Operations Transition to Mitigate COVID-19 on an Interventional Radiology Service

The coronavirus disease pandemic (COVID-19) started in China in December 2019. Countries around the world remain affected several months later. Despite attempts to limit dissemination by social distancing, the United States currently has more total infections than any other nation on earth. ¹ At one point in New York City, COVID-specific admission surges reached 350 patients/100,000 population, stressing the limits of staff and resources. ²

Mitigating in-hospital spread by preparedness has been a central topic of other reviews for diagnostic radiology departments. ^{3 4} The structure of interventional radiology (IR) services introduces additional variables increasing the potential risk of infection for IR team members. In China, 3.8% of all patients infected with COVID-19 were healthcare workers, with 14.8% of infected workers reaching critical status. ⁵ The symptoms from COVID-19 are similar to those seen during the Severe Acute Respiratory Syndrome (SARS-CoV) pandemic in 2002. The primary SARS-CoV treatment center in Korea performed IR procedures in 13.6% of the admitted patients in their center. ⁶ Given the high incidence of disease and volume of admissions related to COVID-19 in the United States, IRs are performing procedures on infected patients. Our division was tasked with engineering operational adaptations to mitigate and minimize risks to inpatients, outpatients, and staff. We report the adjustments in our practice to facilitate preparedness in IR.

Background

Vanderbilt University Medical Center (VUMC) is a tertiary referral center with a catchment area extending into multiple adjacent states, including Kentucky, Mississippi, and Alabama. The institution includes a level 1 trauma service; transplant service performing liver, kidney, heart, lung, and pancreas surgery; as well as busy urology, hepatobiliary, oncology, and nephrology services. The 850-bed adult and 271-bed children's hospital provides service for both inpatients and outpatients. The vein center is off site and outpatient only, while the outpatient IR clinic sees approximately 40 to 50 new and follow-up patients per week. Ultrasound and computed tomographic (CT) biopsies/drains are performed by a combination of vascular IR and body-imaging trained interventionalists. An outline of resources and historic staffing is presented in Table 1 . This article reflects our groups' response to the COVID-19 pandemic; the goal of this article is to report operational changes that can be used for this or future pandemics.

Table 1. Historical staffing at our institution and associated sites.

Location	Number of rooms	IR faculty
University Hospital	4 IR suites	3 attendings, 2 fellows, 2 residents
University Hospital	1 US and 1 CT scanner	1–2 attendings and 1 nurse practitioner, 2 residents
University Hospital	1 US	1 nurse practitioner
Children's Hospital	1 IR suite and 1 fluoroscopy room	1 attending
Vein Center	2 US procedure rooms	1 attending
Clinic	1 nonprocedure room	2 nurse practitioners and associated attendings

Abbreviations: CT, computed tomography; IR, interventional radiology; US, ultrasound.

Note: Fellows and residents rotate through Children's Hospital and the Vein Center, but trainees are not on site at those locations daily.

Outpatient Changes

Procedures

State government and institution leadership mandated elimination of elective procedures/surgeries, and clinical research trials were put on hold during the pandemic. IR procedure requests were categorized as elective, time-sensitive, and emergent as described by Mossa-Basha et al ( Table 2 ). ⁴ Time-sensitive procedures are defined as therapies where a delay in care could lead to worsening morbidity and mortality for the patient. Elective/nonurgent procedures are those in which a delay of 2 or more months will not harm the patient. Time-sensitive procedures can be delayed in the setting of concern about COVID infection until infection is excluded or the patient has recovered. Emergent procedures must be performed as soon as possible in order to avoid immediate patient harm.

Table 2. Categorization of the most common procedures performed in our division.

Elective/Nonurgent

• Enterocutaneous fistula repair

• Inferior vena cava filter removal

• Percutaneous sclerotherapy/embolization for congenital vascular malformations

• Procedures for treatment of venous insufficiency

• Prostate artery embolization

• Uterine artery embolization for bulk symptoms

Time-sensitive

• Central venous access, including port placement for chemotherapy

• Dialysis access maintenance

• Gastrostomy tube placement

• Gastrostomy or gastrojejunostomy tube replacement or exchange (leaking or clogged tube)

• Interventional oncology procedures

• Paracentesis/thoracentesis

• Routine nephrostomy or biliary drain exchange

• Uterine artery embolization for bleeding requiring transfusion

• Transjugular or percutaneous liver biopsy

• Tumor biopsy

Emergent

• Biliary drain placement for obstruction/cholangitis

• Embolization for arterial bleeding

• Percutaneous nephrostomy placement for obstruction/sepsis

• Transjugular intrahepatic portosystemic shunt/balloon-occlusion transvenous obliteration

