Diagnostic screenings in the U.S. have plummeted since the outset of the COVID-19 pandemic. Now, as states gradually begin emerging from lockdown, radiologists are preparing for a surge in patients seeking elective and non-urgent scans. The Hippocratic Oath commands physicians to “first do no harm” and that means these services must not come at the risk of exposing healthy patients and staff to COVID-19. Fortunately, the American College of Radiology has put forth guidelines to help imaging professionals walk that tightrope.

Have a strategy
According to the ACR, resuming non-urgent radiology exams requires a comprehensive plan that can be distilled into one overarching, general principle:

If the risk of illness or death to a healthcare worker or patient from healthcare-acquired COVID-19 is greater than the risk of illness or death from delaying radiology care, the care should be delayed; however, if the opposite is true, the radiology care should proceed in a timely fashion

Many variables make an accurate risk-benefit analysis of postponing versus performing a given routine radiology examination or procedure difficult, if not impossible, so the ACR recommends a number of actions for weighing – and mitigating – risks. Screening patients and healthcare workers for COVID-19 symptoms upon arrival, developing a tiered plan for reengagement of non-urgent radiology care, and ensuring sufficient supplies of personal protective equipment (PPE) are all important bases to cover.

“As a physician who has taken this oath and as chair of the ACR Commission on Quality and Safety, I can’t overemphasize that safety measures for both patients and healthcare workers must be prioritized,” Dr. Jacqueline A. Bello, FACR, told HCB News. “These include screening patients and healthcare workers for signs (temperature) and/or symptoms (cough or shortness of breath), making sufficient PPE and appropriate testing available, focusing on infection control, and optimizing social distancing by streamlining scheduling and patient flow.”

Any effective plan requires all stakeholders to work together, from hospital leadership and radiologists to security personnel and the patients themselves.

"The patient's responsibility is to make sure if the healthcare system has a rule about wearing masks, they should wear a mask," said Dr. Matthew Davenport, FASR FSABI, lead author of the ACR statement, service chief of radiology at Michigan Medicine, and an associate professor at the University of Michigan. "If the radiology department has a rule about making sure patients are effectively distanced, they should enforce those rules. If the health system is coordinating delivery of care so that all the tier strategies are ramping up simultaneously, the system has a responsibility to oversee that the tier strategy is working the way it is supposed to. Everyone should play their role to make sure the patients and healthcare workers are safe."

Implement infection control measures
To minimize risk of transmitting disease, radiologists should adopt appropriate hand hygiene, as it is the most important and easy to comply with practice for ensuring infection control. They should also have enough PPE available, ask patients to wait in their cars to minimize time in the waiting room, and abide by CDC guidelines for cleaning and decontaminating patient care areas.

With respect to procedures, radiologists should remember that different procedures come with different levels of risk and therefore varying levels of precaution. An aerosolizing procedure, for instance, is high-risk and requires clinicians exposed to patients with COVID-19 to wear more sophisticated masks (N95s) to reduce transmission.

"PPE protocols are variable, depending on what procedure you're doing, the risk of that procedure, and the likelihood a patient has COVID-19" said Dr. Stefanie Weinstein, associate chief of radiology at San Francisco VA Health Systems and associate professor of radiology at the University of California, San Francisco. "In radiology, there are different protocols depending on what procedures are being done, and in the diagnostic and interventional spaces there are unique considerations."

Providers must be able to distinguish risks in procedures to keep staff and patients safe and prevent overuse (or underuse) of protective equipment.

Shorten exam time
ACR recommends that practices cut down on protocols to mitigate scanning time with all imaging modalities. The aim is to get patients in and out faster, and to address more cases, thereby minimizing exposure.

"There are ways to take some of those pictures faster or eliminate some of the pictures because they are not as necessary," said Davenport. "Finding ways to make an efficient protocol or to shorten the length of time someone takes to get an image can shorten the time they are exposing the patient to the healthcare environment and the staff to the patient. It also is important to address all the processes around image creation, such as how the patient gets from the door to the check in site, to IV placement (if needed), to the imaging location, and safely back out again."

Any protocol changes, however, should not come at the cost of compromising quality or safety. "You want each radiology exam to be diagnostic," said Weinstein. "You don't want to decrease the length of time it takes to do the exam but then impair the quality. It's a balance between efficiency and quality."

ACR suggests that practices consider expanding hours of operation to space out exams from one another and schedule exams based on the state of the pandemic locally.

“Time-sensitive care should be deferred until at least two weeks after the peak of the local outbreak, and monitoring of institutional data is important,” said Bello.

What to expect in a post-pandemic world
Like other healthcare specialties, the short- and long-term consequences of the pandemic for radiology are still not entirely clear. Many are concerned about backlogs of deferred exams, as well as how fast patient volumes will return to pre-COVID-19 levels.

Weinstein says the pandemic has made many practices like her own aware of the changing landscape for radiology, namely in the growing adoption of teleradiology, which many radiologists are currently using to evaluate exams to minimize exposure.

"There is a changing mindset, with regard to the need for flexibility in providing clinical services, with a focus on broadening the ability to work from home, telehealth, and teleradiology," she said. “It is likely that such changes will persist after the pandemic has ended. I believe that healthcare will increasingly be delivered and received from home, improving access and timely health care delivery, and more radiologists will have home workstations for staggered shift coverage.”

The ACR guidelines encourage providers and radiologists to investigate adopting telemedicine as a practice to reduce the spread of COVID-19 and other diseases. It also notes that losses of employment and insurance among patients, along with revenue losses among practices, may change payment processes.

“ACR Advocacy has engaged CMS on accreditation requirements and has advocated for prior authorization relief from private payers,” said Bello. “The CARES Act provides for Medicare advance payments for COVID-19 emergency care, in addition to loans and other financial assistance for physician practices. Other provisions which may also apply to radiology include supplemental awards for health centers; rural healthcare services outreach, network development and small healthcare provider QI grant programs; increasing access to post-acute care during emergency period; and further expanded access to lab testing without cost sharing.”

Davenport says that healthcare in general should expect a tough road ahead of it now and for some time after the pandemic. "Health systems, because of the way that healthcare is delivered and financed in the United States (based on volume of care rather than patient outcomes), are very financially stressed at present, with many reporting losses of hundreds of millions of dollars. This lack of volume created massive budget deficits that are resulting in furloughs, layoffs, salary cuts, and retirement cuts. These are the same people saving lives and protecting the country against the pandemic, so it can feel quite unjust. While there are federal programs that offer ways to help with these budget shortfalls, they aren't sufficient to deal with the amount of money that has been lost."