Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 121-124

Coronavirus and interventional radiology department: Evidence-based measures to limit transmission – Indian scenario


1 Department of Radiology, MGM IMS and Research Institute, Aurangabad, Maharashtra, India
2 Department of Ophthalmology, Lions Eye Hospital, Udgir, Maharashtra, India
3 Department of Vascular and Interventional Radiology, LTM General Hospital and Medical College, Mumbai, Maharashtra, India

Date of Submission05-Apr-2020
Date of Acceptance10-Apr-2020
Date of Web Publication17-Jun-2020

Correspondence Address:
Dr. Amol Lahoti
Department of Radiology, MGM IMS and Research Institute, Aurangabad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_33_20

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  Abstract 


As we face a countrywide lockdown in view of the international pandemic of coronavirus disease 2019 and deal with never seen before circumstances all over the world including India, health-care personnel are fighting like soldiers and are often first to get affected in view of the direct exposure because of the limited availability of knowledge and personal protection equipments (PPEs). Radiology emerging superspecialty interventional radiology (IR) entails a greater risk of acquiring, transmitting infection due to the close patient contact and invasive patient care the service needs to offer. Due to the high density, limited working space we have, and working in air-conditioned setup that is needed for cath lab and ultrasonography machines, this makes it imperative to set specific guidelines to limit transmission and utilize resources in the best possible way. A multitiered, scientific approach suited to our environment needs to be devised and monitored at the administrative and departmental level, taking into account the IR team and patient contact-operating points. We present an overall systematic scientific review of the infection control measures that cover the different dynamics of utmost patient care and staff protocols without hampering the patient treatment for an interventional department setup. The IR and radiology department should be prepared and educated to continue the servicing emergency procedures and important elective procedures following the strict aseptic precautions, so health-care workers' and patients' safety is maintained. The team members should understand the disease dynamics, routes, and source of transmission and should take utmost precautions to prevent transmission to colleagues and patients by properly suing PPE.

Keywords: Corona, corona and interventional radiology, coronavirus disease 2019


How to cite this article:
Lahoti A, Lakhotiya A, Ukirde V, Gursale A, Satpute S, Bansal A. Coronavirus and interventional radiology department: Evidence-based measures to limit transmission – Indian scenario. Indian J Vasc Endovasc Surg 2020;7:121-4

How to cite this URL:
Lahoti A, Lakhotiya A, Ukirde V, Gursale A, Satpute S, Bansal A. Coronavirus and interventional radiology department: Evidence-based measures to limit transmission – Indian scenario. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Sep 30];7:121-4. Available from: http://www.indjvascsurg.org/text.asp?2020/7/2/121/286906




  Introduction Top


The ongoing coronavirus disease 2019 (COVID-19) outbreak caused by a novel coronavirus known as SARS-CoV-2, has become a global pandemic with more than 550,000 cases reported worldwide at the time of this article, with number of deaths more than 50,000. Many aspects of the organism and manifestations related to short- and long-term consequences are still unknown to us. From the very start of the epidemic, it has been recognized that health-care workers (HCWs) managing this potentially lethal airborne disease are a high-risk group. There are numerous reports of frontline HCWs, both doctors and nurses, contracting the disease from their patients they were treating and several have succumbed to it. In the index outbreak in Wuhan, 1300 HCWs became infected; their likelihood of infection was more than three times as high as the general population.[1] The secondary mode of transmission of any air and fomite borne infection occurs in the hospital setting. This is true for COVID19 as well because it can be transmitted through air and fomite of an infected person. Similarly in India, as on April 3, 2020, 52 HCWs are affected due to exposure while handling coronavirus patients. The primary consideration in preparing the interventional radiology (IR) service for COVID-19 is the prevention of intra- and interhospital transmission so as to protect the patients and HCWs from being contaminated or infected, while providing safe IR service for patients. Recent evidence suggests that a person who is asymptomatic can spread COVID-19 with high efficiency, and conventional measures of protection, such as face masks, provide insufficient protection. A boy aged 10 years who was infected with COVID-19 had no symptoms but had visible changes in lung imaging and blood markers of the disease.[1],[2],[3]

Point of contact of IR and coronavirus-infected patients – Interventional radiologists working in the intensive care unit setup for central line and peripheral line insertions apart from cath lab setup are exposed directly. Apart from this, patients presenting with acute vascular and other interventional-related complaints should be screened for coronavirus-related complaints.


