Radiology Resources for Coronavirus (COVID - 19)

The purpose of this website is to provide information on COVID-19 specific to the Department of Radiology. 
Please continue to use the UCSF website for the most up-to-date information:

COVID-19 UCSF Website 

UCSF Radiology COVID Response Team


Caring for Radiology Patients with Known or Suspected COVID-19

Chest radiography is a component of the evaluation of patients suspected of having COVID-19. At UCSF Health, CT is not considered a screening examination for COVID-19. A multidisciplinary group of experts, including Dr. Brett Elicker, Cardiac and Pulmonary Imaging section, is developing a consensus guideline regarding the proper role of CT imaging in patients with known or suspected disease. Dr. Elicker’s guidelines, and guidelines from the SFVAMC and ZSFG health systems will be posted soon.

On occasion patients with known or suspected infection require urgent imaging or image-guided interventions unrelated to their respiratory illness. Please see below for protocols to ensure safe imaging for patients and healthcare workers.  

Standard Operation Procedures for Safely Imaging Patients with Known or Suspected COVID-19

Modality Workflow Documentation
CT
MRI
Molecular Imaging & Therapeutics
IR

 

Ultrasound

Diagnostic X-ray

Population Specific Guidlines

External Referring Providers (non-UCSF)

Process for ordering imaging for patients with suspected or known COVID-19 infection (pdf - 4/13/20)

Keeping Patient Interactions Safe

Frontline staff, nurses, technologists, and physicians will likely all be in situations where in-person contact with patients with known or suspected COVID-19 is necessary. Additionally, as community spread of the infection has now been confirmed in the Bay Area, strategies to mitigate risk are necessary inside and outside the workplace. In partnership with UCSF Health, Radiology has focused efforts to protect its workforce in the following areas:

Radiology Approach to Patient Screening

All radiology patients are screened for COVID-19 illness and appropriate actions are taken for patients who screen positive for possible illness, including delaying or canceling the scheduled visit or imaging exam where appropriate.

Screening Tools Action Plans
Radiology Precautions for Diagnostic Imaging

Appropriate patient isolation strategies, appropriate actions, and PPE usage have been identified by UCSF Health Epidemiology and Infection Prevent. The tables below provide a summary and the detailed guidelines can be found in this document (This document represents an update to prior guidance published 8/11/20).

Key new information
  • At minimum, healthcare workers are required to use eye protection for all direct, close patient interactions in addition to universal surgical masking at all times in healthcare facilities. Healthcare workers may choose to use eye protection when performing any non-patient facing duties in clinical buildings as well.
  • Healthcare workers should use N95s + eye protection (or PAPRs) for interactions with any patients with suspected or confirmed COVID-19 infection or patients with recent (14 days) close contact with someone with PCR-confirmed COVID-19 infection.
  • In ED patients and inpatients, imaging staff will need to identify if a patient with a COVID-19 chart flag is also under airborne precautions, i.e. undergoing continuous aerosol-generating procedures. This will determine whether the imaging suite should enter downtime following study completion. Such patients will have an “airborne” flag under their isolation status (see Tables 1-3).
  • Radiologist review and approval is no longer required prior to MR imaging of ED patients with COVID-19 flags.

Imaging patients with confirmed or suspected COVID-19

To minimize exposure risk for our patient-facing staff, imaging studies should only be performed on COVID-19 patients and patients under investigation (PUIs) when the results of the study are reasonably expected to alter a patient’s management during the acute phase of illness. Exceptions to this guidance include chest x-rays on inpatients and chest x-rays, CT scans, and MRIs in ED patients.

COVID-19 APEX Flags:

COVID-19 Flag Interpretation

COVID-19 (Confirmed)
COVID-19 confirmed

COVID-19 Infected Patient

COVID-19 (Pending)
COVID-19 pending

Patient Under Investigation (PUI)

COVID-19 (Exposed)
COVID-19 pending
Asymptomatic with test negative or not tested;
Exposure to someone with PCR-confirmed COVID-19 w/i last 14 days

Table 1: Diagnostic Imaging in ED Patients

COVID-19 Flag Isolation Status Action PPE

Any COVID-19
Flag

COVID-19 confirmed COVID-19 pending

Novel Respiratory
+/- Airborne*

Consult radiologist for appropriateness of examination**;
Proceed if approved

 

N95 + Face Shield (or PAPR) + Gown + Gloves

None None or Droplet
+/- non COVID-19 related isolation
Confirm with bedside RN that patient should not be under COVID-19 isolation;
Proceed with imaging study

