This piece is one in a series of articles covering the GEST webinar. For dispatches from the frontlines of the COVID-19 pandemic, and the pertinent takeaways for interventional radiologists, click here.
“What have we learnt in the last month? We have to try to reduce or stop our activity—in the beginning, we thought we could continue to work as in standard life, but we realised that there is a high risk of infection, as the patient or operator could be a virus carrier. You have to really reduce your activity to only emergency cases.” So said Roberto Iezzi (Catholic University A Gemelli Hospital, Rome, Italy), speaking during the GEST (Global Embolization Oncology Technologies Symposium)-hosted webinar on 25 March, where an international group of interventional radiologists discussed the global response to the COVID-19 pandemic.
The first cluster of coronavirus patients was reported in Lombardy, a region of northern Italy, on 21 February. “It is just one month ago, but it feels like a year”, Iezzi stated. Sharing the key takeaways from the last five weeks’ experience, Iezzi summarised:
- Reduce or stop your usual interventional radiology (IR) activity
- Organise your activity: have dedicated routes to the angiosuites, for example, to reduce contamination
- Stratify your patients, based on symptoms and based on testing
- In the absence of test results, consider any patient as COVID-19 positive
Speaking specifically of his institution, the Catholic University A Gemelli Hospital in Rome, Iezzi described the changes made to its usual running. “With COVID, everything changed,” he said.
On 9 March, all IR cases were stopped, except for emergency cases or a few oncological treatments for patients that could not wait until the present pandemic passes. This freed up beds for potential COVID-19 patients, and reduced the risk of infection. In total, the A Gemelli Hospital now has six dedicated COVID-19 wards, one dedicated resuscitation ward, and three wards specifically for suspected COVID-19 patients. A smaller hospital nearby was translated into a COVID-19 only hospital, with 59 beds in its intensive care unit, and a further 80 standard beds.
“We should be ready for COVID patients,” Iezzi said of interventional radiologists, “because we know that COVID patients are [generally] older patients with multiple comorbidities, and they may need interventional treatment, such as a drainage.”
In order to limit the risk of infection, the nine interventional radiologists based at the A Gemelli Hospital (five neuro specialists and four “body” specialists) significantly reduced their case load. Two of the three angiosuites remain open: one is dedicated solely for COVID-19 patients, and the other is open for just six hours a day, the remaining 18 hours of each day being on-call. Usually, Iezzi’s institution has three slots a week for CT-guided procedures and two slots a week for ultrasound (US)-guided procedures; this is now down to one slot a week for CT-guided activity, and no dedicated slot for US-guided activity.
In addition, visitors, students, and external colleagues and specialists have been denied access to the hospital, to limit the number of people present. Operators also have reduced access: at any moment, one operator is on-call, and one is taking up an “active slot” in the hospital scheduling. Residents are only granted access to the IR section of the hospital if needed, and patients are being offered video consultations to limit person-to-person contact.
“We tried to determine which transport routes [to use] in the hospital to minimise exposure for staff and other patients,” Iezzi shared. This measure was also taken by healthcare workers in Singapore.
Furthermore, Iezzi recommended implementing additional precautions. “All patients should wear a medical mask,” he advised, “and for COVID-positive or COVID-suspected patients, try to avoid moving and transporting them out of their room or area. Where possible, you should perform bedside US-guided procedures.
“If we have to use general anaesthesia, for example when performing a stroke thrombectomy, we try to perform induction outside the angiosuite in order to reduce the risk for airborne contamination,” he continued. “We try to avoid or reduce waiting time in preoperative holding areas. It is also very important that we use adequate personal protective equipment (PPE).”
However, he said “there is an issue”, in Italy and in other European countries, notably Spain, with access to adequate PPE. Therefore, Iezzi highlighted the importance of setting up robust guidelines for when PPE is necessary, so as not to waste any protective gear. He recommended stratifying patients based on risk when deciding on what qualifies as appropriate PPE. Low risk patients are defined as those with no fever or respiratory tract symptoms, no loose contact with confirmed or suspected cases of COVID-19, and no residence in or travel to areas or attendance at events where widespread community transmission has been reported. Intermediate risk patients are those with fever and/or respiratory symptoms, but with no close contact with a confirmed or suspected case of COVID-19, and with no residence in or travel to areas or attendance at events where widespread community transmission has been reported. High risk patients have a fever and/or respiratory tract symptoms, and in the past 14 days have either been in close contact with a confirmed COVID-19 sufferer, and/or have lived in, travelled to, or attended an event where widespread community transmission has been reported.
Regardless of risk, Iezzi strongly advised that all patients wear a disposable surgical mask. Physicians should wear PPE appropriate for “contact and droplet precaution” when dealing with low risk patients, and PPE appropriate for “airborne precaution” when treating intermediate or high risk patients (see table 1).
Additionally, Iezzi recommended keeping doors closed when treating suspected or positive COVID-19 patients to reduce the potential for cross-contamination. Similarly, he urged those listening to adjust the team organisation in their own institutions when working with coronavirus patients. “We as interventional radiologists, our problem is devices,” he explained. “We need different devices, and we cannot have everything in the room [at the same time]. So we have a nurse in the room with three pairs of gloves in order to remove one, give the device to the interventional radiologist without touching it, and another nurse is outside. If we need something that we do not have in, they can bring it near the door to the angiosuite. The nurse inside can put on a new pair of gloves and can pick up the device, not touching anything else. This is very important.”
At the end of a procedure, any equipment in the angiosuite must be cleaned and disinfected, Iezzi explained, adding that the doors should remain closed during cleaning. “The IR area should then remain closed for 30 minutes,” he said.
Globally, Italy has experienced the highest death toll due to the coronavirus pandemic. On 9 March, the Italian government implemented a nation-wide quarantine, and on 21 March, they imposed a “significant lockdown” on the country, forcing the shut-down of all businesses and industries deemed “not necessary”.
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