Victoria Preston – Royal Orthopaedic Hospital, Birmingham

COVID-19 has resulted in 745,000 deaths worldwide to date.1 Cases are constantly on the rise, putting significant strain on healthcare systems worldwide. Our medical imaging department played an important role in managing patients with COVID-19 as well as continuing to provide an outpatient service as a tertiary oncology centre.2

Imaging department assistant (IDA) role
The IDA role at the Royal Orthopaedic Hospital (ROH) includes managing the patient flow in CT, x-ray and ultrasound. This includes inpatients and outpatients. The IDA assists radiologists, radiographers and sonographers with escorting patients and preparing them for the imaging examination. More importantly we are the individuals who can provide a helping hand and a smile behind our masks. In particular we are there for vulnerable patients or simply patients who find the hospital environment a stressful experience.

On a more administrative level, we are responsible for managing stock levels for consumables such as needles for injection, biopsy packs, PPE, gowns, etc, and ensuring imaging equipment is cleaned between each patient. IDAs also assist in ensuring all relevant paperwork, such as consent forms, is completed and recorded appropriately.

During the peak of the pandemic, a reduced workflow resulted in more time to develop protocols, standards and expand our CPD. The IDAs were involved in updating protocols in different areas for the department (such as infection control procedures) and completed job description updates and induction checklists for their role.

IDAs are often one of the first points of contact patients will have within the department, so they play an important role in ensuring the patient is comfortable. A hospital environment can often be quite overwhelming for patients and the IDA plays a vital part in helping the patient feel safe.

How the pandemic changed the imaging department
COVID-19 has had a significant impact on the imaging department at ROH. When the first lockdown restrictions were announced, all non-urgent medical imaging was cancelled. The bulk of oncology-related work, however, continued to be performed with strict PPE and safety measures. Our resources were therefore limited to emergency inpatient and oncology cases. ROH also expanded its resources to accept trauma patients from another NHS trust during this time.

This sudden change in workflow resulted in what is normally a very busy department coming to a standstill. The waiting rooms, once full of hustle and bustle, were now quiet and empty. This continued throughout April and May. The table shows the decline in patients seen across the four types of imaging at the ROH during the height of the pandemic. The dates used for this data are March 29 to May 29, 2019, and the same period for 2020.

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

Along with a significant decline in patients, the department also felt the strain of staff shortages. Some staff had to shield with suspected COVID-19 symptoms for a minimum of two weeks (before testing came into force). Other staff who were deemed high risk due to underlying health conditions were advised to shield as per government and local guidelines. This resulted in the usual six IDAs across the different areas of the department dropping to three until late July and August. This had a major impact on the staff that remained in the department during this critical period.

Changes to the IDA role
The IDA role during the pandemic was to work alongside the radiographers as per the Society of Radiographers, government and hospital guidelines. This included implementing new protocols on PPE and infection control. This applied to all patients, not just COVID-19 patients. The main changes were the increased cleaning of the imaging rooms and equipment after each patient using Clorox products, as well as the time needed to do this, and changing into and disposing of full PPE including aprons, gloves, surgical mask (fluid resistant) and eye protection.

The ultrasound department where the IDA usually plays an active role with busy clinics had all non-urgent appointments cancelled, but continued to see oncology patients and inpatients. From an infection control aspect, it was not seen as sensible to scan COVID-19 positive patients in the ultrasound suite, as this would require a deep clean afterwards and potentially affect planning for oncology patients. ROH had two COVID-19 wards at this time and some patients did require an ultrasound scan. The two most common requests were ultrasound Dopplers and ultrasound kidneys, usually as complications of surgery or COVID-19. In order to minimise the spread of infection, these patients were scanned with portable ultrasound on the ward. This required an IDA to assist with transporting the equipment to the ward and acting as a ‘clean’ assistant while the sonographer or radiologist scanned the patient. The IDA would stay outside of the room while the scan was completed still in full PPE. The sonographer or radiologist would perform the first clean of the machine in the room before disposing of their PPE, then clothing and showering on the ward. The IDA acting as the clean person would then perform the second clean of the equipment and perform the deep clean before removing and disposing of all PPE, washing hands and transporting the machine back to the department. This was also the case for COVID-19 positive patients requiring a portable chest x-ray on the ward or high dependency unit, which is essential in the diagnosis of COVID-19. IDAs also assisted the radiographers as the clean person where required. This was a significant change to the role since we would not normally assist with any portable imaging. This showed great teamwork by all imaging staff as we all had an important role to play.

