key: cord-0691025-y8857da3 authors: Desai, Urvi; Kassardjian, Charles D.; Del Toro, David; Gleveckas‐Martens, Nida; Srinivasan, Jayashri; Venesy, Deborah; Narayanaswami, Pushpa title: Guidance for Resumption of Routine Electrodiagnostic Testing during the COVID‐19 Pandemic date: 2020-05-28 journal: Muscle Nerve DOI: 10.1002/mus.26990 sha: 3fcad44a02f86d83b35808a1aa2d196a6cd0959f doc_id: 691025 cord_uid: y8857da3 As the world accommodates to the COVID‐19 pandemic, routine in‐person medical services are resuming. The resumption of non‐urgent electrodiagnostic (EDX) testing faces unique challenges due to the long duration of the procedure and direct close contact with patients, including studies with risk of exposure to oropharyngeal secretions. We provide consensus guidance for resumption of EDX testing, addressing scheduling, patient arrival and registration, use of personal protective equipment, COVID‐19 screening and testing, the performance of EDX in outpatient and inpatient settings, cleaning and maintenance of the EDX equipment and laboratory, balancing trainee safety and training requirements, and patient care issues. These are broad recommendations which need to be adapted to local COVID‐19 risks, institutional guidelines and policies, and changing federal, state and local regulations, and to changes in the pandemic over time. This article is protected by copyright. All rights reserved. The coronavirus disease-2019 (COVID-19) pandemic has necessitated several measures to contain or limit spread of the disease. Social distancing and the use of personal protective equipment (PPE) are two frequently used measures. In healthcare, balancing the risk of infection and the demand for healthcare resources to treat COVID-19 affected patients has resulted in a significant reduction of non-urgent in-person healthcare delivery. Alternative modes of healthcare delivery such as telephone visits or video platforms ("telemedicine") are being increasingly utilized to provide healthcare. 1, 2 However, non-urgent healthcare cannot be delayed indefinitely. Unique challenges with electrodiagnostic (EDX) testing in this context include the long duration of testing, close, direct patient contact (including studies with risk of exposure to oropharyngeal secretions), and potential for contamination of the EDX equipment. The goals of this consensus guidance are to minimize disease transmission in patients and healthcare personnel (HCP), to identify and appropriately triage persons with possible COVID-19 infections, and to balance efficient use of PPE with protecting HCP, while providing EDX services to patients. 3 This article is protected by copyright. All rights reserved. Resuming routine EDX during COVID-19 Page of 25 In response to member requests, the AANEM Quality and Patient Safety Committee (QPSC) developed this practice guidance for resumption of routine EDX services in the COVID-19 pandemic. At an initial video-call of the QPSC members and AANEM staff on May 8, 2020, we considered the document scope and identified a writing group. We reviewed available institutional guidance and Centers for Disease Control (CDC) recommendations and drafted a document. We held video-calls on May 14 and May 15, 2020 and finalized the document with input from QPSC members and AANEM staff. The draft was approved by the AANEM Board of Directors on May 17, 2020. 5. Consider collecting co-payments over the telephone or using contactless methods. Modifications to patient arrival and registration processes should be aimed at avoiding overcrowding and facilitating social distancing. Points of entry to the testing facility should be monitored to limit entry and enforce social distancing. Patients can be asked to wait in their cars upon arrival and present for registration at their appointment time. Alternatively, the patient may check in by telephone from the parking lot and be This article is protected by copyright. All rights reserved. Resuming routine EDX during COVID-19 Page of 25 escorted by staff to the EDX laboratory or called to report for check-in just before their appointment time. 3. If clinic waiting areas are used, the chairs should be rearranged at 6-foot intervals. Social distancing markers 6 feet apart should be placed in the waiting room and around the registration area. There should be clear signage to instruct patients. Discrete entrances and exits should be designated and clearly marked, with the option of using escorts to guide patients in and out of the facility. Accompanying persons should be asked to wait outside the institution unless their presence is necessary to perform EDX testing (e.g., in young children, patients with cognitive impairment). i. All patients should wear face masks. ii. All patients should perform hand hygiene before EDX testing with alcoholbased hand sanitizers (containing 80% ethanol or 75% isopropanol) or soap and water. iii. All HCP in contact with patients should wear PPE. This article is protected by copyright. All rights reserved. i. Limit the number of HCP in the EDX laboratory. Observers (e.g., medical students or visiting trainees/faculty) should be avoided. ii. Plan the study to obtain data efficiently and minimize study duration. Avoid studies that may not add meaningful diagnostic information. iii. There is a risk of contamination of EMG supplies if handled during the procedure (e.g., when replacing the ground electrode with a new one). This may be reduced by using a pre-assembled single-use kit for each study. The kit should contain alcohol wipes, electrode paste if required, disposable electrodes, a measuring tape, adhesive tape, a small pack of gauze, one EMG needle, and a marker pen. iv. Because supplies may need to be replenished during the procedure, a "secondary kit" with an extra needle and electrodes may be useful, while keeping the bulk of supplies outside of the EDX room. This article is protected by copyright. All rights reserved. Resuming routine EDX during COVID-19 Page of 25 v. Strongly consider using disposable electrodes. vi. Use disposable markers or clean and disinfect the markers after each use. vii. Use disposable tape measures or clean and disinfect measuring tapes after each use. viii. Use disposable heating packs or an alternative method of warming such as heat lamps. ix. Cover the patient with a sheet/blanket to minimize direct contact. i. For inpatient EDX studies on patients who are not suspected of having COVID-19 infection, we recommend following the procedures in section 4. ii. Inpatient EDX studies on Covid-19 positive patients, patients on ventilators, and patients using non-invasive positive pressure ventilation (NIPPV): 1. The critical need for the study and the potential utility of EDX results in changing management should be discussed with the ordering clinician. 4 In some instances, the information may be obtained by other testing modalities such as imaging, and in others, the study may be postponed until patient is not infectious. In patients on ventilators or using NIPPV, the study should be postponed until two This article is protected by copyright. All rights reserved. 2. Consider using protective plastic covers that can be wiped for the keyboard, computer mouse, and protective plastic barriers between the patient and machine. 3. Minimize furniture and other non-essential objects in the laboratory. 4 . Remove furniture that is upholstered with fabric or other material that cannot be disinfected. ii. Cleaning of the EDX Laboratory: 1. Custodial services may not be available to clean EDX laboratories between procedures, and EDX laboratory staff will have to perform room cleaning. Use soap and water to clean surfaces where feasible prior to disinfection. 2. Wipe down all hard surfaces including, but not limited to doorknobs, kiosks, elevator buttons, handrails, light switches, chairs, stools, beds, computer keyboards, mouse, screens, telephones, sinks/faucets, counter spaces with disinfecting wipes following product Telehealth Utilization in the COVID-19 pandemic Outpatient and Ambulatory Care Settings: Responding to Community Transmission of COVID-19 in the United States Practical Guidance for Managing EMG Requests and Testing during the COVID-19 Pandemic COVID-19 Personal Protective Equipment (PPE) for Healthcare Personnel Accessed May 14, 2020 6. Sequence for putting on and removing personal protective equipment This article is protected by copyright. All rights reserved. Resuming routine EDX during COVID-19 Page Testing recommendation for COVID-19 (SARS-CoV-2) in patients planned for surgery -continuing the service and 'suppressing' the pandemic Discontinuation of Isolation for Persons with COVID -19 Not in Healthcare Settings Reopening Guidance for Cleaning and Disinfecting Public Spaces We would like to thank AANEM staff Carrie Winter and Millie Suk, Executive Director Shirlyn Adkins and the Board of Directors for their input. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.