Most of the case volume for academic interventional radiologists is time sensitive. Without IR performing these procedures, many patients would require hospital admission or develop worsening of prognosis by progression of symptoms or disease. These guidelines are best developed collaboratively with referring physicians to ensure adequate follow-up based on the planned intervention, such as chemotherapy administration via a port or transplant evaluation for treated hepatocellular carcinoma. For us, the impact of the schedule change has not notably changed the vascular procedure volume. However, the biopsy/drain service is operating at approximately 70% of usual volume with fewer inpatient postoperative drains and research biopsies.

Outpatients scheduled for time-sensitive procedures should be screened for any signs or symptoms of COVID by phone prior to their arrival in radiology, and they are screened again upon arrival to both the hospital and the radiology department ( Fig. 1 ). If a patient arrives for an image-guided procedure and is found to have fever, cough, or other signs or symptoms concerning for COVID infection, the patient should be redirected to a screening/test site. Such a site should be dedicated and remote from other patients; for us, a portion of the parking garage across from the emergency department was repurposed for these patients. If a patient has a pending COVID test, the procedure should be delayed until the test result is obtained. Having screening and testing onsite expedites the diagnostic process to ensure uninfected patients get procedures with minimal delay.

Fig. 1.

The COVID-19 screening tool used for all outpatients prior to procedures.

If a patient reports a history of a positive COVID test and a short delay in performance of their procedure is acceptable, the patient should be rescheduled after being without a fever for 72 hours or in the setting of two negative tests at least 24 hours apart. Preprocedure phone screening calls should again be performed on these patients.

Our institution introduced a no visitors policy for inpatients on March 18 with limited exemptions for special needs. ⁷ Given the relatively compact space of most outpatient IR preparation and recovery areas, disallowing visitors facilitates social distancing. Following routine procedures, communication is important, and physicians should call family members to discuss outcomes, concerns, and follow-up. This personalized communication helps mitigate the stress resulting from the lack of face-to-face communication.

Clinic Visits

Prior to the pandemic, telehealth follow-up consultation was being performed for outpatient interventional oncology patients residing in Tennessee with nongovernment insurance (Medicare, Medicaid, TriCare, Veteran's Affairs). This service worked through an institution-based cell phone application which is also used by patients to schedule/manage outpatient labs, clinic visit scheduling, and imaging. CMS allows these Telehealth visits to limit patient and staff risk of infection. ⁸

Because of the pandemic, telehealth is an ideal option for all IR clinic patients, including initial visits. Most physicians can be temporarily licensed for adjacent high-volume states to allow patients from those states to consult from home. On telehealth, images can be reviewed with patients in real time and questions answered. In addition to institutional phone applications, temporary provisions are allowed as a result of the federal government relaxing privacy and security requirements during the current pandemic. ⁹ Allowed applications include Zoom, Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, WhatsApp video, or Skype. This measure provides multiple potential routes of access for patients to facilitate social distancing. This expansion of telehealth has been quite popular with patients, especially those who normally drive several hours to get healthcare.

Inpatient Changes

New requests for time-sensitive procedures on inpatients should be reviewed by an attending physician. Patients without COVID are treated in the usual fashion, particularly with the intention to facilitate discharge. For patients under investigation of infection, time-sensitive cases are discussed with the referring team and put on hold until a final diagnosis is made. For COVID-positive patients, patients at our institution are deemed no longer contagious when they are asymptomatic and without a fever for 72 hours or in the setting of two negative tests at least 24 hours apart. Each institution must define criteria for this purpose. Procedures falling into the emergent category are performed as soon as possible. Patients under investigation and COVID-positive patients undergoing emergent procedures are treated identically with the goal of limiting the risk of transmission to staff. Regardless of where the procedure is performed, staff in the room during the case are kept to a minimum and personal protective equipment (PPE) is used following institutional policies.

