Preparedness of Australasian emergency departments for point-of-care ultrasound in the COVID-19 pandemic

Introduction

The COVID-19 outbreak was declared a pandemic by the World Health Organisation on 11 March 2020. By 29 April 2020, the virus had infected 3,024,059 people across 213 countries, with 7,891 cases in Australia and New Zealand.¹ It has rapidly changed how Emergency Departments (EDs) provide quality care and maintain healthcare worker safety while limiting cross-infection. Point-of-care ultrasound (POCUS) in EDs is a rapidly growing subspecialty² and is again in the limelight during this pandemic due to the efficacy of lung POCUS in the diagnosis, assessment of severity and monitoring of disease progression in COVID-19 patients.^3-5 Lung POCUS has an excellent correlation to computerised tomography (CT) chest⁵ and is superior to chest X-ray (CXR).⁶ Its use reduces transfers to the radiology department and subsequent exposure to radiology staff, porters and other patients.⁷ However, ultrasound devices can be potential vectors for transmitting pathogens,⁸ as SARS-CoV-2 can persist on plastic for up to nine days at room temperature. Therefore, infection prevention and control (IPC) measures are essential⁹ in limiting potential transmission.

To date, multiple international position statements exist for the safe use of ultrasound,^10-14 but at the time of this survey, apart from the World Federation for Ultrasound in Medicine and Biology (WFUMB),¹⁵ and by AJUM, Basseal et al.,¹⁶ there were no emergency medicine fraternity guidelines for the safe use, or cleaning of POCUS equipment, specific to COVID-19. Anecdotally, ultrasound machines are easily contaminated in busy ED settings due to multiple factors, posing a question on safe POCUS practice in COVID-19 patients. We also anticipated fear and uncertainty among emergency clinicians performing POCUS on these highly infectious patients. This study surveys the preparedness for safe POCUS use in suspected or confirmed COVID-19 patients in Australasian EDs and the current practices, policies and mindset of emergency clinicians using POCUS during the early phase of this pandemic.

Materials and methods

This is a cross-sectional ‘open’ survey of the preparedness and safe use of ultrasound within EDs across Australia and New Zealand during the COVID-19 pandemic. Data were collected from 20 April 2020 to 3 June 2020 through an online survey platform, Survey Monkey™. A short explanation regarding the study's purpose estimated time to complete the study, and investigators' details were provided to participants on the survey's initial page as a preamble. The working group designed survey questions – an expert in POCUS in ED (VM), an expert in microbiology and infection prevention and control (JB) and emergency medicine advanced trainees undergoing training in POCUS (DH, GK, DR, JM). The survey had 36 questions spread across five sections, including participant characteristics, ED preparation for POCUS in COVID-19, sonologist preparation for POCUS in COVID-19, disinfection practices and top three challenges with plausible solutions (Appendix 1—complete survey tool). The estimated time to completion was < 10 min. The options for answers were a mixture of free text and multiple choice, with some of the multiple-choice questions allowing several answers to be selected. Mandatory questions were highlighted, and all questions had a non-response (‘other’) option with free-text functionality. Participants were given the ‘back’ menu option to revise their responses at any time before final submission. To reduce the complexity and improve the completion rate, an adaptive questioning technique or skip technique has been used to reduce the number of questions based on the participant's response. After the initial demographics section, if the participant's ED has decided not to use POCUS in COVID-19 patients, they could skip the remaining sections to exit the survey.

Considering the pandemic situation and the time criticalness to capture this valuable information, this survey was piloted with only three emergency clinicians to assess the content, technical robustness and ease of use. After refinements and amendments, all authors agreed on the final version of the survey questions before dissemination (Figure 1).

RESULTS

The survey received 171 responses. Of these, 27 responses were removed as they were received from respondents outside of Australasia, or they gave no demographic information about their location of the practice. An additional 28 responses were removed due to incomplete answers. Data were analysed for the remaining 116 responses.

Discussion

‘Preparing for the unknown’ is intriguing but scary, as there is an element of uncertainty and fear of failure. But by failing to prepare, we are preparing to fail. Advancement in microbiology and infectious diseases, and through lessons learned from past coronavirus outbreaks, including Middle East Respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS),^{17, 18} health response should have provided a head start in the preparation to combat this COVID-19 pandemic.

Emergency departments are at the forefront of health care and are pregnable to sudden threats like the COVID-19 pandemic. With the increased use of POCUS in current EDs, agreed guidelines and policies should be in place for safe POCUS practice in infectious outbreaks. In the earlier stage of the COVID-19 pandemic, when Australasian ED clinicians were preparing for a safe POCUS practice in ED, there was no gold-standard reference or succinct formal guidance from governing bodies. Individual institutions' preparation was hugely guided by regional infection control units, with inherent variation to suit their needs. Attempting to capture all those variations via this survey revealed interesting findings.

