Contents
Introduction
How do I protect staff and patients during ultrasound lists?
Should sonographers wear PPE?
Should patients with Covid-19 come to the ultrasound department?
How should I clean the ultrasound room?
How else can staff keep safe?
I have a specific health problem, what should I do?
Should we change the way we work in ultrasound?
Is there any advice about students training?
What advice do I give to pregnant patients?
Who should attend pregnancy ultrasound scans?
Should we be reducing scans in pregnancy, eg screening and growth scans?
Should we be cancelling non-urgent examinations?
Will we be covered if we ration services due to unprecedented challenges?
Other resources:
- Point of care ultrasound
- Preparing for Covid-19
Appendix 1 (RCOG 2020)
Introduction
In these challenging times the SCoR and BMUS realise that sonographers are having to deal with managing the demands of providing a high quality service, whilst protecting staff and patients, possibly with limited staffing and concerned patients. This frequently asked questions document aims to help provide answers, where possible, or guide sonographers to relevant sources of current information. The information is changing on at least a daily basis, so it is important to review advice from Public Health England and other relevant bodies.
It is important to realise that the current information regarding Covid-19 is extremely fluid, changing as the situation demands. It is therefore important to follow the advice individual trusts and employers are releasing as this is pertinent to the local situation and will be in line with government advice.
The SCoR has general advice on the website. This includes information about protecting staff and patients in cases of suspected /infected patient contact and service resilience measures needed to ensure the continuity of service, wherever possible. The Health and Care Professions Council (HCPC) have resources on their website, including the document, How we will continue to regulate in light of novel coronavirus (Covid-19).
NHS England and NHS Improvement are co-ordinating information about Covid-19 for health care professionals.
How do I protect staff and patients during ultrasound lists?
Risk assessments should be carried out in all areas of ultrasound practice. Advice should be sought from the infection control team about decontamination of ultrasound machines, transducers and scan rooms. Personal protective equipment should be worn when it is necessary to scan a patient with suspected or known Covid-19. See the SCoR website for more information.
The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) webinar series and the article by Kooraki et al (2020) may also be helpful.
Keeping staff informed of decisions, along with reasons for the action is important. Make sure staff are fully aware of current guidance on how to protect themselves, but also when to call in sick and self-isolate. Occupational health advice should be sought for staff who need additional support, due to the demands of working in such unprecedented times and having to making difficult decisions.
When planning workloads, it is important to ensure that waiting rooms are not overcrowded (ISUOG safety statement 23.3.2020) and seating should be spaced at least two metres apart. Limiting the number of visitors, staff and trainees in the room is also advised.
Patients and relatives can become anxious during these difficult times, particularly in pregnancy and when appointments are cancelled for patients with Covid-19 symptoms. It is important to have local policies in place to safeguard staff and protect them and other service users. See Appendix 1 for suggested template for rescheduling appointments.
Should sonographers wear PPE?
The latest government advice is in the document 'Guidance for infection prevention and control in healthcare settings' and on the gov.uk website. Advice from NHSE & I is that “any healthcare worker providing close patient contact within 1 metre of a patient/client who meets the case definition of COVID-19 should wear appropriate PPE this will be gloves, aprons, fluid repellent face masks and eye protection if risk of splashing from blood or body fluids”.
An ISUOG safety statement (31.3.2020) highlights that as sonographers are unable to maintain recommended distances from patients during an examination, they need to take all necessary precautions. It is was suggested that, as sonographers are in close contact with patients, often in small rooms with limited ventilation they should use contact precautions and droplet precautions. This includes the wearing of a fluid resistant (Type IIR) surgical mask (FRSM) and gloves, ensuring good hand hygiene and cleaning the equipment.
“The FRSM may be reused during the care of multiple patients, if used to for asymptomatic patients. Replace the mask if it becomes damp, damaged, soiled or hard to breathe through. Care should be taken not to touch the mask, until removing.
Disposable gloves should be used during the ultrasound examination and changed after each patient.
The ISUOG guidance (31.3.2020) suggests that “in general, respirators, as opposed to surgical masks, are recommended for healthcare personnel who come in contact with patients with strongly suspected or confirmed COVID-19 infection, however, surgical masks are an acceptable substitute when supply of respirators is limited”
More information and posters to describe the donning and crucially the removal of PPE can be found in the gov.uk document, along with advice on washing uniforms and managing blood and body fluids.