It is ideal to designate one IR suite as the principal room for any COVID-infected patient coming to the department. This room should be isolated from the other IR suites and recovery area if possible. Procedures typically performed in fluoroscopy, such as nasojejunal tube placement, or ultrasound, such as thoracentesis, should be performed in this dedicated suite as well. A single CT scanner should also be designated in the event an abscess drain is required in a patient that is not targetable with ultrasound. For COVID-positive or suspected patients potentially managed with an ultrasound-guided procedure, a determination should be made if the procedure can safely be performed at the bedside without increasing the risk of procedure-related complications. The goal of performing a procedure at bedside is to limit the travel of infected patients throughout the hospital while still providing the highest level of care in a fashion mirroring the approach to other droplet precaution patients. In general, this decision is made based on the treating IR's assessment of risk and benefit, as well as the amount of equipment and staff who would be required to perform the procedure safely on the floor. If a procedure requires advanced imaging or significant equipment or support staff, the patient should be brought to the interventional suite where the environment can be more closely controlled. Examples of cases that can reasonably be performed at bedside include central venous access, paracentesis, thoracentesis, and some solid-organ biopsies. Early attending physician engagement can optimize communication with referring services and minimize time to procedure completion.

Consent

In order to limit exposure, once a procedure is approved for IR intervention, verbal consent from the patient or surrogate should be obtained by telephone per hospital policy. ¹⁰ Triaging sedation needs preprocedure should be determined by the attending physician and the IR nurse and/or the inpatient team nurse. If phone consent is unobtainable, verbal consent is obtained in the procedure room when the patient arrives. All consents should be verbal, as signed documents can be contaminated and require additional management. This approach to informed consent could potentially be applied to patients infected by other communicable diseases.

Bedside Procedures

If it is determined that a procedure will be performed at bedside, a house staff member or attending physician should notify the primary service of the plan and request that the primary service discusses the clinical indication for the procedure with the patient, family, or surrogate before consent is obtained and the IR team arrives to the room. The floor nurse can be asked to assist with the time out and specimen handling and can potentially be asked to assist in handing supplies or moving equipment if available. If the floor nurse is unable to assist, a radiology nurse may be required to travel to the procedure.

In order to protect procedure sterility and limit movement in/out of the room, the attending physician should create a thorough list of supplies required for the procedure and communicate the plan with the IR technologist and nurse. For bedside procedures, an ultrasound unit should be dedicated for travel to patient rooms. Before performing the procedure, the IR team should perform an additional huddle to ensure understanding of the steps of the procedure and assigned roles. Following the appropriate donning of PPE, the procedure can be carried out following standard sterile technique. Upon completion of the procedure, the supplies and equipment that are not used in the case are discarded in the patient's room and the ultrasound machine should be cleaned both outside of the patient room and again upon return to the department. Lastly, all procedural staff need to perform meticulous hand hygiene and change scrub attire.

Treatment Teams for Patients Coming to IR

A model that works for the management of each COVID-positive patient involves two teams: a primary and a support team. The primary procedure team includes the procedure attending, a house staff member, one nurse, and one technologist who remain in the room for the entirety of the procedure. Other personnel, including trainees, may be included as designated by the attending with the understanding to limit the number of engaged staff members in the room. The support team functions as runners; this ideally consists of one technologist and one nurse.

Prior to Patient Arrival

The primary and support teams should huddle prior to patient arrival to confirm the procedure and sedation plans. All supplies expected to be needed should be brought into the procedure room and supplies that may be needed can be kept with the support team immediately outside the room. Unnecessary equipment and supplies should be removed from the procedure room prior to patient arrival.

One member of the support team should be in charge of managing patient transport to the procedure room; this includes directing traffic, clearing hallways, and securing an empty elevator for patient transfer. A separate support staff member can be placed in charge to ensure the designated COVID procedure room is empty of all removable equipment and that the PPE donning and doffing stations have appropriate signage and sufficient PPE equipment. The procedure team radiology technologist prepares for the case in standard fashion.

Patient Arrival and Preparation

The procedure attending, technologist, and nurse should stay in the room for the entire procedure. If the patient is not intubated and requires anesthesia, intubation and extubation are performed on the floor if the patient is in a critical care area. Otherwise, intubation can be performed in IR. When intubation in IR is required, all staff other than the anesthesiologist should leave the room while the tube is placed. If a patient travels to IR on a ventilator, that ventilator should be used throughout the procedure so that the circuit does not become disconnected en route or in the procedure room. Once the patient is ready, the procedure team should don PPE per hospital policy outside the procedure room and sterile gown and gloves should be donned inside the room.

