International Covid-19 support for Radiographers and Radiological Technologists

From the Italian experience with novel coronavirus disease (COVID-19),¹ to lower the risk of contagion as much as possible, it is highly recommended that two radiographers are present when imaging COVID-19 patients.² One of them should be assigned to managing the equipment/X-ray tube, as well as the workstation and the controls (“clean” radiographer), while the other should be assigned to position the patient, the plate and to explain the breath hold instruction during the radiography examination (“dirty” radiographer, due to the direct contact and close proximity, it possessed a higher risk for potential contamination and exposure to COVID-19). It is suggested that, whenever there is demand for a chest radiograph for a suspected or confirmed COVID-19 case, the “dirty” radiographer that helps with patient positioning takes the necessary measures to prevent any contamination or repeated acquisitions that would imply further instrument sanitisation. The “clean” radiographer, conversely, remains stationed in the control room.

The rationale of this practice is to have just one worker (the “dirty” radiographer) in contact with the patient, while the other one (the “clean” radiographer) uses the equipment/X-ray tube (“clean” radiographer) and this help to reduce the wastage of PPE.

The procedure for a portable examination scenario could be structured as follows:

• The “clean” radiographer pulls the machine inside the room and they hand a double-bagged cassette to their colleague
• The “dirty” radiographer places the double-bagged cassette behind the patient’s back, they remove a pair of gloves and perform hand hygiene with alcohol-based hand rub
• The “dirty” radiographer aligns the center ray along the mid-sagittal plane of the cassette; as the “dirty” radiographer should remain in the room, they should stay on the opposite side from the direction of the central ray and as far as possible from the patient.
• The “clean” radiographer performs the radiographic exposure and pulls the machine out of the patient’s room
• The “dirty” radiographer takes the cassette from the patient’s back, they pull the outer bag and hand the cassette to the “clean” radiographer, enclosed by the clean inner bag
• The “dirty” radiographer disposes of the outer bag appropriately.



*If aerosol-generating procedures performed on COVID-19 patients, respirator such as N95 or FFP2/3 are required.
In addition to using the appropriate PPE, frequent hand hygiene and respiratory hygiene should always be performed.
FFP: Filtering Face Piece

	Surgical masks	Surgical caps	Gloves	Eye protection (goggles/face shield)	Disposable shoe covers	Protective clothing	Medical mask FFP2 or higher*
"Clean" radiographer	✔	✔	2 pairs	✔	✔	✔
"Dirty" radiographer	✔	✔	3 pairs	✔	✔	✔	✔

Low or intermediate level disinfectant, such as iodophor germicidal detergent solution, ethyl alcohol (ethanol 75%) or isopropyl alcohol, can be used to disinfect the equipment surface at the end of each examination on suspected or confirmed COVID-19 patient. User manuals of equipment manufacturers state the disinfectant products and procedures that can be performed to avoid possible functional damage of equipment.

Occasionally, from the Singapore experience with the COVID-19 disease, only a single radiographer maybe available to perform the x-ray procedure. This may help minimise exposure to staff in designated high-risk environments. In this scenario, the sequence for a portable examination scenario could be structured as follows:

• Before entering the room, assign and label the imaging plate for the correct patient
• After wearing appropriate PPE, the radiographer pulls the machine inside the room and verbally checks the patient’s identification without any patient contact. At this point, the x-ray tube may be aligned to the general direction of the patient and a exposure parameters may be set
• The radiographer places the double-bagged cassette behind the patient’s back and positions the patient. They remove the outermost pair of gloves and perform hand hygiene with alcohol-based hand rub
• The radiographer adjusts the tube such that the center ray is aligned to the mid-sagittal plane of the cassette, performs the radiographic exposure and pulls the machine out of the patient’s room
• The radiographer wears another layer of gloves to take the cassette from the patient’s back, they open the outer bag and without touching the inner bag, places the cassette enclosed by the clean inner bag outside the room. The outer bag is disposed of appropriately; The radiographer removes the outermost layer of gloves, and performs hand hygiene with alcohol-based hand rub. The machine and cassette are cleaned appropriately with 70% isopropyl alcohol wipes