  Screening and Prioritization Top


The risk of transmission is directly related to the degree of contact between the patient and healthcare personnel (HCP). Therefore, interventional radiologists are predisposed to a risk of acquiring infection. The first step in limiting the propagation of the disease is proper screening of the requested interventional procedures and postponement of the elective procedures till the current situation is brought under control. The interventional radiologist should limit the acceptance of cases to urgent which needs immediate treatment and semi urgent-elective ones which can be performed at a later date when herd immunity-vaccine is developed.

All patients coming for outpatient department and procedures should be screened by general physicians to rule out active or subclinical COVID-19 infection. Apart from this, interventional radiologist at first consultation should ask patient about basic travel and contact history apart from clinical complaints of cough, cold, high-grade fever, and breathlessness. Those having active clinical complaints should be managed first before any IR procedures[2],[3],[4],[5]


  Coronavirus Disease 2019 Suspect Case Definitions Top


A person is suspected of COVID-19 if the person has acute respiratory infection (ARI), shortness of breath, and travel history to regions affected by COVID-19 within 14 days of onset of symptoms or the person has been in close contact with a known COVID-19 patient. All patients with fever, lethargy, and respiratory symptoms such as shortness of breath may have to be considered as suspected COVID-19 cases.


  Elective Procedures Top


All patients who have been scheduled for elective procedures should be contacted by the resident, fellow, and nursing staff and given later date appointment if they have any symptoms suggestive of COVID-19 or have traveled to the endemic areas, or such contacts. Depending on the situation, the decision may be made to defer all elective procedures till further notice as per the government guidelines.


  Urgent Procedures Top


For patients requiring urgent intervention such as acute limb ischemia, stroke, and acute gastrointestinal bleeding, the requesting clinical team must be instructed to assess the patients for fever, myalgia, shortness of breath, or respiratory symptoms and to follow preventive measures such as making the patient wear a facemask and to sanitize the contact surfaces as much as possible. Emergency medical services should inform the receiving health-care facility of suspected or confirmed COVID-19 cases and follow local or regional transport protocol. Effective interdepartmental and ground level communication in a timely fashion allows sufficient time for the HCWs to prepare for such patients.


  Control of Patient and Interventional Radiology Staff Movement in the Hospital Top


  1. Limiting all traffic through the health-care facility is very important
  2. The entry point of all confirmed or suspected cases should be limited to one section only
  3. Signs and posters are recommended at these points, detailing instructions on hand hygiene using sanitizer and cough etiquette, and appropriate use and disposal of masks and other protective apparels
  4. Where possible sufficient physical barriers should be installed to limit interpersonal contact
  5. No more than one visitor should be allowed to accompany the patient after the visitor has been assessed regarding the travel history and clinical symptoms. If found to have affirmative history, the visitor should be asked to leave the premises
  6. Patients and staff entry into accessory regions functioning within the hospital including canteens, shops, security, support offices, and help desks should also be restricted
  7. Good ventilation in the clean working area needs to be ensured at all times to prevent air and contact transmission of the virus.



  Interventional Radiology Patient-Related Precautions and Guidelines Top


Segregation of patients

The clinical referring physicians should be clearly instructed to inform the IR team to know when a procedure is being requested for a confirmed COVID-19 patient, so all precautions should be taken care. Furthermore, whenever possible, such case should be taken at the end of the day so post procedure fumigation and sanitation of the place and department can be carried without hampering department work. Depending on the burden of cases and resources of the institution, a dedicated COVID-19 room with isolated floor space, bathrooms, and designated HCW should be established. Suspected, unconfirmed patients should not be kept in the same unit or room as a confirmed case. The patients should be instructed to wear facemasks at all times to reduce source transmission.

Checking of patients

Clinical samples should be collected from the suspected cases.