In the document Covid-19: Personal protective equipment (PPE) the SCoR recommend “Risk assessment must include the 2m minimum safe distance which we are all instructed to maintain. When the two metres rule is included in risk assessments, it is hard to avoid the conclusion that PPE should be used for ALL patients unless they have been tested negative for Covid-19”.
It is important to remember that it is the practice that is risk assessed not the patient, in relation to whether there is a risk of transmission of the virus to or from sonographers whilst being asymptomatic.
There is limited evidence available on the numbers of asymptomatic people who have tested positive for COVID-19, however figures are starting to be gathered (Infection Control Today, Nishiura (2020), Wang et al (2020) and WFUMB Position Paper).
A document by Health Protection Scotland (HPS) suggests that studies are limited by small sample sizes and the observational nature of studies.
Should patients with COVID-19 come to the ultrasound department?
Advice from ISUOG (23.3.2020) is to try and delay ultrasound examinations, if possible, in someone with known Covid-19 or symptoms.
If it is essential that they are scanned, ideally have a dedicated room for such cases, or for in-patients, consider bedside scanning. If the patient has to be scanned in the main ultrasound department, it is advisable to book their appointment for the end of the working day, to allow for a deep clean of the room after their examination.
Anything that has been in contact with the patient or within the sneezing/cough zone (at last one metre) should be cleaned, in addition to the sink and other areas that may be contaminated. Public Health England advice should be followed in relation to PPE and hands should be washed thoroughly after removal of PPE.
How should I clean the ultrasound room?
Covid-19 is de-natured by common disinfection, so good hand hygiene and cleaning of equipment and all surfaces with which patients or droplets might have come into contact, is central to reducing the spread of the virus. Equipment should include anything that might have become contaminated by contact or droplets such as the ultrasound machine, gel bottle, probes, couch, keyboard, door handles, sink.
There is guidance on general cleaning and decontamination of ultrasound machines from AxREM, BMUS and SCoR (2020).
ISUOG (23.3.2020) have released a safety statement on 'safe performance of obstetric and gynecological scans and equipment cleaning in the context of Covid-19'.
It is important to remember that for effective disinfection, surfaces, transducers and other equipment must be cleaned before disinfecting. Ultrasound manufacturers’ guidance must be reviewed when selecting the appropriate cleaning and decontamination methods for ultrasound machines and transducers, to avoid damage and impacting on warranties (AxREM, BMUS and SCoR 2020).
Consideration of UK regulations and local infection control advice is required when reviewing international guidance on the use of products for decontamination.
The ISUOG safety statement (23.2.2020) recommends limiting the number of transducers connected to the machine and storing accessories in a cupboard to reduce the risk of contamination. This is in line with WFUMB guidance “Unnecessary accessories in the room should be removed and, where possible, individually stored in the cabinets”.
How else can staff keep safe?
Social distancing with colleagues is important.Staff should try to ensure social distancing when possible, if not scanning, in line with the latest Public Health England advice. This is important when taking breaks during the working day. Try to avoid close contact with colleagues in the workplace, unless absolutely necessary.
Conversations should be at a safe distance. Remember that your colleagues could potentially be infected, so follow the government advice. It is not advisable to eat together, as this can cause staff to ‘drop their guard’ and potentially infect each other.
During this difficult time, it is, however, important to ensure good support for all staff. Team working and good communication will be essential, in addition to ensuring adequate rest breaks are provided and staff have facilities to take appropriate periods of rest. Access to occupational health or counselling support should be provided by employers.
It is important to limit the number of people in the ultrasound room, to reduce the spread of the virus.
The website, supporttheworkers.org, is a good place to find useful information for a number of areas such as self-help, leadership, team-working, anxiety and fear and the World Health Organisation (WHO) have a document 'Occupational safety and health in public health emergencies'. This includes information on pandemics, along with advice on strategies for managing fatigue and psychosocial stress for staff during emergencies.
The ISUOG guidance (30.3.2020) recommends that “consideration is given to ventilation in ultrasound rooms in individual workplaces” to “reduce air environmental contamination and exposure to COVID-19 infection”.
Staff should reduce the use of personal equipment such as mobile phones in clinical areas and only before and after good hand hygiene. Mobile phones can be vectors for disease and should be cleaned regularly.
