ASE Statement on Protection of Patients and Echocardiography Service Providers During the 2019 Novel Coronavirus Outbreak

Duke University, Durham, North Carolina (M.S.).Notice and Disclaimer:This statement reflects recommendations based on expert opinion, national guidelines, and available evidence. Our knowledge with regard to COVID-19 continues to evolve, as do our institutional protocols for dealing with invasive and non-invasive procedures and practice of personal protective equipment. Readers are urged to follow national guidelines and their institutional recommendations regarding best practices to protect their patients and themselves. These reports are made available by ASE as a courtesy reference source for its 2 American Society of Echocardiography ASEcho.org members. The reports contain recommendations only and should not be used as the sole basis to make medical practice decisions or for disciplinary action against any employee. The statements and recommendations contained in these reports are primarily based on the opinions of experts, rather than on scientifically-verified data. ASE makes no express or implied warranties regarding the completeness or accuracy of the information in these reports, including the warranty of merchantability or fitness for a particular purpose. In no event shall ASE be liable to you, your patients, or any other third parties for any decision made or action taken by you or such other parties in reliance on this information. Nor does your use of this information constitute the offering of medical advice by ASE or create any physician-patient relationship between ASE and your patients or anyone else.

## American society of echocardiography
ASEcho.org members. The reports contain recommendations only and should not be used as the sole basis to make medical practice decisions or for disciplinary action against any employee. The statements and recommendations contained in these reports are primarily based on the opinions of experts, rather than on scientifically-verified data. ASE makes no express or implied warranties regarding the completeness or accuracy of the information in these reports, including the warranty of merchantability or fitness for a particular purpose. In no event shall ASE be liable to you, your patients, or any other third parties for any decision made or action taken by you or such other parties in reliance on this information. Nor does your use of this information constitute the offering of medical advice by ASE or create any physician-patient relationship between ASE and your patients or anyone else.

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# Background
The 2019 novel coronavirus, or severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) that results in coronavirus disease-2019 (COVID-19), has been declared a pandemic and is severely affecting the provision of healthcare services all over the world.Healthcare workers are at higher risk since this virus is very easily spread, especially through the kind of close contact involved in the performance of echocardiographic studies. The virus carries relatively high mortality and morbidity risk, particularly for certain populations (the elderly, the chronically ill, the immunocompromised and, possibly, pregnant women). [bib_ref] Clinical course and risk factors for mortality of adult inpatients with COVID-19..., Zhou [/bib_ref] Given the risk of cardiovascular complications in the setting of COVID-19, including pre-existing cardiac disease, acute cardiac injury, and drug-related myocardial damage, [bib_ref] COVID-19 and the cardiovascular system, Zheng [/bib_ref] echocardiographic services will likely be required in the care of patients with suspected or confirmed COVID-19. Consequently, echo providers will be exposed to SARS-CoV-2.
Sonographers, nurses, advance practice providers and physicians have a duty to care for patients and are at the frontlines in the battle against disease. We are at high risk, particularly when we participate in the care of patients who are suspected or confirmed to have highly contagious diseases. While dedication to patient care is at the heart of our profession, we also have a duty to care for ourselves and our loved ones and to protect all of our patients by preventing the spread of disease. This means reducing our own risk while practicing judicious use of personal protective equipment (PPE).
ASE is committed to the health, safety and wellbeing of our members and the patients we serve. This statement addresses triaging and decision pathways for handling echocardiographic requests, as well as indications and recommended procedures to be followed for an echocardiographic assessment of cardiovascular function in suspected or confirmed COVID-19
cases. In addition, we list measures recommended to be used in the echo lab for prevention of disease spread. Secondly, there are cases in which the indication for echocardiography is appropriate or may be appropriate, but the exam is unlikely to yield clinically important information in the short termAmerican Society of Echocardiography ASEcho.org with the added risk of potential disease transmission. There are two ways to identify these studies.

## Whom to image?

## Review of indications
- Determine which studies are "elective" and reschedule them, performing all others.
- Identify "non-elective" (urgent/emergent) indications and to defer all others.
In cases considered for deferral, there is no significant risk to patients in terms of morbidity or mortality and no expected benefit in terms of avoiding the use of medical resources (such as emergency department visits or hospitalizations). These tests should be postponed.
Next, it is important to determine the clinical benefit of echocardiography for symptomatic patients whose SARS-CoV-2 status is unknown. Knowing the status of a patient allows for the appropriate application of personal protective equipment (PPE) and its conservation when not needed, in addition to reducing the exposure risk to echocardiography personnel.
TEEs carry a heightened risk of spread of the SARS-CoV-2 since they may provoke aerosolization of a large amount of virus due to coughing or gagging that may result during the examination. TEEs therefore deserve special consideration in determining when and whether they should be performed, and under what precautions (described below Depending on the trajectory of the outbreak, some institutions may face a crisis state with reduced availability of trained staff and/or equipment. In this setting, triage by indication may be necessary, deciding which appropriate and urgent/emergent echocardiograms will be performed and which will not, or deciding which will be performed first. This prioritization of indications will need to be done on a case-by-case basis, while accounting for many patient-level factors such as current indication, current clinical status, past medical history and the results of other tests. Involving referring physicians in the triage process is therefore essential.

