key: cord-0820126-u4rq6vco
authors: Di Matteo, Andrea; Mankia, Kulveer; Filippucci, Emilio; Grassi, Walter; Rowbotham, Emma; Wakefield, Richard J
title: Facing the challenges of running a rheumatology-based ultrasound service in the COVID-19 era
date: 2020-12-28
journal: Rheumatology (Oxford)
DOI: 10.1093/rheumatology/keaa844
sha: 8dded1c8510a53953de485b4172b9f26e725deaf
doc_id: 820126
cord_uid: u4rq6vco

nan

The Covid-19 pandemic has had major implications for clinical rheumatology services. Departments have tried to minimize the spread of the virus by reducing patient attendances, for example by the increased use of telemedicine for the management of stable patients and those conditions deemed non-urgent. This has been largely successful and the practice may well be here to stay. However, US, a service now integral to many rheumatology clinics, cannot be performed remotely and requires close and sometimes prolonged patient contact. While general recommendations now exist for using US in the context of Covid-19 [1] [2] [3] , none specifically address rheumatology-led US services.

We would like to share some of our experiences to date at two large and busy clinical and research centres in countries with a high prevalence of Covid-19 infections.

Reducing scanning exposure risk a. Considering appointment type. We have continued to offer our one-stop services for new early arthritis referrals, to facilitate immediate decisions regarding diagnosis, the commencement of treatment or the discharge of patients. We have advised that clinicians scanning their own patients as part of a face-to-face appointment, should scan in the same room as the clinical assessment. Most of our current scanning, however, is through a formal booking service. We have discouraged ad hoc referrals on the day requests to minimize patient movement around the department. b. Limiting the number of scans to US examinations to those considered essential only. , and so particular attention should be directed to these patients. d. Limiting lengths of scanning time. Rheumatologists often scan multiple joints, which may on average take between 20-25 minutes in a clinical setting. US research protocols, however, may take up to 75 minutes. In contrast, radiology musculoskeletal sonographers usually complete their work in 15-20 minutes, as their scanning is usually limited to one joint/region. We have tried to limit joint numbers to the least that offer the answer to the main clinical question. This is not possible, however, for research patients, for whom predetermined specific groups of joints need to be scanned. It has been suggested that a minimal number of images are saved per examination to minimize annotation time.

a. Wearing appropriate personal protective equipment. This will be dependent on the institution, but as standard, we have opted to wear a face mask, gloves, eye protection and an apron. For sonographers at a higher risk (e.g. those with comorbidities), and who have failed standard FFP3 mask fittings, we have sourced positive pressure headsets on the grounds that they have significant contact times with patients. b. Cleaning scanning environment. Between each examination, the machine, probes and cables, couch and chairs are wiped down using appropriate agents. Published guidance has suggested appropriate regimens for probe sterilization [5] . Additional time has been added to appointments to allow adequate equipment and room cleaning. c. Room ventilation. We have debated the risk of air conditioning. According to the UK Health and Safety Executive [6], risk is very low, assuming there is an adequate supply of fresh air and ventilation. However, with US there is also the potential additional risk of the machine fans stirring up the air. The compromise has been to turn the air conditioning off during patient examinations. It has been suggested that windows and doors are kept open to improve air circulation, but this needs to be considered against the need to maintain patient privacy.

CSs are frequently used in rheumatology, but data with respect to their risk in the context of COVID-19 is lacking. The UK NHS has recently provided guidance recommending for 'patients who require a CS injection', to 'only give a steroid injection if a patient has significant disease activity and/or intrusive and persisting symptoms and there are no appropriate alternatives' [7] .

Conventional US-guided injections should currently be considered on an individual basis, and avoided if alternative treatments are possible. The potential for short-lived immunosuppression has been discussed within the literature [8] , but the risks need to be measured against the high prevalence of musculoskeletal problems that can be effectively managed with a steroid injection.

Pre-Covid-19, we regularly received students or trainees to observe and gain hands on experience in clinics. We now have to reconsider the way we offer training opportunities. It is likely that in the future, some training will be delivered remotely [9] , with only one trainee attending clinic at any one time. In addition, we suggest that trainees' contact time with patients should be limited to more focused examinations of a particular structure rather than the entire examination [10] . We are also looking at virtual reality and simulation systems as potential surrogates for learning both diagnostic and interventional techniques.

In conclusion, the provision of an US service is integral to clinical rheumatology services. However, it poses risks for the transmission of COVID-19. We hope that our observations may be helpful to others who are currently evaluating their own US services.

Data are available upon reasonable request by any qualified researchers who engage in rigorous, independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan (SAP) and execution of a Data Sharing Agreement (DSA). All data relevant to the study are included in the article.

ISUOG Safety Committee Position on safe performance of obstetric and gynaecological scans and equipment cleaning in context of COVID-19

World federation for ultrasound in medicine and biology position statement: how to perform a safe ultrasound examination and clean equipment in the context of COVID-19

ASE statement on protection of patients and echocardiography service providers during the 2019 Novel Coronavirus Outbreak: endorsed by the American College of Cardiology

Management of patients with musculoskeletal and rheumatic conditions who: are on corticosteroids; require initiation of oral/IV corticosteroids; require a corticosteroid injection

Covid-19: a rethink of corticosteroid injection?

E-learning in ultrasonography: a web-based approach

Resumption of Clinical Training in Ultrasound during the COVID-19 Pandemic

The authors would like to thank Drs Jane Freeston and Jackie Nam and research sonographers Mrs Kate Smith and Mrs Borsha Sarker.

Disclosure statement: None of the authors declare any potential conflicts of interest.Funding: The authors have received no financial support for this article.