Specific Considerations for Sonographers When Performing
Echocardiograms During the 2019 Novel Coronavirus Outbreak:Supplement to the American Society of Echocardiography Statement© 2020 American Society of Echocardiography

Carol Mitchell, PhD, ACS, RDMS, RDCS, RVT, FASE, (Chair), Keith Collins MS, ACS,
RDCS, FASE, Lanqi Hua MS, ACS, RDCS, FASE, Carlene McClanahan RDCS, FASE, Elaine
Shea ACS, RCCS, RCIS, FASE, Matthew Umland BS, ACS, RDCS, FASE, Melissa
Wasserman, RDCS, RCCS, FASE, Madison and Milwaukee, Wisconsin; Chicago, Illinois;
Boston, Massachusetts; Berkeley and Oakland, California; Philadelphia, Pennsylvania
From University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin(C.M.); Northwestern University, Chicago, Illinois (K.C.); Massachusetts General Hospital,
Boston, Massachusetts (L.H. and C.M.); Alta Bates Summit Medical Center, Berkeley andOakland, California (E.S.); Aurora Health Care, Milwaukee, Wisconsin (M.U.); Children’s
Hospital of Philadelphia, Pennsylvania (M.W.).
The authors reported no actual or potential conflicts of interest in relation to this document.

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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 proceduresand practice of personal protective equipment. Readers are urged to follow national guidelines
and their institutional recommendations regarding best practices to protect their patients andthemselves. These reports are made available by ASE as a courtesy reference source for its
members. The reports contain recommendations only and should not be used as the sole basis tomake 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 ofmerchantability or fitness for a particular purpose. In no event shall ASE be liable to you, yourpatients, or any other third parties for any decision made or action taken by you or such otherparties in reliance on this information. Nor does your use of this information constitute theoffering of medical advice by ASE or create any physician-patient relationship between ASE andyour patients or anyone else.

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Background
The American Society of Echocardiography (ASE) recently provided the “ASE Statement on
Protection of Patients and Echocardiography Service Providers During the 2019 Novel
Coronavirus Outbreak.”1 This supplement focuses on three key areas of that document: i) whomto scan, ii) where to scan, and iii) how to scan, with additional details and resources to guidesonographer practice.
Whom to Scan
Only emergent essential echocardiography studies should be performed to limit the risk of
exposure to other patients and healthcare providers. Several professional societies have provided
statements that all non-essential ultrasound examinations be rescheduled for a later date to reduce
the risk of exposure to the COVID-19 virus.1-4 Various mechanisms for doing this have been
advocated based on ultrasound specialty; and definitions of essential may be determined by local
and institutional standards.1-4 In addition to the guidance provided in the “ASE Statement on
Protection of Patients and Echocardiography Service Providers During the 2019 Novel
Coronavirus Outbreak” main document, sites are also implementing additional requirements for
placing orders. These include approval of the procedure by a cardiologist or cardiology fellow,
review of the proposed study with the cardiologist to plan the examination and determine if acomprehensive echocardiogram is needed; and justification for why the echocardiogram is to be
performed emergently and why it is essential. In general, there is consensus that echo studies forpatients with heart failure, heart transplant, and ongoing chemotherapy or stem cell transplant areconsidered essential (the list is not all-inclusive). Sonographers are encouraged to work with their
medical team to reschedule and/or defer all non-essential/emergent patients.
Within the echo lab, there should be tracking and rotation of sonographers performing the COVIDsuspected and/or -positive patients in order to reduce exposure of any one team member and thepotential for transmission to an entire team or lab.
Where to Scan
The goal is to limit exposure of the COVID-19 virus to as few individuals as possible. Strategies
for sonographers to consider are as follows: using a dedicated ultrasound system(s) and room(s)for performing all suspected and/or confirmed COVID-19 cases, performing all inpatient
examinations portably, and first using hand-held devices to determine if a complete comprehensive
echocardiogram is needed. The advantage of hand-held devices in the COVID-19 environment isthat these devices can be completely draped and are easily cleaned. Use of hand-held devices byother trained providers may limit exposure to sonographers and conserve PPE. In this scenario, it
is recommended that devices that offer remote connection to PACS systems be utilized.
Sonographers may be involved in producing training videos, and can be available remotely tofacilitate the use of hand-held devices to tailor examinations and acquire additional views that may
not be included as part of the traditional point-of-care ultrasound imaging. Utilizing hand-helddevices that connect remotely (i.e. wireless network, cloud, etc.) is desirable, as the images can be

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sent directly to the echocardiography laboratory workstation for immediate review by a
cardiologist to determine whether a comprehensive echocardiogram is needed.

