Radiology Resources for Coronavirus (COVID - 19)

• Radiology Reading Room Phone Numbers (This document is only accessible via VPN and/or MyAccess)
• PPE: N95 and Eye Protection Update
  • N95 Mask Distribution for Radiologists
• PPE Extended use and Reuse Guidance for Patient Care
• UCSF Adult Outpatient COVID-19 Treatment Guidance
• OHS escalation request for Return to Work 
• Incident Command Systems
  • UCSF Health Incident Command (HICS)
  • Radiology Dept Incident Command (RICS)

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.

• Dr. Brett Elicker’s presentation on interpretation of chest imaging in patients with COVID-19 (ppt)
• ACR Recommendations for the use of imaging in suspected COVID-19 infection

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

External Referring Providers (non-UCSF)

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

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.

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).

COVID-19 APEX Flags:

COVID-19 Flag	Interpretation
COVID-19 (Confirmed)	COVID-19 Infected Patient
COVID-19 (Pending)	Patient Under Investigation (PUI)
COVID-19 (Exposed)	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

Table 2: Diagnostic Imaging in Inpatients (Without Anesthesia)

Table 3: Diagnostic Imaging in Outpatients (Without Anesthesia)

Safe Practice Using PPE:

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

• Donning and doffing procedure (pdf)
• Donning and doffing novel coronavirus covid-19 (videos)

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

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)

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

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)

Isolation Status Links

• Contact Isolation
• Droplet Isolation
• Airborn Isolation
• Enteric Contact Isolation

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

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:

Safety Modifications for Staff:

• Guidance for employees and learners to return safely

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.

• Reading room best practices (pdf)

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)

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: