key: cord-0967031-qm4n7wn7 authors: McMahon, Sean R.; DeFrancis, Garett; Schwartz, Sara; Duvall, William L.; Arora, Bhaskar; Silverman, David I. title: Tablet Based Limited Echocardiogram to Reduce Sonographer Scan and Decontamination Time During The COVID-19 Pandemic date: 2020-05-11 journal: J Am Soc Echocardiogr DOI: 10.1016/j.echo.2020.05.005 sha: a5403eb5e95c79cf0f21d06a01dfd3f89cc986dc doc_id: 967031 cord_uid: qm4n7wn7 Background Limited assessments with handheld ultrasound have found meaningful clinical use in the care of acutely ill patients. However, there are limited data on incorporating handheld based limited echocardiograms into the echocardiogram laboratory. The purpose of this study is to assess the efficacy of a limited handheld tablet echocardiogram as an alternate to traditional echocardiography during the COVID-19 pandemic as a means to limit exposure while providing essential clinical information. Methods Ninety consecutive inpatients with known or suspected COVID-19 infection were scanned according to laboratory COVID-19 guidelines using a limited 11-20 clip protocol on a tablet sonograph. The primary assessment was length of study time. Comparison data was drawn from comprehensive echocardiograms ordered on intensive care patients not under COVID-19 precautions. Results Over a 36 day time period there were a total of 91 requests deemed to be appropriate for echocardiography on COVID-19 positive or suspected patients (average age: 67, 64% male, body mass index 32kg/m2). Of these, ninety (99%) were performed on a handheld device and all were deemed diagnostic and provided sufficient information for the clinical care team. Sonographer scan time decreased from an average of 24±6.8min on a traditional platform to 5.4±1.9min on a tablet. Conclusions Limited handheld echocardiography can be successfully implemented in the echocardiography laboratory for screening of COVID related cardiac conditions. The protocol performed with handheld tablet ultrasound provides adequate diagnostic information of major cardiac complications of COVID-19 infection while decreasing sonographer contact and simplifying decontamination. COVID-19 poses significant risk to those health care workers most proximate to infected patients, 1 including cardiac sonographers. The time it takes to produce a comprehensive echocardiogram, and the difficulty in decontaminating a full ultrasound platform needed to produce it, are likely to only increase the risk of sonographer infection further. While the visual and quantitative fidelity of comprehensive echocardiography is far superior, we believe that the information gathered in COVID-19 patients should be balanced against the risk produced by increased contact time and ultrasound platform contamination. We hypothesized that a handheld ultrasound platform utilized for a bedside limited echocardiogram would provide a safe, practical and adequate diagnostic alternative to standard echocardiography in these patients. [2] [3] [4] [5] Herein we report the results of a consecutive series of focused ultrasound examinations in patients with known or suspected COVID-19 infection using a handheld device. This is a retrospective single center observational study performed at Hartford Hospital in Hartford, CT during the COVID-19 pandemic. Hartford Hospital is an 867 bed quaternary care regional referral center with a high volume echocardiography laboratory performing >14,000 combined studies annually. This study was approved by the institutional review board at Hartford Hospital. In the interest of timely presentation of data given the urgency of the current crisis, a limited assessment on 90 patients was deemed adequate for analysis. During the study period consecutive inpatients with known or suspected COVID-19 infection were scanned according to new laboratory COVID-19 guidelines using a limited 11-20 clip protocol on a tablet sonograph (Table 1) . The studies were requested by the clinical team and individually vetted as clinically appropriate by an attending echocardiographer. Inclusion criteria were all consecutive patients over 18 years of age with COVID-19 or suspected COVID-19 who received a bedside echocardiogram performed during the study period; 3/14/2020 through 4/19/2020. These echocardiograms were performed using a handheld ultrasound device (Philips Lumify, Andover MA) and a focused protocol. The limited protocol (Figure 1 ) was designed to streamline echocardiograms while providing diagnostic information regarding common COVID-19 related cardiac complications. The standard protocol was used in all patients unless specifically ordered for assessment of function only. Ultrasound enhancing agents (UEA) were used for technically challenging patients per American Society of Echocardiography guidelines. 