key: cord-0729829-hbtr9hq6 authors: Maizlin, Nick N.; Ohorodnyk, Pavlo title: Investigating the Initial Effect of COVID-19 on the Functioning of Diagnostic Imaging Facilities date: 2020-08-13 journal: Journal of Medical Imaging and Radiation Sciences DOI: 10.1016/j.jmir.2020.08.005 sha: f64442a1bb7a2f44d0157af2fe1d81ed39917f11 doc_id: 729829 cord_uid: hbtr9hq6 Abstract Introduction As a result of the COVID-19 pandemic, outpatient diagnostic imaging (DI) facilities experienced decreased operations and even unprecedented closures. The purpose of this study was to examine the impact of COVID-19 on the practices of DI clinics, and investigate the reasons for the change in their operations during the initial period of the pandemic starting in mid-March 2020. Materials and Methods A questionnaire was created and distributed to the managers of eighteen outpatient DI clinics in London, Hamilton, and Halton, Ontario, Canada. The managers indicated whether their clinics had closed or decreased operations, the reasons for closure, and the types of imaging examinations conducted in the initial period of the COVID-19 pandemic. Results Fifty percent of the DI clinics surveyed (9/18) closed as a result of COVID-19, and those that remained open had decreased hours of operation. All 9 clinics that closed indicated decreased referrals and suspension of elective imagining as the primary reasons for closure, followed by staff shortage and concerns for safety. Chest radiography and obstetric ultrasound were the most commonly conducted examinations. Clinics that were in close geographical proximity were able to redistribute imaging examinations amongst themselves. All DI clinics had suspended BMD examinations and elective breast screening, and transitioned to booked appointments only. Conclusion Many DI clinics needed to close or decrease operations as a result of the COVID-19, a phenomenon that is unprecedented in radiological practice. The results of this study can assist outpatient DI clinics in preparing for subsequent waves of COVID-19, future pandemics, and other periods of crisis. Introduction : En raison de la pandémie de COVID-19, les installations d'imagerie diagnostique pour les patients ambulatoires sont confrontées à une baisse de leurs activités et même à des fermetures. Cette étude vise à examiner l'impact de la COVID-19 sur la pratique des cliniques d'ID, et à examiner les raisons du changement dans leurs activités durant la période initiale de la pandémie, qui a débuté à la mi-mars 2020. Matériel et méthodologie :un questionnaire a été créé et envoyé aux gestionnaires de 18 cliniques d'imagerie de London, Hamilton et Halton, en Ontario, au Canada. Les gestionnaires ont indiqué si leur clinique avait fermé ses portes ou réduit ses activités, les motifs de la fermeture, et le type d'examens d'imagerie effectués durant la période initiale de la pandémie de COVID-19. Résultats : Cinquante pour cent des cliniques d'imagerie sondées (9/18) ont fermé leurs portes en raison de la COVID-19, et celles qui sont restées ouvertes ont réduit leurs heures d'ouverture. Les neuf cliniques qui ont fermé ont indiqué une baisse des demandes d'examens et la suspension de l'imagerie élective comme principaux motifs de la fermeture, suivis par une pénurie de personnel et des préoccupations pour la santé. Les radiographies de la poitrine et les échographies obstétriques ont été les deux types d'examens les plus fréquemment effectués. Les cliniques en étroite proximité géographique ont pu se partager les examens d'imagerie. Toutes les cliniques d'imagerie ont suspendu les examens de DMO et de mammographie de dépistage élective, et sont passés à une formule sur rendez-vous seulement. Conclusion: Plusieurs cliniques d'imagerie diagnostique ont dû fermer ou diminuer leurs activités en raison de la COVID-19, un phénomène sans précédent dans la pratique radiologique. Les résultats de cette étude peuvent aider les cliniques de radiologie pour patients ambulatoires à se préparer aux prochaines vagues de COVID-19, aux pandémies futures et à d'autres périodes de crise. Results: Fifty percent of the DI clinics surveyed (9/18) closed as a result of COVID-19, and those that remained open had decreased hours of operation. All 9 clinics that closed indicated decreased referrals and suspension of elective imagining as the primary reasons for closure, followed by staff shortage and concerns for safety. Chest radiography and obstetric ultrasound were the most commonly conducted examinations. Clinics that were in close geographical proximity were able to redistribute imaging examinations amongst themselves. All DI clinics had suspended BMD examinations and elective breast screening, and transitioned to booked appointments only. The COVID-19 pandemic, which began in mid-March 2020, impacted the operations of many healthcare institutions. Decreased patient volumes were reported across ambulatory practices (1), many non-urgent consultations were rescheduled (2) (3) (4) (5) , and numerous physician practices transitioned to conducting online telemedicine consultations to prevent the spread of COVID-19 (6) . Patient imaging was also impacted, as there was a significant decrease in imaging volumes due to factors such as governmental quarantine orders, rescheduling of elective imaging, and patient hesitancy in visiting healthcare settings due to fear of exposure to COVID-19 (3) (4) (5) 7) . Naiditch et al. examined the effect of the pandemic on various imaging modalities and found