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Like any other healthcare professional, radiologists are doing their best to protect their patients with limited resources. It is time for you to prepare to establish a preparedness protocol during and after the epidemic.
In the wake of the global health crisis due to COVID-19, each and every doctor has been urged to combat this deadly disease. The radiology community is currently contributing to this cause by extending its diagnostic services when necessary. However, the fraternity is preparing for a shift in its roles from diagnostic capacity to preparation.
According to the Radiological Society of North America (RSNA), radiological preparation is a set of policies and procedures directly applicable to imaging departments
- to achieve sufficient capacity for continuous operation during a health care emergency of unprecedented proportions,
- to support the care of patients with COVID-19,
- to maintain radiological diagnosis and interventional support for the entire hospital and health system. Due to different infection control policies (both nationally and regionally), the steps for radiological preparation for COVID-19 will vary between institutions and clinics.
In this article, we explore how radiologists in India are prepared for this emergency.
The relevance of radiology in COVID-19
In early December and January, when the COVID-19 outbreak occurred in China, findings of chest CT (eg, frosted glass peripheral infiltrates and / or organized pneumonia) temporarily became part of his criteria. Official diagnostic tests for COVID-19 as a viral nucleic substitute. acid test. With a better understanding of the disease and the development of rapid test kits, the findings of chest CT are no longer part of the diagnostic criteria for COVID-19.
When the pandemic hit India, we were well prepared with test kits. Therefore, radiology does not play an important role in confirming cases of COVID 19 positive cases. However, chest radiographs and CT scans are still used as an adjunct in the diagnosis of some cases. Additionally, chest CT can help at a time when there is a shortage of RT-PCR kits and the response time is high.
According to Dr. Sona Pungavkar, senior consulting radiologist at Mumbai Global Hospital, a CT scan of the chest is helpful in this crisis when urgent diagnosis is required, although RT-PCR is the most effective. A CT scan of the chest can be read in 10 seconds, while a radiologist would take at least 15 minutes. In addition, a database could be collected from around the world at one central point to analyze and create learning for the future.
She mentions: “Basic chest radiography is performed for all patients as a primary modality and then for serial follow-up. Worsening serial radiographs in the form of subtle peripheral patchy opacities should be noted for better prognosis and management. Chest CT is used, when symptoms worsen in proven cases, to measure the degree of lung involvement, which has an impact on the prognosis of these patients. “
Says Dr. Amit Janu, consultant radiologist at Tata Memorial Hospital and associate professor at the Homi Bhabha National Institute, Mumbai says: “CT as an investigation continues to appear in the picture where there is a lack of RT-PCR test kits and the response time is high, although it shows characteristics of viral pneumonitis and some common and constant patterns in patients, it can help in the evaluation of severity, ruling out other alternative diagnoses, even so, it is not a confirmatory test. it is the only test to confirm or rule out COVID-19 infection, whether it is present or not. The new RT-PCR tests are easy, more accurate and require fewer resources with a response time of less than one day. the test depends on several things from where and how the sample is collected. “
In addition, he mentions: “In our current workflow, hospital recommendation, and with the precision and speed of RT-PCR testing, there is no need for immediate CT imaging as a screening tool for patients with COVID-19. In addition to the above, even if worsening of symptoms is believed to be secondary to COVID-19, imaging would not significantly alter patient management, as current treatment consists of oxygen, symptomatic and supportive care, and traces They are found in many antivirals and anti-inflammatories. medications to see the efficacy of any medication. With a better understanding of the disease, chest CT findings are no longer part of the diagnostic or detection criteria for COVID-19. “
Dr. Deepak Patkar, President of the Indian Radiology and Imaging Association, and Director of Medical Services, Head of the Imaging Department at Nanavati Super Specialty Hospital, Mumbai, notes: “The CT chest has a sensitivity and specificity ranging from 80 to 90 percent and 60 to 70 percent, respectively. All current national and international guidelines differ from the use of CT for the detection or diagnosis of COVID-19. Therefore, images should be strictly reserved for cases they will impact patient management. It provides help when considering alternative causes of dyspnea or worsening disease or evaluating unrelated indications. “
Dr. Patkar adds: “CT can also help identify patients with negative tests at the beginning of the disease. But these are rare cases. In addition, unintended use of contrast injection should be avoided, which will help reduce equipment exposure. One more small addition to our protocols is to scan the chest in all suspect / positive patients, even if they come for a CT scan of some other part of the body, so if the COVID corridor has been created and the patient is already being taken to scan, we address the state of lung parenchymal compromise. “
According to Dr. Sona Pungavkar, senior consulting radiologist at Global Hospital Mumbai, the positive predictive value of these typical CT findings is estimated to be 92 percent in a population with a high prior probability of the disease (eg. , 85 percent prevalence by RT -PCR). These findings include patchy or diffuse frosted frosted glass densities with or without dense peripheral border (reverse halo sign), perilobular consolidation, associated crosslinks resulting in a crazy paving pattern.
She adds: “The image is indicated in case of worsening of symptoms in proven cases, in which it will have a significant impact on patient management. It is also used to evaluate patients to rule out an alternative diagnosis or with other related or unrelated emerging indications. The presence of lobular pneumonia, a bud-like tree, pleural effusions, cavitary consolidation should raise suspicion of a diagnosis other than COVID. “
How well is the radiology community prepared?
At a time when front-line health workers are battling all odds to save patients, radiologists have found ways to prevent the spread.
