key: cord-0828337-svsxxyqt
authors: Anand, Vidhu; Thaden, Jeremy J.; Pellikka, Patricia A.; Kane, Garvan C.
title: Safe Operation of an Echocardiography Practice During the COVID-19 Pandemic: Single Center Experience
date: 2020-12-28
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2020.12.015
sha: 986791e9096131ff9ad802c4d41e1c3a37c63d18
doc_id: 828337
cord_uid: svsxxyqt

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up of other cardiac conditions. [1] [2] [3] We present our opinion and review of the practices currently involved in the echocardiography practice at Mayo Clinic during the COVID-19 pandemic.

All patients coming for outpatient evaluation undergo a clinical survey encompassing questions about recent symptoms or exposures for COVID-19 infection prior to the appointment and again upon arrival. In addition, many patients referred for outpatient transthoracic echocardiography (TTE) undergo PCR testing as a requirement for other clinical evaluations. All patients have a PCR nasopharyngeal swab testing 48-72 hours prior to exercise stress test (EST) or transesophageal echocardiography (TEE) and on admission to the hospital; results are typically available within 24 hours. In patients with a positive clinical screen or positive PCR, the indication and acuity of the study are evaluated by the responsible echo physician to determine whether the indication for the study is urgent/emergent or whether the test can be safely postponed. Patients in whom the study (TTE, EST or TEE) indication is deemed to be urgent/emergent where the PCR test results are pending are managed similar to PCR test positive patients with respect to requirements for personal protective equipment (PPE) (Figure 1 ).

Universal precautions:

Universal precautions include universal masking at all times for patients and staff, protective eyewear or face shield by healthcare workers for all patient interactions, monitoring daily symptoms and twice daily temperature by all staff, and hand sanitation before and after every patient interaction. 4,5 Equipment, scanning bed and the examination room are wiped after each patient. 

For the typical patient without COVID-19 or in whom testing is pending but without clinical suspicion of infection, the sonographer wears a surgical mask and protective eye-wear. For patients with known or suspected COVID-19, although a surgical mask may be sufficient in some cases, to provide a consistent approach, the sonographer performing a TTE wears an N95 respirator, face-shield, gown and gloves. This policy was strongly influenced by the close proximity of the sonographer's front and side of face to the patient's face, the duration of exposure (30+ mins), and the common frequency that the inpatient is unable to wear a mask and that many patients have had a concomitant aerosol generating procedure (AGP) (recent intubation, positive pressure ventilation or nebulizer use or high flow oxygen).. studies done on patients with COVID-19, the machine is cleaned in the room and again after leaving the room. We have dedicated machines for use on COVID-19 positive patients which we store in a separate location. The standard procedure for TEE scope processing is adequate to kill the virus but staff must follow standard processes carefully including the use of PPE while cleaning the probe.

TEE is recognized as a high-risk AGP with increased risk of transmission, therefore, airborne precautions are necessary for all team members (gown, gloves, N95/PAPR, surgical cap, and face-shield ( Figure 3 )) in all patients with an unprotected airway, regardless of COVID-19 PCR status.. For the intubated and paralyzed patient (e.g., in the operating room), TEE staff are not required to wear N95/PAPRunless the patient is known or suspected to have COVID-19 infection.

EST is also considered aerosol-generating. For the supervision of EST, all staff members wear N95 respirators (or PAPRs) and face shields during exercise and recovery periods. EST is not performed J o u r n a l P r e -p r o o f in patients with active COVID-19 infection. Pharmacologic testing and pericardiocentesis procedures, as non-aerosol generating, are treated similarly to TTE with respect to PPE. As cardiopulmonary resuscitation is considered aerosol-generating, PPE kits (N95 and gown) are available outside all stress rooms in case of emergency.

All AGP rooms used were tested for air exchange by our department of engineering with alterations (additional air filtration units) to increase air flow made where possible. Following TEE or exercise stress testing, the room must be left idle for 7 complete air exchanges to allow for 99.9% clearance before the next patient can be roomed. Air exchange rates dictated that most rooms have a 10-30 minute idle time between procedures. For TEE, the time starts upon removal of the TEE probe and for EST, 6 minutes following termination of exercise.

