Risk assessments should be carried out in all areas of ultrasound practice. Advice should be sought from the infection control team about decontamination of ultrasound machines, transducers and scan rooms. Personal protective equipment should be worn when it is necessary to scan a patient with suspected or known Covid-19. See the SCoR website for more information.

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) webinar series and the article by Kooraki et al (2020) may also be helpful.

Keeping staff informed of decisions, along with reasons for the action is important. Make sure staff are fully aware of current guidance on how to protect themselves, but also when to call in sick and self-isolate. Occupational health advice should be sought for staff who need additional support, due to the demands of working in such unprecedented times and having to making difficult decisions.

When planning workloads, it is important to ensure that waiting rooms are not overcrowded (ISUOG safety statement 23.3.2020) and seating should be spaced at least two metres apart. Limiting the number of visitors, staff and trainees in the room is also advised.  

Patients and relatives can become anxious during these difficult times, particularly in pregnancy and when appointments are cancelled for patients with Covid-19 symptoms. It is important to have local policies in place to safeguard staff and protect them and other service users. See Appendix 1 for suggested template for rescheduling appointments.

The latest government advice is on the gov.uk webpages ‘COVID-19: infection prevention and control (IPC)’ Advice recommends that an initial risk assessment should take place. In symptomatic patients appropriate personal protective equipment (PPE) should be worn. This includes fluid resistant surgical mask, gloves, aprons and eye protection.

If “potential risk” cannot be established or if “there is perceived to be close or prolonged interaction with patients in a context of sustained community COVID-19 transmission” sessional use of fluid resistant surgical mask, gloves, aprons and eye protection should be available.

PHE also include a statement about individual risk assessment “Ultimately, where staff consider there is a risk to themselves or the individuals they are caring for they should wear a fluid repellent surgical mask with or without eye protection, as determined by the individual staff member for the episode of care or single session”. 

The Royal College of Radiologists and the SCoR have produced a poster summarising the PPE guidance for imaging departments and teams.

The International Society of Radiographers and Radiological Technologists (ISRRT) have also provided guidance on protective measures and an e-learning site “International Covid-19 support for radiographers and radiological technologists”.

An ISUOG safety statement (31.3.2020) highlights that as sonographers are unable to maintain recommended distances from patients during an examination, they need to take all necessary precautions. It is was suggested that, as sonographers are in close contact with patients, often in small rooms with limited ventilation they should use contact precautions and droplet precautions. This includes the wearing of a fluid resistant (Type IIR) surgical mask (FRSM) and gloves, ensuring good hand hygiene and cleaning of the equipment.

The FRSM may be reused during the care of multiple patients, if used for asymptomatic patients. Replace the mask if it becomes damp, damaged, soiled or hard to breathe through. Care should be taken not to touch the mask, until removing. On removal good hand hygiene is needed after safe disposal to avoid cross-contamination.

More information and posters to describe the donning and crucially the safe removal of PPE can be found in the gov.uk website along with advice on washing uniforms and managing blood and bodily fluids.

In the document Covid-19: Personal protective equipment (PPE) the SCoR recommend “Risk assessment must include the 2m minimum safe distance which we are all instructed to maintain. When the two metres rule is included in risk assessments, it is hard to avoid the conclusion that PPE should be used for ALL patients unless they have been tested negative for Covid-19”. It is important to remember that it is the practice that is risk assessed not the patient, in relation to whether there is a risk of transmission of the virus to or from sonographers whilst being asymptomatic.

There is limited evidence available on the numbers of asymptomatic people who have tested positive for COVID-19, however figures are starting to be gathered (Infection Control Today, Nishiura (2020), Sutton et al (2020), Wang et al (2020) and WFUMB Position Paper. A document by Health Protection Scotland (HPS) suggested that studies are limited by small sample sizes and the observational nature of studies.   

Advice from ISUOG (23.3.2020) is to try and delay ultrasound examinations, if possible, in someone with known Covid-19 or symptoms.

