key: cord-0954994-tle14vtm authors: Martini, Chiara; Nicolò, Marco; Tombolesi, Alessandro; Negri, Jacopo; Brazzo, Oscar; Di Feo, Daniele; Devetti, Angie; Rigott, Irene Gertrud; Risoli, Camilla; Antonucci, Giuseppe Walter; Durante, Stefano; Migliorini, Matteo title: Phase 3 of COVID-19: treat your patients and care for your radiographers. A designed projection for an aware and innovative radiology department. date: 2020-10-23 journal: J Med Imaging Radiat Sci DOI: 10.1016/j.jmir.2020.08.019 sha: 92fcd2650e4a4706268b3f24e7235188123f729c doc_id: 954994 cord_uid: tle14vtm Since the spread of Covid-19 outbreak, healthcare workers (HCWs) have faced an unprecedented and unpredictable situation on the frontlines. The aim of this document is therefore to provide useful and operative recommendations to radiographers who perform imaging services, such as chest X-ray (XR) and Computer Tomography (CT) scans to three types of patients: negative, suspected or suffering from Severe Acute Respiratory Syndrome by Coronavirus (SARS-CoV-2). It is paramount to design two different paths’ layouts for patients entering the Radiology Department. One path should care for the confirmed and suspected SARS-CoV-2 patients, whereas the other path should be for negative patients. A setting envisaging two radiographers is highly recommended when managing Covid-19 patients. One radiographer fully-equipped with proper personal protective equipment (PPE) should deal with the patient in the scanning or x-ray room. The second one should stay in the console room wearing essential PPE. Disinfection plays a crucial role in reducing the risk of disease transmission. Moreover, having clear protocols is key to ensure personal safety and avoid cross-infections. Taking care of patients and HCWs, such as radiographers, is crucial to minimize the risk of disease transmission. Within a Radiology Department, different designed pathways should be taken into consideration both for everyday and epidemic/pandemic healthcare situations. Though Covid-19 pandemic has been a harsh experience in terms of world health and care systems for patients and health professionals - being radiographers among the most involved - we must not miss this chance to learn from what happened. There is the need to address wider causes through learning and in order to prevent failures. The distinction between passive learning (where lessons are identified but not put into practice) and active learning (where those lessons are embedded into an organization’s culture and practices) is crucial in understanding why truly effective learning so often fails to take place. suffering from Severe Acute Respiratory Syndrome by Coronavirus (SARS-CoV-2). It is paramount to design two different pathways for the patients entering the radiology department: one should include the confirmed and suspected SARS-CoV-2 patients, whereas another should be used for negative patients. A two-radiographer scenario is highly recommended in managing Covid-19 patients. Finally, disinfection plays a crucial role in reducing the risk of disease transmission and having clear protocols is paramount to ensure personal safety and avoid cross-infections. Taking care of patients and healthcare workers, such as radiographers, is paramount to minimize the risk of disease transmission. Within radiology department, different designed pathways should be taken into consideration for common and epidemic/pandemic healthcare situation. Though Covid-19 pandemic has been a tremendous experience both for world health and care systems even for patients and health professionals, we must not miss the chance to learn from this experience that has involved everyone firsthand. Activity to learn from and prevent failures therefore needs to address their wider causes. The distinction between passive learning and active learning is crucial in understanding why truly effective learning so often fails to take place. J o u r n a l P r e -p r o o f Phase 3 of COVID-19: treat your patients and care for your radiographers. A designed projection for an aware and innovative Radiology Department. Since the spread of Covid-19 outbreak, healthcare workers (HCWs) have faced an unprecedented and unpredictable situation on the frontlines. The aim of this document is therefore to provide useful and operative recommendations to radiographers who perform imaging services, such as chest X-ray (XR) and Computer Tomography (CT) scans to three types of patients: negative, suspected or suffering from Severe Acute Respiratory Syndrome by Coronavirus (SARS-CoV-2). It is paramount to design two different paths' layouts for patients entering the Radiology Department. One path should care for the confirmed and suspected SARS-CoV-2 patients, whereas the other path should be for negative patients. A setting envisaging two radiographers is highly recommended when managing Covid-19 patients. One radiographer fully-equipped with proper personal protective equipment (PPE) should deal with the patient in the scanning or x-ray room. The second one should stay in the console room wearing essential PPE. Disinfection plays a crucial role in reducing the risk of disease transmission. Moreover, having clear protocols is key to ensure personal safety and avoid cross-infections. Taking care of patients and HCWs, such as radiographers, is crucial to minimize the risk of disease transmission. Within a Radiology Department, different designed pathways should be taken into consideration both for everyday and epidemic/pandemic healthcare situations. Though