In ED:
N95 + Eye Protection (or PAPR) + Gown + Gloves

In Department:
Mask + Eye Protection + Gown + Gloves + any non COVID-19 related isolation precautions

*For patients under airborne precautions, 1 hour imaging suite downtime should be instituted after patient departure, followed by routine cleaning.  
 For patient NOT under airborne precautions, routine cleaning should occur immediately following patient departure without downtime.
**Chest x-ray, CT, and MR imaging do not require radiologist approval in ED patients

Table 2: Diagnostic Imaging in Inpatients (Without Anesthesia)

COVID-19 Flag Isolation Status Action PPE

Any COVID-19 Flag
COVID-19 confirmed COVID-19 pending

Novel Respiratory
+/- Airborne*

Consult radiologist for appropriateness of examination**;
Proceed if approved

 

N95 + Face Shield (or PAPR) + Gown + Gloves

None None or Droplet
+/- non COVID-19 related isolation
Proceed with imaging study

Mask + Eye Protection + any non COVID-19 related isolation precautions

*For patients under airborne precautions, 1 hour imaging suite downtime should be instituted after patient departure, followed by routine cleaning.  
 For patient NOT under airborne precautions, routine cleaning should occur immediately following patient departure without downtime.
**Chest x-ray does not require approval in inpatients

Table 3: Diagnostic Imaging in Outpatients (Without Anesthesia)

COVID-19 Flag Isolation Status* Action PPE

Any COVID-19
Flag

COVID-19 confirmed COVID-19 pending

N/A

Consult radiologist for appropriateness of examination;
If approved, imaging should follow department outpatient
PUI/COVID-19+ imaging workflows

 

N95 + Face Shield (or PAPR) + Gown + Gloves

None N/A Proceed with imaging study

Mask + Eye Protection

*Isolation status is not functional in APEX for outpatient encounters

Safe Practice Using PPE:

Properly Don and Doff PPE Well covered in the PDF and videos:

Radiology Precautions for Image-Guided Interventions and Diagnostic Imaging Under Anesthesia

Background

This document provides guidance for the management of patients and facilities during image-guided interventions and diagnostic imaging performed under anesthesia in the Department of Radiology and Biomedical Imaging. This document represents an update to prior guidance published 5/7/20 and maintains alignment with anesthesia and perioperative practice at UCSF and national standards.

Summary

Several important concepts underpin these guidelines. These include:

  1. asymptomatic patients may be sources of SARS-CoV-2 disease transmission
  2. disease transmission may occur by aerosol inhalation in addition to droplet spread
  3. certain surgeries and procedures carry higher risk than others for disease transmission to healthcare workers due to aerosolization of virus
  4. intubation, extubation, and certain forms of respiratory support are aerosol-generating

The details of radiology guidance can be found here.  The key points are summarized in the tables below.

Table 1:  Guidance for ADULT patients with COVID-19 PCR test results within last 4 days (outpatients) or 7 days (inpatients) and for PEDIATRIC patients with COVID-19 test results within last 4 days (1st test, inpatient or outpatient) or last 14 days (if previous negative test and no new symptoms or exposures)

Scenario Radiology Personnel PPE Room Management Room Cleaning

1.  COVID-19 Positive/PUI/COVID-19 Exposed for diagnostic imaging under general anesthesia or ANY image-guided intervention

  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • Minimize number of providers present
  • No radiology trainees present
  • Last case of day preferable
  • Room downtime 1 hour after patient departure
  • Technologist cleans equipment 1 hour after patient departure
  • Terminal clean
2.  COVID-19 test negative, HIGH RISK image-guided procedure and/or general anesthesia
  • Standard procedural PPE
    or
  • Reusable N95 + face shield/goggles (or PAPR) + standard procedural PPE
  • No room downtime required
  • Routine cleaning upon patient departure
3.  COVID-19 test negative, LOW RISK image-guided procedure under local anesthetic, conscious sedation, or monitored anesthesia care
  • Standard procedural PPE
  • No room downtime required
  • Routine cleaning upon patient departure

Table 2:   Guidance for ADULT patients without COVID-19 test results within last 4 days (outpatients) or 7 days (inpatients)

