Updated 6/25/20b Yale New Haven Health Role Of Imaging .

Updated 6/25/20bYale New Haven HealthRole of Imaging patients with Suspected or Confirmed Covid-19 Infection in ED/In-patient and AmbulatorySettingsSituation:No guidelines exist for enhancing the safety process for imaging patients with suspected or confirmed COVID-19infection. There also remains lack of clarity on the role of chest imaging.Background:The goal of imaging in COVID-19 patients is to provide high level care while minimizing risks to healthcare staff andother patients. For in-patients and ED patients some radiology exams can be performed portably (US, radiographs,head CT, minor procedures), other exams require patient transport off the floor (MR, CT, Nuclear Medicine,Fluoroscopy, IR).Assessment:The transport of suspected/confirmed COVID-19 patients for imaging should be minimized. As such, ensuringappropriate imaging utilization is necessary. For ED and in-patients, portable alternatives to off floor imaging shouldalso be used whenever possible. The use of chest imaging should follow best practice guidelines. Any non-criticalimaging or procedure should be deferred until COVID-19 diagnosis is either confirmed (and patient recovers from theirillness) or excluded.Recommendation:1. For in-patients and ED patients, all imaging requests (excluding radiographs) for patients with pending orconfirmed COVID-19 will be approved by a radiologist whenever possible. For out-patients, medical necessityof any imaging test should be determined by the ordering provider and/or radiologist. COVID test results arenot necessary to proceed with indicated ED imaging orders.2. From 8am to 5pm approval will be sought by the relevant radiology technologist before performing the study(Appendix A, B, C for technologist work-flow).3. After normal business hours, the technologist may need to discuss case with relevant working/on call radiologyteams.4. Best practice guidelines should be followed for a) chest imaging (Appendix D) and b) technologist use of PPE(see seperate FAQ doc) .5. Radiology COVID Call Center has been established to assist in Radiology related questions for Yale New HavenHealth. Call center number is 475-246-9660.

Appendix A: Ultrasound and X-Ray ED and In-Patient Tech workflow for CONFIRMED orSUSPECTED COVID-19 cases. All studies should be PORTABLE whenever possible.Order for radiologyexam that can beperformed inicalteamNot Necessary*Radiologist approval isnot necessary unlessthe technologist feelsorder may not beneededMedicalnecessityreviewwith aradiologistNecessaryArrive to the unit andprepare to put on yourpersonal protectiveequipment before enteringthe patients roomProper PPE currently includes:- N95 Mask- Gown- Gloves-Face shield (or any type of eyeprotection)Enter room andperform examProperly take offall PPE beforeexiting thepatient’s room.Reuse select PPEper most currenthospital protocolExit the room andcompletely wipe down theentire portable machine*Face mask may be used instead ofN95 depending on supplyavailability

Appendix B: CT/MRI/Nucs/Fluoro ED and In-Patient workflow for CONFIRMED orSUSPECTED COVID-19 casesOrder for radiology examthat CANNOT be performedportableFor MRI, CT, NucMed, Fluoroscopy,and invasiveprocedures oninpatients/ED*Note* Expected that radiographsand ultrasounds will rarely have tobe performed in diagnosticradiology departmentDiscuss the examto determinemedical necessitywith a radiologistRadiologistcontacts clinicalteamDiscuss transport withnurse. Precautionsneed to be takenduring transport tominimize spread.Before entering the imaging room,proper PPE must be put on.Proper PPE currently includes:- N95 Mask- Gown- Gloves-Face shield (or any type of eyeprotection)Equipment in the pavilion closestto the patient unit should be usedto limit travel time*Face mask may be used instead ofN95 depending on supplyavailability.Confirm patientwearing face mask(if they cantolerate) beforeperforming examFor select studies, technologistsmay need to remain in the roomfor the exam in order to conservePPEProperly take off allPPE before exiting theimaging room. Reuseselect PPE per mostcurrent hospitalprotocolIf the patient wears their facemask properly throughout theirentire stay in our imaging room,the room can be used againafter proper disinfection of allimaging equipment and surfacesIf a patient mask was not utilized, orhas been deemed compromised duringany part of the exam, the room mustbe cleaned and left vacant for aspecified time (1 hour for most rooms,shorter for some CT scanners)