Covid-19 pandemic has been a harsh experience in terms of world health and care systems for patients and health professionals -being radiographers among the most involved - Since the Covid-19 outbreak, healthcare workers (HCWs) have faced an unprecedented and unpredictable situation on the frontlines. Clear and solid instructions are crucial to manage Covid-19 patients and protecting HCWs. Operating in safe conditions is extremely important to minimize the risk of contracting the disease. The aim of this document is therefore to provide useful operative recommendations to radiographers who perform imaging services, such as chest X-ray (XR) and Computer Tomography (CT) scans, aimed at three kinds of patients: negative, suspected or suffering from Severe Acute Respiratory Syndrome by Coronavirus (SARS-CoV-2). The following information may undergo modifications and therefore can be adjusted according to individual department guidelines as Covid-19 situation evolves. Considering recent evidence, it is necessary to design two different paths for patients who enter a Radiology Department [2, 3, 9] : one should be followed by confirmed and suspected SARS-CoV-2 patients, whereas the other should be used by negative patients [15] . This measure aims to keep Covid-19 patients as much distant as possible from the non-Covid-19 patients. Every hospital or department dealing with this situation should arrange its layout accordingly. If the Radiology Department only has one single entrance, scheduling or postponing the confirmed or suspected Covid-19 patients at the end of day might be a suitable solution to perform the examinations safely [7, 13] . Besides, it is encouraged to designate and have a clean area, a buffer room and a contaminated area before entering the imaging room [6] . Finally, the implementation of proper signs to easily differentiate the two paths is strongly recommended [2] . Several hospitals have chosen to avoid the term "Covid" on their signs in order not to scare patients. This might be a valuable option to obtain patient's compliance. Wordings such as "respiratory" or "fever path" may be used instead [3] . HCWs who daily face Covid-19 management should work in pairs [8, 13] when it comes to imaging in order to minimize the risk of contamination and the usage of PPE. A tworadiographers scenario is highly suggested when possible [13, 14] . The rationale is to have one radiographer fully equipped (three-level protection standard) with all the PPE dealing with the patient in the scanning or x-ray room, while the other one working on the console wears only essential PPE in a clean zone. Although this operation might be time-consuming, wearing the proper PPE is mandatory [19, 20] . If the two-radiographers scenario is not feasible due to staff shortage, a couple of other options might be considered, such as having a team of one radiographer and one HCW, or having one radiographer only. This last one might be the worst-case scenario with a higher risk of contamination. Overall, dedicated CT scanners, standing and mobile radiographic units are strongly recommended to avoid disease spreading among patients [2, 3] . A period of at least thirty minutes for each patient should be considered for the exam administration. The fully-PPE-equipped radiographer would be called "Radiographer 1" and the essential PPEequipped radiographer would be called "Radiographer 2". In the radiology room: • At the end of the procedure, Radiographer 1 disinfects the mobile radiographic unit. As mentioned above, the fully-PPE-equipped radiographer would be called "Radiographer 1" and the essential PPE-equipped radiographer would be called "Radiographer 2". • Radiographer 1 takes care of the patient and wears three pairs of gloves, • Radiographer 2 remains in the control room and wears two pairs of gloves (in case the colleague needs help) • Radiographer 1 places the patient on the CT couch, removes a pair of gloves and performs hand hygiene with alcohol-based gel, • Radiographer 1 proceeds to patient centering and moves to an isolated protected area, • Radiographer 2 performs the examination, • Radiographer 1 wears a third pair of gloves, takes care of the patient on his way out, removes a pair of gloves and proceeds with disinfection of the CT scan unit. A low-dose high resolution protocol is strongly advised for detecting Covid-19 [16, 18, 21] due to patient radiation protection concerns [17] , mostly when it comes to patient screening [16] . Surface wiping disinfection, floor disinfection and air exchange must be performed daily. Every time a radiological exam is carried out, the equipment must be disinfected by wiping the surface J o u r n a l P r e -p r o o f with alcohol 75%. Floor disinfection is performed with 1000 mg/L of chlorine-containing disinfectant every four hours at least, or when needed. Disinfection sprays must be used carefully because they might infiltrate into the equipment circuits. To facilitate disinfection, it may be useful to cover any electronic part (keyboards, pushbutton panels, touchscreen monitors) with plastic. Using negative air pressure in the imaging room could be a suitable option to minimize the risk of disease spreading. Otherwise, the recommendation is to keep air temperature in a range between 19 and 21 degrees. Furthermore, to gather information about proper disinfectant products, the suggestion is to contact the application specialist in advance. A Hospital Readiness Checklist developed by WHO-Europe is supporting hospital managers and emergency planners