We are facing unprecedented times in the United States with the coronavirus (COVID-19) pandemic. While attention has been focused on the providers actively caring for the critically ill patients, little guidance has been provided to healthcare workers with essential positions who are in constant contact with the general public without a confirmed diagnosis (asymptomatic or mild symptoms). The CDC and our professional organizations including ACOG, SMFM, AWHONN have released valuable resources for the inpatient setting or care of the COVID-19 infected patient, but there are no official recommendations or guidelines for the outpatient obstetrical unit staff, especially the medical assistants, nurses, and ultrasonographers. Below is a summary of some steps we feel would help in risk mitigation during this peak infection time, and we hope this list provides a starting point for discussions at the outpatient practice.
Remember, every medical procedure, examination, or intervention must meet certain criteria in order to be indicated/justifiable. Providers and organizations have to assess the risks and benefits in light of the patient's medical condition and the context of the care environment. In the midst of this pandemic, the context has changed, and the risks and benefits of each interaction has shifted drastically. Many interventions and examinations that were considered to be advisable a few months ago are no longer justifiable in this current environment.
Each of us has a responsibility as healthcare workers and as citizens amidst this crisis. Some of these recommendations are directed to the healthcare worker in order to minimize their own risk; but our responsibility does not end there. We must also put in place practices and procedures that protect our patients and the community at large.
In a separate post found here, we provide our thoughts on what components of routine prenatal care can be altered during the social distancing phase of the COVID-19 response.
- Wash and clean hands at the door before and after every exam
- Wear gloves on both hands while operating the US machine
- Wear a mask when social distancing is not possible
- Increase ventilation by opening windows or adjusting air-conditioning to improve air-flow
- Disinfect surfaces before/after each patient interaction and be sure to observe the recommended dry time for the product utilized (Ultrasound equipment, door knobs, chairs, exam beds, countertops, sink knobs, etc.)
- No food or beverages allowed in rooms
- Stay home if a patient you've scanned in the past week is under evaluation for COVID-19, or you are sick, or have a sick family member
- Ask the facility to reschedule non-essential exams to when social distancing measures are relaxed. In our opinion, the following exams may be considered non-essential: dating ultrasound in the first trimester, nuchal translucency assessment, routine cervical length screening in patients at low-risk for preterm labor or cervical insufficiency, serial growth ultrasounds less than 4 weeks apart in non-IUGR cases, weekly antenatal testing in lower risk patients (i.e. AMA over 40-years old, BMI over 40, GDMA1)
- Be courteous and professional, be kind, but limit any unnecessary discussion during the exam that could contribute to increased duration of the interaction.
- Limit exam to the bare minimum required images. Many of us, as part of our accreditation compliance (i.e. AIUM) have protocols to follow. Given today's extraordinary circumstances, we must adapt. For example, a single HC, AC, and FL shot, along with DVP and FHR should suffice for a follow up growth assessment limiting the exposure between the sonographer and the patients. Recommend meeting with the interpreting provider to delineate the minimum images required to render a clinical opinion. This also includes non-diagnostic related images such as keepsake 3D renderings. However, if you have the appropriate equipment, diagnostic 3D volumes and cine loops may be helpful in decreasing the length of the examination.
- Consult with your medical director to alter your anatomy survey protocols in order to account for the highest priority areas: brain, upper lip, heart, abdomen (stomach, kidneys, bladder, intact abdominal wall), and spine. As above, use cine loops or 3D volumes to decrease scan time. Perform the majority of the examination with the patient in the left lateral decubitus position with her face directed away from the examiner. As much as possible, perform measurements and other detailed assessments after the examination. In many environments this can be accomplished from cine loops or 3D volumes. Do not schedule anatomy scan follow ups for suboptimal anatomy unless a critical diagnosis is suspected.