  Interventional Radiology in Coronavirus Disease 2019 Patients Top


Basic precautions and vascular access

As instituted in the guidelines by the centre for disease control and occupational safety and health administration, society of interventional radioology recommends the use of protective eyewear, facemask, full gowns, and shoe covers in the event of droplet or splash risk. Maximum barrier precautions (cap, mask, sterile gown, sterile gloves, double glove use, and large sterile drape) are advised during the insertion of central venous catheters and all invasive interventional procedures. Two-handed needle recapping technique should be avoided, and if recapping is indicated, a recapping device or a one-handed method is advised. The use of a designated sink for bodily fluid disposal and the use of personal protective equipment (PPE) by the IR staff during the disposal process are highly recommended.[6],[7],[8]

Prioritization of interventional radiology procedures

In COVID-19 infected patients, an IR procedure should be performed by the patient's bedside in the isolation room if the procedure can be done solely under ultrasound guidance (for example, pleural or ascitic drain insertions, PICC or central venous catheter insertions, abscess drainages, and peripheral vascular access-related pseudoaneurysm).[6],[7]

Staff leave

All nonessential leaves are put on hold so that there is sufficient workforce available. This is necessary as infection prevention measures need more staff, and there is the possibility staff quarantine which can reduce the workforce.

Disinfecting the surface equipment decontamination

Patient movement outside designated units should be limited, and portable imaging and laboratory work should be performed in the room when feasible, and post use cleaning and sanitation of the surface should be strictly performed using disposable disinfectant wipes containing 75% ethanol, at least three times a day. According to the contaminant treatment regulations, the used cleaning wipes and other materials shall be uniformly incinerated. It is forbidden to disinfect the medical equipment or room with spray. The flat detector of special mobile X-ray equipment is wrapped with disposable sheet or clothing. Every time after the completion of imaging, the equipments are disinfected (wiped with 75% alcohol solution or sanitizer).[9] Similarly, computed tomography and magnetic resonance gantry machines' surfaces are disinfected every time after use. This might be little time and energy consumables but need of the hour.

Standard and contact precautions

Blood, body fluids, secretions, and excretions might contain transmissible infectious agents through nonintact skin and mucous membranes. Standard precautions and disposal criteria are determined by the nature of the patient interaction and the extent of anticipated blood, body fluids, and pathogen exposure. The detection of SARS-CoV-2 in the gastrointestinal tract, saliva, and urine may suggest other potential portals of transmission other than routine respiratory droplet mode.[10] If splashes, sprays, coughs, contact with nonintact skin, and mucous membranes are expected, facemask, gloves, and eye and body protection should be worn and discarded or sterilized regularly. Hand hygiene should be performed with alcohol-based sanitizer containing 70%–95% alcohol or by washing hands with soap and water for at least 20 s. It should be done before and after all patient interactions or contact with potentially infectious material and before putting on and after removing PPE.[6] Personal protective equipments needed as per the level of protection [Table 1].
Table 1: Personal protective equipments needed as per the level of protection

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Respirator or facemask must be donned before entry into the patients' ward. Disposable respirators and facemasks should be immediately discarded after exiting the patient's care area; closing the door and hand hygiene should be carried out as advised.

Emotional needs of HCWs should not be ignored and in fact they should be encouraged. HCWs at the front-line of COVID-19 infection fight are under constant extreme physical and mental stress. They are physically overworked beyond conceivable limits; they are forced to make tormenting triage decisions and are racked by guilt and pain from losing patients and colleagues in spite of the best possible treatment. This is in addition to worrying about their own health and the constant anxiety of passing the infection on to their families and loved ones[11] way back their home.

Segregation of the workforce

Many departments have some staff who provide services at multiple locations and departments. These cross-covering staffs who have been in contact with a COVID-19 patient risk exposing other health-care teams to the contagion. It is very important to create a separate clinical team which includes the treating physician and an entire unit of nurse, technician, as well as other support staff, who are necessary for complete patient care at one particular center.[6]

Temperature checking and condition of staff

Many reports have shown that people of certain demographic parameters and those with comorbidities are at higher risk of acute respiratory distress syndrome if infected. Exclusion criteria as working IR staff with these parameters include age above 60, smokers, diabetics, hypertensives, those with previous lung damage, chronic heart disease, cancer, Hepatitis B, and chronic kidney disease. These people should refrain from working in covid-set up unless emergency and that too with utmost care and precautions.