How to Scan
As stated previously, the goal is to limit exposure. Appropriate personal protection equipment
should always be used based on the patient status (See Figure 1 in the main document, “ASE
Statement on Protection of Patients and Echocardiography Service Providers During the 2019
Novel Coronavirus Outbreak”). In addition to the use of appropriate PPE, sonographers canemploy strategies that limit exposure while actually scanning (adjusting protocols/technique) andthrough appropriate cleaning of equipment. These are described below. Refer to your institution’s
safety guidelines for appropriate PPE and protocol for donning & doffing the PPE1. Additional
information regarding the types of PPE are described in sections 4b and 10 in the “ASE Statement
on Protection of Patients and Echocardiography Service Providers During the 2019 Novel
Coronavirus Outbreak.”1
One strategy for limiting exposure is shortening the examination time. To shorten exam time,sonographers should have discussions with their medical team to determine if a comprehensive
echocardiogram (with or without contrast) is needed based on the patient’s history and current
medical history. Cardiovascular sequelae associated with COVID-19 have been previously
described,5-8 and an abbreviated, limited, or focused examination might yield the desired
information while decreasing the amount of time needed for the sonographer to be exposed to thepatient.
In addition to using abbreviated imaging protocols, measurements should be made offline in theechocardiography laboratory to shorten the time in the room with the patient. In general, there isconsensus that echo studies in de novo patients be limited to assessing LV and RV size andfunction, with screening for valvular disease. As myocarditis is a potential COVID-induced
pathology, global longitudinal strain assessment may be performed from this limited study.
Follow-up studies should be discussed ahead of time to identify the imaging goals in an effort to
reduce the exam time and exposure.
Sonographers may want to consider scanning right-handed so that they are positioned away fromthe patient’s face. Right-handed scanning should only be considered providing the sonographer is
proficient at scanning right-handed and would not incur additional scanning time. Anotherstrategy is to utilize providers who are trained in point-of-care cardiac imaging to perform ascreening echocardiogram and send images remotely to PACS for expert interpretation. Then,after the expert has reviewed the images, a decision can be made if a full comprehensive
echocardiogram is needed.

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Another way to limit exposure is to keep equipment clean and disinfected. Systems with flattersurfaces and fewer crevices will be easier to clean and disinfect. Thus, if an echocardiographylaboratory has the choice of selecting an ultrasound system with a touch screen and fewer crevices(such as a keyboard), it may be desirable to use this piece of equipment to perform all
suspected/confirmed cases of COVID-19.6 Single use gel packets (not bottle) should be used whenentering a room to scan a suspected and/or confirmed COVID-19 patient and unused gel packets
can be discarded in room. If single use gel packets are not available, an alternative may be to fillsyringes with ultrasound gel to be used in place of the single use packet. The gel filled syringes
can then be discarded after the exam is completed. In addition, draping the equipment with plastic
covers and using transducer covers (if available) will further help with cleaning and disinfecting
equipment (see Figure 1).9-13 In rooms in which patients are on ventilators and individuals andequipment are exposed to airborne pathogens, the transducer should be draped.10 Hand-helddevices again may be used as a first line screening device, as these systems are easily cleaned.
Based on current CDC Guidelines11 and American Institute of Ultrasound in Medicine’s updated
statement “Guidelines for Cleaning and Preparing External- and Internal-Use UltrasoundTransducers and Equipment Between Patients as well as Safe Handling and Use of UltrasoundCoupling Gel,” low level disinfection (LLD) is still appropriate for external and interventional
procedures and a list of approved disinfectants for use with COVID-19 is available online.9,12,14

Figure 1. Panel A draped ultrasound system. Panel B draped transducer. Panel C draped hand
held system. Images reproduced with permission from: Stainback R, Plana JC, Coulter SA,
Krajcer Z. Cardiology in the Time of COVID-19: Troponin Assessment, Telemetry & Echo Lab.
Texas Heart Institute. Available online: https://youtu.be/ZoNrhzkgLhY. Accessed April 2, 2020.

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Prior to entry into a room to scan a suspected and/or confirmed COVID-19 patient, all ancillaryequipment (extra transducer, EKG leads, linens, etc.) should be removed from the ultrasoundsystem to limit exposure of additional equipment. Sonographers should explore if the patient isalready hooked up to an ECG system that could be imported into the echocardiography machine,
versus taking the ultrasound system cable and ECG leads. This reduces the need for cleaning ECG
cables and leads, which may be difficult to disinfect. If available, the use of a barrier between thebed (where the patient is lying) and sonographer could be set up prior to imaging (see Figure 2).
15-17

Figure 2. Barrier example used between the patient and the sonographer. 15-17 This is a posed
photograph demonstrating the barrier technique and how the sonographer arm can maneuverunder the barrier shield. If this were a real situation the sonographer would be wearing
appropriate personal protective equipment.

