key: cord-0829848-qn9iz2ym authors: Childs, Jessie; Maranna, Sandhya; Osborne, Brooke; Lamb, Kathryn; Esterman, Adrian title: The initial impact of COVID‐19 on Australasian sonographers part 2: Changes to sonographic examination protocols and access to personal protective equipment date: 2021-07-04 journal: Sonography DOI: 10.1002/sono.12275 sha: 61be9752d11de13d1824f4152f9511ead0d8192d doc_id: 829848 cord_uid: qn9iz2ym INTRODUCTION: COVID‐19 brought with it the requirement for healthcare workers to limit community transmission of the virus as much as possible by limiting patient contact and wearing Personal Protective Equipment (PPE). This study aimed to capture the initial adaptations to sonographic examination protocols within ultrasound departments and sonographer access to PPE. METHODS: An online survey was used to gather data on sonographer reflections of sonographic examination protocol changes seen in their departments and access to PPE between the 11th of March 2020 and the 14th of June 2020. RESULTS: To reduce the time sonographers spent with the patients and hence reduce the risk of exposure to COVID‐19, sonographers reported adjustments to sonographic examination protocols including their duration and scheduling. Access to PPE was reported as poor. CONCLUSION: Numerous sonographic examination protocol changes were observed within ultrasound departments in Australasia in the initial response to COVID‐19. Access to PPE was varied along with sonographer feelings around the impact of these changes. COVID-19 was characterised as a global pandemic by the World Health Organisation (WHO) on the 11th of March 2020, 1 with the first Australian case being reported on the 25th of January 2020. 2 Australia and New Zealand adopted an early response which appears to have been successful in limiting the impact in these countries when compared to the impact globally. This article is part two of a survey series which evaluates and reports on the initial impact of COVID-19 across the Australasian sonographer community. Part one of this survey series evaluated and reported changes in numbers of sonographic examinations performed, examination types, and the changes in sonographer working hours. 3 Evidence-based sonographic examination protocols are recommended by imaging departments and the professional bodies for sonographers, namely the Australasian Sonographers Association (ASA) and Australasian Society for Ultrasound in Medicine (ASUM). In the face of a pandemic and the necessity for physical distancing, changes were likely to be required to limit patient contact. Several modifications in relation to sonographic examination protocols were adopted by imaging departments to cope with the initial impact of COVID-19 to protect both the staff and the patients during April and May 2020. 3 The reporting or documentation of these changes are unclear or unknown. Around the same time, the WHO guidelines recommended personal protective equipment (PPE) for all healthcare workers including sonographers, although there have been several reports of a shortage or lack of PPE for healthcare workers. 4 Sonographer specific data was unavailable. A study by Devani, 2012 5 investigating the willingness of healthcare workers to continue to work in public health emergencies, found that the availability of PPE and confidence in one's employer were strong influencing factors for staff during influenza outbreaks. It was therefore deemed essential by the research team to investigate similar impacts of the COVID-19 outbreak on sonographers in Australia and New Zealand. Knowledge of the sonographic examination protocol changes and availability of PPE to medical sonographers during the initial stages of the COVID-19 pandemic would be beneficial for future planning. This article reports the changes in ultrasound examination protocols instigated by imaging departments as a result of the COVID-19 pandemic, the availability of PPE for sonographers and changes to the scheduling of appointments in the initial stages of the COVID-19 pandemic (11th March 2020-14th June 2020). This article is part two of a three-part series reporting the results of an online survey which evaluated the initial impact of COVID-19 on Australasian sonographers. Institutional human research ethics approval (protocol number 203084) was granted prior to the commencement of the study. Accredited sonographers across Australia and New Zealand were invited to participate in the study. An online survey was developed to collect data relating to participant demographics, changes to sonographic examination protocols and access to PPE. Further free text response questions were posed to evaluate sonographer perceptions to these sonographic examination protocol changes and how these perceptions affected their routine clinical work. The survey questions were developed and sent to the ASA and ASUM boards for comment and feedback, and subsequently adjusted accordingly. The survey was distributed as an anonymous internet survey using an online survey tool (Survey Monkey Inc©, San Mateo, CA) via the online newsletters, social media, and websites of the ASA and the ASUM. It was released on the 8th of May 2020 and closed on the 14th of June 2020. An information