Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that has quickly spread across the globe causing coronavirus disease 2019 (COVID-19), with cases rapidly increasing in the United States. On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic. Given the importance of protecting health care workers during the pandemic, SIR is releasing information and guidance for interventional radiologists to plan for the management of COVID-19 patients. This is a rapidly changing situation, and information will be updated as new information is released.
There is no available data for the role of IR in management of COVID-19 patients and persons under investigation (PUIs). Nonetheless, IR has a critical role in the management of patients within the health care system and could conceivably be called to assist in the management of a COVID-19 positive patient. IR suites may also be located near radiology services where COVID-19 patients may undergo imaging. Proper and early preparation is therefore crucial to reduce exposure to health care workers and other patients in IR.
As of March 22, 2020, cancellation of all elective and nonurgent procedures has been recommended or required, and most of the country has been declared at substantial risk. The COVID-19 toolkit has been updated to reflect that.
1. Should we be using N95 masks for all of our procedures?
With the shortage of N95 masks across the country, it is critical to preserve the usage for indicated procedures. The CDC has published methods to preserve PPE, including gowns, eye protection, facemasks and N95 masks. Based on WHO and CDC recommendations, N95 masks should be conserved and used only in those performing or present for aerosol-generating procedures in COVID-19 patients or in those with prolonged contact with COVID-19 patients. Therefore, when performing procedures on COVID-19 patients, a surgical N95 mask is recommended. If a surgical N95 mask is not available, CDC recommends wearing a faceshield over a conventional N95 mask. Strategies can be implemented during surge periods to conserve N95 masks. An example of conservation strategies can be found through the CDC for conventional, contingency and crisis periods, large health care systems (see video at 41:53), and through other crisis approaches.
In situations where a procedure is requested on a PUI, a discussion should be held with the referring team to determine the urgency of the procedure, the risk level for the patient being COVID-19 test positive, and the possibility of performing the procedure after COVID-19 testing results have returned. Use of N95 masks should then be determined accordingly.
N95 masks should not be used routinely in procedures for patients who are not a PUI or who have not tested posted for COVID-19, unless the patient has an infectious disease (e.g., tuberculosis) that would otherwise require an N95 mask.
2. We are experiencing a significant shortage of N95 masks. What can we do to re-use N95 masks?
NIOSH offers guidance for extended use and limited reuse of N95 respirators. Recommended storage between uses includes placing respirators in breathable containers, such as paper bags, or hanging them in dedicated storage areas where they will not touch other respirators and risk cross contamination.
For crisis situations, CDC and N95DECON provide detailed evidence-based information on respirator decontamination techniques. Both conclude that existing data suggest that moist heat, ultraviolet irradiation, and vaporous hydrogen peroxide are generally the most promising decontamination methods with the caveat that none of the studies are specific for SARS-CoV-2.
3. What procedures are being performed for COVID-19?
No publications are available detailing the type and volume of procedures being performed on COVID-19 patients. In an SIR webinar with interventional radiologists in Singapore (see time point 1:01:12), it was noted that the most commonly requested procedure was stroke thrombectomy, with fewer requests for procedures such as drainages and catheters. During email communications with IR physicians in high-volume COVID-19 areas, the most common requests have been drainage and central venous catheters in either PUIs or COVID-19 patients.
Some practices are considering early embolization on patients with bleeding to avoid prolonged hospitalizations and need for transfusion. The blood supply is anticipated to be compromised and this should be taken into consideration when determining how to address hemorrhage. If early embolization (e.g., for GI bleeding, postpartum hemorrhage, etc.) will be practiced, consider increasing inventory of embolization materials in advance.
4. As a health care provider, should I be tested for COVID-19? When should I recommend members of my team be tested?
The CDC has issued guidelines on testing for health care providers. In the health care setting, even those HCPs with mild signs and symptoms should be tested if there has been close contact with a COVID-19 patient. Close contact is defined as proximity of less than 6 feet for a prolonged period of time with a known COVID-19 patient or direct contact with COVID-19 patient secretions (such as being coughed on) without any use of PPE.
5. As a healthcare provider, the COVID-19 pandemic has placed significant stress on myself and the team I work with. What resources can I use or recommend to my team?