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The equipment should be cleaned after the exam is performed. The ultrasound equipment needs
to be cleaned in entirety from top to bottom including the wheels. Equipment should be cleaned
in the anteroom or immediately outside of the patient’s room to limit exposure to others. Cleaningof equipment and doffing of PPE should be followed per institutional standards.1
The focus above has been to address sonographer specific issues for performing transthoracic
echocardiography examinations (TTE). Transesophageal echocardiography considerations are
addressed in the Council on Perioperative Echocardiography (COPE) “Specific Considerations for
the Protection of Patients and Echocardiography Service Providers when Performing Perioperative
or Periprocedural Transesophageal Echocardiography during the 2019 Novel Coronavirus
Outbreak: Council on Perioperative Echocardiography Supplement to the Statement of theAmerican Society of Echocardiography.” 18

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References:
1. Kirkpatrick JN, Mitchell C, Taub C, Kort S, Hung J, Swaminathan S. ASE Statement on
Protection of Patients and Echocardiography Service Providers During the 2019 Novel
Coronavirus Outbreak. J Am Soc Echocardiogr 2020; Article in Press. DOI:
10.1016/j.echo.2020.04.001.
2. American Institute of Ultrasound in Medicine. Guidelines for Cleaning and Preparing
External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as
Well as Safe Handling and Use of Ultrasound Coupling Gel. Updated Statement March
27, 2020. Available at: https://www.aium.org/officialStatements/57. Accessed March
29, 2020.
3. American Institute of Ultrasound in Medicine. Quick Guide on COVID-19 Protections Patient and Ultrasound Provider Protection1. Available at:https://aium.s3.amazonaws.com/covid19/Covid19_Quick_Guide_PUPP.pdf. Accessed
March 29, 2020.
4. Society of Vascular Ultrasound. Vascular Laboratory Responses During the COVID-19
Pandemic. March 26, 2020. Available at: https://www.svu.org/svu-news/4183/. Accessed
March 29, 2020.
5. Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Bondi-Zoccai G, et al.
Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems
During the Coronavirus Disease 2019 (COVID-19) Pandemic. J Am Coll Cardiol 2020;
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mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort
study. Lancet 2020. DOI: 10.1016/s0140-6736(20)30566-3.
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Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases fromthe Chinese Center for Disease Control and Prevention. JAMA 2020
DOI:10.1001/jama.2020.2648.
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COVID-19 Based on an Analysis of Data of 150 Patients from Wuhan, China. Intensive
Care Med Mar 3, 2020. DOI: 10.1007/s00134-020-05991-x [E-pub ahead of print].
9. American Institute of Ultrasound in Medicine. Quick Guide on COVID-19 Protections— Ultrasound Transducers, Equipment, and Gel. Available at:https://aium.s3.amazonaws.com/covid19/Covid19_Quick_Guide_UTEG.pdf . Accessed
March 29, 2020.
10. Minardi, J. Point-of-Care Ultrasound in COVID-19. WVU Medicine, Departments ofEmergency Medicine and Medical Education. Available at:https://www.youtube.com/watch?v=nx6eHINDveM. March 17, 2020. Accessed March
25, 2020.

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11. van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN,
et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N
Engl J Med. 2020 Mar 17, DOI: 10.1056/NEJMc2004973. [E-pub ahead of print]
12. National Center for Immunization and Respiratory Diseases (NCIRD) DoVD.
Environmental Cleaning and Disinfection Recommendations. Available at:https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/cleaningdisinfection.html. Accessed March 29, 2020.
13. Stainback R, Plana JC, Coulter SA, Krajcer Z. Cardiology in the Time of COVID-19:
Troponin Assessment, Telemetry & Echo Lab. Texas Heart Institute. Available online:
https://youtu.be/ZoNrhzkgLhY. Accessed April 2, 2020.
14. Agency USEP. List N: Disinfectants for Use Against SARS-CoV-2. Available at:https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2.
Accessed March 29, 2020.
15. Kolias TJ, Eberhart D, Bradsher K. Echo Scanning Barrier Drape Procedure with Video.
Submitted by Theodore J. Kolias, MD, FASE, University of Michigan, “Provider
Protection Strategies Shared by ASE Members, COVID-19 Resources.” Accessed March
31, 2020.
16. Dean M, Schwarz K, Steinmetz, Hills D, Stoddard T. URMC Echo COVID-19 Shield.
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Accessed March 31, 2020.
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March 31, 2020.
18. Nicoara A, Maldonado Y, Kort S, Swaminathan MS, Mackensen GB. Specific
Considerations for the Protection of Patients and Echocardiography Service Providers
when Performing Perioperative or Periprocedural Transesophageal Echocardiographyduring the 2019 Novel Coronavirus Outbreak: Council on Perioperative
Echocardiography Supplement to the Statement of the American Society of
Echocardiography. J Am Soc Echocardiogr 2020; DOI: 10.1016/j.echo.2020.04.008.

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