The World Health Organization separates airborne and droplet particles by size: airborne particles are less than 5 micrometers and droplets are greater than 5 micrometers. While SARS-CoV is droplet sized, procedures involving the airway such as intubation can shear droplets and generate infectious droplet nuclei that are less than 5 micrometers. ¹¹ Beyond direct airway manipulation, IR services should collaborate with the rest of the institution to identify and define airborne-generating procedures that could potentially need to be performed in COVID-infected patients.

During the Procedure

The support team technologist and nurse can communicate via overhead speaker, leaving the procedure room door closed. If needed, additional supplies can be passed into the room using a Mayo stand. Supplies can be pulled off the stand while attempting to avoid physical contact with the stand. The procedure nurse/technologist can open sterile supplies. The stand, including the wheels if applicable, should be cleaned in the control room by the support team technologist.

After Procedure Completion

Upon completion of the procedure, the support staff from the procedure room should help facilitate return of the patient to the floor. The procedure team can then remove their sterile gowns, gloves, and shoe covers within the procedure room and discard PPE immediately upon exiting. A member of the support team can assist in wiping down protective lead as each member from the procedure team exits. Face shields should be removed outside the room and cleaned for reuse. Hats and N95 respirators can be discarded outside the room in the appropriate bins. The procedure technologists can then wipe down the room and Environmental Services (EVS) should be called for terminal cleaning. All members of the procedure team should change scrubs following completion of each procedure. Most institutions will have hospital policy regarding room cleaning recommendations following a case with a suspected or confirmed COVID-19 patient; at VUMC, the room must stay empty for 1 hour. During this time, the EVS staff clean the room using PPE in accordance with institution guidelines. Use of a negative pressure room can limit the risk of spread of droplets or generated aerosols outside the room, but it does not decrease the time required for necessary air exchange to make the room available for another procedure. ¹¹

Staffing Adjustments

IR service

On March 22, the local government prohibited groups of greater than 10 individuals to gather to facilitate social distancing. ¹² To maintain compliance, daily morning rounds can be completed via Zoom meetings ( Fig. 2 ). Teaching conferences including didactic lectures, morbidity/mortality, and journal club can be similarly repurposed. The faculty, house staff, and physician extenders are ideally placed on staggered schedules, dividing into two groups to work weekly shifts at the hospital and from home. Outpatient elective clinics, like a vein center, should be closed with faculty redirected to the university hospital. Faculty and staff should wear surgical masks while at work and stay at least 6 feet apart whenever possible.

Fig. 2.

Rounds prior to staggered scheduling. Several team members are behind and beside the photographer and others are obscured in the back corner. Changing to Zoom for rounds improved compliance with social distancing guidelines.

Staff members should be assigned to a specific angiography suite or CT procedure room and instructed to stay within their room assignments throughout the day. This can prevent widespread infections, and it can help track exposures in the event that a team member gets sick or tests positive for COVID-19. Rather than utilizing float nurses or technologists to relieve staff for breaks, providing breaks to the entire room can also mitigate risk.

Redeployment of Staff

To prepare for a potential surge in critically ill patients, employees might be surveyed regarding potential roles outside current responsibilities. Some may be repurposed to provide temperature screening at the hospital entrance, covering COVID-specific screening areas, or assisting in the intensive care units. Interventional radiologists can be requested to perform bedside procedures, along with other procedure-oriented specialties. Most of these services currently focus on central venous access and arterial line placement.

Future Applications

Other authors have applied lessons learned from SARS-CoV to the current pandemic. Many of the current operational changes highlighted in this article can likely be applied in the event of future pandemics. These lessons learned include mitigation by prescreening phone calls, screening on arrival, and limiting visitors. Telehealth will likely to continue to evolve following the current pandemic; we strongly recommend that IRs get involved with telehealth services at their institutions. It is likely that patients will demand increase use of this technology. Intraprocedural management with a dedicated room, support team, and virtual consent can be maintained for existing pathogens such as mycobacterium tuberculosis or future pandemics. Finally, new collaborations with referring physicians should facilitate the IR's role in partnering with our colleagues to promote optimal patient care.

Conclusion

IR is inherently patient facing. Given the likelihood that approximately 14% of COVID-positive patients will require intervention and the high incidence of this disease in the United States, meshing mitigation with service sustainability is required for patients and referring physicians. Our VUMC IR division's preparedness strategy has maintained our ability to treat time-sensitive and emergent cases while maximizing protection of our patients and staff and mitigating the spread of COVID-19. Additionally, this process has allowed us to help other providers in the hospital in the event of a surge.

Funding Statement

Funding This work was not supported by any internal or external sources.