Written by : Luh Oliva Saraswati Suastika, MD, FIHA
The World Health Organization (WHO) in beginning of April had reported that more than 22,000 healthcare workers across 52 countries and regions are infected with COVID-19.1 In Indonesia, 31 doctors and nurses died during this pandemic, even in recent case in Semarang, 46 healthcare workers are COVID positive after treating one patient who was not suspected of COVID-19. Hence, during this COVID-19 pandemic, protection of healthcare workers has been one of the top priority since these frontline workers are very prone to transmission of the infection.
Protection of echocardiography personnel should always start with meticulous and frequent hand washing. Different level of personal protection equipment (PPE) is required depending on the policy of each institution. Some institutions divided patients into three risk levels (minimal risk = not suspected, moderate risk = suspected, and high risk = confirmed), others treated suspected and confirmed cases similarly.
In performing transthoracic echocardiography (TTE) and stress echo exams, both the American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) have stated that application of PPE can vary according the level of the risk of each patient, the local nature of pandemic and the availability of PPE.2,3 Standard care for virus protection includes hand washing for healthcare workers and patients and the use of gloves. Hand washing should be done before and after each patient. After every patient, take off the gloves, wash hands and use new non-sterile gloves before scanning the next patient.
The WHO had recommended the use of facemask for everyone and in the setting of healthcare workers, surgical face mask is preferred. Patient with respiratory symptoms should also use surgical facemask during imaging. Airborne precautions are required during transesophageal echocardiography (TEE) due to its increased risk of aerosolization, this generally includes gown, gloves, head cover or cap, facemask and eye or face shield with the addition of N-95 or N-99 respirator mask or powered air purifying respirator, and shoe covers. Limited exposure with patients (and avoiding contact with suspected or confirmed COVID-19 patient) should be practiced by staffs who are >60 years old, with chronic conditions, are pregnant or immunocompromised since they are more susceptible to severe complications of COVID-19.
The Indonesian Society of Echocardiography (ISE) has recommended to perform focused TTE exams (based on the clinical diagnosis or suspicion) instead of full study TTEs with minimal contact during scan, acquiring all images first and measuring all the parameters later after the patient leaves.4 All suspected or confirmed cases should be evaluated in separate room, with PPE for droplet precaution in suspected patient and airborne precaution for positive COVID-19 patients. A specific room should be addressed for donning, doffing and storage of all the PPEs.
Other than the general precaution similar to ASE and ISE recommendations, in order to reduce the exposure of sonographer or operator to high viral load, the British Society of Echocardiography (BSE) had several suggestions to limit scanning time: avoid breath holding, do not use the ECG, record time loops and do not measure during scan.5 They also suggested level 1 BSE scan (biventricular function and major structural valve disease) should be sufficient in most cases to answer the clinical questions.
Performing TEEs in suspected or confirmed patient warrants the use of airborne precaution, irrespective of the intubation status of the patient. All personnel should be educated well in appropriate utility of PPE, and if possible, there should be a trained observer to check the appropriate donning and doffing of the PPE. Meanwhile, PPE for droplet precautions is required in TEEs in all non-COVID patients. To limit the amount of staffs exposed, there should be at most three personnel during TEE to handle the probe, to operate the machine controls, and to administer sedation.
Different recommendation is available for equipment protection which is vital in the prevention of transmission since the equipment that is used in close contact with patients may carry droplets containing the virus. In high-volume centers, ideally one dedicated echo machine in a specific designated area should be used in scanning confirmed patients. The furthest position from the patient’s face to echocardiographer is that the patient on left-lateral position and the scanner on the right side of the bed (scanning with right hand). However, each echocardiographer has personal preference on performing the scans, hence this position should be adjusted to not interfere with the ability of the operator to perform the echo exams.
Before the scanning starts, remove all the probes that are not necessary on the scans. EACVI recommended to avoid using ECG leads during TTEs or TEEs in COVID-19 positive patients. Probes and machine consoles may be covered with disposable plastic but this may result in suboptimal images and prolonged scanning time. Thus, if covered, screen and keyboard should be fully accessible to the sonographers. Protective coat for the TEE probe might also be considered, again the risk of suboptimal images may arise.
