The summary statement of the new American College of Radiology (ACR) guidelines states: to safely resume routine care, practices must balance local risk from illness or death to workers and patients from health care-acquired COVID-19 with the patient-specific risk of illness or death from postponing an examination or procedure.
Designated as the lead charged with forming the new ACR guidelines, Jacqueline A. Bello, MD, FACR, Chair of the ACR Commission on Quality and Safety Chair, assembled the 14-member writing group and collaborated with medical professionals across the U.S. representing diverse health care facilities, corporate organizations, universities, and private practices in diverse geographical locations relative to COVID incidence. The group collectively and collaboratively generated probable solutions in the form of responses to most, if not all, potential who, what, where, when, why, and how questions related to resuming non-urgent radiological services during the COVID-19 pandemic.
The new ACR guidelines serve as a consistent set of directions for the clear and cautious re-engagement of routine radiology care during the COVID-19 pandemic for resuming radiology practices as safely as possible by offering mammograms, oncologic and orthopedic imaging, image-guided biopsies, and other non-urgent care previously postponed due to the COVID-19 pandemic, Bello noted.
"Radiology practices largely followed World Health Organization, Centers for Disease Control and Prevention, and ACR guidance to postpone non-urgent care," she said. "While local conditions prevent a single prescriptive strategy to resume such care, general principles can apply in most settings. These ACR recommendations can help practices safely and efficiently resume non-urgent care in areas where pandemic conditions allow."
Supplemental Checklist of Questions
With coronavirus cases and deaths declining in some areas, radiology practices in certain regional areas are resuming such care, Bello stated.
As practices consider when and how to re-engage routine clinical care, the ACR writing group prepared a Supplemental Checklist of Questions to guide local decision-making regarding competing risks.
"The checklist of questions provides a comprehensive strategy for the safe resumption of routine radiology care during the COVID-19 pandemic which includes consideration of local COVID-19 statistics," she said.
One of the questions includes the specific date in which to reopen.
"Each site may vary by readiness with respect to special or additional construction that may be needed such as new signage, protective barriers, and one-way corridors," said Bello.
One such question, "When should we open?" was followed by "The date that will work best for each clinic and the pandemic statistics in the region of their practice" in response.
The ACR writing group prepared a checklist of questions with responses to guide local decision-making regarding competing risks, explained Bello.
"Answers to these questions will vary by site due to local and site-specific information," she said. "As COVID-19 testing becomes more widely available, the relevance of some questions may change."
According to Bello, the checklist of questions is organized in two major categories: 1) how to estimate the risk from COVID-19 and 2) how to estimate the risk from postponing.
"The checklist takes a question and answer format to provide practices with a reference point as a possible answer to consider for their respective practice," Bello explained. "In this determination, the probability of illness or death (from COVID-19 and non-COVID-19 disease) should take precedence."
Overriding Guiding Principle
If the risk of illness or death to a health care worker or patient from health care-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, Bello stated, quoting the ACR document.
"The risk from health care-acquired COVID-19 can be made very low for most diagnostic radiology examinations and interventional radiology procedures if appropriate safety measures are in place (screening, testing, infection control processes, PPE, etc.)," she explained.
Availability of PPE
Bello said initially overall PPE was low when the pandemic began to crest. "However, with the expansive outreach by our nation's corporate organizations combined with pure creativity and resourcefulness by individuals and teams of professionals, our PPE inventory is much stronger now."
The ingenuity of skilled radiologists at Montefiore Medical Center located in the Bronx, NY, applied the advancements of 3D printing and sourcing plastic page protectors to create the basic framework to produce greatly needed face shields. As stated in the new ACR guidelines, local practices will need to consider their inventory and availability of PPE to accommodate the re-engagement of routine radiology care based on local and state government mandates, institutional regulatory guidance, and local safety measures, she explained.
"Preparing for PPE estimations that may include the consideration for universal masking strategies, as well as the use of PPE for low-risk routine care may compromise PPE availability for high-risk care," explained Bello.
Screening Patients & Visitors
Effective temperature screening of patients and visitors at door entry and a universal masking policy for patients and visitors, as well as appropriate signage indicating safe social distancing to ensure safe restrictions into the health system must be taken into consideration, said Bello.
"To ensure a safe re-engagement, we can apply the knowledge and skills, as well as some creative engineering, as professionals in the radiology field, while following these new guidelines to flatten the curve," said Bello.
One of the possible solutions is installing a window of plexiglass between the receptionist and/or pre-registration office IT modules, as well as electronic patient registration to prevent the touching of paper and pen exchanges, she said.
Weighing Risks
The new guidelines will serve as a communications platform in which to build constructive dialogue or talking points within the workers of each practice environment.
"Prioritizing the examination or procedure acuity, from most risk to least risk from a delay, for example, and questioning whether it is an urgent or emergent imaging procedure, such as severe abdominal pain," she said. "An accurate risk-benefit analysis of postponing versus performing a given routine radiology examination or procedure often is not possible due to many unknown and complex factors. Therefore, decision-making will be guided by imperfect attempts to estimate these risks."
Additionally, practices should do their best to determine the risk to health care workers and patients of developing illness or death from health care-acquired COVID-19 in their local environment, as well as the patient-specific risk of illness or death from postponing an examination or procedure, and then use that information to guide the re-engagement of routine radiology care, she added.
"Social distance lengthens the overall hours of operation, but appointments can be spaced out to prevent a crowded waiting area with patients waiting in line," said Bello. "Radiologists can handle volume by extending the hours or streamlining scan protocols. There are three ways to 'slice' a scan, and instead of doing individual scan sequences in all three directions, or planes, scanning in a single plane can be performed."
An MRI scan is one example, she said. "Radiologists are trained with the 3-dimensional in mind," said Bello, "and from a high-resolution single-plane sequence, the other planes can be reconstructed."
The ACR offers a variety of clinical resources for radiologists and allied health care providers available at https://www.acr.org/Coronavirus-Covid-19-Resources.
Amy Gallagher is a contributing writer.