Scenario Radiology Personnel PPE Room Management Room Cleaning
1.  Asymptomatic patient for HIGH RISK image-guided procedure
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • Non-anesthesia personnel should leave room for intubation and extubation
  • Minimize number of providers present
  • Room-specific downtime after last AGP, per signs in room and Appendix B
  • Routine cleaning after downtime complete
2a. Asymptomatic patient for diagnostic imaging under general anesthesia or LOW RISK image-guided procedure, intubation/extubation take place in imaging suite
  • For rooms with 15 minute downtime, enter after 15 minutes with standard PPE
  • For all other rooms, enter after intubation with:
    • Reusable N95 + face shield/goggles or PAPR
    • Gown
    • Double Gloves
  • Non-anesthesia personnel should leave room for intubation and extubation
  • Room-specific downtime after last AGP, per signs in room and Appendix B
  • Routine cleaning after downtime complete
2b. Asymptomatic patient for diagnostic imaging under general anesthesia or LOW RISK image-guided procedure, intubation/extubation take place elsewhere
and patient is transported to/from imaging suite
  • Standard procedural PPE
  • No room downtime required
  • Routine cleaning after patient departure
3. Asymptomatic patient for LOW RISK image-guided procedure under local anesthetic, conscious sedation, or monitored anesthesia care
  • Standard procedural PPE
  • Conscious sedation/MAC: if airway rescue is necessary, support patient and transition to #2a PPE instruction
  • No room downtime required
  • Routine cleaning after patient departure

Table 3:  Guidance for PEDIATRIC PATIENTS without COVID-19 test results within last 4 days (1st test, inpatient or outpatient) or last 14 days (if previous negative test and no new symptoms or exposures)

Scenario Radiology Personnel PPE Room Management Room Cleaning
1.  Asymptomatic patient for HIGH RISK image-guided procedure
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • Non-anesthesia personnel should leave room for intubation/ extubation
  • Minimize number of providers present
  • Room-specific downtime after last AGP, per signs in room and Appendix B
  • Routine cleaning after downtime complete
2a. Asymptomatic patient for diagnostic imaging under general anesthesia or LOW RISK image-guided procedure, induction and emergence take place in imaging suite
  • ET tube used, room downtime = 15 minutes: enter 15 minutes after intubation with standard PPE
  • ET tube used, room downtime ≧ 30 minutes:
    • Reusable N95 + face shield/goggles or PAPR
    • Gown
    • Double Gloves
  • Some forms of anesthesia will not be aerosol-generating. Follow anesthesia provider instructions for safe timing of entry in standard PPE
  • Non-anesthesia personnel should leave room for intubation/ extubation
  • Room-specific downtime after last AGP, per signs in room and Appendix B
  • If anesthesia provider does not place endotracheal tube and confirms absence of aerosol generation, no room downtime required
  • Routine cleaning after downtime complete
2b. Asymptomatic patient for diagnostic imaging under general anesthesia or LOW RISK image-guided procedure, induction and emergence from anesthesia take place elsewhere and patient is transported to/from imaging suite
  • Standard procedural PPE
  • No room downtime required
  • Routine cleaning after patient departure

Isolation Status Links

PPE Supply Shortage - How Radiology Can Help

Radiology is largely not on the frontlines in this pandemic and not in the highest risk categories (anesthesiology and critical care colleagues are in the highest risk categories) with critical care serving as the last line of defense. Do NOT use N95 masks or other inappropriate PPE unless appropriate to the situation.

For more information, please refer to ZSFG PPE use and re-use instructions (pdf - internal access only)

Social Distancing and Transmission Prevention

Social distancing is a public health safety intervention used to reduce the likelihood of transmitting communicable disease. We are encouraging and practicing social distancing in our department in the following ways:

  • Canceling all large faculty and staff gatherings (e.g. radiology grand rounds)
  • Moving recurring departmental and clinical conferences to video, where possible
  • Zoom, telephone and the eUnity collaboration tool (pdf); we aim to decrease foot traffic in radiology reading rooms by encouraging remote consultations via telephone, Zoom, or the use of collaboration software eUnity.
  • Faculty assigned to non-clinical duties (research, administrative) are encouraged to work from home
  • Alternative clinical workflow models, including decentralizing on-site workstations, and developing infrastructure to allow clinical work from home
  • Converting ambulatory clinic visits (interventional radiology, neurointerventional radiology) to UCSF Telehealth visits whenever possible
  • Staying home when sick or feverish
  • Consistent hygiene practice: Wipe down the mouse, keyboard, and dictaphone between all readouts (i.e. with each new/alternate use throughout the day). Attendings should use alcohol gel between all readouts with trainees
  • All diagnostic radiology and interventional radiology sections should cohort teams of faculty and trainees within specific reading rooms to the extent possible

Maintaining Clinical Operations During a Pandemic

There is much uncertainty surrounding the COVID-19 pandemic and the effects it will have on the department and health system’s care delivery in the coming days, weeks, and months. Increasing numbers of patients with COVID-19 will require reallocation of clinical resources. In addition, healthcare worker illness, school closures, mass transit interruptions, or other factors may deplete our workforce and require scaling back clinical operations.