6 Statistical analysis was performed using SPSS software (IBM SPSS Statistics for Windows, version 26, IBM Corp., Armonk, N.Y). Baseline characteristics are described using means for continuous variables and categorical variables were described using frequencies or percentages. Continuous variables were analyzed using an unpaired t-test and categorical variables were analyzed using either 2X2 or 2X3 contingency tables. P values ≤ 0.05 were considered significant. Over a 36 day time period there were a total 657 transthoracic echocardiograms performed by the laboratory including 91 performed on COVID-19 positive or suspected patients (mean age: 67±14yrs, 64% male, body mass index 32±10kg/m 2 ). Of these, ninety (99%) were performed on a handheld device and one patient was determined to require comprehensive echocardiography on a traditional platform. Indications for handheld echocardiography were: congestive heart failure or suspected cardiomyopathy (23%), shortness of breath or hypoxia (19%), chest pain, suspected myocarditis or acute myocardial infarction (16%), shock, hypotension or cardiac arrest (14%), atrial fibrillation or other atrial arrhythmia (12%), pulmonary embolism or RV failure (4%), stroke (3%), pericardial effusion or suspected tamponade (2%), miscellaneous (6%). Fifty seven studies (63%) were performed on intubated patients. Of those studies performed with a limited handheld echocardiogram, all were deemed diagnostic and provided sufficient information for the clinical care team. Nine patients received UEA to improve endocardial definition. The average BMI in patients receiving contrast was significantly greater than patients not receiving contrast (43±25kg/m 2 vs. 29±7.7kg/m 2 ; p=0.02) .There were no immediate requests for additional imaging due to inadequate studies, however, there were a total of five patients (8%) who later had repeat imaging, all in the context of rapid clinical decline. In the control group 7 (12%) patients underwent repeat imaging due to change in clinical status ( Table 2) . The present study demonstrates the feasibility of tablet based limited cardiac ultrasound for the evaluation of patients with suspected or confirmed SARS-CoV-2 infection during the COVID-19 pandemic. The study provides the blueprint for an alternative workflow during the pandemic, or any other circumstance in which study time or operator risk are important factors. Our approach reduces scan time and simplifies device decontamination without sacrificing the ability to obtain the information necessary for the clinician to make critical decisions. Point of care (POC) focused cardiac ultrasound using a handheld device has been widely adopted as a diagnostic tool in critical care settings, including the intensive care unit and emergency department (ED). In ED patients with hypotension of unclear etiology, POC ultrasound provided useful diagnostic information within 6 minutes on average. 8 For COVID-19 patients, however, the advantage speed provides is an increase in operator safety. The portability, simplified features, and easy decontamination of a handheld ultrasound provides an ideal alternative for imaging these highly contagious patients. Our limited examination focused on biventricular size, function, wall motion assessment, pericardial effusion, brief assessment of valve function, and right atrial pressure. Similar protocols specific to COVID-19 patients have been suggested in recent publications with the additional emphasis upon diligently screening for appropriateness. 9, 10 Our approach serves as a "gatekeeper" to the use of comprehensive echocardiograms performed on full ultrasound platforms. A prior study demonstrated the feasibility utilizing handheld echocardiography as a screening tool for appropriateness. 11 The current study validates the use of a preliminary limited assessment with a handheld ultrasound in inpatients meeting appropriate use criteria in the COVID-19 population. Severe cases of COVID-19 have been associated with greater viral load and longer duration of viral shedding. 