Guidance and considerations have been offered at various stages of the COVID-19 pandemic through this BSE COVID-19 resource website. The UK is now in its third wave, indices for infection and numbers hospitalised are generally on a downward trend. In addition to this, we are due to receive the Government’s strategy on relaxation of the current lockdown. There is also ongoing vaccination of the public as well as new virus strains.
These factors naturally lead to questions on the performance of echocardiography, particularly transoesophageal (TOE) and stress echocardiography (SE), whether by dobutamine (DSE) or exercise (ESE).
Earlier guidance has rightly focussed on the risks of potential infection between patients and healthcare staff, in relation to hospital attendance and diagnostic tests. It is increasingly important to acknowledge that cardiac conditions themselves are a source of potential morbidity and mortality. The provision of cardiac diagnostics is a vital component of recognising this risk in individual patients and providing a platform for further treatment to then be put in place, in line with Department of Health and NHS England aims.
Guidance on the performance of TOE and SE and measures to reduce the risk of COVID-19 transmission has been published here previously. We therefore continue to advise the following:
Local infection control policies and local pandemic trends, strains and considerations
Local public health, departmental and trust policies for working in the era of COVID-19 will require consideration in addition to those set out below. It is therefore not considered appropriate or possible to dictate each aspect of echo provision at a national level, but the following considerations alongside local factors should together afford the optimum policies. As situations evolve over time, certain factors may change and the response should accordingly change. Where outpatient and inpatient capacity has reduced due to the pandemic, the goal should be to work to increase capacity, perhaps with more lists but fewer patients on each list. The specifics on how to manage this will depend on centre-specific factors, and we encourage close communication with your local infection prevention (IP) team. Nevertheless, methods to work around barriers to service provision with appropriate safety considerations and measures should be our goal.
All factors should also be weighted up against the requirement to maintain diagnostic echo services for the local population and to both deal with and prevent further backlogs of patients waiting for tests. The aim of this document is to provide a structure for the provision of TOE and SE that provides reasonable mitigation against infection whilst affording the cardiac investigations that patients require. Periodic review of local strategy against local and national COVID-19 trends should also be performed.
Turn-around times between successive patients on a list
The time period between cases to reduce the risk of aerosol-related infection transmission will depend on local factors that consider the TOE room, its size, rate and method of air clearance, and a discussion of these factors with the local IP team.
The effect of vaccination of patients or staff and the effect upon performance of TOE and SE, whether ESE or DSE, is currently unknown. Personal and local policy may shape this until firm data is available to guide this better.
A COVID-19 questionnaire and COVID-19 swab within 72 hr of the procedure. The mandate for and duration of self-isolation prior to elective cases should be agreed in accordance with local IP policy.
Vetting of cases
Where clinical need requires the test, the test should be performed unless there is an alternative test that can provide the required information without incurring extra risk to the patient or potentially harmful delay in access to the alternative investigation. Where TOE is unlikely to result in a material change in the patient’s management, performance of the test should be reviewed with the referring team.
Outpatient waiting lists
These should be reviewed to see if the test is still indicated. Clinical status may have changed, the patient may have had a procedure negating the need for the original TOE request, or an alternative test may have answered the question. In some case the priority for performing a TOE may well have increased.
Inpatient versus outpatient considerations
As per the above, inpatient activity should be performed where it will materially change management. Outpatient provision will depend on local department considerations. Ideally such outpatients should be brought into a green day case area; if the area is not green, local policy should determine whether the outpatient service should continue.
Strict infection prevention measures depending on patient’s COVID-19 status:
- Positive (or clinically presumed positive despite negative swab) or COVID-19 contact should be dealt with by wearing full PPE.
- COVID-19 negative swab: In this situation, the clinical picture, the operator’s own risk level, and local infection prevention policies will influence the level of PPE worn.
National and local policies should be observed to reduce footfall, and maximise distances between patients and staff as far as practicable while maintaining a responsive service. Turnaround times between patients may be increased or decreased depending on local pandemic activity.
Pre-procedure screening: A COVID-19 questionnaire should be completed. COVID-19 testing within 72 hr of the procedure determined by local IP policy. The mandate for and duration of self-isolation prior to elective cases should be agreed in accordance with local IP policy.
Outpatient waiting lists
These should be reviewed to see if the test is still indicated. Clinical status may have changed, the patient may have had a procedure negating the need for the original TOE request, or an alternative test may have answered the question. In some case the priority for performing a SE may well have increased.
Consensus between operators and emerging data is that exercise stress is more likely to increase the risk of COVID-19 infection than pharmacological stress, despite exercise not being listed as an aerosol-generating procedure by Public Health England. Consideration of operator risk profiles, local viral trends., departmental expertise and the clinical question to be answered by the test e.g. aortic stenosis, hypertrophy cardiomyopathy, mitral stenosis assessments will require exercise rather than pharmacological stress (unless purely an ischaemia study).
Strict infection prevention measures depending on patient’s COVID-19 status: This may be determined by a COVID-19 questionnaire +/- temperature +/- COVID-19 swab within 72 hours of the test. Positive (or clinically presumed positive despite negative swab, where performed) or COVID-19 contact should be dealt with by wearing full PPE. COVID-19 negative: in this situation, the clinical picture, the operator’s own risk level, and local infection prevention policies will influence the level of PPE worn.