Dr. Patkar says: “The primary focus of most radiology departments in hospitals is preparation with the intention of maintaining continuous operation of the imaging setup during this health care emergency along with maintaining capacity diagnostic radiology for the entire hospital. “
The radiology department of Nanavati Hospital is trying to avoid, as far as possible, non-emergency investigations and diagnostic procedures. The department is encouraging physicians to prescribe radiology investigations only when essentially necessary, such as in emergency and semi-emergency indications such as stroke, obstetrics, pulmonary thromboembolism, etc., where it will affect patient management. According to Dr. Patkar, “this will serve to preserve available resources and also limit individual exposure.”
Mentions Dr. Pungavkar: “The images will only be for those patients with COVID 19, where the images will affect management. This will help reduce the level of exposure to staff in the department. “
She suggests that image performance is suggested in places with less foot traffic. The immediate waiting area outside the CT gantry room should be vacated before transferring the patient with suspected or positive COVID test and, whenever possible, you are looking for a portable image with proper protection.
Recent news on substandard PPE from China has been circulating. Around 63,000 Chinese PPE kits would have helped the Indian government more broadly, but the faulty kits made the Indian government think otherwise, which would have compromised front-line caregivers.
Echoing the same, Dr. Sameer Shah said: “The radiology community is partially prepared. Providing PPE kits and other protective measures is the key solution and appears to be suboptimal in quantity and quality (some reports indicate that kits imported from China are of suboptimal quality). This is an additional cost. “
Protocols and preparation
Several hospitals have taken a series of measures to prevent the spread of the virus at a time when healthcare workers are most susceptible to infection.
Nanavati Super Specialty Hospital has created appropriate protocols for each radiological investigation. These are in the form of flow charts and each and every step is strictly followed. The screening and classification procedures followed at the hospital admission level are reinforced by a second screening history using self-reporting forms in the radiology department. The steps are followed for all positive patients including making COVID corridors for patient transfers, minimal essential personnel stationed in the department, following strict cleaning and disinfection guidelines using hypochlorite and alcohol based solutions, fixed slots for positive patients along with the staff. All procedures are held for one hour after cleaning is done.
The hospital has also ensured that there are no chairs in the waiting room in an attempt to avoid unnecessary overcrowding. The staff has been reduced to almost a third to preserve resources. The radiology department at the hospital has provided remote access by providing home workstations to radiologists whenever possible.
Dr. Patkar says: “Few key points to keep in between ensure minimal staff exposure, machine and machine room readiness, fast scan protocols, optimize use of the most valuable resource at this time which is the staff and the PPE and also to ensure proper cleaning of the terminal or the machine as well as the department after the scan is done. “
Dr. Patkar also recommends the use of portable CT scanners for COVID patients, if possible. Assigning a dedicated portable radiography machine and USG machines, if possible, is also a good alternative.
Dr. Sona says: “Image performance is suggested in places with less foot traffic. Clear the immediate waiting area outside the CT gantry room, before transferring the patient with suspected or positive COVID test. Whenever possible, portable images are suggested with proper protection. “
Teleradiology, a means
In this difficult time, social distancing is strictly followed worldwide and teleradiology is playing an important role. Patients in remote locations can obtain the doctor’s advice with the help of telemedicine. Furthermore, there is minimal physical contact between doctors and patients.
Dr. Janu says: “The most common imaging used in COVID-19 is chest radiography and chest computed tomography, which does not require a radiologist on-site if standard imaging protocols are followed. In such a situation, the Teleradiology has come to the rescue and doctors can read their scans and give expert opinions even when they are quarantined due to exposure. In India, we have machines in Tier III cities and remote parts of the country, however, most Radiologists are based in subways and level two cities and teleradiology connects that bridge.
Dr. Patkar says: “As president of the Indian Radiology and Imaging Association, I would encourage all my fellow radiologists to support teleradiology services. Teleradiology has proven to be a key facilitator in this battle against the coronavirus. In the emergency setting, teleradiology ensures that when a scan is performed, it can be reported immediately and treatment decisions can be made immediately. This novel technique is ideal for today’s pandemic, where the radiologist can provide his expert services without any possible risk of exposure. “
Dr. Pungavkar mentions: “Teleradiology services can be established to evaluate images of patients in remote areas. This will help identify and change those patients who require tertiary care services. Another advantage of teleradiology services following this pandemic is that it reduces the exposure of the disease to medical and paramedical personnel, such as transcriptionists in medical centers and hospitals. “
AI and deep learning
Many researchers these days are using AI and deep learning mechanisms to develop various solutions to combat COVID-19. Radiologists are also using AI to improve diagnostic capabilities.
Dr. Janu says: “Basically, in deep learning, volumetric CT scans are processed, the first lung is removed and segmentation is performed, and then the images are processed through the AI tool to make predictions. Once the deep learning model is trained, it is very fast to process a new test exam for the unimaginable fast processing time for a CT exam which is around 4.51 seconds! On a high graphics workstation. The accuracy of various models ranges from 80 to 90 percent. “
Dr. Janu further says, “A robust hourly deep learning model is needed, so we use convolutional networks to distinguish COVID-19 from other community-acquired pneumonia.”
“AI can help address the problem of evaluating radiological research, based on clinical priorities. It can actually help to categorically identify suspicious features of COVID-19. Furthermore, it will provide reliable support to radiologists with this increasing number of patients and, therefore, with an increasing number of radiological investigations, “summarizes Dr. Patkar.
In the future, hospitals and the radiology department should establish protocols to handle the burden of patients in the event of advanced spread and even after hospitals resume services.
