COVID-19: Guidance, Community Diagnostic Imaging Services

Further to the ASR media release dated March 18^th 2020, Diagnostic Imaging leadership in Alberta has meetings frequently by teleconference to guide best practice issues, with representation from various Radiology practice groups across the Province, as well as the AHS DI Zone Leads from Edmonton and Calgary.

We have reviewed the CMOH order March 27^th 2020 https://open.alberta.ca/publications/cmoh-order-07-2020-2020-covid-19-response#summary and have noted subsequent guidance on implementation from the Registrar of the College of Physicians and Surgeons of Alberta April 3^rd  2020 (https://mailchi.mp/cpsa/cpsa-advice-to-the-profession-defining-urgent-care-covid19?e=2e5cfd2bb0) as to what constitutes an ‘essential’ or ‘urgent’ physician service under the circumstances.  Some considerations include:

• Does the patient feel the benefit of therapy exceeds the risk of the leaving their home?
• Is the benefit to the individual patient worth the risk of having them leave their home? Special consideration must be given to high-risk patients (e.g.: patients with pre-existing health conditions or who are over 60 years old)
• Could scarce resources, like acute care, need to be accessed if the procedure does not go as planned? How will this be coordinated?
• Will the care provided prevent the need for a patient to access acute care in the foreseeable future?
• Would a group of peers support the decision the care is urgent? Would colleagues perceive these actions as being self-serving, rather than putting the needs of patients, staff and society first?

Additionally, clinics continuing to provide services must implement up-to-date COVID-19 specific Infection Prevention and Control strategies appropriate to their settings as recommended by AHS including patient screening; physical distancing; PPE use as required; and other staff, patient, visitor, and environmental precautions such as:

• https://www.albertahealthservices.ca/assets/healthinfo/ipc/hi-ipc-respiratory-additional-precautions-assessment.pdf
• https://www.albertahealthservices.ca/assets/healthinfo/ipc/hi-ipc-emerging-issues-ncov.pdf
• https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-ppe-continuous-use-guidance-masking.pdf

Further information at:

• https://www.albertahealthservices.ca/topics/Page16947.aspx#resources
• https://www.albertahealthservices.ca/topics/Page17048.aspx

Within Diagnostic Imaging, the general consensus is that community DI providers who can meet these standards should continue to provide support to referring physicians for the issues that patients are still seeking care for from their medical home, that those health care providers can still accept patients for, that they are still sending patients to DI facilities for, and that patients are subsequently choosing to prioritize rather than postpone. Continuing to care for these patients promptly in the community / ambulatory care setting may reduce overall exposure risk by avoiding care-seeking in other venues or facilities including Urgent Care or Emergency Departments, or repeat visits within primary care.

• Screening-type exams (screening mammography or whole breast ultrasound, bone densitometry) are nevertheless being deferred if at all possible until at least May 1^st, per Canadian Association of Radiologists advice;
• Cancer surveillance studies may still be performed if deemed necessary by the most responsible physician, but should not be prompted / initiated by DI departments at this time;
• For pain management interventions specifically, additional verification with the patient is recommended to confirm that the procedure is essential, such as for their self-care or independent living status, care of a dependent, maintenance of employment, or that the pain is severe or otherwise unmanageable at home without seeking other care.  If none of these are the case, postponement for 60-90 days is advisable.  
• Other diagnostic studies in asymptomatic (ILI/RTI) patients are generally acceptable, however:
• Symptomatic patients with ILI/RTI should defer for 10-14 days if at all possible, unless the issue is a potential emergency or very time sensitive such as:

X-ray

Chest: new cough, chest pain, shortness of breath, difficulty breathing, low oxygen levels, pneumonia, pneumothorax

Abdomen: obstruction, perforation / free air

Extremity: fracture or subluxation, foreign body, infection

Ultrasound:

obstetrical ultrasounds;

acute neck, abdominal, abdominal wall, pelvic, or scrotal pain

deep venous thrombosis, arterial occlusion, acute bleeding concern;

possible abscess or deep infection;

biopsy of highly suspicious lesions

Diagnostic mammogram: new concerns only.

• Additional consideration should be given to segregating all asymptomatic vulnerable patients from those with ILI/RTI symptoms.

With this combination of circumstances and measures, Community Diagnostic Imaging facilities are typically reporting 50-75% reductions in patient visits at this time.

Thank you,

Robert Davies, MD, FRCP(C)

President, Alberta Society of Radiologists

President, Section of Diagnostic Imaging (AMA)

(by consensus, April 15th 2020 Alberta DI leaders’ teleconference)