Lessons Learned From the COVID-19 Response in a Major New York City Hot Zone.

The COVID-19 pandemic had significant impact on radiology departments across the United States. Radiology departments have adjusted to the effects of the pandemic. This article presents the changes made by the Radiology department at the Montefiore Medical Center (MMC) of the Albert Einstein College of Medicine located in the Bronx, New York City which is one of the major hot spots of the COVID-19 pandemic.

Institutional Approach to COVID-19

Elective Imaging Volumes

Elective imaging volumes dropped sharply at the onset of the pandemic due to public fear of contracting COVID-19 while seeking imaging care as well as rescheduling of outpatient cases. During New York City's (NYC) first wave in March and April 2020, MMC's inpatient wards were filled with COVID patients. Paradoxically, overall imaging volumes fell by 60%-70% during this time. (Fig 1 ) This decrease in imaging volume occurred because most COVID-19 patients did not require advanced imaging and many patients with non–COVID-19 related medical conditions postponed care. During April 2020 outpatient imaging volumes showed the steepest decline by about 85% compared to 2019 volumes followed by emergency radiology volumes which decreased by about 50%. (Fig 2 ) Inpatient imaging volume decreased approximately 20% at the start of the pandemic and remained at this level for the remainder of 2020. Most radiology divisions experienced decreased imaging volumes except for the divisions of thoracic and interventional radiology (IR). Thoracic radiology experienced sustained volumes as chest imaging, most notably portable radiographs, continued, and even increased above baseline at times for patients with known or suspected COVID-19 pneumonia. IR also had sustained case volumes as surgical specialties deferred cases.

FIG 1

Montefiore Radiology volume by month in 2020 as a percentage of 2019 baseline. (Color version of figure is available online).

FIG 2

Montefiore Radiology volume by patient class in 2020 as a percentage of 2019 baseline. (Color version of figure is available online).

Lab Testing

Significant efforts were directed toward detecting symptomatic individuals through widespread testing with subsequent quarantine of positive cases. Availability of in-house rapid testing is essential to this effort, allowing for accurate and timely recommendations for quarantine, and contact tracing. When rapid testing capacity was overwhelmed during the first wave of the pandemic, non–rapid testing at off-site facilities was utilized. However, results often took up to 5 days to return, delaying isolation, and contact tracing of positive patients. This lack of rapid-testing resources negatively impacted patient care by leading to unnecessary quarantine of asymptomatic staff who had contact with either COVID-19 positive individuals or with persons who had COVID-19 like symptoms.

Imaging of COVID-19 Positive or Suspected Patients

At MMC the Radiology department followed the Fleischner Society consensus statement and the American College of Radiology (ACR) recommendations regarding the role of chest imaging during the COVID-19 pandemic. The statement suggests that imaging is not routinely indicated as a screening test for COVID-19 in asymptomatic or symptomatic individuals with mild features unless they are at risk for disease progression. The ACR recommends that chest CT scan should not be used to screen for or as a first-line test to diagnose COVID-19, unless there are constrained resources and limited availability of COVID-19 testing.

During NYC's initial surge in March and April 2020 a need for increased portable CXR capacity was seen across the health system. This challenge was met by immediately securing loaner units at no cost from multiple vendors. Prior to the surge, MMC, consisting of about 1500 inpatient beds was performing on average 250 portable CXR's daily, whereas in March, and April of 2020 the daily average was 380, an approximate 50% increase.

To limit personnel exposure, CT and MR scan requests were triaged by radiologists to ensure that the most appropriate examination was performed. Whenever possible the use of designated CT and MRI units for COVID-19 positive patients was implemented, and served as a useful tool for streamlining operations, controlling exposures and limiting downtime required for scanner room air exchange and cleaning. A COVID-19 radiology response team comprised of radiologists, administrators, nurses, technologists, and IT personnel was established. This team helped to rapidly develop and maintain procedures and workflows and was critical for communicating new or updated policies and processes throughout the health system.

Protection of Radiology Staff

Developing sufficient PPE stores and instituting strict inventory control are critical for adequately protecting front-line health care workers. Particular emphasis is made on the importance of the availability of N95 masks. Other essential PPE includes face shields, goggles, gowns, and gloves.  If there is a shortage of PPE, innovative measures tailored to the institution's resources should be developed. At MMC, on-site 3D printing of face shields was implemented to address an initial shortage. Moreover, consideration of sharing PPE supplies from departments or facilities where they are less acutely required, such as research laboratories, may serve as an additional resource. Proactively seeking donations of properly certified PPE was also beneficial during the pandemic.

An important measure to ensure front-line staff protection is the institution of a mandatory mask policy for all patients in the radiology department. Hand hygiene should be encouraged among the staff and patients. Thorough cleaning and disinfection of equipment is a mandatory routine precaution.

Site considerations

The rapid increase of infected patients within hospitals requires efficient bed expansion readiness. At MMC converting available spaces into hospital beds for COVID-19 was rapidly accomplished during the worst of the pandemic. ICU beds were increased by using converted PACU, cardiac catheterization laboratories, and GI suites. The availability of inpatient medicine beds was expanded by converting pediatric wards and large conference spaces into adult COVID-19 units. The pediatric ER was employed for adult COVID-19 ER care. For critically ill patients, there was also a need to increase the stock of mechanical ventilators and associated medications.