The survey received responses from Australia and New Zealand, but as most of the responses were from NSW (Australia), the results may not accurately represent widespread Australasian practices. As almost half of the responses are from CLUS in ED, who have in-depth knowledge about the status of POCUS in their ED, these data hold significant value. The general acceptance of a ‘Hot or Red Zone’ model to separate potential COVID-19 patients from others, and to have a dedicated ultrasound device in these hot zones, is in line with the recommendation by WUFMB.¹⁵ The need for a dedicated ultrasound machine in these hot zones is also echoed by respondents who did not have one (Table 4). Most of the respondents have access to large portable ultrasound machines and were not prepared to cover the entire machine with a plastic drape. This was likely due to a lack of suitably large drapes coupled with the difficulty in using the machine while draped. The preference was to cover the transducer and cord with a long sterile probe cover. A small, portable, even handheld ultrasound device in these hot zones would ease the logistical issues of cleaning and disinfection.¹²

SARS-CoV-2 is a small lipid-based enveloped virus that is efficiently inactivated by disinfectants such as 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite, which are used in standard low-level disinfectants.¹⁶ Almost all the respondents had access to LLD wipes; however, practices on how and when these were used varied significantly (Table 3). This reflects the lack of clear departmental or governing body-issued policy on ultrasound device disinfection. Basseal et al. recommended cleaning the entire machine, but mainly the keyboard, screen and ultrasound probe cord, with LLD wipes.¹⁶ Most ultrasound manufacturers have waived rules about machine-specific disinfectants and support the use of any product effective against COVID-19.¹² ILD wipes (e.g. Tristel Duo™) and HLD chemical-based systems (e.g. Trophon™ and high-intensity UV light, used in Chronos™/Antigermix™) are also effective in destroying SARS-CoV-2, but its availability in ED is scarce. A low proportion of respondents have access to HLD technology in ED, and use differed significantly after scanning COVID-19 patients. Some EDs share an HLD unit with other departments like radiology, making it logistically more challenging to safely and frequently disinfect probes. The survey's free-text option highlighted that respondents preferred to use small disposable gel packets when scanning COVID-19 patients, which was later widely recommended by most organisations.^{12, 15, 16}

Despite low access to an SOP or guidelines for safe POCUS in COVID-19 (only half of the respondents had either) most of the respondents demonstrated a willingness to perform scans on these highly infectious patients. Consensus and recommendations are to minimise exposure during the examination by performing a truncated POCUS study¹⁶ and avoiding educational or practice scanning. The use of lung ultrasound in COVID-19 patients has been used to identify lung changes, assess severity and monitor progress,^{3, 19} but in this survey, the majority of the respondents were not intending nor aware of assessing the severity of lung involvement in COVID-19 with lung ultrasound and the majority did not have a COVID-19 specific lung scanning protocol.

The significant gaps identified by this survey include staff education and governance of POCUS in ED and lack of awareness of protocols and guidelines for safe scanning techniques and ED-specific effective cleaning and disinfection techniques. There was also a lack of resources such as handheld ultrasound devices, HLD units, purpose-built plastic drapes to cover entire ultrasound device and smaller disposable ultrasound gel packets.

To date, this is the most significant viral pandemic that EDs have encountered since POCUS has become a widely-used practice. There have been several guidelines for safe medical ultrasound practices during COVID-19 published since launching the survey, mainly in speciality areas like obstetrics and gynaecology, critical care and general ultrasound^{10, 11, 13, 16, 19}; however, there is still a lack of official guidelines readily available specifically for emergency clinicians. As the world of medicine continually evolves and accommodates newer technologies and practices such as POCUS in EDs, it is essential to upskill infection prevention and control practice to combat infectious disease outbreaks like COVID-19.

Conclusion

POCUS is widely used by clinicians and is crucial for diagnosing and managing clinical conditions in EDs. Whilst lung ultrasound has proven to be valuable in the management of COVID-19, there is a significant lack of investment in adequate training, protocol development, and infrastructure to conduct safe POCUS in the ED. This survey has highlighted the importance of clear and timely guidance from governing bodies. A framework for supporting POCUS in EDs is required to ensure patient and staff safety, and the time is now to invest in preparedness for future infectious disease outbreaks.

Author contributions

Vijay Manivel: Conceptualization (lead); Data curation (equal); Formal analysis (equal); Methodology (equal); Project administration (lead); Resources (equal); Software (equal); Supervision (lead); Validation (equal); Writing-original draft (lead); Writing-review & editing (equal). David G Herbert: Conceptualization (equal); Data curation (lead); Formal analysis (supporting); Methodology (supporting); Software (equal); Writing-review & editing (equal). Gareth Ian Kitson: Conceptualization (equal); Data curation (supporting); Formal analysis (supporting); Methodology (supporting); Writing-original draft (supporting); Writing-review & editing (supporting). Dougal Buchanan Robertson: Conceptualization (equal); Formal analysis (supporting); Methodology (supporting); Writing-original draft (supporting); Writing-review & editing (supporting). James Manion: Data curation (equal); Formal analysis (equal); Methodology (supporting). Jocelyne Basseal: Conceptualization (supporting); Formal analysis (supporting); Methodology (supporting); Resources (supporting); Supervision (supporting); Visualization (equal); Writing-original draft (supporting); Writing-review & editing (supporting).

Conflict of interest

No competing or conflict of interest.

Funding

No funding or financial support was received for this project.

Authorship declaration

Authors declare that the entire research work including manuscript writing is their original work and it is not been published or presented in any other scientific journals or meetings or conference. All authors agree with the content of the manuscript. All authors agree to AJUM’s authorship policy.