Although fever, dry cough and breathing difficulty, myalgia, and fatigue are the most common symptoms, there have been documented instances of isolated symptoms of sore throat, sneezing, and nasal discharge with a far less occurrence of headache, sputum production, hemoptysis, and diarrhea. To prevent further spread, the onset of fever and respiratory symptoms should be closely monitored among HCP. When available, testing of respiratory specimens should be done immediately once a diagnosis is suspected. Serum antibodies and fecal and urine samples should also be tested among HCP before and after their exposure to SARS-CoV-2 for the identification of asymptomatic infections.[12]

Donning (wearing) of PPE sequence – (1) Hand wash, (2) cap, (3) shoe cover or protective boot, (4) inner gloves, (5) body gown/disposable dress, (6) mask (preferably N95 or surgical mask), (7) goggle, and (8) outer gloves.

Doffing (removing) of PPE sequence – (1) Outer gloves, (2) hood, (3) shoe cover or protective boot, (4) hand rub (gloved hand), (5) goggle, (6) mask, (7) cap, (8) inner glove, and (9) Hand wash.


  Conclusion Top


Public health implications: at present, it is not clear to what extent the COVID-19 epidemic would establish itself and how long it is going to continue in India. As the introduction of cases may take anywhere from a minimum of 14 days to a few months to be visible, we need to enhance surveillance and prepare the community in a proportionate way.[13] The IR department should be prepared to continue the servicing emergency procedures and important elective procedures following the strict aseptic precautions, so HCWs' and patients' safety is maintained. The team members should understand the disease dynamics, routes, and source of transmission and should take utmost precautions to prevent transmission to colleagues and patients by properly suing PPE. Anticipating that constant updates will be necessary in this volatile situation, the above recommendations may be used as basic guidelines which may vary from department to department management decisions and strategize in order to optimize the resources while minimizing risk to staff and delivering quality emergency patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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De Chang, Xu H, Rebaza A, Sharma L, Dela Cruz CS. Protecting healthcare workers from subclinical coronavirus infection. Lancet Respir Med 2020;8:e13.  Back to cited text no. 1
    
2.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID19) outbreak in China: summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA 2020;323:1239-124.  Back to cited text no. 2
    
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Bedford J, Enria D, Giesecke J, Heymann DL, Ihekweazu C, Kobinger G, et al. COVID-19: Towards controlling of a pandemic. Lancet 2020;395:1015-8.  Back to cited text no. 3
    
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Centor RM, Marrazzo J. Annals on call-Protecting health care workers from COVID19. Ann Intern Med 2020;172:OC1. doi: 10.7326/A20-0002. Epub 2020 Mar 31.  Back to cited text no. 4
    
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Heymann DL, Shindo N; WHO Scientific and Technical Advisory Group for Infectious Hazards. COVID-19: What is next for public health? Lancet 2020;395:542-5.  Back to cited text no. 5
    
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Chandy PE, Nasir MU, Srinivasan S, Klass D, Nicolaou S, B Babu S. Interventional radiology and COVID-19: Evidence-based measures to limit transmission. Diagn Interv Radiol 2020;26:236-40.  Back to cited text no. 6
    
7.
Reddy P, Liebovitz D, Chrisman H, Nemcek AA Jr, Noskin GA. Infection control practices among interventional radiologists: Results of an online survey. J Vasc Interv Radiol 2009;20:1070-4.e5.  Back to cited text no. 7
    
8.
Malavaud S, Joffre F, Auriol J, Darres S. Hygiene recommendations for interventional radiology. Diagn Interv Imaging 2012;93:813-22.  Back to cited text no. 8
    
9.
An P, Ye Y, Chen M, Chen Y, Fan W, Wang Y. Management strategy of novel coronavirus (COVID-19) pneumonia in the radiology department: a Chinese experience. Diagn Interv Radiol 2020;26:200-3.  Back to cited text no. 9
    
10.
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20. doi: 10.1056/NEJMoa2002032. Epub 2020 Feb 28.  Back to cited text no. 10
    
11.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.  Back to cited text no. 11
    
12.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 12
    
13.
Mandal S, Bhatnagar T, Arinaminpathy N, Agarwal A, Chowdhury A, Murhekar M, et al. Prudent public health intervention strategies to control the coronavirus disease 2019 transmission in India: A mathematical model-based approach. Indian J Med Res 2020;151:190-9.  Back to cited text no. 13
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   Abstract
  Introduction
   Screening and Pr...
   Coronavirus Dise...
  Elective Procedures
  Urgent Procedures
   Control of Patie...
   Interventional R...
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