If it is essential that they are scanned, ideally have a dedicated room for such cases, or for in-patients, consider bedside scanning. If the patient has to be scanned in the main ultrasound department, it is advisable to book their appointment for the end of the working day, to allow for a deep clean of the room after their examination.

Anything that has been in contact with the patient or within the sneezing/cough zone (at last one metre) should be cleaned, in addition to the sink and other areas that may be contaminated. Public Health England advice should be followed in relation to PPE and hands should be washed thoroughly after removal of PPE. 

Covid-19 is de-natured by common disinfection, so good hand hygiene and cleaning of equipment and all surfaces with which patients or droplets might have come into contact is central to reducing the spread of the virus. Equipment should include anything that might have become contaminated by contact or droplets such as the ultrasound machine, gel bottle, probes, couch, keyboard, door handles, sink.

There is guidance on general cleaning and decontamination of ultrasound machines and transducers from  AXREM, BMUS and SCoR (2020). ISUOG (23.3.2020) have released a safety statement on “safe performance of obstetric and gynecological scans and equipment cleaning in the context of Covid-19”. It is important to remember that for effective disinfection surfaces, transducers and other equipment must be cleaned before disinfecting. Ultrasound manufacturers’ guidance must be reviewed when selecting the appropriate cleaning and decontamination methods for ultrasound machines and transducers, to avoid damage and impacting on warranties (AXREM, BMUS and SCoR 2020). 

Consideration of UK regulations, local infection control and manufacturer advice is required when reviewing international guidance on the use of products for decontamination.

The ISUOG safety statement (23.3.2020) recommends limiting the number of transducers connected to the machine and storing accessories in a cupboard to reduce the risk of contamination. This is in line with WFUMB guidance “Unnecessary accessories in the room should be removed and, where possible, individually stored in the cabinets”. This should include personal items belonging to staff and patients e.g. mobile phones and bags.

Staff need regular and possibly more frequent breaks, particularly when wearing PPE.

Social distancing with colleagues is important. Staff should try to ensure social distancing when possible, if not scanning, in line with the latest Public Health England advice. This is important when taking breaks during the working day. Try to avoid close contact with colleagues in the workplace, unless absolutely necessary. Conversations should be at a safe distance. Remember that you or your colleagues could potentially be infected, so follow the government advice to protect each other. It is not advisable to eat together, as this can cause staff to ‘drop their guard’ and potentially infect each other.

During this difficult time, it is however important to ensure good support for all staff. Team working and good communication will be essential, in addition to ensuring adequate rest breaks are provided and staff have facilities to take appropriate periods of rest. Access to occupational health or counselling support should be provided by employers.

The website https://www.supporttheworkers.org/ is a good place to find useful information for a number of areas such as self-help, leadership, team-working, anxiety and fear and the World Health Organisation (WHO) have a document “Occupational safety and health in public health emergencies”. This includes information on pandemics, along with advice on strategies for managing fatigue and psychosocial stress for staff during emergencies.  

The SCoR have provided a link to a range of resources ‘Wellbeing, emotional and mental health support and resources’

ISUOG safety statement (31.3.2020) recommends that “ultrasound providers of advanced age or with specific health conditions that predispose them to infection and severe disease should avoid scanning patients with suspected or confirmed Covid-19 disease”. Further details are in the document.

The RCOGprovide guidance for pregnant staff during the pandemic.

• Pregnant staff at any gestation “should be offered the choice of whether to work in direct patient-facing roles during the Covid-19 pandemic”
• Prior to 28 weeks pregnant staff should practise social distancing but can “choose to work in a patient-facing roles after occupational health risk assessment”, provided the necessary precautions are taken
• Staff over 28 weeks pregnant, or with underlying health conditions, should avoid direct patient contact and are “recommended to stay at home”

ISUOG (23.3.2020) advise the following, in their safety statement:

• "Use of single-use gel packs is recommended as opposed to gel containers.
• Consider transducer cover for non-endoluminal probes (this is not a CDC absolute requirement).
• Attempt to shorten the duration of the examination by arranging for the most experienced sonologist/sonographer to perform the examination.
• Inform the patient that a detailed explanation will not be given during the examination."