sheet was present as the first page of the survey and participation was assumed consent. These results are reflective of changes as reported by sonographers between the 11th of March and the 14th of June 2020 comprising the initial stages of the COVID-19 pandemic. A total of 444 sonographers responded to the survey, either in full or partially. Of these, 89% (n = 396/444) were female and 11% (n = 48/444) were male. Student sonographers comprised 9% of the survey participants (n = 43/444). In relation to workplace, 60% (n = 266/444) were employed in private imaging practices, 19% (n = 86/444) in public hospitals and 21% (n = 92/444) employed in both private and public hospitals. This paper discusses the sonographic examination protocol changes, sonographer perceptions to these changes, impact on their routine work and the availability of PPE within departments as reported by sonographers. The main protocol changes included targeted sonographic examinations to answer only "the clinical question," rather than completing full ultrasound protocols which require more time to be spent with the patient. Other adaptations included instructing sonographers to perform limited physical assessments of their patients such as clinical tests to elicit tenderness of a particular area. In instances where incidental findings were seen, these were documented but the sonographic examination itself was not extended to evaluate the abnormality, which would otherwise occur in a routine setting. Further approaches to reducing patient contact time included placing time limits on sonographic examinations to a maximum of 15-minutes per patient (n = 7), or "tagging in" a second sonographer after the 15-minute time limit had been exceeded (n = 2). Several cardiac sonographers (n = 5) reported truncated sonographic examination protocols with offline analysis or the use of less advanced techniques rather than 3D or strain echocardiography. Time spent performing vascular sonographic examinations was also limited, or only one limb was examined per session as reported by some sonographers (n = 7). In some circumstances where patients required additional sonographic assessment, they were booked over consecutive days with a 30minute limit each day (n = 3). Extensive vascular cases were reportedly being sent to computed tomography (CT) instead (n = 2), along with patients presenting for hernia examinations (n = 1) and cases of suspected renal calcification (n = 1). For women's health examination, some departments (n = 3) ceased performing transvaginal sonographic examinations, limiting examinations to transabdominal alone. When performing pelvic sonographic examinations, assessment of the kidneys was omitted in instances where they were routinely included in the protocol (n = 2). Reductions to overall obstetric sonographic examination times were reported through a range of modifications to normal established sonographic examination protocols (Table 1) . Finally, from student sonographers' perspectives, required reductions in contact time between patient and sonographer heavily impacted their ability to meet training requirements. Some departments only allowed 20 min of patient contact per appointment, which impacted on observation and hands-on scanning times for student sonographers (n = 5). Several students (n = 9) reported a cessation in their training programs in order to ensure efficient examination times and to limit staff time spent with patients and colleagues. Other students (n = 5) reported that they were limited in the types of examinations they could perform and were no longer allowed to complete longer examinations such as the 18-22 week morphology examination. Efforts were made to reduce the immediate risk of exposure of sonographers to patients potentially infected with COVID-19. Seventy three percent of respondents (n = 325/444) reported that their departments reduced the total number of people allowed in a sonographic examination room, including partners, accompanying children, and student sonographers. At various sites (n = 26) partners of obstetric patients were either not allowed within the sonographic examination room or were only allowed within the room for a limited amount of time. One participant reported that male sonographers were no longer allowed to perform breast or pelvic ultrasound examinations, in order to avoid the need for a chaperone as an extra person in the room. Student sonographers were only allowed to perform sonographic examinations on patients if they could complete them autonomously, according to their advancement in training (n = 2). Conversely some sonographers (n = 3) reported that they were required to extend sonographic examination times to make longer obstetric videos because the partner was not allowed in the room. To limit the immediate risk to imaging department staff of exposure to COVID-19, patients were asked not to touch or fill in forms, with sonographers or other clinical staff doing it for them (n = 2), or electronic forms were used as an alternative to paper (n = 1). Patients who presented for examinations with inadequate preparation, such as an empty bladder, were either re-booked, or examined as they presented (n = 4). This worked to limit the number of