Appendix C: NON-“HOT-SITE” OUT-PATIENT work-flow for technologist/front-desk staffPatients should wear theirown face mask to ALL outpatient appointments.Mask should be given ifpatient does not have one.In the last month, have you been in closecontact with someone who was confirmed orsuspected to have COVID-19?ORDo you have any of the following?·Fever 100F·New cough·New shortness of breath·New sore throat·New chills or muscle pain·New loss of taste or smell·New vomiting or diarrheaORHave you been advised to stay home by amedical professional due to illness that mightbe COVID-19 or have you been tested forCOVID within last 2 weeks?ORAre you currently living in or have you beendischarged (within last 2 weeks) from nursingfacility, senior housing, rehab facility, extendedcare, shelter, or correctional facility?Some sites can offertemp. check at frontdeskNOProceed as routine visit. Staff andpatient should wear face mask.Disinfect room and all patientsurfaces after.YESIf possible, obtain patient’s cellphone number or phone in thewaiting room. Use phonecommunication wheneverpossible.SCREENER isolatespatient per facilityprotocol. Emphasize tothe patient that maskneeds to stay on.Screener notifies technologist*If medical indication clearlynecessary (acute DVT/PE,obvious fracture deformity,stroke/tia, etc) additionalconfirmation will be unnecessary.CHEST XRAY is not part ofroutine respiratory infectionwork-up currently. See nextpageTech confirms withreferring provider (orresponsible radiologistwhen needed) onmedical necessity* ofexamNoNOFor the safety of patients and staff, thepatient will not be permitted to proceedwith the appointment, and should returnto his or her car. They patient cancontact the responsible clinician forfurther guidance. If patient does nothave a responsible clinician or PCP,instruct to call contact Yale COVID-19 CallCenter 203.688.1700.YESRoute to designated “hot”site where staff will useappropriate PPETechnologist performs imaging.*If the patient wears the face mask properlythroughout their entire stay in our imagingroom, the room can be used again after properdisinfection of equipment and surfaces. If thepatient has NOT worn the face maskthroughout the procedure, the room will needto be left vacant for a specified time (1 hourfor most rooms, shorter for CT suites).Proper PPE includes:- N95 (or face mask based onavailability)- Gown- Gloves-Face shield or Googles

Appendix D.1:Role of Chest Radiographs (CXR):CXR plays a role in the imaging management of pneumonia in immunocompetent patients, despite known lowsensitivity.Any CXR of a suspected or confirmed COVID infection should be done portably for ED or In-Patient. CXR should NOT be obtained to rule out COVID infectiono A normal CXR does not rule out the possibility of COVID. CXR is reported to have 25-60% sensitivityin detecting pneumonia for these patients. Ground glass opacities commonly seen with COVID can beoccult on CXR.CXR should only be obtained when absolutely necessary and xrays should be minimized when possible (e.g.for line placement, get one film after all lines placed).Examples of indications for CXRo Initial baseline imaging for a COVID Suspect or Known patient being admittedo To evaluate for complicated pneumonia (cavitation, effusions, etc)o To assess ETT placement after intubation or after line placement if concerned for malpositiono When change in clinical status raises concern for possible superimposed pulmonary processRole of Chest CT:Chest CT plays a role in the imaging work-up of immunocompetent patients with pneumonia, mainly to detectcomplications such as cavitation, intra-parenchymal abscess and empyema. The role of CT in patients with suspectedviral pneumonia is controversial.Following recent statements by the American College of Radiology (ACR) and the Society of Thoracic Radiology(STR), CT is considered indicated in the following situations involving patients with suspected or confirmed COVID19 infection:1. CT should NOT be used to screen for or as a first-line test to diagnose COVID-19. It may play a role in helpingtriage and make management decisions in select cases where PCR test is negative, chest xray is negative andclinical suspicion for COVID remains high.2. CT may be indicated in patients with positive COVID PCR testing AND suspicion for complications such ascavitation, intra-parenchymal abscess and empyema not adequately assessed via portable CXR.

Appendix D.2- Current ADULT in-patient COVID treatment guideSee full guideline posted on YNHHS COVID clinical resource site

Appendix D.3- Current adult URI work-up for out-patients

Guidance for PPE Don and Doff use can be found at le.eduCLICK HERE FOR FULL PPE GUIDANCE POLICY INCLUDINGREUSE PROCEDURESReferences:(1) Global surveillance for COVID-19 disease caused by human infection with the 2019 novel coronavirusInterim guidance. World Health Organization. 27 February 2020. WHO reference number: WHO/2019nCoV/SurveillanceGuidance/2020.4(2) ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID19 on.(3). Mossa-Bossa et al. Radiology Department Preparedness for COVID19: Radiology Scientific Expert Panel.Radiology 2020. 8(4). YNHHS Covid Resource Website(5.) Rubin et al. The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: AMultinational Consensus Statement from the Fleischner Society. Radiology 201365

For out-patients, medical necessity of any imaging test should be determined by the ordering provider and/or radiologist. COVID test results are not necessary to proceed with indicated ED imaging orders. 2. From 8am to 5pm approval will be sought by the relevant radiology technologist before performing the study