WFUMB position statement recommends:

• “Respect the time of scheduled visits
• Widen the appointment intervals in order to prevent crowding in the waiting room
• Space the seats to at least 2 meters apart”

The best practice guidance recommends limiting the number of people in ultrasound rooms to protect both staff and patients. If a chaperone is needed for TV scans, it could be a way for the student to continue to see best practice and learn more about pathologies by reviewing images after the patient has left the room, as long as they keep to social distancing guidelines where possible.

Alternatively, if they are near to the end of the training and are almost ready for running lists independently, they could potentially complete scans under supervision with the supervising sonographer using social distancing. For a fairly new student, who would extend the examination time significantly, it may be more pragmatic to suspend training, after discussion with the education provider, until the restrictions are relaxed and/or pressure on the service reduces.

Again this needs to be balanced locally, the use of simulation tools to support learning for this group could be very beneficial if in the early stages of their training.

There is also the consideration about staffing needs in other areas e.g. in the main radiology department. Due to potential shortages, it may be more important for the student to be deployed for the duration of the pandemic in their original clinical setting.

As restrictions are lifted, it is important to balance sonographer/patient safety with the need to ensure the successful education of the future sonographic workforce. Local decisions should be made about how and when it is appropriate to introduce students who have had their clinical placement interrupted back into the service, taking into consideration staffing levels, social distancing and other government and PHE guidance, availability of PPE and education providers’ advice.

The RCOG Coronavirus (Covid-19) Infection and Pregnancy guidance suggests that women with suspected or confirmed Covid-19, who should be attending for routine antenatal care, including growth scans, should delay their appointment until they have completed the recommended period of self-isolation.

Urgent appointments “will require a senior decision on urgency and potential risks/benefits”.

Anyone with suspected or confirmed Covid-19 requiring an urgent scan should ideally be booked to attend at the end of the day.

Urgent, unplanned appointments for those with suspected or confirmed Covid-19 should ideally be triaged over the phone. “Local protocols are required to ensure women with confirmed or suspected Covid-19 are isolated on arrival to EPU or triage units and full PPE measures are in place for staff.”

“Medical, midwifery or obstetric care should otherwise be provided as per routine.”

Patient advice is available from the RCOG website as FAQs.

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) have published interim guidance and a document, Coronavirus in pregnancy and delivery: rapid review, which may be useful.

The RCOG recommend assessing patients to determine if they or their partner have symptoms suggestive of Covid-19, or who meet the ‘stay at home’ guidance, before they enter the department. If they do, they are given written information about why their appointment is to be postponed and contact details are taken, to arrange a rescan after a period of self-isolation (see Appendix 1 for template).

During these difficult times it would be useful to agree a local policy to reduce the number of people in the ultrasound room. The RCOG guidance for fetal medicine units recommends that “patients should be asked to attend alone if possible or with a maximum of one partner/visitor” and for early pregnancy units, the recommendation is to attend alone. The ISUOG Consensus Statement on organization of routine and specialist obstetric ultrasound services in the context of Covid-19 recommends that “The number of visits should be reduced to the essential minimum and women should be advised to attend with no accompanying person to avoid virus spread”.

If the patient is required by a trust to attend alone for their antenatal scan the SCoR, RCOG, RCM and BMUS joint statement “Obstetric ultrasound examinations during the Covid-19 pandemic” provides advice on recording of NHS examinations. At a time when guidance is recommending completing the examination as quickly as possible to reduce the chance of spreading the virus, it is important to explain to patients the nature of the examination and the impact the additional video/phone recordings would have on the scan time, sonographer concentration and the potential for more fetal abnormalities to remain undetected.