12 Inpatients with COVID-19 may present particularly high risk for disease transmission. Thus, mitigating risk by reducing exposure time is essential. In our study, the duration of scanning time for patients receiving a limited echocardiogram was reduced by 79%. Further, the total duration of time spent in the patient's room decreased by 71%. The ease of use, rapid image acquisition, and absence of plug in/startup/powering down time all contribute to this significant reduction in exposure. Additionally, following the manufacturer recommended protocol, the time required for the disinfection decreased 86% with using a tablet sonograph. In our cohort, only 12 (13%) patients performed on the tablet sonograph underwent repeat imaging. The repeats were clinically appropriate reassessments in the setting of critical illness. There were no studies repeated due to inadequate imaging/interpretation of the preliminary study performed on the tablet. There was no significant difference in number of repeat echocardiograms between the limited tablet cohort vs the control group. The efficacy of our protocol has produced immediate benefits. To date, the lab has performed one comprehensive echocardiogram on a traditional platform on a COVID-19 suspected patient as a primary study. The indication was cryptogenic stroke; the superior imaging of a full platform and the ability to perform and record a saline contrast injection provided better sensitivity for detection of suspected interatrial shunt. The handheld system is best seen as an alternative and not a substitute for a comprehensive study. All three forms of resolution, axial, lateral and temporal, are superior on a traditional platform compared to a handheld device. Focusing, harmonic imaging, compression, time-gain-compensation, and strain imaging are all available on the former and not later. The comprehensive hemodynamic assessment that spectral Doppler provides is absent. Given the ubiquitous presence of dyspnea in these patients, an assessment of pulmonary artery systolic pressure might be desired. However, in the unique circumstances produced by the pandemic the advantages of the handheld device, it may be argued, thoroughly outweighed its limitations. Even the use of ultrasound enhancing agents injected with the tablet set to reduced output power was possible when indicated (Figure 1 ). Tablet based ultrasound proved sufficient to guide pericardiocentesis in the catheterization laboratory in a suspected COVID-19 patient with cardiac tamponade. Furthermore, images are stored and are reviewable in our PACS system in accordance with American Society of Echocardiography recommendations 13 and undergo billing as limited echocardiograms allowing complete integration into the laboratory workflow. This is a single center retrospective study with a small sample size. Readers could not be blinded to study type during interpretation. During this pandemic, ordering of diagnostic testing on COVID-19 positive patients is likely done with more prudence out of concern for staff. This may have led to less repeat echocardiograms in the COVID-19 population as compared to the control group. In facilities without proper integration of handheld ultrasound equipment to a PACS system a similar protocol may not be feasible. In the absence of the urgency produced by the pandemic, we would have preferred to study more patients, collect more data, and perform a validation study comparing tablet based and comprehensive echocardiograms on the same patients. Under the direction of the echocardiography laboratory, limited tablet ultrasound can be successfully used for screening of SARS-COV-2 related cardiac conditions. A limited protocol performed with handheld ultrasound provides adequate diagnostic information of the major cardiac complications of COVID-19 infection while decreasing sonographer exposure and simplifying decontamination. Handheld portable ultrasound is an effective alternative to standard platform imaging in patients with suspected or confirmed COVID-19 infection. An overwhelming majority of handheld studies are sufficient to answer the relevant clinical questions being asked and to guide further management in these patients. Study time is markedly reduced (79% less) thereby reducing sonographer exposure and infection risk. A contrast agent can be used to enhanced image fidelity when necessary. COVID-19 and the Risk to Health Care Workers: A Case Report Diagnostic accuracy of a hand-held ultrasound scanner in routine patients referred for echocardiography Validation of a new bedside echoscopic heart examination resulting in an improvement in echo-lab workflow The use of handheld ultrasound devices: a position statement of the European Association of Cardiovascular Imaging Echocardiography in the Time of COVID-19 American Society of Echocardiography Guidelines Update Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients ASE Statement on Point-of-Care Ultrasound (POCUS) During the 2019 Novel Coronavirus Pandemic Utilization and Appropriateness of Transthoracic Echocardiography In Response to the COVID-19 Pandemic Handheld ultrasound to reduce requests for inappropriate echocardiogram (HURRIE) Viral dynamics in mild and severe cases of COVID-19 Recommendations for Echocardiography Laboratories Participating in Cardiac Point of Care Cardiac Ultrasound (POCUS) and Critical Care Echocardiography Training: Report from the American Society of Echocardiography