I have a specific health problem, what should I do?
ISUOG safety statement (31.3.2020) recommends that “ultrasound providers of advanced age or with specific health conditions that predispose them to infection and severe disease should avoid scanning patients with suspected or confirmed COVID-19 disease”. Further details are in the document.
The RCOGprovide guidance for pregnant staff during the pandemic.
- Pregnant staff at any gestation “should be offered the choice of whether to work in direct patient-facing roles during the COVID-19 pandemic”
- Prior to 28 weeks pregnant staff should practise social distancing but can “choose to work in a patient-facing roles after occupational health risk assessment”, provided the necessary precautions are taken
- Staff over 28 weeks pregnant, or with underlying health conditions, should avoid direct patient contact and are “recommended to stay at home”
Should we change the way we work in ultrasound?
ISUOG (23.3.2020) advise the following, in their safety statement:
- "Use of single-use gel packs is recommended as opposed to gel containers.
- Consider transducer cover for non-endoluminal probes (this is not a CDC absolute requirement).
- Attempt to shorten the duration of the examination by arranging for the most experienced sonologist/sonographer to perform the examination.
- Inform the patient that a detailed explanation will not be given during the examination."
WFUMB position statement recommends:
- “Respect the time of scheduled visits
- Widen the appointment intervals in order to prevent crowding in the waiting room
- Space the seats to at least 2 meters apart”
Is there any advice about students training?
The best practice guidance recommends limiting the number of people in ultrasound rooms to protect both staff and patients. If a chaperone is needed for TV scans, it could be a way for the student to continue to see best practice and learn more about pathologies by reviewing images after the patient has left the room, as long as they keep to social distancing guidelines where possible.
Alternatively, if they are near to the end of the training and are almost ready for running lists independently, they could potentially complete scans under supervision with the supervising sonographer using social distancing. For a fairly new student, who would extend the examination time significantly, it may be more pragmatic to suspend training, after discussion with the education provider, until the restrictions are relaxed and/or pressure on the service reduces.
There is also the consideration about staffing needs in other areas e.g. in the main radiology department. Due to potential shortages, it may be more important for the student to be deployed for the duration of the pandemic in their original clinical setting.
What advice do I give to pregnant patients?
The RCOG Coronavirus (Covid-19) Infection and Pregnancy guidance suggests that women with suspected or confirmed Covid-19, who should be attending for routine antenatal care, including growth scans, should delay their appointment until they have completed the recommended period of self-isolation.
Urgent appointments “will require a senior decision on urgency and potential risks/benefits”.
Anyone with suspected or confirmed Covid-19 requiring an urgent scan should ideally be booked to attend at the end of the day.
Urgent, unplanned appointments for those with suspected or confirmed Covid-19 should ideally be triaged over the phone. “Local protocols are required to ensure women with confirmed or suspected Covid-19 are isolated on arrival to EPU or triage units and full PPE measures are in place for staff.”
“Medical, midwifery or obstetric care should otherwise be provided as per routine.”
Patient advice is available from the RCOG website as FAQs.
The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) have published interim guidance and a document, Coronavirus in pregnancy and delivery: rapid review, which may be useful.
The RCOG Guidance for antenatal screening and ultrasound in pregnancy in the evolving coronavirus (COVID-19) pandemic recommend assessing patients to determine if they or their partner have symptoms suggestive of Covid-19, or who meet the ‘stay at home’ guidance, before they enter the department. If they do, they are given written information about why their appointment is to be postponed and contact details are taken, to arrange a rescan after a period of self-isolation (see Appendix 1 for template).
Who should attend pregnancy ultrasound scans?
During these difficult times it would be useful to agree a local policy to reduce the number of people in the ultrasound room. The RCOG guidance recommends that “Patients should be asked to attend alone if possible or with a maximum of one partner/visitor.”
The ISUOG Consensus Statement on organization of routine and specialist obstetric ultrasound services in the context of Covid-19recommends that “The number of visits should be reduced to the essential minimum and women should be advised to attend with no accompanying person to avoid virus spread”.
If the patient is required by a trust to attend alone for their ante-natal scan, SCoR and BMUS do not advocate the use of virtual attendance by partners with on-line video calls such as ‘FaceTime’, or the filming of the examination, because of the potential to distract the sonographer during the scan, and because of confidentiality issues.
