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 here.

Table 1: Diagnostic Imaging in ED Patients

COVID-19 Flag Isolation Status Interpretation Action PPE

COVID-19 (Confirmed)
COVID-19 confirmed

Respiratory Illness Evaluation without Negative Pressure
OR
Novel Respiratory Isolation

COVID-19 Infected Patient

Consult radiologist for appropriateness of examination;*

Proceed if approved

 

In ED:  
airborne + contact

In Department:
follow isolation status

COVID-19 (Pending)
COVID-19 pending

Respiratory Illness Evaluation without Negative Pressure
OR
Novel Respiratory Isolation

Patient Under Investigation (PUI)

Consult radiologist for appropriateness of examination;*

Proceed if approved

In ED:  
airborne + contact

In Department:
follow isolation status

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

In ED:
airborne + contact

In Department:
droplet + contact + any other non COVID-19 related isolation status

*Chest x-ray and CT imaging do not require radiologist approval in ED patients

Table 2: Diagnostic Imaging in Inpatients

COVID-19 Flag Isolation Status Interpretation Action PPE

COVID-19 (Confirmed)
COVID-19 confirmed

Respiratory Illness Evaluation without Negative Pressure
OR
Novel Respiratory Isolation

COVID-19 Infected Patient

Consult radiologist for appropriateness of examination;*

Proceed if approved

EITHER
airborne + contact
OR
droplet + contact depending on isolation status

COVID-19 (Pending)
COVID-19 pending

Respiratory Illness Evaluation without Negative Pressure
OR
Novel Respiratory Isolation

Patient Under Investigation (PUI)

Consult radiologist for appropriateness of examination;*

Proceed if approved

EITHER
airborne + contact
OR
droplet + contact depending on isolation status

None

Droplet Precautions
+/- non COVID-19 related isolation status

Asymptomatic Patient with COVID-19 test pending Proceed with imaging study

Droplet
+/- non COVID-19 related isolation status

None

None

+/- non COVID-19 related isolation status

COVID-19 test negative**

Proceed with imaging study

Standard precautions + surgical mask
+/- non COVID-19 related isolation status

*Chest x-ray does not require approval in inpatients
**Some inpatients whose admission predates 4/23/20 will have been asymptomatic and never tested

Table 3: Diagnostic Imaging in Outpatients

COVID-19 Flag Isolation Status Interpretation Action PPE

COVID-19
(Confirmed)

COVID-19 confirmed

N/A COVID-19 Infected Patient Consult radiologist for appropriateness of examination; Escalate to supervisors to plan safest site and process to image patient** droplet + contact

COVID-19
(Pending)
COVID-19 pending

N/A Patient Under Investigation Consult radiologist for appropriateness of examination; Escalate to supervisors to plan safest site and process to image patient** droplet + contact
None N/A Asymptomatic patient with or without test pending Proceed with imaging study

Ensure patient wears mask
standard precautions + surgical mask

*Isolation status is not functional for outpatient encounters
**Standard operating procedure to manage this scenario will be developed

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 updates previously published interim guidance on the same topic. The interim guidance was created in the context of a new UCSF Anesthesia and Perioperative Care policy approved on March 26, 2020. The goal of this guidance is to align our practice with UCSF Health practice and national standards.

Summary

Several important concepts underpin the anesthesia and radiology 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, and 4) intubation, extubation, and certain forms of respiratory support are aerosol-generating.

Key changes were incorporated (April 24, 2020): 

  • Incorporation of COVID-19 test results: Based on current estimates of COVID-19 prevalence among asymptomatic patients in San Francisco and surrounding areas and the performance of the UCSF RT-PCR test, the likelihood is very high that a patient with a negative test result does not have COVID-19 infection (~99.7% negative predictive value) (see Appendix A). Pre-procedural testing has begun for all patients undergoing anesthesia and for selected patients undergoing image-guided interventions under local anesthetic or conscious sedation. Pre-visit testing is expected to expand in coming weeks.
  • Incorporation of site-specific air exchange into room downtime guidance: At the time of interim guidance publication, air exchange data was not available for the majority of imaging suites. These data are now available (see Appendix B).
  • Incorporation of changes in the UCSF Anesthesia and Perioperative Guidance: An updated guidance document was published on 4/21/20. This document reflects these changes while providing additional information to allow this policy to be operationalized in the Department of Radiology and Biomedical Imaging.