Thejoint guidance states:

“We support locally agreed policies that allow women to share their experience of the ultrasound scan with their partner (or other family members or friends), such as an offer to save a short 10–30 second cine clip of the fetus at the end of selected examinations. This could then be recorded by the woman while the scan report is being completed. Allowing a recording of the cine clip would ensure that the woman has control over their image data and can share with family after the examination”

“All staff should work to the same local policy, to provide a consistent service to women”.

“It should be explained to women that mobile phones are vehicles for transmission of the virus, so good hygiene is needed if using their phone in this way at the end of the examination”.

Local decisions and arrangements should be in place for communicating with partners and /or other family members, in the event of unexpected findings being detected during an ultrasound examination.

Some centres and private clinics offer ultrasound examinations for bonding and reassurance. These clinics may become increasingly busy, if the NHS has to reduce the number of examinations it can offer during the pandemic. Current government and RCOG advice should be followed in all ultrasound settings, to ensure staff and patient safety. The joint statement by the SCoR, RCOG, RCM and BMUS states that “Where antenatal ultrasound is offered in private clinics, the clinician offering the scan should consider the clinical benefit of the ultrasound compared with the risk to the woman and the sonographer of possible infection with Covid-19, should they attend a clinic setting. Any ultrasound offered is expected to be supportive to clinical practice and recommended either by national guidance or expert consensus”. Examples of examinations are given within the document.  

During an ISUOG webinar on 17.3.2020 the SCoR asked about this and the implications of reducing routing screening examinations and growth scans in pregnancy, particularly when staffing levels are impacted by the virus. Routine examinations should continue for those with no symptoms of Covid-19, however capacity will need to be reviewed if staffing levels reduce. Team working with early pregnancy, fetal medicine and sonography departments will be essential to ensuring service provision can be maintained as much as possible.

In England all advice on the operational delivery of screening programmes during the Covid-19 response will come from NHS England and NHS Improvement. This will ensure co-ordination and consistency with the advice being given to NHS symptomatic services. It is likely that this will be similar for the devolved countries.

If policy is changed to accommodate staff shortages during this period of uncertainty it would be prudent to document this in protocols and get sign off from the Trust board. Any changes to protocols should be clearly documented with a name/date and kept for future reference with other previous protocols.

24.3.2020 The RCOG have produced guidance for antenatal screening and ultrasound in pregnancy in the evolving coronavirus (COVID-19) pandemic.

The key points include:

• “These screening programmes are time critical and we should continue to offer timely screening”.
• “If staffing levels start to impact on such time critical services, the local screening team should inform their senior management team and commissioners to discuss contingency and mitigation planning.”
• “All women should be asked to attend alone if possible or with a maximum of one partner/visitor”
• “All women should be initially screened before entering the department to see if they have symptoms that are suggestive of COVID-19, or if they meet current ‘stay at home’ guidance. If a woman currently meets ‘stay at home’ guidance the appointment should be rebooked after the isolation period ends”
• Guidance on delaying appointments for patients with symptoms of Covid-19 is given within the document and a suggested template provided (see appendix 1)
• “The woman should be informed that if she remains symptomatic or develops symptoms she must not attend her appointment, instead she should phone her maternity service for advice”.
• If a patient wants screening and is too late for the combined test,
  - between 14⁺² to 17⁺⁶ weeks a dating scan should be performed and a quadruple test offered for trisomy 21. Head circumference (HC) used for the quadruple test.
  - between 18⁺⁰ to 20⁺⁰ weeks an anomaly scan should be performed and a quadruple test offered for trisomy 21. HC used for the quadruple test.
  - Between 20⁺¹ to 23⁺⁰ weeks an anomaly scan can be performed.
• If there are capacity issues due to the pandemic and it is not possible to continue providing the screening service there should be discussions with senior staff. “If the service can only provide a single scan, it is recommended that this is performed at 18⁺⁰ to 20⁺⁰weeks, with the option of the quadruple test for women who wish to be screened for trisomy 21”. 
• Daily discussion should be scheduled with senior team members with oversight of the pathway to review service provision. In the event that there is insufficient staff to provide the service, scans should be prioritised in the following order:

1. Anomaly scan at 18+0 -23+0 weeks
2. Ultrasound +/- screening at 11+2 -14+1
3. Growth scans

If, for any reason, an ultrasound examination is not possible the quadruple test can be offered based on the Last Menstrual Period (LMP) between 14⁺² to 20⁺⁰ weeks.

• Growth scans: “To reduce the workload to the ultrasound screening unit a local policy should be implemented to review all referrals for a growth scan prior to booking an appointment”.

The ISUOG consensus statement (2020) offers additional advice on the “organization of routine and specialist obstetric ultrasound services in the context of COVID-19”.

RCOG ‘Guidance for rationalising early pregnancy services in the evolving coronavirus (COVID-19) pandemic’ recommend telephone triage system is in place for all patients, to allow prioritisation. Suggested actions are given in the document to “minimise hospital attendance for social distancing of pregnant women”.

It is also worth reviewing the RCOG (2020) guidance for fetal medicine units (FMU). This guidance suggests that if delay is not “clinically acceptable” precautions should be taken and PPE should be worn in line with PHE guidance. It also advises that

“If capacity allows the FMU should support staff or capacity shortages in antenatal ultrasound. Scans should be prioritised in order of clinical urgency by a senior fetal medicine doctor, with the following suggested priority:

• Urgent scans for fetal growth (e.g. where there is already a suspicion/diagnosis of growth restriction, or for persistently reduced fetal movements).

• Anomaly scan at 18+0 -23+0 weeks

• Ultrasound +/- screening at 11+2 -14+1

• Growth scans”

This will depend on local staffing levels and will need to be monitored on a regular basis. Any decisions should be made within the wider Trust contingency planning, to reduce risk to patients and staff.

The “RCR advice on non-urgent and cancer imaging during the coronavirus pandemic” suggests that “Routine hospital attendances for patients should be stopped to reduce Covid-19 transmission. National specialty guidance advises against routine outpatient work where possible.

Departments should plan to minimise non-urgent imaging as they will have fewer staff available and more demand for in-patient services.”

Also NHS England have included statements within their document such as:

“In response to pressures on the NHS, the elective component of our work may be curtailed. However, non-elective patients continue to need care. We should seek the best local solutions to continue the proper management of these patients while protecting resources for the response to coronavirus.”

“Senior vetting of requests for radiology will limit unnecessary imaging”

Additional RCOG advice is available for “Coronavirus (COVID-19) and gynaecological services”, this includes guidance for rationalising early pregnancy services, if required, abnormal uterine bleeding, abortion care, gynaecological cancer and links to resources for fertility. ISUOG have also released a “Consensus Statement on rationalization of gynecological ultrasound services in context of SARS-CoV-2”.

Any changes to protocols and practice should be clearly documented in protocols and records dated and saved. This will help defend any decisions made, should evidence be needed at a later date (HSJ 20.4.2020)

The guidance will need to be monitored as the restart programme begins to develop. Screening restart guidance may be helpful to highlight factors to consider as routine work begins again in ultrasound departments.

NHS Resolutions are not able to provide specific advice, but responded to enquiries from SCoR stating:

“Should claims arise from any such rationing, the courts in future would be expected to take account of extreme national circumstances when reaching a decision on legal liability, but it is impossible at this point to gauge precisely where they would set the boundaries of negligence in such a situation.  If your members are employed by NHS trusts or other healthcare organisations belonging to our schemes, they will still be protected by our indemnity”

There is now a Covid-19 page on the NHS Resolutions website

The SCoR has been contacted by members with enquiries about indemnity coverage under the Clinical Negligence Scheme for Trusts (CNST) maternity incentive scheme if they fail to meet the requirements for Saving Babies Lives Care Bundle version 2 (SBLCBv2), should services be reduced due to the current pandemic, resulting in cancellation of some examinations during pregnancy.

