Tran Nguyen and Hodon Ali – Royal Orthopaedic Hospital, Birmingham

Imaging has always played an important role in the diagnosis of numerous diseases and it was no different when it came to the pandemic caused by the coronavirus disease 2019 (COVID-19). This virus is known to cause respiratory infection so a chest x-ray has typically been used, in conjunction with clinical presentation, as the first line of investigation for suspected COVID-19 patients. Consequently, as radiographers, we played an essential role during this pandemic by working on the front line. We had to be equipped with the best information available to understand the potential risks posed by the virus to patients and healthcare professionals, and to optimise imaging quality as a tool to facilitate more accurate diagnosis, management and follow-up of suspected and confirmed cases of COVID-19.

The Royal Orthopaedic Hospital (ROH) is a specialist NHS trust, which means we predominantly perform imaging for elective procedures. As an elective hospital, at the height of COVID-19 all of our routine services were suspended and we took on trauma cases from neighbouring trusts. The absence of elective patients meant we were able to concentrate our services and resources to help neighbouring trusts that were inundated, predominantly, with COVID-19 patients. This meant that as a department we had to adjust our ways of working to manage the demand of trauma. Due to the decreased workload, there were more opportunities available to reflect on our practices and the ever-changing pandemic that was evolving around us. Hence, while our role was focused on imaging elective patients before COVID-19, our role expanded and constantly changed during and after the peak of the virus.

Firstly were the risks associated with COVID-19. It was fundamental that we were aware of the potential risks to protect not only patients but ourselves too. This meant we had to make sure we were adhering to strict social distancing guidelines and wearing the correct PPE. This was made challenging by the evolving daily updates from the government and Public Health England, which meant we had to constantly be prepared for change. The safety of staff is paramount and so risk assessments were completed to determine if COVID-19 would exacerbate any underlying health issues, meaning some staff members had to shield.

As front-line staff we were in constant uncertainty about the whole situation as it developed, which stemmed from not knowing what was around the corner. We could only go by what we heard on the news and what guidelines and procedures to follow. The national shortages of PPE heightened the concern felt by all of us. We all wanted to fulfil our duty as front-line staff but were always conscious as to whether we would have enough PPE to enable us to do our job safely. However, our management was very supportive in this and we never experienced any PPE shortages in our trust.

To allow our patients to safely adhere to social distancing policies we had to stop our walk-in service and implement an appointment-only system. Our x-ray, CT, MRI and ultrasound services had decreased numbers of patients in attendance as appointments were staggered to allow for extra cleaning in between. This also permitted us to effectively manage the workload. In addition, doing a portable chest x-ray typically required one person and a few minutes to complete. We established that it was much more efficient to use portables with two staff members, allowing one person to be the designated ‘clean’ person who would handle the equipment and the other the ‘dirty’ person who would be in direct contact with the patient. The duration of the portable appointments was further increased to allow time for the donning and doffing process.

Another sizeable change to our working was the implementation of a ‘long day rota’ allowing us to accommodate an increased number of patients. As a trust, we are striving to continue to be a COVID-free hospital by making sure all patients self-isolate for 14 days before their procedure, and inpatients are swabbed twice to determine their COVID-19 status. A one-way flow system was put in place around the hospital, as were screens to reduce contact with patients and ongoing individual temperature and hand sanitising checks at hospital entrances.

Year X-ray Fluoroscopy Ultrasound CT
2019 10,773 1,244 1,831 990
2020 934 312 364 460

The table shows the decline in patients seen across the four types of imaging at the ROH during the height of the pandemic, pre and post-COVID-19 for periods between March 29 and May 29 in 2019 and 2020.

As expected, we had to adapt the way we worked, which saw some new standard operating procedures (SOP) brought in. In addition, due to the decrease in elective cases, we found that we had the opportunity to update our existing SOPs and create new ones as part of our goal to achieve Quality Standard for Imaging accredited status. This involved meeting a set of standards that our services can be measured against. As a department, we had to adapt our pathways to be in line with recommendations from Public Health England for optimal and safe imaging practices.

Accordingly, we were undertaking procedures not typically performed at ROH, alongside surgeons unfamiliar to us from different hospitals. This meant we had to quickly adapt and familiarise ourselves with new techniques. However, there was an apparent difficulty with communication due to all staff wearing filtering face piece (FFP3) masks and visors. This meant we all had to speak up to be able to be understood. Communication was made even more difficult with patients, as was building rapport with them. This was especially the case with the elderly and young children; it can be hard for those groups as they were unable to lip-read or see any facial expressions, which are an aid they use to communicate easier. Additionally, appointments were cancelled by patients themselves; they were either unable to attend hospital due to travel restrictions or had a fear of infection while visiting the hospital.

Having spoken to many colleagues and patients and through observation, we can clearly see the effects this disease had on all of us. The uncertainty caused increased emotional distress and anxiety in staff, as well as patients. This also included supporting those patients for whom the disease meant they lost a loved one. This was especially difficult as we can sometimes empathise too closely with how our patients are feeling and what they might be going through. COVID-19 was right on our doorsteps and very real. As staff we were extremely apprehensive that we would unknowingly catch the disease and spread it, especially to our families at home. Therefore we made a conscious effort to always make sure we wore the appropriate PPE and adhered strictly to the social distancing guidelines.

Having gone through this significant period of uncertainty we are now trying to get back into a routine and a new ‘normal’. We have experiences behind us that are helping us to adapt and constantly improve the service while continually streamlining the process of how we deal with COVID-19. This experience has strengthened us as a department and has shown the remarkable teamwork and solidarity that our colleagues have for one another. In the event of another wave of this disease, we are confident that we will be able to cope as a department, and as a trust.

We would like to acknowledge consultant musculoskeletal radiologist and clinical radiology liaison Dr Rajesh Botchu, consultant musculoskeletal radiologist Dr Christine Azzopardi and head of imaging Sandra Milward for their help in writing this article. We would like to thank our hospital management, imaging department, clinicians, porters and allied professionals for their help and support.

Picture: CT radiographer Tran Nguyen, consultant musculoskeletal radiologist and clinical radiology liaison Dr Rajesh Botchu, CT team lead Hodon Ali and imaging department assistant Victoria Preston.

Submitted by CT radiographer Tran Nguyen and CT team lead Hodon Ali, Royal Orthopaedic Hospital, Birmingham.

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