in order to ensure a rapid and effective response to the Covid-19 outbreak [10] . The step-by-step list is designed to help hospitals to review systems, resources and protocols, and outline specific actions to strengthen responsiveness to Covid-19 spread [11] . Some of the elements in the checklist include: • Surge capacity -the ability of a hospital to expand beyond its normal capacity and to meet an increased demand for clinical care; • Adapted human resource management to guarantee adequate healthcare staff capacity; J o u r n a l P r e -p r o o f • Accurate and timely communication to ensure informed decision-making, effective collaboration, public awareness and trust; • An operational infection prevention and a control programme to minimize the risk of transmission of healthcare-associated infections to patients, hospital staff and visitors; • An efficient and accurate triage system and a management strategy to ensure adequate treatment of Covid-19 patients; • The ability of HCWs to recognize and immediately report suspected cases as the cornerstone of hospital-based Covid-19 surveillance. A rapidly evolving outbreak requires all hospitals to be able to adapt to a swift increase in demand while continuing to ensure safe environments for HCWs. All hospitals need to take precautions against potential interruptions of critical support services and in case of shortage of equipment, supplies and healthcare personnel. In Radiology Departments, radiographers performing CT scans and x-ray examinations are at a high risk of direct or indirect exposure to pathogens from infected patients [18] . Hence it is critical to ensure personal safety and avoid cross-infection. Overall, when working under pressure, clear messages are strongly needed and need to be put into practice in order to guarantee and maintain patient safety [12] : Non-Technical Skills (NTS) as effective communication, good teamwork and clear leadership will give HCWs and patients a better chance of safety. Taking care of patients and HCWs, such as radiographers, is fundamental to minimize the risk of disease transmission. Within a Radiology Department, different paths' layouts should be designed to separate ordinary from epidemic/pandemic healthcare situations. A two-radiographers scenario is highly suggested to deal with suspected or confirmed patients, alongside proper disinfection to prevent cross-infections. The first radiographer should be fullyequipped with proper PPE and deal with the patient in the scanning or x-ray room. The second one wears essential PPE and remains in the console room. Therefore, having solid and clear protocols is key to reducing the risk of disease spreading. Though Covid-19 pandemic has been an unsettling experience for global health, healthcare systems and also for patients and HCWs, we must not miss this chance to learn from such experience that has involved everyone firsthand. Activity to learn from and prevent failures therefore needs to address their wider causes. This requires stretching beyond simple diagnostic J o u r n a l P r e -p r o o f activities and sharing lessons taken from incidents, to ensure that such lessons are embedded in practice. The distinction between passive learning and active learning is necessary in understanding why truly effective learning so often fails to take place. J o u r n a l P r e -p r o o f RSNA COVID-19 Task Force: Best Practices for Radiology Departments during COVID-19, M. Mossa-Basha et al Strategies for radiology departments in handling the COVID-19 pandemic COVID-19): Emergency Management and Infection Control in a Radiology Department Is Radiology Ready? Mass Casualty Incident Planning, Lee Myers et al, ACR Infection Control for CT Equipment and Radiographers' Personal Protection During the Coronavirus Disease (COVID-19) Outbreak in China Radiology department strategies to protect radiologic technologists against COVID19: Experience from Wuhan Planning and coordination of the radiological response to the coronavirus disease 2019 (COVID-19) pandemic: the Singapore experience Prokop: radiographers work in pairs for Covid-19 scans (www.auntminnieurope.com) Infection Control against COVID-19 in Departments of Radiology Hospital Readiness Checklist for COVID-19" World Health Organization Regional Office for Europe Italian Network for Safety in Healthcare (INSH) & International Society For Quality In Health Care (ISQua) -12th Clinical Human Factors Group, A charity working for safer healthcare Management of patients with suspected or confirmed COVID-19 Initial data from an experiment to implement a safe procedure to perform PA erect chest radiographs for COVID-19 patients with a mobile radiographic in a "clean" zone of the hospital ward Protecting health care workers in the front line: innovation in COVID-19 pandemic Chest CT for detecting COVID-19: a systematic review and meta-analysis of diagnostic accuracy Radiographer research in radiation protection: National and European perspectives COVID-19 in the radiology department: what radiographers need to know, N. Stongiannos et al, Radiography Summary strategies to optimize the supply of PPE during shortages Guidance for wearing and removing personal protective equipment in healthcare settings for The authors provided final approval of the version to be published.The authors declare no conflict of interest.The authors declare that they had full access to all the data in this study and the authors take complete responsibility for the integrity of the data and the accuracy of the data analysis.