Echo During COVID-19? New Advice Weighs Doctor Safety, Patient Needs

Practitioners performing echocardiography during the current COVID-19 pandemic should change their practice to limit their exposure, a precaution that will ultimately increase patient safety, according to a new statement from the American Society of Echocardiography.

“The echocardiogram as it is performed is actually quite an intimate procedure,” writing committee chair James N. Kirkpatrick, MD (University of Washington Medical Center, Seattle), told TCTMD. “We wanted to put together something that would provide some guidance, employing the best information that we had at the time, with the recognition that things are changing very, very quickly to try to get some guidance to echocardiography professionals about safe ways of performing these studies.”

Additionally, he continued, while protecting healthcare workers is crucial, “we don't want to get in a situation in which healthcare workers are pitted against the good of patients—to see every patient as a potential threat to us.”

Who, Where, and How

The statement, published this week in the Journal of the American College of Cardiology, is full of practical tips for echocardiographers centered around three questions: who, where, and how to image.

First, Kirkpatrick explained that as orders come in for scans, it is important to determine which need to be done and which can be postponed until a later date. “If something is rarely appropriate or is maybe appropriate, those may be the ones in particular that you want to either not do or postpone for a later time. But then the ones that are deemed appropriate are often deemed appropriate because they make a clinical impact,” he said. “The bottom line is trying to figure out: if we defer this echo, is this patient likely to experience morbidity or mortality or end up using healthcare resources that really we should avoid using in this difficult time?”

The echocardiogram as it is performed is actually quite an intimate procedure. James N. Kirkpatrick

To this end, Kirkpatrick said he has seen a considerable drop-off in orders at his institution, a shift he attributed both to the decrease in elective procedures requiring imaging and to the realization among many referring doctors that echo labs are being more selective about performing scans. “But a lot of orders have already been placed well before all of this happened, and so those are the ones that are also getting adjudicated over time,” he explained. “Some labs have said they're not going to do any stress testing at all, and some labs are really, really restricting their transesophageal echocardiograms as well in that setting.”

With regard to where the tests should take place, the authors advocate imaging in the patient's room, when possible, rather than transporting the patient through the hospital. “The portability of echocardiography affords a clear advantage in imaging patients without having to move them and risk virus transmission in the clinic or hospital,” they write. “All forms of echocardiography (including chemical stress tests) can be performed in emergency departments, hospital wards, intensive care units, operating theaters, recovery areas, and structural heart and electrophysiology procedure laboratories, in addition to echocardiography laboratories.”

One tool that might be especially helpful for imagers now is point-of-care ultrasound (POCUS), Kirkpatrick and colleagues suggest. Taken with portable, often handheld devices, the images gleaned from POCUS can be acquired by someone who already has to be in the patient’s room, so long as he or she is properly trained, and can be useful in determining whether further scanning is needed.

Regardless of what tool is used for imaging, Kirkpatrick said it is critically important for the imager to minimize their time spent in the patient’s room. “That means that if you need something or expect you're going to need something such as echocardiographic enhancing agent, also known as echocontrast, bring that in right away so you're not waiting around for it or, god forbid, going out to get more protective equipment to go get it and bring it back in,” he said.

The statement also outlines guidelines for proper use of personal protective equipment for echocardiographers that mostly follow recommendations from the Centers for Disease Control, according to Kirkpatrick.

Implications for Training

A big issue for many echocardiography labs is what to do with trainees who are either learning to image or have been actively helping in acquiring images up until this point.

“I agree with the way most people are doing things and what we say in the document is there really should be a hiatus on [involving trainees],” Kirkpatrick said. “It is an issue of protection—protecting the person, the trainee; protecting the person the trainee is going to interact with, whether it's colleagues or other patients; and then also the use of personal protective equipment.”

Nonetheless, “we need to find other ways to have people get trained to do these studies because we are going to continue to need our pipeline of people who are scanners—there's no question,” he continued. “We can't put education completely on hiatus during this time, but we have to do it in a responsible and appropriate way.”

Simulators, although not popular in the field of echocardiography thus far, can help trainees learn how to acquire ideal images and learn to interpret them, Kirkpatrick said, adding that there are several online versions that can be used if an institution does not have mannequin models.

Ultimately, Kirkpatrick predicted, this pandemic is going to result in sweeping changes within echocardiography labs even after the worst passes. “There's change in the short term and change in the long term,” he said, noting that he expects to see an increased reliance on simulators and virtual education as well as greater scrutiny of orders and use of POCUS. “This more comprehensive and collaborative environment will be greatly enhanced by what is being put into place right now.”

Photo Credit: James N. Kirkpatrick