## Where to image?
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. All forms of echocardiography interpretive assistance from more experienced echocardiographers. Archiving these images for review should help to focus future imaging studies and provide comparisons of cardiac structure and function over time. In some cases, review of these images by a consulting cardiovascular specialist may obviate the need for an echocardiogram (and therefore reduce staff exposure), as pertinent clinical questions will be answered (e.g. etiology of hypotension). In other cases, they will indicate the need for more advanced imaging (e.g. wall motion and quantitative valvular assessment). Therefore, these images should be saved and archived whenever possible. Some devices use a camera that allows a sonographer or other imaging expert to remotely guide probe placement.
Along the same lines, echocardiographic studies performed on patients with suspected or confirmed COVID-19 should be as focused as necessary to obtain diagnostic views but should also be comprehensive enough to avoid the need to return for additional images. Each study should be tailored to the indication and planned in advance, after review of images from past exams and other imaging modalities. Complete exams may be necessary in some circumstances.
Plans for ultrasound enhancing agent (UEA) utilization should be made in advance in order to prevent a sonographer having to wait for the agent to be delivered or having to use more personal protective equipment to exit the patient's room to obtain the agent. While the safety of UEAs specifically in COVID-19 cases has not yet been determined, they have been used and proved safe in ICU patients. The use of UEAs may therefore be considered in such cases as long as the benefits in terms of diagnostic yield and scan time are favorable. [bib_ref] Multimodality imaging of left atrium in patients with atrial fibrillation, Guglielmo [/bib_ref] American Society of Echocardiography ASEcho.org
Regardless of the type of study (UAPE, POCUS, CCE or comprehensive echo), prolonged scanning can expose these clinicians to added risk. An additional consideration when performing a limited transthoracic echo exam is the limitations that may be posed by layers of protective equipment on image quality. Therefore, these studies should not be performed by a sonography student or any other novice/inexperienced practitioner, in order to minimize scanning time while obtaining images of the highest possible quality.
Finally, the results of the exam should be rapidly reviewed and key findings recorded immediately on the patient's record and communicated to the primary care team to allow hemodynamic management to be optimized.
The group therefore recommends the following:
- Echocardiographic exams be planned ahead, based on indications, clinical information, laboratory data and other imaging findings to allow for a focused sequence of images that help with management decisions.
- The use of UEAs should be considered prior to the exam to avoid the need to prolong scan time while awaiting preparation of the agent.
- Scan times should be minimized by excluding students or novice practitioners from performing imaging.
- Imaging team should ensure rapid review and reporting of key findings in the patient's record and communicating them with the primary care team.American Society of Echocardiography ASEcho.org

## Protection

## Personnel
Imaging should be performed according to local standards for the prevention of virus spread.
Meticulous and frequent hand washing is crucial. In some institutions, the level of PPE required may depend on the risk level of the patient with regard to COVID-19 (minimal risk=not suspected, moderate risk=suspected, high risk=confirmed). In some institutions, suspected and confirmed cases are treated similarly. The types of PPE can be divided into levels or categories (see .
- Standard care involves handwashing or hand sanitization and use of gloves. The use of a surgical face mask in this setting may also be considered.
- Droplet precautions include gown, gloves, headcover, facemask and eye shield.
- Airborne precautions add special masks (e.g. N-95 or N-99 respirator masks, or powered air purifying respirator -PAPR systems), and shoe covers.
The local application of each component of PPE can vary according to level or type of risk for TTEs and stress echo exams, but airborne precautions are required during a TEE for suspected and confirmed cases, due to the increased risk for aerosolization. A surgical face mask for patients is recommended for those who are symptomatic, undergoing surface echo examination provided institutional resources allow this strategy for source control.It is important to reiterate that the type of PPE to be used on specific cases will depend on local institutional policy and resources. The US Centers for Disease Control (CDC) provides updated guidelines for PPE use for healthcare workers. (AIUM) has specific guidelines for disinfection of ultrasound equipment.Role of learners

## Other considerations
In addition to limiting the number of echocardiography practitioners involved in scanning, consideration should be given to limiting the exposure of staff who may be particularly susceptible to severe complications of COVID-19. Staff who are >60 years old, have chronic conditions, are immunocompromised or are pregnant may wish to avoid contact with patients suspected or confirmed to have COVID-19, depending on local procedures.
The risk of transmission also occurs in reading rooms. Keyboards, monitors, mice, chairs, phones, desktops, and door knobs should be frequently cleaned, and ventilation provided wherever possible. In some institutions the echo lab reading room is a place where many clinical services congregate to review images. In the current environment, it may be advisable to ask 13 American Society of Echocardiography ASEcho.org these services to review images remotely while speaking with the echocardiographer-consultant by phone, or review images together via a webinar.

# Conclusion
The provision of echocardiographic services remains crucial in this difficult time of the SARS-CoV-2 outbreak. Working together, we can continue to provide high quality care while minimizing risk to ourselves, our patients and the public at large. Carefully considering 'Whom to Image', 'Where to Image' and 'How to Image' has the potential to reduce the risks of transmission.