Modifications to Radiology Operations

May 4, 2020, UCSF Radiology’s diagnostic clinical operations initiated the first phase of expansion of non-urgent clinical operations.

  • To support efforts to resume medical care that has been delayed as a result of COVID-19, the UCSF Department of Radiology and Biomedical Imaging will return to scheduling of all ordered imaging examinations.
  • Capacity for imaging services is being expanded starting, May 4th by extending weekday hours, providing weekend availability and opening sites that have been closed through the pandemic. The Bay Area shelter-in-place order, recently extended through May 31st, makes it clear that medical services should be fully accessible to patients.

March 17, 2020, UCSF Radiology’s diagnostic clinical operations initiated the first phase of reducing non-urgent clinical operations.

  • All screening imaging studies (screening mammography, lung cancer screening, colon cancer screening, DEXA) were postponed.
  • Interventional radiology ambulatory services were limited to caring for those patients for whom a 2-3 month delay in care was expected to result in a worse patient outcome. Interventional radiology clinic transitioned to telehealth visits only.
  • The department completed a second phase of clinical operation service reductions, wherein all non-urgent (as defined by the patient’s referring provider in partnership with the Radiology team), outpatient imaging studies were postponed.
Working From Home (WFH)

Reusing Existing Resources

RadVerify
Many faculty have devices that are capable of remote interpretation from a hardware/display perspective. Most of our faculty use Apple laptops, which have displays that meet the minimum standard (based on SIIM/AAPM/ACR technical guidance) for interpretation of cross-sectional studies. Our RadVerify service assists faculty, and trainees with evaluation of existing laptops and external displays. Faculty e-mail photos and screenshots from their equipment our support team and receive guidance on how their hardware can be used. Our diagnostic software suite requires Windows, so we created a custom virtual machine image with our primary PACS, dictation, and EHR access installed. This VM is automatically distributed to faculty after the RadVerify process.

We had a small stockpile of diagnostic displays that were leftover from lifecycle replacement. We distribute these to faculty with priority given to those who interpret plain films.

Net New Resources

For faculty that don’t have a VM capable device, we acquired a limited number of Windows laptops from the UCSF central IT stockpile. These laptops are configured with our primary PACS, dictation, and EHR software integrated. These are deployed to faculty who read primarily cross-sectional imaging and have factors that require them to work off-site.

Our Chair secured funding from the medical center for 30 home workstations (HDS). Unlike the laptops, which are a temporary solution, the investment in HDS is durable and will be used following the COVID-19 crisis. We recognize that there is controversy and substantial cost-differential using consumer or medical grade displays for primary interpretation. Our in-house standard is to use medical-grade displays and our opinion is that a differential between in-house and WFH hardware difficult to justify.  We tested several medical-grade displays and selected a recently FDA-approved 8MP 32” display from LG that offers substantial cost savings over other displays.

Note: due to MQSA requirements we do not support WFH solutions for breast imagers.

General Considerations

All of our solutions make use of our Central IT-provided VPN. Early in the crisis we were able to obtain a high-bandwidth VPN segregated from general VPN use for clinical WFH.

When deploying any of the solutions (VM, laptop, or HDS) above we provide the following guidance:

  1. Use of a WFH solution is subject to approval by your section chief, VC of Ops, and the Dept Chair.
  2. The WFH solution is a scarce resource, we may need to re-deploy to another home or location depending on how the crisis unfolds.  We may also request that the solution be returned after the crisis abates.
  3. Imaging IT will provide remote support through the installation and use of the home workstation.  At this point, we are not resourced to provide in-person support in your home.  
  4. If the workstation can’t be fixed remotely - you’ll need to use another method to get your work done.  If you’re on call that might just be eUnity, if you’re covering a routine shift you may need to come to work.
  5. Transportation of the WFH solution between Parnassus and your home is your responsibility.  We’re not resourced for delivery and setup services at this time.
  6. Use of a WFH solution is an employee-driven benefit, and is not required by the department.
  7. Internet costs related to the WFH solution remain the responsibility of the individual faculty/resident/fellow.