If a patient required an urgent x-ray or CT that could not be performed on the ward (such as a pelvis x-ray) they would come to the department. This was a real team effort: porters were required to wear full PPE and act as marshals along the corridors to stop any footfall while the patient was transported to the x-ray department and when returning to the ward. If the patient was not mobile they required a Patslide to transfer them safely to the table. This is where the IDAs would also be involved. All imaging staff were in full PPE to transfer the patient. It was with a feeling of trepidation that we dealt in direct handling of COVID-19 positive patients; however, we did this professionally making sure the patient felt safe and comfortable at all times. Once completed, all staff were obligated to have showers, dispose of clothing and PPE and the room was deep cleaned by domestic staff.

The ROH has a duty of care for both patients and staff to ensure they are safe. During this time many staff members were very apprehensive about coming in to work. Protocols around COVID-19 were changing daily, with updates from WHO, government guidelines, SoR guidelines and local guidelines. All imaging staff were now to wear full PPE whenever in contact with a patient. Some staff were off not only for sickness or shielding but with anxiety related to working in the hospital environment during the pandemic. This created more pressure on the staff in attendance. Some staff began to struggle with the worry of how coming to work could potentially affect their health and their family’s health and about spreading the disease to their loved ones. The staff who have worked through the pandemic from the beginning reported they have felt the pressure of the changes, staffing levels and the ‘new normal’ and were now ready for some respite.

Recognising the potential impact on staff mental health, the SoR website offered links and tips on staff well-being stating that the increased demand on our health services, along with uncertainty in society, have brought with them significant stress and anxiety. Therefore, it is very important that, while continuing to provide the best standards of care and taking precautions to protect ourselves, we look after our mental health.4

ROH supported staff and offered updates on how to keep safe and improve mental health via daily emails. These offered links to mindfulness apps and well-being tips. They also allocated a designated well-being and mindfulness room in the outpatients department where any staff member could go if they felt they needed some time out. The room provided refreshments, adult colouring books, well-being reading and a relaxing atmosphere.

The new normal
On June 1 we started to re-introduce non-urgent imaging to our department. Of course, because of the cancellations at the peak of the pandemic there was a large backlog of appointments. The trust has now implemented safety measures that include everyone having their temperature checked on arrival at the hospital. Wearing a mask is a requirement as per government guidelines and this is provided on entry to the hospital, as is alcohol rub for hand sanitisation. All reception areas were fitted with Perspex screens to keep staff protected.

Patients were screened using risk assessments via telephone initially and invited to attend an appointment if considered low risk. This meant that for the first few weeks we were still only seeing patients at a lower capacity. Appointment times were longer to enable staff to deal with the increased load of PPE and cleaning the rooms and equipment. The seating area in the waiting room has been rearranged for only six patients to wait at one time. Infection control protocols have been introduced to enhance safety in the department. IDAs and reception staff ensure that all seats are wiped with a dedicated sanitisation wipe after each person has used it and that everyone who enters the department sanitises their hands using the alcohol gel provided.

As the pandemic ensues, we are all still adjusting to this new normal. The experience has been harrowing for all those concerned on both a practical and emotional level. As an IDA working in such a high risk environment, the experience has made me stronger as I have learnt to appreciate things that before we all took for granted. I am looking forward, along with the rest of my colleagues, to seeing what the future brings.

I would like to acknowledge consultant musculoskeletal radiologists Dr Rajesh Botchu and Dr Christine Azzopardi, lead sonographer Sharon McGarry 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: Consultant musculoskeletal radiologist and clinical radiology liaison Dr Rajesh Botchu, IDA Victoria Preston, lead sonographer Sharon McGarry and consultant musculoskeletal radiologist Dr Christine Azzopardi.

References
1, European Centre for Disease Prevention and Control – Covid-19 situation update worldwide (August 13, 2020). www.ecdc.europa.eu/en/geographical- distribution-2019-ncov-cases.
2, Revel M P, Parkar A P, Prosch H et al. COVID-19 patients and the radiology department – advice from the European Society of Radiology (ESR) and the European Society of Thoracic Imaging (ESTI). Eur Radiol 2020. doi.org/10.1007/s00330-020-06865-y.
3, Zamboni P. Covid19 as a vascular disease: lesson learned from and blood biomarkers. Diagnostics 2020,10,440;doi:10.3390. www.scilit.net/article/ 7eca5912062fd4a669395153708035a1.
4, Ross Mcghee (April 2020) Wellbeing, emotional and mental health support and resources. The Society of Radiographers. covid19.sor.org/wellbeing,-emotional-and-mental-health/support-and-resources.
5, Introducing the Quality Standard for Imaging (QSI) The Royal College of Radiologists. www.rcr.ac.uk/ clinical-radiology/service-delivery/quality-standard-imaging-qsi.

Submitted by Victoria Preston, imaging department assistant, Royal Orthopaedic Hospital, Birmingham.

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