The Covid-19 pandemic appears to have decimated outpatient imaging volumes. With communities across the U.S. in various stages of re-opening for business, Strategic Radiology (SR) member practices with outpatient assets are beginning to carefully and mindfully take steps to safely resume non–Covid-related imaging of patients.

In a retrospective review of imaging volumes during the 16 weeks between January 1 and April 18 by Naidach et al, Northwell Health, a large New York health system, saw the greatest decline registered in outpatient imaging (-88%) during week 16, with mammography (-94%), nuclear medicine (85%), and MRI (-74%) hit the hardest. In nearby New Brunswick, NJ, Sandip Basak, MD, president of SR member group University Radiology, reported a 66% decline in office volumes by March 22 during a webinar that shared early Covid experiences.

"Pre-Covid-19, we were screening about 2,200 patients per day in our offices," he said. "By week 2, we were down to 1,832, by week 3 we were down to 1,090, and as of [March 26], we were down to 722.

In Maryland, new SR member and all-outpatient practice Chesapeake Medical Imaging (CMI) with 13 outpatient sites experienced abrupt and “huge” declines in volume followed by commensurate reductions in revenue a few weeks later. “That has been a challenge,” notes Mark Baganz, MD, CEO. “It is not just medicine, not just radiology, it is all sectors, whether retail, restaurants, manufacturing. How do you survive a catastrophic event from the business standpoint? We have had to be very careful.”

“Maryland is beginning to open back up, and we are seeing patient volumes start to ramp up,” he continued. “We are able to respond more quickly than the larger organizations in returning back to more normal operations, so we are going to be OK.”

The biggest challenge has been keeping patients and staff not just feeling safe but actually being safe and as protected as possible, said Dr. Baganz. “We’re learning new workflows where we have essentially closed down our waiting rooms and used our parking lots as waiting rooms,” he reports. “We’ve been fortunate enough to have the geography where most of our offices have a parking lot right outside the main office door.” 

Webinar: Patient Safety Best Practices

Quality teams from a number of SR practices gathered online recently to share steps taken to keep patients and staff as safe by guarding against all potential vulnerabilities during a webinar conducted within the SR Patient Safety Organization by Executive Director Lisa Mead, RN, CPHQ. One bright note is that all practices report having adequate patient protective equipment for patient-facing radiologists and staff.

Pre-screening and Registration

• Patients are asked a series of questions on the phone before they are scheduled regarding symptoms—these questions have morphed over time.
• Patients are asked the same questions again when they arrive.
• Some practices take patient temperatures and not admitting patients with a temperature over 99 degrees.
• Some practices use a decision tree to help differentiate patients with Covid-19 from patients with temperatures due to other factors; some use an on-call radiologist.
• Some practices have implemented electronic online registration forms that are saved to the exam in the RIS.
• Achieving a 100% paperless check-in has been elusive—even those practices that have implemented electronic registration must ask for insurance cards.
• 
  Maintaining Social Distancing
• Patients text when they arrive, wait in car, and are texted when their exam time nears.
• Masks required for all patients and staff and provided for patients who arrive without them.
• Acrylic barriers added at desks.
• Limit number of patients in waiting room to one at a time, less than 5, or less than 10.
• Take high-risk patients directly into dressing rooms if waiting room near “capacity.”
• Limit people who accompany patients to parents of minor children and those requiring assistance.

Exam Times

• Add 15 minutes to each exam time to allow for cleaning rooms, exam tables, doorknobs, pens, and anything else a patient may touch
• Extending exam times and finding the greatest need is for longer MRI appointment times
• Staggering exam times
• Opening slots in the early evening and on the weekends as demand increases

Policy for Walk-in Patients

• Varies and working with referring community to prioritize.

Use of Signage

• All signage provided by CDC—downloaded, printed and posted.
• Use of signage to communicate what the site is doing to patients safe and precautions expected of patients.
• Use of floor markers to show what 6 feet looks like.

Backlog

• Relying on referring physicians.
• Run lists of cancellations and calling them along with current orders to let patients know the site is open and ready to take care of their needs.
• Resume screening exams.

Sanitizing

• Educate staff to make sure everyone knows the dry time after disinfecting a room.
• Clean stairwells every hour.
• Remove water fountain and coffee station.
• Establishsafety team to clean common areas and equip with aprons for visibility to patients.
• Place bottles of disinfectant lon counters in staff room; instruct staff to clean after use.

Room Turnaround Process

• Use room light to signal when room is ready to be cleaned; light is turned off after room is cleaned.

Preparedness

• Committee formed that meets twice a week with all modality managers and executive leaders.
• Schedule town halls; enabling employees to question executives is reassuring.

Keeping Radiologists Safe

• Restrict reading rooms to one radiologist.
• Re-purpose outpatient sites that are temporarily closed as reading rooms.
• Many radiologists are reading remotely from home.
• Reading rooms are equipped with “purple-topped napalm wipes” and radiologist assistants who make sure everyone uses them.
• Masking outside reading rooms.

Comeback Task Force

Mead asked members if they had a plan in place for a repeat de-engagement of non-urgent care in the event of a second surge.  One practice reported that they had implemented a Comeback Task Force that meets several times a week to review data, including number of cases, number of hospitalizations, and number of deaths.

“Keeping data part of the plan is best practice,” said Mead. “Also, remember that it is important to keep written plans as part of your Patient Safety Evaluation Systems (PSES), and important to have a plan ready to put into action based on triggers—these could be a state or local edict.”

Mead subsequently hosted another Covid-19-related related webinar that featured Peggy Binzer, JD, executive director of the Alliance for Quality Improvement and Patient Safety (AQIPS), "Preparing for the Upcoming Covid-19 Litigation." While Mead does not expect radiology to be a primary target, it will be a good opportunity to review relevant legislation, including the PREP  Act that emerged after the Katrina disasters and immunity declarations and how they work, and the importance of member groups’ Patient Safety Evaluation Systems, the system the practice uses to document how it analyzes and deliberates patient safety and quality information in a privileged and confidential manner.  Binzer also will address the steps SR-PSO members need to take to protect metadata, or EHR audit trails, as Patient Safety Work Product.