has worked with health system leadership to ensure adequate supplies of necessary PPE. Staff and faculty champions were recruited and serve to educate and reinforce appropriate donning and doffing techniques for PPE.

5. Implementation of “social distancing” strategies for staff, trainees, and faculty. All large staff gatherings (eg, radiology grand rounds) have been cancelled. We have aimed to decrease foot traffic in radiology reading rooms by encouraging remote consultations by video and telephone rather than in person. Recurring departmental meetings and multiple clinical conferences have been moved to videoconferencing. We are exploring strategies to allow diagnostic radiologists to work from home and are developing guidance for when this is appropriate.

6. Planning for a potential surge of patients. A surge in patients with known or suspected COVID-19 illness will require reallocation of resources. Illness or factors such as school closings may deplete our physician and staff workforce. We have developed contingency plans for maintenance of our clinical activities and staffing in such cases.

To maintain hospital bed availability, schedules for interventional radiology and neuro-interventional radiology have been frozen (no additional patient slots) for 2 weeks for procedures that require patients to have overnight observation or hospitalization.

Singapore General Hospital

Singapore General Hospital is a 1773-bed academic tertiary hospital in the city center of Singapore. Singapore General Hospital has 1 million patient visits annually. Singapore is an international travel hub. The first patient with COVID-19 in Singapore was diagnosed in Singapore General Hospital on January 23, 2020. As of March 12, 2020, there were 187 confirmed cases of COVID-19 in Singapore.

The activities for infection control in the radiology department are highly coordinated with our institution-wide infection control staff. We have separate imaging facilities for inpatients and outpatients and negative air pressure rooms for radiography, US, CT, and MRI to cater to patients with infection control risks.

Even before the COVID-19 outbreak, radiology had an infection control committee that included infectious disease physicians. In addition, there is an institutional disease outbreak task force that includes several members from radiology leadership, as there is acknowledgment that radiology is a key component in an outbreak situation (2).

At the present time, the national strategy for COVID-19 is that of containment. Our institutional strategy is to minimize any possibility of in-hospital transmission and to achieve zero health care worker transmission to ensure a safe environment for both patients and staff.

Top Priorities for Radiology for the Control of COVID-19 in Our Environment

1. Ensure sustainable radiology operations. Our goal is to ensure that every staff member has shown competence with standard infection control practices and use of appropriate PPE. At the present time, our priority is to ensure continuous and consistent practice to avoid staff fatigue or complacency that can otherwise easily result in lapses in infection control. Daily audits of infection control procedures are conducted.

We have allocated staff into hybrid teams working in separate physical locations to avoid large numbers of radiology staff members being subject to quarantine. Meetings are conducted by means of electronic platforms to avoid congregation. Staff are encouraged to practice social distancing. Imaging equipment status is tracked daily to ensure adequate imaging capacity.

2. Monitor and respond to rapid changes in the COVID-19 pandemic. Our existing radiology management structure was too large and cumbersome to effectively respond to the rapid scenario changes. We established a smaller radiology disease outbreak task force, incorporating faculty with experience in disaster preparedness (eg, colleagues who have held senior positions in the armed forces). This task force meets daily (eg, 20 minutes each morning) to assess overnight incidents and anticipated changes during the day.

Radiology has inserted itself into our infectious disease clinical team due to the key role of imaging in timely diagnosis as well as infection control (nosocomial infection related to imaging tests). The radiology task force actively disseminates information to all staff members electronically (eg, website, e-mails, text messaging).

3. Long-range planning for COVID-19: A new norm for radiology operations. At 7 weeks into the COVID-19 outbreak, we have minimized in-hospital transmission. Due to the global spread of COVID-19, we are looking at new norms of practice. Our goal is to inculcate an ongoing culture of infection control practice embraced by all staff members. We are rethinking how radiology can deliver optimal imaging and treatment while reducing unnecessary movement and congregation of patients within our hospital environment. Teleconsultation and electronic smart appointment applications and counseling are being fast-tracked for implementation and will have far-reaching impact on our future practice.

Disclosures of Conflicts of Interest: M.M.B. disclosed no relevant relationships. C.C.M. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: is a paid board member at the RSNA; is a paid consultant for MD Anderson; is employed by Emory University; institution has grants/grants pending from the National Institutes of Health; received payment for expert opinion from Forensic Panel. Other relationships: disclosed no relevant relationships. D.C.K. disclosed no relevant relationships. M.J.T. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: receives royalties from Elsevier. Other relationships: disclosed no relevant relationships. K.P.K. disclosed no relevant relationships. B.S.T. disclosed no relevant relationships.

References

Article History

Received: Mar 13 2020
Revision requested: Mar 13 2020
Accepted: Mar 13 2020
Published online: Mar 16 2020
Published in print: Aug 2020