The NHS resolutions incentive scheme means trusts can recover funds if they meet ‘ten safety actions’. One of those actions is Safety Action 6: ‘Can you demonstrate compliance with all five elements of the Saving Babies’ Lives care bundle Version 2?”.

Gill Harrison, SCoR professional officer for ultrasound said, “Many departments are working extremely hard to continue to offer the full range of obstetric ultrasound services in these difficult times.

"NHS Resolutions has issued a statement saying that ‘the majority of reporting requirements relating to the maternity incentive scheme 10 safety actions’ will be paused until the end of August 2020 to help ease the pressure on overstretched clinical departments For those who are unable to provide all the requested scans, the statement will provide much needed reassurance.

“We have every confidence that sonographers will be doing their upmost to try and meet the expectation from NHS Resolution to continue, where possible, to adhere to the principles of SBLCBv2 ‘to support the delivery of safer maternity care.

"Sonographers are providing excellent care across the UK, managing to provide high quality patient care in obstetric ultrasound and other areas, whilst working under extremely challenging conditions and wearing full PPE."

Resources

Maternity incentive scheme – year three

Covid-19 Guidance for trusts 

Coronavirus outbreak indemnity FAQs

Clinical Negligence Scheme for Coronavirus

Clinical Negligence Scheme for Trusts

For more guidance and Covid-19 resources for those working in ultrasound, please see the organisations listed below:

• American Institute of Ultrasound in Medicine
• Australasian Society of Ultrasound in Medicine
• Australasian Sonographers Association
• British Medical Ultrasound Society
• Gov.uk
• Health Protection Scotland
• International Society of Ultrasound in Obstetrics and Gynecology
• NHS England and NHS Improvement
• NICE Coronavirus (Covid-19)
• Public Health Agency
• Public Health Wales
• Royal College of Radiologists
• World Federation for Ultrasound in Medicine and Biology

Point of care ultrasound guidance

There are many articles and websites about how to use ultrasound in the diagnosis of lung disease such as:

• BMUS (2020) Lung Ultrasound
• Falcetta et al (2018) The role of lung ultrasound in the diagnosis of interstitial lung disease. Shanghai Chest, 2 (5).
• Huang et al (2020) A Preliminary Study on the Ultrasonic Manifestations of Peripulmonary Lesions of Non-Critical Novel Coronavirus Pneumonia (Covid-19). Also available at http://dx.doi.org/10.2139/ssrn.3544750

• Smith, M.J., Hayward, S.A., Innes, S.M. and Miller, A.S.C. (2020) Point‐of‐care lung ultrasound in patients with COVID ‐19 – a narrative review. Anaesthesia. doi:10.1111/anae.15082

• Qian‑Yi P et al (2020) Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic
• Features of lung ultrasound in Covid-19 infection
• Wiley have made their lung ultrasound articles available free 

Preparing for Covid-19

• Mossa-Basha et al (2020) Radiology Department Preparedness for Covid-19: Radiology Scientific Expert Panel. Radiology 0 0:0 

Appendix A: Template (that can be adapted with local details) for maternity services to use if they wish Information for pregnant women who cannot have their scheduled appointment today and need to have their appointment rescheduled due to Covid-19.

If you have symptoms of Covid-19, you must not attend your appointment but phone your maternity service for advice.

Maternity units may wish to provide additional information to pregnant women, which includes the following:

• Reason they are unable to have their appointment today. For example, they have suspected Covid-19, or have been in contact with someone who has recently had the infection.
• When they will have their appointment rescheduled.
• How they will be contacted about the new appointment date.
• If they don’t hear from maternity service (it would be advisable to have a time frame, for example, if you don’t hear within one week, please contact), how and who they should contact.