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

Table 1:  PPE and Radiology Guidance for ADULT PATIENTS with COVID-19 test results within last 4 days

Scenario Anesthesia PPE Radiology Personnel PPE Room Management Room Cleaning

1.  COVID-19 Positive/PUI for ANY image-guided intervention (diagnostic imaging will continue to follow existing guidelines)

  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • 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 within last 4 days, any procedure
  • Standard PPE
  • Standard procedural PPE
  • No room downtime required
  • Routine cleaning upon patient departure

Table 2: PPE And Radiology Guidance for ADULT PATIENTS without COVID-19 test results within last 4 days

Scenario Anesthesia PPE Radiology Personnel PPE Room Management Room Cleaning
1.  Asymptomatic patient for HIGH RISK procedure (aerosol-generating procedure (AGP)) under local anesthetic, conscious sedation, or general anesthesia
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • 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
  • Routine cleaning after downtime complete
2a. Asymptomatic patient for LOW RISK procedure
(non-aerosol-generating) or diagnostic imaging under general anesthesia, intubation/extubation take place in imaging suite
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • 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
  • personnel should leave room for intubation and extubation
  • Room-specific downtime after last AGP, per signs in room
  • Routine cleaning after downtime complete
2b. Asymptomatic patient for LOW RISK procedure
(non-aerosol-generating) or diagnostic imaging under general anesthesia, intubation/extubation take place elsewhere
and patient is transported to/from imaging suite
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • Standard procedural PPE
  • No room downtime required
  • Routine cleaning after patient departure
3. Asymptomatic patient for LOW RISK
(non-aerosol-generating) procedure under local anesthetic, conscious sedation, or monitored anesthesia care
  • Standard procedural PPE
  • 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: PPE And Radiology Guidance for PEDIATRIC PATIENTS with COVID-19 test results within last 4 days at BCHSF

Scenario Anesthesia PPE Radiology Personnel PPE Room Management Room Cleaning
1.  COVID-19 Positive/PUI for ANY image-guided intervention (diagnostic imaging will continue to follow existing guidelines
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • Minimize number of providers present
  • No radiology trainees to be 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 within last 4 days, any procedure
  • Standard PPE
  • Standard procedural PPE
  • No room downtime required
  • Routine cleaning upon patient departure

Table 4: PPE And Radiology Guidance for PEDIATRIC PATIENTS without COVID-19 test results within last 4 days at BCHSF

Scenario Anesthesia PPE Radiology Personnel PPE Room Management Room Cleaning
1.  Asymptomatic patient for HIGH RISK procedure (aerosol-generating*) under local anesthetic, conscious sedation, or general anesthesia
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • Routine cleaning after downtime complete
2a. Asymptomatic patient for LOW RISK procedure (non-aerosol-generating) or diagnostic imaging involving general anesthesia, induction and emergence take place in imaging suite
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • 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 LOW RISK procedure (non-aerosol-generating) or diagnostic imaging involving general anesthesia, induction and emergence from anesthesia take place elsewhere and patient is transported to/from imaging suite
  • Reusable N95 + face shield/goggles or PAPR
  • Gown
  • Double Gloves
  • 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.
  • Modified hours of operation (pdf)

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:

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)

All Radiology Staff, MD, and Leadership

Ongoing

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

Radiology campus and Health Weekly

UCSF Daily 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
COVID-19 Visitor Restriction Policy 4/15/20
COVID-19 Guidance: Image-guided procedures and diagnostic imaging under anesthesia 5/7/20
Dr. Brett Elicker’s presentation on interpretation of chest imaging in patients with COVID-19  
Guidance for Diagnostic Imaging During the COVID-19 Pandemic 4/27/20
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  4/3/20
Isolation status and PPE use in patients with pending COVID-19 tests  4/14/20
Modified Hours of Operations 5/5/20
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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