people in the waiting room and the time the patients spent in the clinics. More rigorous disinfection of equipment and rooms was required between patients, sometimes including all transducers, the ultrasound machine, and all exposed surfaces including chairs and doorknobs, as reported by 17% sonographers (n = 74/444). One sonographer reported that their department allowed only the specific ultrasound transducer being used for the examination to be present in the room to avoid repeated cleaning of all the unused transducers. Some departments (n = 8) required patients to wash their hands before and after sonographic examinations and required them to always wear gloves and masks (n = 3). Several sonographers (n = 6) reported that they felt they had not been allowed sufficient cleaning and disinfecting time between patients, whilst others (n = 7) reported that they were provided sufficient extra time. Efforts to decrease the contact risk for sonographers during examinations were reported in patient positioning adaptions; for example, patients were scanned whilst being rolled away from the sonographer to reduce direct contact with patient's breath during expiration. Alternatives included asking patients not to talk during procedures, not having them hold their breath to avoid them A series of questions seeking sonographers' perceptions of sonographic protocol changes, in the initial stages of the COVD-19 pandemic received an 83% response rate (n = 367/444). Most sonographers felt they were not being rushed to complete their examinations (24% never, 27% rarely, 29% sometimes, 16% often, 4% always) and that COVID-19 was not strongly impacting how well they executed their jobs (6% always, 13% often, 33% sometimes, 27% rarely, 21% never). Twenty seven percent (n = 5/18) of those in New Zealand reported that they often or always felt that COVID -19 was impacting how well they did their job. Within Australia, there was a statistically significant difference (p = 0.003) between states (Figure 1) . Twenty-four percent of those in Queensland (n = 12/51) and 23% (n = 19/82) of those in Victoria often or always thought COVID-19 was impacting how well they did their jobs. This is in comparison to no impact reported in Western Australia (3%, 1/32), Tasmania (0%, 0/4) and the Northern Territory (0%, 0/2). Sonographers working in private practices (20%, n = 45/225) felt COVID-19 impacted their clinical practice more than those in public hospitals (15%, n = 11/73). When asked whether people felt they were interacting less with their patients, there was another statistically significant difference between states (p = 0.020). Nearly half of sonographers in South Australia (42% n = 14/33) and Victoria (42% n = 34/82) noted a negative impact on their time interacting with patients ( Figure 2 ). Sonographer access to PPE was a primary concern in the initial stages Regarding the appropriateness of equipment, six participants (2%, 6/300) reported that their protective equipment was out of date and 24% (n = 88/366) reported that their protective equipment was not appropriate when compared to prescribed standards for COVID-19 protection. Sixty percent (n = 229/382) of the respondents stated that they had been offered adequate personal protection at work. Several sonographers (n = 42) indicated they were rationed to one mask per sonographer per day, while some sonographers (n = 4) reported that they had to source their own masks if they wanted one. Access to PPE was relatively consistent across the geographical locations apart from statistically significant differences seen with bootie access (p = 0.021) and eye protection (p = 0.004). New Zealand and the Northern Territory had the highest access to both eye protection and booties. In contrast, zero respondents from Western Australia or Tasmania reported access to booties (Figures 3 and 4) . Other statistically significant differences were seen between sonographers working in public hospitals compared to those in private F I G U R E 1 Percentage of sonographers by state who felt that COVID-19 was often or always impacting how well they did their jobs (number of participants = 367) F I G U R E 2 Percentage of sonographers by state who often or always felt they were interacting less with their patients (number of participants = 362) practices. There was a higher percentage of access reported by sonographers working in public hospitals across all types of protective equipment ( Figure 5 ). Interestingly, there was a statistically significant difference (p = <0.001) to the type of access to PPE between the two groups, with 43% (n = 99/228) of respondents who worked in private practice reporting unconditional access compared to only 18% (n = 14/76) for those in public hospitals. Access to PPE for sonographers in public hospitals was predominantly conditional and dependent on the status of the patient (72%, 55/76), that is, whether the patient was at high risk of COVID-19 or not ( Figure 6 ). Significant changes were made to sonographic examinations protocols within individual imaging departments to limit the community Sonographer access to PPE also varied depending on the type; with 90% of sonographers having access to gloves, 75% to masks, 60% to gowns, 49% to eye protection and 7% to booties. Of those who had access, 24% reported that the equipment was not appropriate for COVID-19 protection when compared to recommended standards. Comparison to other healthcare workers is difficult due to a sparsity of literature however a large study amongst Australian frontline nurses revealed 63% of nurses having sufficient access to a masks compared to the 75% reported amongst sonographers. 