After examinations, echo machines and probes should be thoroughly cleaned and disinfected. Each ultrasound vendor has specific disinfectants and cleaners for different machines and transducers, and the cleaning guideline is available on their websites.6,7,8 Special care taken for TEE probes includes initial cleaning in the scanning room (probe, handle and chord) then put in a closed container then disinfected according to the cleaning routine in each institution. Any parts that come to close contact with patients should be cleaned with duration of contact with cleaners of at least two minutes and use recommended cleaners and disinfectants (contains alcohol with minimal concentration of 60%).2,3,4
Parameters should be measured after the scans are finished. To reduce the risk of transmission among cardiologists and/or sonographers in the reading room, if applicable, please review images remotely or via conference call. Surfaces that are frequently touched on daily basis should be routinely cleaned (including desks, chairs, door knobs, keyboards and monitors, sinks, etc).2,4
We are hopeful that if the echo lab staffs follow the recommendations of putting the correct PPE for each case, hand washing before and after each scanning, and proper equipment cleaning and disinfection, although the practice of these may vary in different area, it will help in reducing the risk of transmission of COVID-19 and protecting all the personnel involved in echocardiography examinations.
Luh Oliva Saraswati Suastika, MD, FIHA serves as lecturer and cardiologist at Department of Cardiology and Vascular Medicine, Udayana University, Udayana University Hospital, Bali, Indonesia
1. World Health Organization. Coronavirus disease (COVID-19) Pandemic. [Online]. 2020. Available: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/.[Accessed on April 16th, 2020].
2. American Society of Echocardiography. ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak. [Online]. 2020. Available: https://www.asecho.org/wp-content/uploads/2020/03/ASE-COVID-Statement-FINAL-1.pdf. [Accessed April 16th, 2020].
3. Skulstad, H., Cosyns, B., Popescu, B. A., Galderisi, M., Salvo, G. D., Donal, E., Petersen, S., Gimelli, A., Haugaa, K. H., Muraru, D., Almeida, A. G., Schulz-Menger, J., Dweck, M. R., Pontone, G., Sade, L. E., Gerber, B., Maurovich-Horvat, P., Bharuca, T., Cameli, M., Magne, J., Westwood, M., Maurer, G. & Edvardsen, T. COVID-19 pandemic and cardiac imaging: EACVI recommendations on precautions, indications, prioritization, and protection for patients and healthcare personnel. Eur Heart J Cardiovasc Imaging. 2020;0: 1-7.
4. Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Protokol Tindakan Ekokardiografi Transtorakal / Transesofageal dalam konteks kewaspadaan Infeksi Covid-19. Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. [Online]. 2020. Diunduh dari: http://www.inaheart.org/perki/upload/files/
5. British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during he COVID-19 pandemic. [Online]. April 2nd, 2020. Available: https://bsecho.org/covid19. [Accessed April 16th, 2020].
6. Philips. Disinfectants and cleaning solutions for ultrasound system and transducers. [Online]. Sept, 2015. Available: https://www.philips.co.uk/c-dam/b2bhc/master/whitepapers/ultrasound-care-and-cleaning/disinfectant-tables-manuals/453561820512a.pdf. [Accessed April 16th, 2020].
7. Siemens Healthineers. Ultrasound Transducers. [Online]. Available: https://www.siemens-healthineers.com/en-uk/ultrasound/ultrasound-transducer-catalog#Care. [Accessed April 16th, 2020].
8. GE Healthcare. Cleaner and Disinfectant Material Compatibility. [Online]. Available: https://cleaning.gehealthcare.com/. [Accessed April 16th, 2020].
9. Sarah-Jane MacAllister. Echo staff and patients safety. Melbourne Heart Care. [Online]. Maret 23rd, 2020. Available: https://www.melbourneheartcare.com.au/echo-staff-and-patients-safety/. [Accessed April 28th, 2020].
10. Gugus Tugas Percepatan Penanganan COVID-19. Rekomendasi standar penggunaan APD untuk penanganan COVID-19 di Indonesia. Maret 2020. [Online]. Diunduh dari: https://covid19.go.id/p/protokol/rekomendasi-standar-penggunaan-apd-untuk-penanganan-covid-19-di-indonesia-revisi-1. [Diakses pada 23 April 2020].