For questions, or more information contact [email protected]

Safety Practices for Patients and Staff

Safety Modifications for Patients:

  • Increase frequency of cleaning
  • 6ft separation of furniture in waiting rooms
  • Communicate cleaning practices
  • Encourage use of e-check-in technologies
  • SMS text messaging for remote patient waiting

Safety Modifications for Staff:

Safety Modifications for Reading Rooms:

This document provides suggested best practices for Reading Rooms during the COVID-19 pandemic.  Its goal is to protect from exposure and dissemination of COVID-19 while maintaining the organization's mission of providing excellent clinical imaging and educating tomorrow’s leaders in radiology.

UCSF Interventional Radiology Tiered Disaster Plan

UCSF Interventional Radiology has prepared a tiered plan to modify operations, clinical services, and staffing specific to situations such as a global pandemic or other natural disasters.  See the plan in detail (pdf)

Communicating Effectively

The coming weeks and months present a time of uncertainty. The state of the COVID-19 pandemic in our community and health systems is fluid. We aim to communicate clearly and regularly across the department and stay aligned with the health system’s efforts. Communication forums include:

Type of Communication Audience Frequency
Start-of-day operational huddle All radiology leadership including; manager, supervisors, MDs Daily 8 AM
Clinical leadership COVID response team meeting MD leadership and radiology director Daily 9 AM
COVID-19 Radiology Website All internal and external staff Ongoing
WhatsApp messaging Various groups to communicate specific changes to operations As needed

UCSF Radiology COVID-19 Virtual Town Hall (internal access only)

Fostering Resilience During the Pandemic
(Inaugural UC-Wide Radiology Grand Rounds: Women in Medicine)

All Radiology Staff, MD, and Leadership

Ongoing

UCSF Radiology Chair COVID-19 Updates (internal access only)

Radiology campus and Health Weekly

UCSF Radiology Operations Newsletter (internal access only)

Frontline staff Daily - twice weekly

Resources

UCSF Radiology Guidelines and Forms Last Updated
Ambulatory Pre-Intervention Screening Form – COVID-19 4/28/20
APeX Radiant Prescreening Radiology Appointments Tipsheet  4/10/20
APeX Radiant Tipsheet (internal access only) 4/1/20
Aerosol generating procedure stop signs 5/11/20
Contrast Coverage Shift Guidance 7/14/20
COVID-19 Visitor Restriction Policy 4/15/20
COVID-19 Guidance: Image-guided procedures and diagnostic imaging under anesthesia 8/9/20
Dr. Brett Elicker’s presentation on interpretation of chest imaging in patients with COVID-19  
Guidance for Diagnostic Imaging During the COVID-19 Pandemic 9/3/20
How is COVID-19 diagnosed and managed at UCSF?  3/19/20
Incidental Detection of Lung Findings That Could Represent COVID-19 in Patients Without Respiratory Symptoms  7/23/20
Isolation status and PPE use in patients with pending COVID-19 tests  4/14/20
Reading Room Best Practices 6/2/20
What is the overall control plan for COVID-19 at UCSF (includes information on room cleaning)?  3/17/20
UCSF Radiology Communications Link to internal box
Town Hall Videos (internal access only)
External Tools and Resources
UCSF Coronovius Updates webstie 
UCSF Coronovius Patient Resources website
UCSF Health Epidemiology and Infection Prevention COVID-19 website
UCSF Remote Work Tools Guide ITS website
Respiratory virus shedding in exhaled breath and efficacy of face masks
How to fight the coronavirus SARS-CoV-2 and its disease by Michael Z. Lin, MD, PhD, Department of Neurobiology, Stanford University
CDC Coronavirus Info for Healthcare Professionals website
ACR Recommendations for the use of Imaging in Suspected COVID-19 Infection
COVID-19 Science Report

Departmental COVID-19 Response Feedback

In an effort to improve our sensitivity to evolving issues, we invite you to share any concerns or suggestions for how we can continue to improve our COVID-19 response. We will store all comments provided anonymously. We specifically want to solicit feedback that, for a variety of reasons, may be difficult to communicate through other channels. Please provide whatever relevant details you feel are needed to enable our department to effectively respond to your concerns or suggestions.

We will review these comments on a weekly basis and work to strategically address any concerns as quickly as possible.

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