6 Similar reports of nurses providing their own PPE were also made within this study. 6 A national shortage of PPE was well documented in the early stages of the COVID-19 pandemic and future research will show if these figures change across subsequent surveys. Past research demonstrates that healthcare workers' willingness to work during an influenza outbreak is associated with the availability of PPE. 7 This study showed that in some cases, PPE was not readily available and that 40% of sonographers felt that they had not been offered adequate personal protection. Paper 1 in this series reported that many sonographers chose to reduce their work hours 4 and these two things may be related. In North America, it was reported that the lack of available PPE led to the use of PPE that was not of adequate protection against COVID-19. 7 Regarding locations, sonographers in New Zealand most felt the changes adversely affected how well they did their job, this was closely followed by Queensland and Victorian sonographers. Several sonographers (n = 16) indicated that they were interacting less with their patients and that this was impacting patient care. This finding was echoed amongst frontline nurses where 34% of respondents felt quality of care was significantly or slightly worse than before COVID-19. 6 Student sonographers appeared to be impacted the most. With the necessity to limit community exposure by limiting the amount of time spent with patients and the number of people in a scanning room, several departments were forced to reduce the amount of training student sonographers were receiving or cease training positions all together. Whilst the university system appeared to adopt an online learning experience relatively easily for students, clinical learning whilst maintaining safety presents a more challenging situation. The removal of students from clinical medical situations has been well documented within the literature as medical and radiology students are removed from their frontline positions. 8, 9 Suggestions to overcome this include better access to PPE, the use of telemedicine and video interaction with patients and the increase in virtual learning experiences. 8, 9 Participant numbers from the Northern Territory, Western Australia, Tasmania, and New Zealand were low, so these results should be viewed with caution. The perceptions of how the changes during COVID-19 impacted routine work is based on sonographers' self-reports only, presenting another limitation to this study. Future research is scheduled to capture the interim changes experienced during COVID-19 and the changes following the distribution of a vaccine. In an effort to reduce community transmission of COVID-19, departments have reacted in multiple ways. This includes the modification of existing sonographic examination protocols to reduce examination times and changes in the timing of appointment bookings and interval between follow up examination to limit human to human contact. This is coupled with an increase in cleaning procedures, and the requirement of PPE. These changes have in turn affected the way sonographers perceive their jobs. Future surveys will aim to document whether these factors return to pre-COVID-19 levels. These results will aid advocating bodies to amend relevant policies in the future and will inform imaging departments for future planning. WHO declares COVID-19 a pandemic Department of Parliamentary Services COVID-19; a Chronology of state and territory government announcements. Parliament of Australia Impacts of COVID-19 on Medicare Benefits Scheme and Pharmaceutical Benefits Scheme service use report 17 The initial impact of COVID-19 on Australasian sonographers part 1: changes in scan numbers and sonographer work hours. Sonography The impact of COVID-19 on allied health professionals The experiences of primary healthcare nurses during the COVID-19 pandemic in Australia Factors associated with the willingness of health care personnel to work during an influenza public health emergency; an integrative review Medical education and safety as co-priorities in the coronavirus disease 2019 (COVID-19) era: we can do both The impact of COVID-19 on radiology trainees The initial impact of COVID-19 on Australasian sonographers part 2: Changes to sonographic examination protocols and access to personal protective equipment The authors would like to acknowledge the Australasian Sonographers Jessie Childs is an editorial board member for Sonography and a coauthor on this article. JC was blinded and not involved in the peer review process; management of the peer review process and decisionmaking for this article was undertaken by the Editor-in-Chief, Kerry Thoirs, acting as Handling Editor. https://orcid.org/0000-0003-2128-8907Sandhya Maranna https://orcid.org/0000-0003-3051-2915