Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic

Updated guidance on provision of echocardiography 25/03/2020

This consensus statement was drafted in an attempt to ensure that exposure to viral load is minimised for sonographers. Whilst standard face masks will stop droplet spread, we are concerned that smaller particles exist within the environment that have been generated by the patient (through coughing or sneezing), or by Aerosol Generating Procedures (e.g. suction or NIV) in an asymptomatic COVID +ve patient (pre COVID diagnosis), and that this is the route of viral transmission to the sonographer. Added to this is the face to face nature and close contact of echocardiography which is different from almost all other forms of diagnostic imaging.

We understand the anxiety of sonographers and it is important we also understand the real risk to healthcare professionals as we have seen in China, Italy, now evolving in Spain and recently in the UK. Anything that can be done to minimise this will be beneficial and may avoid individual and department transmission.

There is a shortage of PPE worldwide. This makes echo triage critical to ensure that echo is only undertaken when it will make an immediate change to management. We encourage all departments to escalate triage appropriately to ensure this happens in all hospitals.

Echocardiography is not an interchangeable skill that can be provided by non-trained personnel. Keeping sonographers well (and their colleagues out of isolation) will help to deliver time dependent scans during this COVID pandemic.

For these reasons the British Society of Echocardiography have recommended that full PPE should be provided to sonographers as per the following consensus pathway.

TTE consensus pathway

We hope this consensus pathway will help our members to stratify transthoracic echocardiography within their departments. This is not intended to be a guideline but should be adapted within your own department accordingly.

Provision of TOE 25/03/2020

In light of our evolving understanding of the COVID-19 pandemic, and in particular response to recent communication from the British Laryngological Association¹, the British Society of Echocardiography has produced updated clinical guidance regarding trans-oesophageal echocardiography (TOE).

Performing TOE necessitates exposure to aerosolised secretion and accordingly carries an increased risk of COVID-19 transmission. In addition, the symptom profile of COVID-19 is imprecise and heterogenous; making it hard to assess who is currently a vector. Lastly it is assumed that COVID-19 is now widespread in the UK.

The Society therefore now recommends the following:

1. All routine TOE cases should be cancelled
2. For cases where it is still felt that a TOE will have a significant and immediate impact on patient management, clarification with other key MDT members should be undertaken first (e.g. liaising with surgical colleagues to ensure that an operation remains possible if indicated or with microbiology colleagues to discuss potential treatment strategies for the management of infective endocarditis)
3. Perioperative TOE should be performed only if there is a favourable risk:benefit ratio whilst taking into account the added risk of COVID-19 transmission. The added airway protection provided by a cuffed endotracheal tube and closed circuit ought to reduce the risk of aerosol generation in an anaesthetised, paralysed and ventilated patient. However, the longer duration and exposure to airway secretions may increase infection risk. Care must be taken to avoid accidental extubation and disconnection of the anaesthetic circuit
4. Full personal protective equipment should be worn by all operators and assistants for all TOE examinations, including the use of an appropriate fit tested mask
5. Appropriate decontamination of the procedure room and equipment should be undertaken after each procedure

It is clear that the coming weeks will be very demanding for all healthcare professionals; please look out for each other and stay safe. Anyone who feels able to please share your learning points and experiences using the COVID-19 community on our website.

Authors:

• Tom Ingram - Consultant Cardiologist
• Dan Augustine - Consultant Cardiologist
• Claire Colebourn - Consultant Medical Intensivist
• Keith Pearce - Consultant Cardiac Physiologist
• Sandeep Hothi - Consultant Cardiologist
• Mahesh Prabhu - Consultant Cardiothoracic Anaesthetist

References

1. Message from the BLA President

Clinical context 16/03/2020

• On average a person infected with COVID-19 will transmit the virus to approximately three times more people than someone with seasonal influenza. This high reproductive factor has led to an unprecedented burden on the healthcare systems where the virus has become endemic. It is expected that the UK will experience a very high number of cases over the coming weeks and months.
• Evidence so far suggests that coronavirus has a mortality rate of approximately 2%. However, the toll is significantly greater in patients with established cardiovascular disease and cardiovascular risk factors (particularly increasing age)¹.
• In addition to the development of acute respiratory distress syndrome, COVID-19 has been associated with the development of myocarditis, heart failure, arrhythmias and myocardial infarction.
• Reports from colleagues in China and Italy emphasize the importance of establishing a patient’s cardiovascular status (and reserve) early in the disease process. It is therefore extremely likely that the UK will see a significant increase in demand for hospital in-patient trans-thoracic echocardiography (TTE) during the COVID-19 pandemic.

