Letter from Dr Ian McCafferty and Dr Phil Haslam

Created - 30.03.2020

The following are the personal opinions of Dr Ian MCafferty and Dr Phil Haslam, 30th March 2020

There has been a lot of discussion within departments and on social media, within a number of allied BSIR groups regarding the correct advice for PPE in Interventional radiology theatres for image guided surgical procedures. We have produced a number of guidance documents to try and give a balanced view but there still exists anxiety and differing implementation within Trusts. It is likely that the number of image guided surgical procedures will be low volume in COVID + patients and therefore I felt we should give balanced view based on the evidence. Staff should also respect the social distancing rules and consider wearing surgical masks in all clinical areas, changing them when damp.

We would recommend the current local and national COVID plans and DOH guidance but would also draw on international experience from areas worse affected than ourselves. We would agree with the recent published surgical PPE guidelines form the Royal College of Surgeons especially as we are Image guided surgeons working in identical environments.

The general advice for interventional procedures in COVID + or presumed patients is the following:

• Ensure that the intervention is necessary and cannot be delayed.
• Patient consented by team on ward.
• Plan and prepare the interventional room prior to attendance, including trolley preparation – limit movements.
• Have a dedicated IR theatre for COVID + patients with a separate entrance.
• All unnecessary equipment to be removed from the dedicated COVID IR room, all essential equipment to be covered with plastic drapes or equivalent.
• Patients to attend via a dedicated route that is separate from low risk groups and to enter the IR room for checking and obtaining second consent.
• Minimal staff to be in attendance.
• ALL patients should wear a surgical mask.
• ALL IR staff should use PPE during IR procedures as determined locally. Those protocols however need to be revised dependent on risk related to proximity, length of case and potential viral load. Interventional radiology theatres are small and have positive pressure ventilation. The majority are performed under sedation with the inherent risk of urgent intubation and coughing. For the majority of cases in COVID positive patients IR’s will be extremely close to the patient often near the head end and with international experience, we would recommend FFP3 for all. We fully understand the potential shortages and requirements for limiting FFP3 usage, but we are going to be a small volume group spending significant time next to a COVID + patients. If we can perform the procedure without a scrub nurse and the radiographer remains behind the screen >2/3m away, then we limit FFP3 usage as well.
• Appropriate donning and doffing protocols are required with the donning being performed outside the high risk “hot” IR theatre.
• Room clean as per local protocol.

• Keep a record of all staff that were present in the room for COVID + patients so that contact tracing possible. Please note that the super-infectors in China and Singapore were healthcare workers.
• Consider temperature monitoring of staff to identify early potential carriers and isolate as per protocol. This was extremely successful in Singapore and China to limit hospital acquired COVID-19.

References:

1. COVID-19: Guidance for infection prevention and control in healthcare s ettings. Version 1.1, 27 /03/20. Issued jointly by the Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS) and Public Health England as official guidance.
2. Interventional radiology and COVID-19: evidence-based measures to limit transmission. Diagn Interv Radiol published 27/03/20.
3. Society of Interventional radiology toolkit for COVID-19
4. Global embolisation (GEST) webinar 25/03/20: Interventional radiology in the time of COVID-19; Learning from global experience (Singapore, China, Italy and USA).

COVID-19 RESOURCE PAGE