Sick or Exposed Employees

Quarantine of exposed staff can hamper recovery efforts in the aftermath of a surge. Although the CDC guidelines initially required 14 days of quarantine after a high-risk exposure, CDC guidelines were revised in the fall of 2020 to 10 days. The New York Department of Health issued revised protocols for personnel in healthcare to return to work following COVID-19 exposure or infection, in which Occupational Health Services may recommend a “modified quarantine” which may apply to asymptomatic associates whose quarantine would negatively impact patient safety. In practice this means that certain essential personnel could return to work without waiting through the quarantine period. Precautions taken included repeated COVID PCR tests and continuous mask wearing while indoors.

Distribution of Patients for Imaging Procedures

To provide a safe environment for elective imaging, individuals with possible COVID-19 symptoms may be directed to hospital sites for their imaging needs reserving outpatient imaging sites for patients without suspected COVID-19 who pass a screening questionnaire. Reconfiguring seating arrangements in waiting rooms and placement of floor markers to indicate 6 feet separation help to enhance social distancing. Hand sanitizer should be displayed and easily accessible to encourage hand hygiene for staff and patients. Installation of barrier screens should be considered for the protection of patients and staff, particularly in high volume areas such as reception desks.

Radiology Faculty and Staff Protection

Cohorting radiologists into on-site and off-site reading teams proportionate to the imaging workload and other departmental needs can decrease the risk of infection among the faculty and ensure sufficient coverage redundancy in case one cohort becomes infected. It is crucial to maintain social distancing of on-site radiologists and trainees by providing an increased number of on-site reading locations to reduce the number of individuals per reading room. Radiologists could work remotely to help cover inpatient and ED Radiology needs on weekends, and to balance workloads in the setting of decreased volumes.

Education and Research

Maintaining resident education is essential, and we suggest pairing each resident with an attending according to their assigned division. Residents should proactively continue training and education opportunities on-site and off-site. Electronic learning opportunities using tools like Zoom or Microsoft Teams for lectures and screen-sharing during read-outs can be instituted when in-person lectures and “at the workstation” teaching are deferred.

During the most challenging times of the pandemic, on-site laboratory research will likely be halted. Continued off-site research activities, including grant submissions, virtual team meetings, and manuscript preparation should be maintained.

Personnel Considerations

At MMC, significantly decreased imaging volumes during peak months of the pandemic propelled our department to shift vacation and academic time to when case volumes were low. In turn, this allowed for more faculty to be available during the recovery phase when imaging volumes increased. Personnel who could not work due to medical or family reasons were provided with reasonable accommodation and/or allowed to take leave according to the The Family and Medical Leave Act (FMLA).  With the severe strain on staffing of health systems, there may be a need for radiology staff redeployment to multidisciplinary front-line clinical teams taking care of COVID-19 patients. This redeployment may cause significant stress and anxiety, and appropriate orientation, training, and support should be made available to the staff.

Staff Well Being and Support

Staff well-being and support are critical to help radiology personnel cope with the highly stressful environment that develops during a pandemic. Institutions can support their staff by providing hotel nights to avoid the anxiety-provoking situation of infecting household members. Car rentals can be provided to staff who normally would take public transportation which may be unsafe or unavailable during the pandemic. Other actions to support staff may include providing free childcare, hospital meals, scrubs, and laundering.

We highly recommend implementing support centers and hotlines to help staff cope with their stress and anxiety. The initiation of an emotional support ally system can be a personal way to deal with the burden of the pandemic. We also encourage developing a system allowing expedited referrals to psychiatry for short-term therapy regarding emotional and psychological burnout during and after the pandemic. Other successful measures to help with staff well-being include providing clergy for spiritual support and virtual parenting skills workshops.

Outcomes of Institutional Changes in Practice

Since the beginning of the pandemic, we have adapted with great success to the challenging and unprecedented situation imposed by COVID-19. Due to its location in the Bronx, New York, MMC provided care for many vulnerable patients in one of the first and one of the largest COVID-19 epicenters in the U.S. The department proactively performed continuous monitoring and re-evaluation of daily challenges with rapid development of new processes and guidelines to manage PPE, changing volumes, shifting locations for inpatients and outpatients, and imaging equipment needs. In conjunction with active management, the Radiology department effectively maintained patient access to imaging exams and interventional procedures during the peak of the pandemic while instituting protocols to ensure the safety of our patients and staff. Additionally, the education of our trainees was never halted as we made use of virtual methods to maintain the educational and academic missions of our program.

Future Directions

A ‘Post-Pandemic Planning Task Force’ was created based on lessons learned from our first experience with the pandemic. The focus of this task force has been on maintaining infection control and PPE management. We have designated certain sites as restricted to those patients who screen negative for COVID-19 by history, travel and symptoms, which has served to reduce the risk of transmission to outpatients seeking imaging care. Hospital-based sites have been designated for COVID+ care and for screening positive by history, travel and symptoms, with waiting room protocols and workflows in place to provide a safe environment for all patients at those sites as well.

We have optimized scheduling of imaging appointments and social distancing strategies have been incorporated in waiting rooms. We have made great efforts at patient outreach to inform them of the comprehensive safety protocols and precautions that have been implemented to increase their confidence in returning to our health system. Although some research has continued throughout this time, reaching pre-pandemic levels remains a challenge. The focus of research pivoted to focus on COVID-19 related projects which have been highly fundable.