At a time when guidance is recommending completing the examination as quickly as possible to reduce the chance of spreading the virus and rationing of scans may be required, it is important to explain to patients the nature of the examination and the impact the additional video/phone recordings would have on the scan time, sonographer concentration and the potential risk of missing abnormalities.
Suggested wording could include some/all of the points below:
- First and foremost, a scan is a clinical examination. The sonographers fully appreciate the bonding that parents develop during ultrasound imaging but the clinical aspect of the examination is our priority in these difficult times. Sonographers should not be distracted in any way.
- Being distracted significantly increases the risk of a loss of concentration by the sonographer and a subsequent misdiagnosis including those of fetal abnormality. Being filmed in any context is distracting.
- Patients undergoing antenatal scans are required to lay in a neutral positions to be able to obtain diagnostic imaging. Various positions have been trialled that patients would need to be in to be able to film the scan / themselves and it is apparent this causes undue twisting and tensing of the abdominal muscles making the scan near impossible.
- Confidential information is held on the scan machine screen and within the scan room and the inadvertent sharing of this cannot be mitigated against if filming is allowed.
- During the pandemic, international advice is to reduce the number of people and equipment within 2 meters of the ultrasound machine, to limit the chance of virus contamination to you and your baby or other parents and staff, so we are unable to have phones
Some centres and private clinics offer ultrasound examinations for bonding and reassurance. These clinics may become increasingly busy if the NHS has to reduce the number of examinations it can offer during the pandemic. Government and RCOG advice should be followed in all ultrasound settings, to ensure staff and patient safety.
Limiting the number of people in the ultrasound room and the guidance on managing patients with symptoms, or a diagnosis of Covid-19, is essential.
Should we be reducing scans in pregnancy, eg screening and growth scans?
During an ISUOG webinar on 17 March 2020, the SCoR asked about this and the implications of reducing routing screening examinations and growth scans in pregnancy, particularly when staffing levels are impacted by the virus.
Routine examinations should continue for those with no symptoms of Coivid-19, however, capacity will need to be reviewed if staffing levels reduce. Team working with early pregnancy, fetal medicine and sonography departments will be essential to ensuring service provision can be maintained as much as possible.
In England, all advice on the operational delivery of screening programmes during the Covid-19 response will come from NHS England and NHS Improvement. This will ensure co-ordination and consistency with the advice being given to NHS symptomatic services. It is likely that this will be similar for the devolved countries.
If policy is changed to accommodate staff shortages during this period of uncertainty, it would be prudent to document protocols and get sign off from the trust board. Any changes to protocols should be clearly documented with a name/date and kept for future reference with other previous protocols.
24 March 2020: The RCOG have produced guidance for antenatal screening and ultrasound in pregnancy in the evolving coronavirus (Covid-19) pandemic.
The key points include:
- “These screening programmes are time critical and we should continue to offer timely screening”.
- “If staffing levels start to impact on such time critical services, the local screening team should inform their senior management team and commissioners to discuss contingency and mitigation planning.”
- “All women should be asked to attend alone if possible or with a maximum of one partner/visitor”
- “All women should be initially screened before entering the department to see if they have symptoms that are suggestive of Covid-19, or if they meet current ‘stay at home’ guidance. If a woman currently meets ‘stay at home’ guidance the appointment should be rebooked after the isolation period ends”
- Guidance on delaying appointments for patients with symptoms of COVID-19 is given within the document and a suggested template provided (see appendix 1)
- “The woman should be informed that if she remains symptomatic or develops symptoms she must not attend her appointment, instead she should phone her maternity service for advice”.
- If a patient wants screening and is too late for the combined test,
- between 14+2 to 17+6 weeks a dating scan should be performed and a quadruple test offered for trisomy 21. Head circumference (HC) used for the quadruple test.
- between 18+0 to 20+0 weeks an anomaly scan should be performed and a quadruple test offered for trisomy 21. HC used for the quadruple test.
- Between 20+1 to 23+0 weeks an anomaly scan can be performed.
- If there are capacity issues due to the pandemic and it is not possible to continue providing the screening service there should be discussions with senior staff. “If the service can only provide a single scan, it is recommended that this is performed at 18+0 to 20+0 weeks, with the option of the quadruple test for women who wish to be screened for trisomy 21”.