Approach to the provision of echocardiography staffing

• Sonographers are advised to follow their individual Trust’s policy regarding the use of personal protective equipment. This will require an initial assessment for mask fitting. Several Trusts are requesting that men’s faces are clean shaven for this process.
• Departments should consider how they will create the additional capacity required to cope with the anticipated increase in demand for in-patient TTE. This may include delaying elective activity, a process that is supported by the UK government as it minimises exposure of an at-risk group of patients to potential COVID-19 contact in the hospital environment.
• It is anticipated that the available workforce will be reduced by approximately a third at any one time due to the requirements of self-isolation and associated constraints. As the effects of COVID-19 spread, this workforce may also be required to provide support during unsociable hours.
• Sonographers with specific health problems that place them at greater risk to COVID-19 may need to be excluded from in-patient scanning.
• In their recent Joint statement, the Chief Executives of the UK statutory regulators of health and care professionals wrote ‘We recognise that in highly challenging circumstances, professionals may need to depart from established procedures in order to care for patients’². In practical terms this acknowledges that sonographers may inevitably need to work outside of their current level of practice during the anticipated exceptional circumstances; providing that the care given remains within an over-arching institutional supervision structure. This is particularly relevant for the interface between level 1 and level 2 TTE.

Approach to the provision of echocardiography scanning

• It is essential to minimise exposure of healthcare professionals to aerosolized particulate matter from COVID-19 infected cases. Accordingly, transthoracic echocardiography offers a safer approach than trans-oesophageal echocardiography (TOE) both in the unventilated and invasively ventilated patient where disturbance of the airway protective cuff of the endotracheal tube may occur during intubation with the oesophageal probe.  Where TOE becomes absolutely necessary the procedure should be carefully planned with the caring team to minimise patient and staff risk.
• Many patients who become critically ill with COVID-19 will have cardiovascular disease, this may worsen during the acute illness.  Secondly, patients with no previous cardiovascular disease may develop a range of cardiovascular manifestations of COVID-19 during their illness mandating cardiac imaging at the bedside.  Lastly, patients who require advanced ventilatory support have alveolar shadowing similar to that seen in heart failure necessitating establishment of current ventricular function and left ventricular end-diastolic pressure. It is therefore likely that TTE will become a key test in guiding both decisions to escalate care to invasive ventilation and the optimisation of invasive ventilation. Departments are recommended to be proactive and liaise closely with their Acute Medical and Intensive Care Units to provide timely scans to aid with this complex decision-making process.
• In many cases the information provided by a Level I study will provide the information needed by the requesting clinicians. Additional specific questions may require more advanced scanning and therefore longer time at the bedside, on a case by case basis.
• Bedside echocardiography performed using a dedicated portable machine is the preferred option in all of the above situations.
• Manufacturer guidance regarding the approved agents to adequately decontaminate probes/machines is available³.
• Utmost care must be taken to decontaminate the machine between patients and to adhere to core governance principles even whilst under unusual work pressures: specifically appropriate upload of studies, review where necessary and reporting in a clinically time-relevant and helpful way.

Research

Part of the global strategy for tackling COVID-19 is the rapid roll-out of research programs to explore this new disease. The British Society of Echocardiography would urge all of its members to participate in this gathering of vital new information. We will keep you informed of ethically approved registries as they are generated through our website.

Authors:

• Tom Ingram - Consultant Cardiologist
• Claire Colebourn - Consultant Medical Intensivist
• Keith Pearce – Consultant Cardiac Physiologist

References:

1. ACC Clinical Bulletin: COVID 19 Clinical Guidance For the CV Care Team
2. COVID-19 Joint Regulators Statement
3. Philips Ultrasound Care and Cleaning guideline
   Siemens Ultrasound Cleaners and Disinfectants
   GE Healthcare Ultrasound Cleaners and Disinfectants

Useful links

• Infection prevention and control in healthcare settings
  Updated government guidance on PPE and masks
• COVID-19 community
  Member-only discussion forum
• GE Healthcare cleaning advice
• Philips cleaning advice
• Siemens Healthineers cleaning advice