that the greatest decline in imaging volume was for mammography examinations (94% decrease), and the least decrease for radiography imaging (22%) (3). Outpatient diagnostic imaging (DI) facilities were particularly affected by the pandemic in comparison to other imaging locations, experiencing as much as approximately an 88% decrease in imaging volumes relative to 2019 (3) . As examined in this study, many outpatient DI clinics decreased operations or closed down entirely as a result of the pandemic. While previous literature examines the decreased patient volumes and operations of hospitals during prior disease outbreaks, such as SARS-CoV-1 (8) (9) (10) (11) (12) (13) (14) (15) (16) , there is no recorded instance of DI clinics closing during the prior outbreaks, making this a potentially unprecedented phenomenon. Thus, the objective of this study was to investigate the initial impact of the COVID-19 pandemic, starting in mid-March 2020, on the functioning of outpatient DI clinics by examining the reasons for the change in their operations, including closures, and to gain insight into their practice during the initial period of the outbreak. The results of the completed questionnaires for the 18 DI clinics are summarized in Table 1 Eight of the clinics that had closed also indicated staff shortage as a reason for the closure, citing issues with childcare as a contributing factor to the shortage. This was likely due to the closure of kindergartens and schools as a result of the provincial Ontario shut-down, forcing parents to take time off work and stay at home to care for their children. The same eight clinics that closed additionally indicated concerns for safety as reason for closure. While the exact concerns were not specified, it can be hypothesized that initially limited experience dealing with potential COVID-19 patients can be among the contributing factors to concerns for safety, as many institutions (healthcare and otherwise) were required to rapidly change their methods of operation with little preparation as a result of the pandemic. Interestingly, none of the clinics surveyed indicated a shortage of PPE as a reason for closure, despite the fact that many medical institutions were experiencing severe disruptions in PPE supply at that time (21). It may be that closing some DI clinics allowed the managing companies to re-distribute PPE resources to the clinics that did remain operational. Additionally, the closure of some clinics possibly allowed for the concentration of the remaining available staff resources in the clinics that remained open, as was similarly reported by Lee et al (19) . All the imaging clinics that had remained opened had decreased hours of operation. They had also all transitioned to booked appointments and cancelled walk-ins. The reduced clinic hours, combined with the increased time required for safety precautions such as disinfection between patient encounters (20, 22) , suggest that even clinics which had remained operational faced decreased referrals as compared to the pre-pandemic period. In the clinics which remained operational, the most common examinations were chest radiography and obstetric ultrasound. The prevalence of chest radiography studies correlates with the reports that radiography examinations experienced the least decrease in patient imaging volume during COVID-19 (3) , and this may be due to several reasons. The first is that chest radiography is one of the most commonly conducted examinations in regular DI clinic practice (23) , and it is possible that this remained the case during the pandemic. The second reason may be that many patients and referring physicians were concerned for COVID-19-related findings and wished to investigate them. The prevalence of obstetric US cases can likely be explained by the fact that, for the patients and referring physicians, the importance of tracking the course of pregnancy and its outcome outweighed the risks of the patient contracting COVID-19. In Group A, most US examinations (primarily obstetric US) were conducted in one location, while all the other locations focused on conducting X-ray examinations. Upon examination of the distances between the clinics, it may be suggested that close geographical proximity between the DI clinics allowed them to effectively redistribute referred cases (in Group A, the distance between most clinics was around 5.5 km). The study is limited in that it only assessed clinics in a limited geographical area, and it is possible that investigating the operations of DI clinics over a greater area (i.e., the whole province of Ontario) would have provided different statistical results. The study also did not investigate the exact dates when DI clinics reopened following the start of the pandemic. Investigating the aforementioned aspects would have been beyond the scope of the study, which was intended to specifically assess the initial impact of the pandemic on the general everyday functioning of DI clinics and the possible reasons for their closure. Finally, the study relied on self-reported data from clinic managers, and the results may have been affected by the managers' ability to recall information; however, this is unlikely as the data on the operations of clinics was collected at a time very close to the period being investigated (within two to three weeks). The COVID-19 pandemic in March 2020 had caused unprecedented effects on outpatient DI clinics. 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