- Daily discussion should be scheduled with senior team members with oversight of the pathway to review service provision. In the event that there is insufficient staff to provide the service, scans should be prioritised in the following order:
- Anomaly scan at 18+0 -23+0 weeks
- Ultrasound +/- screening at 11+2 -14+1
- Growth scans
- If, for any reason, an ultrasound examination is not possible, the quadruple test can be offered based on the Last Menstrual Period (LMP) between 14+2 to 20+0 weeks.
- Growth scans: “To reduce the workload to the ultrasound screening unit, a local policy should be implemented to review all referrals for a growth scan prior to booking an appointment."
The ISUOG consensus statement (2020) offers additional advice on the “organization of routine and specialist obstetric ultrasound services in the context of Covid-19”.
It is also worth reviewing the RCOG (2020) guidance for fetal medicine units(FMU). This guidance suggests that if delay is not 'clinically acceptable', precautions should be taken and PPE should be worn in line with PHE guidance.
It also advises that:
“If capacity allows, the FMU should support staff or capacity shortages in antenatal ultrasound. Scans should be prioritised in order of clinical urgency by a senior fetal medicine doctor, with the following suggested priority:
- Urgent scans for fetal growth (e.g. where there is already a suspicion/diagnosis of growth restriction, or for persistently reduced fetal movements).
- Anomaly scan at 18+0 -23+0 weeks
- Ultrasound +/- screening at 11+2 -14+1
- Growth scans”
Should we be cancelling non-urgent examinations?
This will depend on local staffing levels and will need to be monitored on a regular basis. Any decisions should be made within the wider trust contingency planning, to reduce risk to patients and staff.
It is, however, recommended that restrictions of non-essential relatives within departments and scan rooms should be considered in order to minimise risk to staff and patients.
Will we be covered if we ration services due to unprecedented challenges?
NHS Resolutions are not able to provide specific advice, but in responce to enquiries from SCoR stated, “Should claims arise from any such rationing, the courts in future would be expected to take account of extreme national circumstances when reaching a decision on legal liability, but it is impossible at this point to gauge precisely where they would set the boundaries of negligence in such a situation.
"If your members are employed by NHS trusts or other healthcare organisations belonging to our schemes, they will still be protected by our indemnity.”
Other resources
American Institute of Ultrasound in Medicine: various including YouTube links to point of care ultrasound in Covid-19.
Australasian Society of Ultrasound in Medicine:
Australasian Sonographers Association
British Medical Ultrasound Society
Health Protection Scotland
International Society of Ultrasound in Obstetrics and Gynecology: links to webinars, guidance and updates.
NHS England and NHS Improvement
Society and College of Radiographers
World Federation for Ultrasound in Medicine and Biology
Point of care ultrasound
There are many articles and websites about how to use ultrasound in the diagnosis of lung disease such as:
BMUS (2020) Lung Ultrasound
Falcetta et al (2018) The role of lung ultrasound in the diagnosis of interstitial lung disease. Shanghai Chest, 2 (5).
Huang et al (2020) A Preliminary Study on the Ultrasonic Manifestations of Peripulmonary Lesions of Non-Critical Novel Coronavirus Pneumonia (Covid-19). Also available at http://dx.doi.org/10.2139/ssrn.3544750
Qian‑Yi P et al (2020) Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic
Features of lung ultrasound in Covid-19 infection
Wiley have made their lung ultrasound articles available free
Preparing for Covid-19
Mossa-Basha et al (2020) Radiology Department Preparedness for Covid-19: Radiology Scientific Expert Panel. Radiology 0 0:0
Appendix 1 RCOG 2020
Appendix A: Template (that can be adapted with local details) for maternity services to use if they wish Information for pregnant women who cannot have their scheduled appointment today and need to have their appointment rescheduled due to Covid-19.
If you have symptoms of Covid-19, you must not attend your appointment but phone your maternity service for advice.
Maternity units may wish to provide additional information to pregnant women which includes the following:
- Reason they are unable to have their appointment today. For example: they have suspected Covid-19, or have been in contact with someone who has recently had the infection.
- When they will have their appointment rescheduled.
- How they will be contacted about the new appointment date.
- If they don’t hear from maternity service (it would be advisable to have a time frame, for example, if you don’t hear within one week, please contact), how and who they should contact.