Altered anatomy protocol:
- LUS for closed cervix and r/o previa
- Heart rate
- Growth assessment (HC, AC, FL)
- Axial cine through the brain
- Axial cine from mandible through orbits
- Axial cine from the stomach through the four chamber and three vessel trachea view
- Axial cine from the bladder to the stomach
- Transverse cine of the spine (cerebellum to sacrum)
- Limits visitors to the partner only (I suggest no visitors), would allow videoconferencing (i.e. Apple FaceTime). Similarly, if possible, restrict children from attending the ultrasound exam.
- Visitors should be instructed to follow the recommended 6’ social distancing recommendations throughout the visit.
- If a visitor is present, designate an area in the room that is a 6’ distance from the patient (when possible) and sonographer in the ultrasound room
- Ask the facility to screen or symptoms prior to entry into the exam room, and reschedule exams in the patient with positive symptoms
OB Nurses and Medical Assistants
- Perform new patient intake on the phone. On the day of visit, have the patients check in from their car, and do not have them enter the facility until the appointment room is available.
- Perform follow-up patient review of systems on the phone. On the day of visit, have the patients check in from their car, screen for symptoms/fever and do not have them enter the facility until they have been appropriately screened and the appointment room is available. For patients who screen positive or have symptoms, they should be rescheduled to a later date and time.
- Ask your providers which patients absolutely need vital signs checked (i.e. CHTN, GHTN), and which patients need a current weight. If unnecessary, skip the unnecessary exposure.
- When placing the patient in the room, remain by the door or 6-feet away to minimize your exposure.
- Ask your providers which patients absolutely need a blood draw? Similarly, ask to reduce number of non-stress tests to those absolutely required. Many prenatal visits, as well as the 2-week postpartum check-up may be moved to telemedicine. If your facility has not implemented telemedicine, feel free to connect them with us at support@TelePerinatal.com as we can set them up on our platform or refer them to other cost-effective solutions.
- Move patient facing tasks such as diabetic teaching (including how to use glucometer), or self-injection teaching move to videoconferencing.
- Limits visitors to the partner only, or allow videoconferencing (i.e. Apple FaceTime). Similarly, if possible, restrict children from visits. (No visitors)
- For those patients who screen positive or are COVID positive and must be seen, identify a location where they can be seen and cared for, and use PPE. If no location is possible, schedule these patients at the end of the day, to minimize contact with other patients.
- Ask the facility to set aside time for patients with any symptoms (i.e. cough, sore throat), and use PPE during those visits.
- Wash and clean hands at the door before and after every patient.
- Increase ventilation by opening windows or adjusting air-conditioning to improve air-flow
- Disinfect surfaces such as door knobs, desks, handrails regularly
- Limit food sharing
- Stay home if a patient you've cared for in the past week is under evaluation for COVID-19, or you are sick, or have a sick family member
- Any objects that are brought to work from home, or from home from work should be disinfected during the transition (cell phone, tablet, laptop, hospital badge, etc.)
- Leave work shoes outside your house, change your clothes and place in laundry to wash, and shower immediately.
- Practice social distancing with patients and coworkers when possible. Maintain 6 feet between yourself and others at all times unless absolutely necessary.
- Clean all surfaces between each interaction. Be sure to apply the sanitizer thoroughly and allow for the recommended dry time. Things to remember to clean: door knobs, chairs, desks, workstations, and ultrasound equipment.
- Minimize rotations on workstations. Assign each key staff member (physician, sonographer, front desk, etc.) to a given room/space/workstation.
- We recommend that patients check-in remotely and wait in their car until their exam room is prepared, if this is not possible, ensure that there are no more than 10 patients in the waiting area and that there is at least 6 feet between each person. Remove any non-essential items such as magazines, remotes for the TV, toys for children, etc. Wipe down each chair when the patient is called back to an exam room.
- Practice responsible utilization of PPE. These supplies need to be maintained for the care of patients who are sick.
William Lindsley is a Maternal-Fetal Medicine Ultrasound Consultant and currently serves as an Ultrasound Practitioner at Access Physicians. He can be reached via LinkedIn.