May 21, 2020 — The American Society of Echocardiography (ASE) has issued a statement on how centers may consider to reopen cardiac ultrasound services as hospitals begin resuming elective procedures and tests amid the COVID-19 (SARS-CoV-2) pandemic.
The authors of the expert census statement said the pandemic has changed the manner in which echocardiography services are provided. As the pandemic unfolded, many non-urgent echo studies were deferred in an attempt to reduce coronavirus transmission among patients and healthcare workers, conserve personal protective equipment (PPE) and prepare for the expected surge of COVID-19 patients. Although COVID-19 disease prevalence and new case trends continue to differ substantially by region, many facilities are now planning resumption of non-urgent and elective medical services.
ASE said the safe and efficient reintroduction of outpatient echocardiography services will require consideration of appropriate timing of reopening. This is based on projected COVID-19 case trends, prioritizing procedure scheduling based on current or change in disease acuity, applying exam protocols to address the clinical question while enhancing lab throughput, implementing appropriate PPE and sanitization protocols, and performing pre-procedural COVID-19 testing in certain patient cohorts, according to the statement.
When to Reopen Echocardiography Services
The timing of reintroduction of non-urgent and elective echo procedures should be aligned with institutional policies and follow recommendations of regional public health authorities, ASE stated. Important considerations include local COVID-19 disease prevalence and new case trends, as well as available institutional resources including facilities, staffing and equipment (including adequate supply of appropriate PPE).
It is suggested that gradual introduction of echo services should be part of a phased reopening plan, which will vary by institution and region.
Scheduling of Deferred Cases Due to COVID-19
Scheduling prioritization should be developed based on time in queue, patient symptom status, and exam indication urgency. ASE suggests higher priority exams would include patients with acute cardiovascular symptoms, or when echo is needed to guide further management. These include chemotherapy and pre-operative evaluations. Routine indications for echo, such as annual echo evaluation for chronic valve disease), may be deferred until more urgent cases have been scheduled. In cases where the urgency is unclear, consultation with the referring physician is critical, the statement suggests
Social Distancing Required for Re-opening of Imaging Services
Efficiency will likely be impacted by the need for social distancing protocols in patient registration areas and waiting rooms. ASE said potential solutions include staggered scheduling, with additional appointments in the early morning, evening and potentially during weekends.
One suggestion by ASE is to have patients may be requested to wait in their cars in facility parking areas until contacted by phone or text just prior to their scheduled appointment.
Most hospitals will have new entrance procedures at hospital or clinic facilities, new sanitization protocols and use of PPE may result in additional time required for the echocardiogram appointment. For reception and waiting areas, the ASE statement suggests floor markings and signs should guide arriving patients so they may queue at appropriate distances apart from others. If possible, plexiglass or other physical barriers can be placed between front desk staff and patients. Intake staff may also need to wear face shields for added protection.
The physical layout of the reception area should also be re-evaluated and altered to provide sufficient spacing between seated patients. Patients should also arrive without escorts unless absolutely necessary for their appointment, and should leave the facility immediately following the examination. Institutional and regional guidelines for universal masking will need to be followed during the initial phase of reintroduction of services.
Considerations for Scheduling of TEE Exams During the COVID-19 Pandemic
Transesophageal echocardiography (TEE) requires more advanced PPE because of the high risk of aerosol generation from coughing in the unintubated patient and the need for the operator to be in close proximity to the patient, ASE stressed. In addition to appropriate room cleaning protocols, it is also important to schedule sufficient time between TEE studies to allow adequate air flow exchanges within the TEE procedure room. This time is typically institution and exam room specific, and guided by infection control policies. This time is generally one hour if HEPA filters or other airflow management systems are not in place. Protocols will vary among institutions depending on the phase of the reintroduction of services. Special rooms may be designated for TEE procedures in COVID-19 positive or suspect cases, the document stated.
COVID-19 Screening and Testing for Imaging Exams
Facilities should establish COVID-19 symptom screening for all patients, the ASE document states. This should be done at multiple time points, including when the appointment is scheduled, during registration, and upon arrival. Ongoing COVID-19 screening should include a symptom questionnaire and temperature testing for all patients prior to any echocardiographic examination, regardless of level of response, ASE said.
Appropriate triage should be established for patients with symptoms consistent with COVID-19. Subsequent COVID-19 testing may be reserved for symptomatic patients or those who have failed the initial screening. Testing affords the opportunity to defer exams in patients who are COVID positive, particularly when echo results are unlikely to alter immediate management.
The sensitivity of different types of lab tests for COVID-19 remains variable. At the time of writing the statement,
ASE said there were more than 65 different kinds of COVID-19 molecular or serologic tests available in the United States tests that received emergency use authorizations by the U.S. Food and Drug Administration. Since this is a new virus, past experience and recommendations for standardized testing do not exist, leading to variability in sensitivity and specificity of each test type. ASE said the principal concern with these tests that were rushed into production is false negative results in asymptomatic individuals presenting for an echocardiogram who could pose a transmission risk that could be amplified in a healthcare setting. It is likely that as the pandemic abates, testing protocols will vary among institutions to minimize the risk to both patients and providers, the document states.
Rapid point-of-care tests that are based on lateral flow technique to detect specific antibodies may be used for emergent inpatient echocardiograms, while antigen-based tests with a longer turnaround time are recommended for surveillance testing for electively scheduled cases. Testing and re-testing for SARS-CoV-2, and procedures for patients to self-quarantine, if required, should follow institutional protocols guided by local and regional health authorities.
The document goes into more detail on how to handle COVID-positive patients, sanitation, PPE, workflow consideration, sedation, and two tables offering suggested protocols.
Assess the full document at www.asecho.org/wp-content/uploads/2020/05/ASE-Reintro-Statement-FINAL.pdf.
Related COVID-19 Cardiac Imaging Content:
1. Judy Hung, Theodore P. Abraham, Meryl S. Cohen, et al. ASE Statement on the Reintroduction of Echocardiography Services During the COVID-19 Pandemic. American Society of Echocardiography. Issued May 2020. https://www.asecho.org/wp-content/uploads/2020/05/ASE-Reintro-Statement-FINAL.pdf.
2. CDC. Opening Up America Again. https://www.cms.gov/files/document/covidflexibility-reopen-essential-non-covid-services.pdf. Published 2020. Accessed May 11, 2020.
3. FDA. Emergency Use Authorizations. https://www.fda.gov/medical-devices/emergencysituations-medical-devices/emergency-use-authorizations#covid19ivd. Published 2020. Accessed May 5, 2020
4. Patel R, Babady E, Theel ES, Storch GA, Pinsky BA, St. George K, et al. Report from the American Society for Microbiology COVID-19 International Summit, 23 March 2020: Value of Diagnostic Testing for SARS–CoV-2/COVID-19. mBio. 2020;11:e00722-20.