|Ahead of print publication
Preparedness of nuclear medicine departments during the severe acute respiratory syndrome-coronavirus-2 (covid-19) pandemic
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||03-Apr-2020|
|Date of Decision||04-Apr-2020|
|Date of Acceptance||04-Apr-2020|
|Date of Web Publication||16-Apr-2020|
Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
|How to cite this URL:|
Singh H. Preparedness of nuclear medicine departments during the severe acute respiratory syndrome-coronavirus-2 (covid-19) pandemic. Indian J Nucl Med [Epub ahead of print] [cited 2020 May 29]. Available from: http://www.ijnm.in/preprintarticle.asp?id=282642
The novel coronavirus disease-19 (COVID-19) pandemic has reached an unprecedented magnitude with approximately 1 million cases and 50,000 deaths worldwide. The virus has been renamed as severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) due to its similarity to the virus which caused the SARS epidemic of 2003. SARS-CoV-2 is a single-stranded RNA virus with a crown-like appearance. The disease mainly affects the lungs, is highly contagious, and spreads by respiratory droplets and fomites. Currently, real-time polymerase chain reaction is used for confirmed diagnosis with a reported sensitivity of up to 90%.
Health-care systems throughout the world are struggling to cope up with the COVID-19 due to high number of patients requiring isolation and intensive care facilities. The high chances of transmission of infection to health-care workers (HCWs) is a major professional hazard faced by the medical fraternity. Imaging departments including radiology and nuclear medicine are facing major challenges in an effort to continue routine operations, image patients with suspected or proven COVID-19, and ensure the health of workers by providing proper training and equipment to reduce the risk of transmission of infection.
There are limited number of publications on how imaging departments are tackling these issues till date.,,,,, Most procedures done in nuclear medicine departments are elective and require longer stay of patients in the department compared to other radiology services. In addition, most scanners in nuclear medicine departments are nonportable, requiring shifting of patients to the department for imaging. Radionuclide and radiopharmaceutical supply chains have been impacted. All nuclear medicine departments need to prepare to deal with these challenges. The concepts of “Time, Distance and Shielding,” used in radiation protection, are essential in the prevention of the transmission of SARS-Cov-2 infection. In this context, personal protective equipment (PPE) kits provide shielding.
| Protection of Staff|| |
Any person coming in close or physical contact with a COVID-19-positive case is at high risk for transmission of the infection. These include nuclear medicine physicians, residents in training, nursing staff, technologists, physicists, hospital attendants, receptionists, security guards and other patients. Ensuring the health of staff is necessary to ensure the maintenance of services. Nuclear medicine department leadership should actively engage with the hospital infection control committee and train staff in respiratory infection control practices, hand hygiene, and proper donning and doffing of masks and PPE kits. Standard operating procedures (SOPs) should be established and routine audits of infection control practices should be carried out.
Staff members should be divided into small teams, if possible and instructed to work on separate days. Instructions should be given to work in a single area of department and avoid unnecessary movement to other areas and gatherings. Meetings, academic activities, and interdepartmental rounds should be done online. Regular updates should be given to all staff members using E-mail. Daily temperature monitoring should be encouraged.
Any staff member who is feeling unwell should be instructed to work from home, if possible. Any HCW who develops fever, flu, cough, headache, anosmia, muscle ache, or breathlessness should inform the in-charge and the hospital's/area's COVID-19 management team for necessary action. To protect family members, one should change clothes and bath immediately after reaching home.
| Patient Scheduling|| |
The general consensus is to postpone all elective medical, surgical, nuclear medicine and other imaging procedures till this crisis subsides. Most departments have reduced patient volume by rescheduling nonurgent and follow-up cases. Research studies have been minimized or stopped at academic institutes. Any radiopharmaceutical imaging should be done if it will have a major impact on further management, especially if patient is an in-patient and suspect or confirmed COVID-19 case. Screening of patients should be done at the time of scheduling.
| Screening|| |
Hospital in-patients and suspect or confirmed COVID-19 cases should be assigned into high-risk category. According to the revised Indian Council of Medical Research testing strategy for COVID-19, the following group of patients are suspect cases.
- All symptomatic individuals who have undertaken international travel in the last 14 days
- All symptomatic contacts of laboratory-confirmed cases
- All hospitalized patients with severe acute respiratory illness (fever and cough and/or shortness of breath)
- Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact.
All patients and visitors to the department should be screened at the first point of contact. Front desk team should be trained or reassigned for this work. Notice/pamphlets should be pasted for patient information. Screening can be done using a combination of thermal screening, taking pertinent history at the first point of contact using a questionnaire, self-declaration by the patient or discussion with the referring physician.