Inpatient studies are performed at the patient's bedside. Studies are focused to address the specific indication accurately, while minimizing the contact time of staff with the patient. The study scope is discussed with the physician prior to entering the patient's room. Usually this will be a focused study evaluating biventricular function, assessment for pericardial effusion, and initial 2D and color Since myocardial injury reported in up to half of patients, point-of-care ultrasound (POCUS), has a role in bedside assessment and triage of patients with clinical deterioration. 6,7 POCUS can help diagnose acute left ventricular dysfunction (myocarditis or acute coronary syndrome or stress cardiomyopathy), RV systolic dysfunction (worsening hypoxia or pulmonary embolism), and worsening pulmonary status (consolidation, effusion and pulmonary edema). TTE is often needed for confirmation of findings, and when POCUS is non-diagnostic. 7 The POCUS protocol includes basic cardiac views (parasternal long, parasternal short, apical and subcoastal view) for cardiac function assessment; and lung views

Prone positioning is reported to improve outcomes in intubated and non-intubated patients with COVID-19 lung infection. 8, 9 Due to unstable respiratory and hemodynamic status in these patients, TTE is often requested and can provide important information on biventricular function. Apical views can be obtained by deflating the mattress on left thorax or slight re-positioning of the patient.

Modification of previously described "swimmers' position" with patient's left arm up may be used. 10 The sonographer is positioned on the left side of the patient and scans with their left hand.

To ensure adequate trainee teaching and experience while maintaining safety, we adopted the following measures. Echocardiography reading sessions was changed to live sessions on zoom within 2 weeks of declaration of pandemic, additional teaching sessions included those on congenital echocardiography, core curriculum sessions and informal reading sessions for Level 1 fellows led by advanced fellows. We scheduled simulator training for basic understanding of different TEE views for J o u r n a l P r e -p r o o f fellows as TEE practice was restricted to urgent cases and only advanced fellows with prior training and experience in TEE participated in performing these studies. As the elective clinical practice returned, fellows returned to in-person training, working one-on-one with sonographers (learning to scan) and with physicians (learning to interpret and perform TEE). With careful organization of the schedule, almost all learners (approximately 40 at one time) have been accommodated with only modest limitations placed on numbers. All echocardiography educational conferences and meetings are now held virtually, including a weekly morning imaging grand rounds and a noon case conference in which the interesting cases of the week are informally presented and discussed by fellows and faculty.

Whether as part of clinical practice or a clinical research trial, monitoring with echocardiography is important in serial assessment of cardiovascular function, and has continued throughout the pandemic. Many investigators, both trainees and staff, were able to take advantage of the reduction in clinical volume, to engage in research activities that normally occurred off hours.

Within the current era of COVID-19, it is important to provide echocardiography services safely for staff and patients as echocardiography remains the cornerstone of diagnosis and follow up of most cardiac conditions and cardiac manifestations of COVID-19 infection. Here we provide our experience of safe practices while maintaining excellent patient care and learner education. 

ASE Statement on the Reintroduction of Echocardiographic Services during the COVID-19 Pandemic

The Spectrum of Cardiac Manifestations in Coronavirus Disease 2019 (COVID-19) -a Systematic Echocardiographic Study

ST-segment Elevation, Myocardial Injury, and Suspected or Confirmed COVID-19 Patients: Diagnostic and Treatment Uncertainties

Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and metaanalysis

COVID-19 Testing: The Threat of False-Negative Results

Global evaluation of echocardiography in patients with COVID-19

ASE Statement on Point-of-Care Ultrasound (POCUS) During the 2019 Novel Coronavirus Pandemic

A Collaborative Multidisciplinary Approach to the Management of Coronavirus Disease 2019 in the Hospital Setting

Use of Prone Positioning in Nonintubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure

Transthoracic cardiac ultrasound in prone position: a technique variation description

The authors appreciate the tireless work of the Echocardiography Laboratory Administration and