Several resources are available to help provide assistance. Check with local leadership to see if any resources have been developed to assist with burnout including support groups or literature. In addition, several online resources are available. Some that stand out include the Veterans Affairs National Center for PTSD COVID-19 Resources page, the ACR page, and the American Medical Association COVID-19 caring for caregivers page. The JAMA has recently published a piece on Understanding and Addressing Sources of Anxiety in Healthcare Professionals. It is important for individuals to focus on their own care and well-being during this crisis. The Hastings Center has also devloped an ethical framework and guideline in support of ethical responses to both immediate and potential ethical challenges brought on by this pandemic. Effectively managing these challenges is important in mitigating stress for both providers and service users.
6. I am concerned about exposure to my family when returning from the hospital. How can I keep them safe?
No evidence-based literature exists, but in an informal survey of the SIR COVID-19 Workgroup and other healthcare providers, many individuals are using techniques to isolate themselves from family after returning from work including using dedicated/separate entrances, showering, and changing/laundering clothes immediately upon arrival home and prior to any interaction with family. While no single solution will work for everyone, careful discussion with your family and assessment of your living situation should help you to decide what will work best for your individual situation. Should you have any COVID-19 exposure, several online resources are available to assist in self-quarantining methods, including from the CDC and Johns Hopkins.
7. What practices can we incorporate at work to reduce the risk of COVID-19 infection between staff?
Reports have been received of significant COVID-19 breakouts within IR services. Proper assessment of the number of staff and the availability of workspace will help to decide how best to institute safety measures. Many safety measures are detailed by the CDC but are not specific to IR. Examples of measures to incorporate for Interventional Radiologists include:
- Reinforcement of appropriate hand hygiene
- Social distancing of at least 6 feet between persons
- Limit points of entry and traffic though the procedure area and department
- Segregation of staff
- Geographic assignments to reduce the number of people using any given work area
- Staggered shifts
- Using the minimum number of staff required to perform each procedure safely
- Universal masking
- Maintaining communication and transparency
- Practice exercises for donning/doffing PPE and equipment preparation/disinfection drills
8. As an OBL/Outpatient center, is there anything in the new stimulus package that can help my practice?
The recently passed Coronavirus Aid, Relief and Economic Security (CARES) Act (S.3548) contains several provisions designed to help small and medium businesses. The American Medical Association has a summary describing how physician practices can benefit from the bill.
For personal guidance, independent business owners should consult with their financial advisors for clarification. Below are some important highlights:
- The Paycheck Protection Program (PPP) provides small businesses (500 or fewer employees) the ability to obtain loans for up to two months of the average monthly payroll costs from the last year plus an additional 25% of that amount, up to $10 million. Payments may be deferred for 6 months. The amount of that loan that is used for payroll costs, and most mortgage interest, rent, and utility costs over the 8 week period the loan is made will be forgiven tax-free. Loans can be obtained through the SBA and other lenders.
- Economic injury disaster loan of up to $2 million to be used on Economic injury disaster loans payroll and other operating expenses. An advance of up to $10,000 can be made available within 3 days of a successful application
- Financial relief by covering non-reimbursable expenses attributable to COVID-19 such as increased staffing or training, personal protective equipment, and lost revenue.
- Expansion of telehealth
9. What precautions should we take if we only have a positive pressure room to use as our COVID-19 procedure room?
CDC guidelines recommend all aerosol generating procedures (AGP's) be performed in Aerosol Infection Isolation Rooms (AIIR). For non-AGP's, if a negative pressure procedure room is unavailable, the procedure should be done in the patients inpatient negative pressure room if possible.
Non-AGP's can be safely performed in a positive pressure room when appropriate precautions are taken:
If feasible a small negative pressure anteroom can be created to assist with safe donning/doffing of personal protective equipment (PPE) and transfer of materials required during the procedure. The American Society of Healthcare Engineers has guidance for options to create negative pressure rooms.
If a negative pressure anteroom cannot be created, PPE should be donned prior to entering the procedure room and doffed prior to exiting the room according to CDC guidelines. The respirator should not be removed until exiting the procedure room.
The procedure should be performed with the least amount of people required in the IR suite. Limit traffic during procedure and only enter the suite/open the door if it is absolutely necessary. Signage should be considered when a patient is in the room to alert others.
Following completion of the procedure and the patient leaving the room, entry should be delayed until sufficient time has elapsed for enough air exchanges to remove aerosolized infectious particles. Obtaining proper measurements of the number of air exchanges per hour is important to estimate how long the room should remain closed, and can typically be performed by engineering. The current CDC guidance states that routine cleaning and disinfection procedures using an EPA-registered, hospital-grade disinfectant from List N, are appropriate for SARS-CoV-2 in healthcare settings.
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