key: cord-0927210-2pd50lgn
authors: Ndakwah, Gabrielle; Tucker-Bartley, Anthony; Cochran, Rory L.; Daye, Dania; Sheridan, Robert; Som, Avik; Smolinski-Zhao, Sara; Kalva, Sanjeeva; Uppot, Raul N.
title: Infection Control in Interventional Radiology During the COVID-19 Era
date: 2021-01-09
journal: Curr Probl Diagn Radiol
DOI: 10.1067/j.cpradiol.2020.12.011
sha: a10f5a3527f77e14d2ff2bcbbaaeb13a6e28a9cf
doc_id: 927210
cord_uid: 2pd50lgn

The COVID-19 pandemic has challenged the capacity of interventional radiology departments worldwide to effectively treat COVID-19 and non-COVID-19 patients while preventing disease transmission among patients and healthcare workers. In this review, we describe the various data driven infection control measures implemented by the interventional radiology department of a large tertiary care center in the United States including the use and novel re-use of personal protective equipment, COVID-19 testing strategies, modifications in procedural workflows and the leveraging of telehealth visits. Herein, we provide effective triage, procedural, and management algorithms that may guide other interventional radiology departments during the ongoing COVID-19 pandemic and in future infectious disease outbreaks.

Ethics approval and consent to participate 1. We certify that ethics approval or consent for participation was not required for this manuscript. Consent for publication 1. We certify that all authors consented to the publication of this manuscript. Availability of data and materials 1 (2, 3) . Given SARS-CoV-2 infection appears to have a higher mortality rate, additional adjunctive measures will likely be necessary (4) . The Society of Interventional Radiology (SIR) published online guidelines to help interventional radiologists navigate COVID-19 patient care during the pandemic. The purpose of this review is to discuss the practical infection control guidelines for interventional radiology practices based on published data and our experience at a large tertiary medical center. These policies can be summarized in three major categories -PPE and testing, workflow modifications, and adoption of telehealth for clinic visits.

Without an approved vaccine or treatment option for COVID-19, the first step in management is prevention. Prevention can be achieved with social distancing and wearing masks to minimize airborne spread. In a hospital setting, the most efficient way to minimize transmission is to require all employees wear a mask. Early in the pandemic, our hospital instituted a policy requiring everyone in the hospital to wear a mask at all times and all visitors were prohibited with few exceptions. Additionally, all providers underwent daily symptom checks, via app questionnaire completed by all employees daily, with mandatory two-week selfquarantine for those who became symptomatic.

Furthermore, procedures were stratified to high risk or low risk groups based on whether or not the procedures were aerosol generating. For high risk procedures, including all aerosolgenerating procedures (AGPs) as shown in Table 1 , we required all personnel apply droplet precautions, which includes the wearing of an N95 mask, gown, gloves, and eye protection regardless of the COVID-19 status of patients. This was accompanied by mandatory training for the appropriate donning and doffing of personal protective equipment (PPE) (e.g. appropriate fitting, no objects between N95 and the provider's skin, limit use to 1 shift, etc). For low risk procedures, PPE requirements included gowns, gloves, and surgical masks. To address PPE shortages, extended use of masks and eye protection was allowed and encouraged provided the PPE was not soiled, contaminated, or damaged. Finally, to mitigate N95 scarcity we utilized a mask sterilization plant which enabled safe reusage of N95 masks. This novel approach greatly extended our reservoir of N95 masks while increasing the availability of N95 masks for other healthcare systems.

Procedures were also stratified into emergent or urgent, elective, or case-by-case distinctions and were postponed or performed based on these definitions in order to decrease hospital volume and ensure personnel safety (5) 

In addition to the general infection control practices outlined above, our interventional radiology department revised our daily workflow practices based on prior literature. Pua et al. suggested that a useful approach for minimizing risk may be to limit the movement of COVID-19 positive patients throughout the hospital by performing more procedures at the patient's bedside (6) . To that end we developed an interventional radiology (IR) bedside procedure protocol which outlined the necessary staff, equipment, communication, and steps as shown in Table 2 . We performed as many requested procedures on COVID-19 (+) patients as possible at the bedside to minimize patient travel within the hospital. For COVID-19 (+) patients whose procedures were not deferrable, we established a routine ambulatory care for COVID-19 (RACC) space within IR to reduce the risk of infection to non-COVID-19 patients and staff, conserve and manage PPE effectively, and ensure standard processes and workflows are maintained. This unit included ambulatory care of patients in the following disease areas: oncology, obstetrics/gynecology, orthopedics, pediatrics, transplant, medical specialties, and surgical specialties. The RACC team was maintained in a consistent location of the IR unit and was staffed with 1-2 IR operators, 2 technologists, and 2 nurses (1 technologist and 1 nurse 

In summary, the COVID-19 pandemic has required major infection control modifications in IR departments worldwide. The adaptations outlined herein enabled our IR department to effectively treat COVID-19 and non-COVID-19 while minimizing the risk of COVID-19 transmission among staff. These strategies may serve as a guide for other large tertiary care centers during the ongoing COVID-19 pandemic and in future infectious disease outbreaks. 

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