Radiography Department and Mobile Radiography on at risk COVID-19 patients

1. Preparation

1. Radiographer/RT Tasks
2. Patient Considerations
3. Equipment Considerations
4. Imaging Room Environmental Considerations

1.1. Radiographer/RT Tasks

Radiographer/RT Tasks

• Ensure that patients and staff use the main department entrance and do not enter the department without permission and without specific reason.
• Do not allow patients to wait in the waiting room for long periods, adapt international social distancing or or adapt best practice of local and national guideline.
• For mobile radiography liaise with clinical team to arrange an appropriate time
• Confirm that medical exposure has been justified as urgent accordingly and/or cannot be rescheduled
• Inform the referring physician that the patient should enter the department wearing the appropriate mask in accordance with the Hospital Infectious Diseases Committee guidelines.
• Appropriate fit-tested radiographer to undertake general and mobile radiography where aerosol generating procedures are performed and if possible, to work in pairs
• Ensure areas and equipment have been adequately disinfected-decontaminated.
• Disinfect - wash hands.
• Don PPE appropriate for the clinical task being performed with all appropriate steps - for AGP situations:-
  • Perform Hand Hygiene
  • Put on long sleeve fluid resistant gown
  • Put on N95/FFP2/FFP3 or PAPR (If radiographer wears glasses take off until FFP is secured in place- put glasses back on)
  • Place Face mask (if reuses N95/FFP2/FFP3 mask face serves as barrier) or googles in place (If reuses N95/FFP2/FFP3 put surgical mask over your N95/FFP2/FFP3) (The facial mask should be put on first, then head/hair cover that covers all hair and both ears.)
  • Clean hands with antibacterial liquid before putting on gloves and put on non-Sterile Nitrile gloves (be sure gloves cover cuffs of gown)
  • You may now enter the patient room

1.2. Patient Considerations

• Controlled arrival and departure of patients and staff in the radiology department and only using the central entrance
• Patient to wear a mask wherever possible

1.3. Equipment Considerations

Disinfection-Decontamination with the use of appropriate technique and means according to Hospital Infectious Diseases Control Committee between patients depending on their infection status (i.e. asymptomatic-suspected-confirmed COVID- 19):

• X-ray table or Vertical Bucky (immobilization straps, positioning sponges which should be covered with plastic protection)
• Auxiliary equipment (i.e. ECG, Defibrillator, suction device, Oxygen mask)
• Mobile X-ray machine with DDR detector or CR cassettes
• DDR/CR detector to be placed in a protective bag

1.4. Imaging Room Environmental Considerations

Disinfection-Decontamination with the use of appropriate technique and means of areas and patient contact surfaces according to Hospital Infectious Diseases Control Committee between patients depending on their infection status (i.e. asymptomatic-suspected-confirmed COVID 19)

2. During

1. Radiographer/RT Tasks
2. Patient Considerations
3. Equipment Considerations

2.1. Radiographer/RT Tasks

• Preferably work in pairs with one radiographer to facilitate contact/non-contact technique
• Introduce yourself and colleague by name and explain what you are about to do
• Get consent for the examination if that is possible
• For supine radiography cover the X-ray couch with disposable paper.
• For imaging that requires the detector/cassette to be in contact with the patient, such as mobile radiography, insert the image receptor with a disposable plastic cover
• Remove any radiopaque objects in the region of interest from the patient
• Patient and image receptor positioned – for mobile radiography the DDR/CR detector placed under the thorax for CXR.
• Contact radiographer undertaking imaging in the department stands in the radiation protected area – without touching anything
• Contact radiographer undertaking mobile radiography stands outside the controlled area without physical contact with the team or any objects
• Ensure correct anatomical marker in beam
• Image acquisition/exposure made by non-contact radiographer, ensuring the principles of justification, optimization, radiation dose limitation as well as the radiographer’s/Radiologic Technologist’s Ethical Code and RG/RT Professional Rights at all times
• Image checked and if optimum image quality send to PACS
• Remove gloves and dispose of them in the clinical waste bin (yellow hazardous-contaminated waste) in accordance with the regulation of your Hospital Waste Management Committee. (HWMC)
• Remember, when exiting the X-ray room (contaminated area) or Ward bed location clothing may be contaminated.
• Don't take off mask!
• Disinfect hands with an  hand sanitizer before you enter the console area (clean area) i.e. before touching the keyboard and mouse, the control console, and the injector.

2.2. Patient Considerations

Patient continues to wear mask

2.3. Equipment Considerations

• If working alone X-ray generator and mobile control screen keys are considered contaminated so they must be used with gloves
• X-ray couch is covered with single use paper per patient.
• Working in pairs in an X-ray room the generator console keyboards, mouse and exposure control panel are considered clean.
• For mobile radiography where there is the risk of droplet transmission it is prudent to wear gloves for all equipment that has been in the patient care area.