Patients should be moved to an isolation room and COVID-19 team should be contacted in case of suspicion.
| Isolation Room|| |
An isolation room should be designated to hold any suspected case till COVID-19 team takes over. The room should have negative air pressure and label on outside door to warn staff and visitors.
| Patient Waiting Area|| |
Patient waiting area should have enough space to accommodate all patients while maintaining a distance of 3–6 feet in-between. The number of attendants should be limited to one to prevent overcrowding. The waiting area should have good ventilation.
Patients should be made aware of cough and sneeze hygiene using pamphlets/notice, etc.
Separate hand washing area and tissue boxes should be available to patients. Masks should be provided to patients with respiratory symptoms.
Temporal and spatial segregation may be used to separate high-risk cases from others. High-risk cases/inpatients should be imaged at the end of day, using separate waiting areas or cameras, if available.
| History Taking|| |
The doctor taking patient history should follow hand hygiene practices, wear Mask, and maintain a distance of 3–6 feet with the patient/attendants. One should try to avoid any physical contact and reduce the time spent with each patient.
| Nursing Staff|| |
Nursing staff comes into close physical contact with the patients to check vitals, cannulation, and de-cannulation. Nursing staff should be provided with proper PPE including triple-layered surgical masks, gown, disposable gloves, and goggles. Nurses should be instructed to discard gloves, wash hand, and use hand sanitizer after physical contact with each patient. Hospital gown should be given to each patient, and masks should be given to patients having cough.
| Radiotracer Injection/administration|| |
Persons injecting/administering radiotracer to a high-risk case should wear PPE (safety goggles or face shield, gown, disposable latex gloves and shoe covers).
| Post Injection Waiting Area|| |
Instruct patients to maintain a distance of 3–6 feet and avoid overcrowding. A sign should be put up to close toilet lid before flushing as aerosols are generated during flushing.
| Scanning|| |
Patients must be advised to wash hands or use hand sanitizer before and after scanning to avoid contamination of scanner couch. Disposable sheets should be used on patient bed and changed after every scan. Technologists should wear mask and practice frequent hand washing/use sanitizer.
| Disinfection/decontamination|| |
Parts of scanner that come in contact with a patient should be decontaminated after every scan. Computer, mouse, keyboard and other surfaces should be decontaminated at regular intervals during the day or at the end of the shift. Staff should be trained for decontamination procedures. SOPs for spills should be established. Many disinfectants are effective against SARS-Cov-2. Manufacturer's recommendations should be followed for disinfection of equipment. Electronic parts should be disinfected after turning off the system. Spray or liquid should never be poured on any system part to avoid electric shock or damage to the system. Deep decontamination of scanner room is needed after imaging a COVID-19 positive case.
| Imaging a Covid-19 Positive Patient|| |
It is preferable to postpone the study if it is not going to impact management in a significant way. All staff members should be aware of the patient's COVID-19 status before he/she is shifted, and those coming in close contact with a confirmed case should wear proper PPE. Patients should wear mask and gown during imaging and procedures. Patients should be made to stay in an isolation room with air filters/negative air pressure. Such cases should be scheduled as last case for the day and made to spend as less time as possible in the department. Deep cleaning of the room is performed after each patient (30 min for decontamination and 1 h for passive air exchange). Other patients and staff in the practice at the time of the patient visit should be logged.
| Contact Tracing|| |
Take care to note down the name of doctor, nurse, technologist and other staff on file for each patient for contact tracing if need arises later on.
| Reporting|| |
Large reporting rooms with multiple workstations should be restructured in the current scenario to single-station reading rooms. Tele reporting from home may be done if there is need for isolation. Home workstations may be deployed. One should screen positron emission tomography (PET)/single photon emission-computed tomography (CT)-CT for suspicious COVID-19 findings such as 18F- fluorodeoxyglucose avid peripheral ground-glass opacities in the lung fields. Asymptomatic patients with such findings should be immediately shifted to the isolation room and COVID-19 team should be informed for further action.
| Special Considerations|| |
Ventilation perfusion scan (V/Q scan)
Most centers have stopped ventilation part of scan for the time of outbreak.
Stress myocardial perfusion imaging
Exercise stress leads to increase in respiratory rate and can cause increased aerosols in exhaled air. Efforts should be made to use the fastest stress first 1-day protocol with pharmacological stress.
Consensus it to postpone nonurgent radionuclide therapies. Few have proposed that thorough screening with/without COVID testing should be done prior to performing any radionuclide therapy because dealing with any patient who may have developed COVID symptoms after radionuclide therapy will be difficult. CT chest may be used to rule out subclinical lung involvement before therapy is planned.
Positron emission tomography-guided interventions
PET-guided biopsies from lung can be associated with a high risk of aerosol exposure.
| Summary|| |
Nuclear medicine departments should prepare to continue operations and to reduce the possibility of in-hospital transmission of COVID-19. Hygiene and respiratory infection control practices should be reinforced, and SOP should be established. The principles of “Time, Distance, and Shielding” should be followed to tide through COVID-19 crisis.
| References|| |
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