3. Post procedure

1. Radiographer/RT Tasks
2. Patient Considerations
3. Equipment Considerations
4. Imaging Room Environmental Considerations

3.1. Radiographer/RT Tasks

• Contact radiographer re-enters the X-ray room (dirty area) or patient bedside, wearing PPE equipment
• Carefully remove the used paper cover from the X-ray couch, if used, without touching your clothing and dispose of it in the corresponding bin according to hospital policy.
• Ensure decontamination-disinfection of Vertical Bucky or X-ray couch CTS gantry/LBD keypad, surfaces contact points (sponges, fixing pads, knobs) and the DDR/CR detector by the use of a suitable disinfectant in accordance to Hospital Infectious Diseases Control Committee equipment manufacturer’s instructions.
• After disinfection/decontamination/deep cleaning, the RG/RT must visually inspect the X-ray room and auxiliary equipment without removing gloves and mask.
• Must not remove your mask yet!
• Carefully remove your gloves carefully FIRST!
• Dispose of them in the clinical waste bin (yellow hazardous contaminated waste) in accordance with the regulation of your HWMC
• Disinfect hands immediately as there is danger of being contaminated without gloves!
• Remove mask carefully so that the cords or bands of the mask do not touch the face or mucous membranes of the face (and eyes), and dispose of it in the clinical waste bin (yellow hazardous contaminated waste) in accordance with the HWMC
• Disinfect - Wash hands well (again because you touched your mask)!
• For mobile radiography
  • The mobile X-ray machine should be move to the clean area where the detector cover is disposed into a clinical waste bin by ensuring that the detector is not touched by gloves and disinfected
  • Dispose of PPE equipment in the clinical waste bin as per the visiting ward instructions
  • Wash hands before leaving the area
  • Return to the radiography department and complete any post imaging tasks and record dose

3.2. Patient Considerations

Patient keeps mask on

3.3. Equipment Considerations

• If used, Single use X-ray couch paper cover is removed and deposed of into the corresponding bin according to hospital policy.
• Disinfection-Decontamination-Deep Cleaning by the use of a suitable disinfectant in accordance to Hospital Infectious Diseases Control Committee X-ray manufacturer’s instructions of:
  • X-ray couch
  • Vertical Bucky
  • CTS gantry and LBD keypad
  • Immobilization Velcro straps and positioning sponges

3.4. Imaging Room Environmental Considerations

Disinfection-Decontamination-Deep cleaning of:

• surfaces
• contact points (knobs) by the use of a suitable disinfectant in accordance to Hospital Infectious Diseases Control
• the room should be vacant for a suitable time, up to two hours, before the next patient is examined to facilitate the exchange of the air in the X-ray room - the duration should be based on local practice recommendations.

Attention to the knobs, keyboards, console, mouse, phone, mobile phones, pagers, lighting switches, as they are also contaminated.

4. Radiography Department and Mobile Radiography General Advice

• Radiographers, as the first healthcare professional to see diagnostic images, should be trained to recognise appearances suspicious for Covid-19, especially in asymptomatic patients, and triage for an immediate/urgent clinical report.
• Where possible, designate a mobile unit for investigation of suspected or confirmed Covid-19 cases and leave this within the patient care area to reduce transmission risk
• Ensure appropriate personal protective equipment is available for staff and that staff are trained in the safe use of all PPE based on local risk assessment and national/international guidance
• Use Direct Digital Radiography (DDR) imaging whenever possible, this reduces transmission risk and minimises radiographer workload
• Designate one or two image receptors specific for COVID-19 patients if Computed Radiography (CR) or film/screen technology is to be used
• Cover x-ray detector/cassettes with plastic cover or disposable cellophane wrapper and make sure to clean X-ray cassette in between each patient
• Clean and disinfect all imaging equipment, including mobile X-ray machine, X-ray couch and chest stand between each patient. Recognise that appropriate air exchange is also required and to allow sufficient time between patients to reduce cross-contamination
• When performing imaging, both within the department and undertaking mobile radiography, wherever possible, one radiographer positions the X-ray tube and makes the exposure, the second positions the patient and the covered detector and applies the anatomical marker.
• Inform superiors/other health care professionals/colleagues of patients that are at risk
• Remove students from high risk scenarios
• Activate retired/vacationing radiographers/technologists when possible, ensuring appropriate risk assessment, access to supervision and refresher training is available
• Do not allow staff who are potentially ill to work
• Triage patients (only urgent cases)
• Adjust protocols to limit exposure and speed up though put while maintaining quality
• Inform patients of need for hand hygiene and the use of tissues when sneezing
• Split staffing into multiple shifts to limit exposure of the entire team, ensuring appropriate skill ix and experience wherever possible