Global medical practices continue to adapt to the challenges of COVID-19. On one hand is responding to the pandemic itself and on the other is ensuring minimal disruption to non-COVID related procedures and hospitalizations. Clinicians of every specialty will long reckon with the challenges imposed, from infection control and financial effects to continuing backlogs, the lingering risk of staff burnout and ongoing anxieties from patients about visiting healthcare facilities. Nuclear medicine shares these challenges, and nuclear medicine departments are also continuing to confront barriers unique to their own field of medicine.
Here’s what we see for the next few months and beyond:
Ongoing Training for Infection Control in Nuclear Medicine
Since the start of the year medical organizations worldwide have issued guidelines to help practitioners navigate COVID-19. These have continued to iterate in the months since. Some of these include:
- Statement on Safe Resumption of Routine Radiology Care During the Coronavirus Diseases 2019 (COVID-19) Pandemic (American College of Radiology)
- COVID-19 Interim Guidance on Restarting Elective Work (The Royal College of Radiologists)
- Nuclear Medicine Services After COVID-19: Gearing Back Up to Normality (European Journal of Nuclear Medicine and Molecular Imaging)
- Guidance for COVID-19 Recovery Phases (British Nuclear Medicine Society)
Universally, recommendations cover the selective requirement for a Covid-19 test in advance of some procedures, key logistical areas for infection control including clear separation of COVID and non-COVID spaces in hospital settings, wearing PPE, social distancing, layout and flow, telehealth, cleaning, and new policies for scheduling and check-in.
Following all measures requires close attention, as well as ongoing investments in education and training. Because a single error could invite more risk, all practitioners and practice managers are continuing to exercise caution and follow applicable guidelines.
As different markets grapple with ensuring continuity of imaging procedures, there is consensus around the postponement of imaging potentially leading to a lack of appropriate treatment and disease progression. Some publications have remarked on the large numbers of potentially treatable conditions that in some markets are still not able to receive medical consultation, due to limitations in hospital throughput or patient fear of contagion at healthcare facilities.
Different scientific societies have published guidelines to help prioritize depending on the prevalence of the pandemic and any individual healthcare system’s ability to continue standard procedures. The British Nuclear Medicine Society suggests a flexible workplan approach that should be updated on a regular basis. It recommends a traffic light system that guides clinicians to prioritize those examinations that should not be delayed and highlights the importance of involving the referring physicians in this process. Examinations that should not be delayed include most of the indications for oncology patients including diagnosis, staging and therapy decisions and myocardial perfusion imaging for acute chest pain. PET for follow up or routine MPI could be delayed after discussions with the referring physician, and other examinations - such as lymphoscintigraphy, gastrointestinal or diagnosis of neurodegenerative diseases - could be postponed for longer if required. There are also other drivers for these decisions. For example, patient distancing protocols may be easier to enable for those examinations that require only a very short waiting time in between injection and acquisitions such as MAG3 or fast protocols for MPI. Likewise, where radiopharmacy support is not required, there can be more flexibility and potential to schedule those procedures outside normal hours.
The UK Royal College of Radiology translates this tiered concept into a set of five priority levels based on the degree of urgency in terms of whether imaging can facilitate immediate treatment and the potential outcomes of a delay. A publication of a group of international experts at The European Journal of Nuclear Medicine and Molecular Imaging provides a stepwise chart with different levels of restrictions according to the benefit/risk ratio and the severity of the pandemic. Regardless of which guidelines are followed, however, all practitioners should keep in contact with facilities and referrers for safe, effective care delivery.
Some patients remain reluctant to continue their care pathway due to infection fears. To address these concerns, patients need information and reassurance to mitigate gaps in care, they need to understand the additional safety protocols being implemented, understand the risks and benefits of delaying their procedure, and - importantly - they need to be heard.
Infection control measures add time to every patient encounter, but physicians can help make up that time by optimizing resources without compromising on quality.
Striking that balance is difficult in medicine, particularly as facilities confront staff shortages, backlogs, and cost pressures. Gleaning clinical and operational efficiencies is a good strategy. Switching to time-efficient imaging protocols and procedures and leaning on AI technologies for scheduling and other workflows can also help.
All the while, healthcare providers must continue to be aware of staff fortitude. Given the high risks of burnout -even pre-coronavirus -many physicians have been pushed to their physical and mental limits this year. Now, as they work long hours, implement new workflows, and worry about bringing workplace risks home, those concerns are growing.
It’s a tough time for everyone, so department leaders must do what they can to mitigate and manage healthcare worker stress, call outside reinforcements when necessary, and ensure an open-door policy so that staff feels empowered to speak up.
It’s not just operational workflows; procedures have adapted as well. For example, consider the standard treadmill test, and all its vulnerabilities for contamination—the frequently-touched handlebar, proximity to staff, and even sweat or saliva droplets flying through the air. That’s why guidelines from the American Society of Nuclear Cardiology and the Society of Nuclear Medicine and Molecular Imaging have both recommended pharmacological stress agents instead of physical exercise. These modifications, and others, can help mitigate risks and shorten visits with fewer impacts to care quality or safety.
Even before the pandemic, Nuclear Medicine’s supply chain was highly complex, depending on the availability of raw materials, operations of manufacturing facilities, and reliability of air transportation. Due to the nature of decaying radioactive material, providers always had to be good stewards of time management and resource allocation, so as to deliver doses on time.
All of those factors have come into sharp focus since the pandemic. Now more than ever, practices benefit from access to tried and tested global supply chains with manufacturers who have strong partnerships with logistics companies and transportation services.
Nuclear medicine reverting to full “normal service” globally depends on the evolutions of the pandemic and the geopolitical climate from region to region. Infection spikes in some countries - or even sub-regions have again reduced some elective procedures—only months after they reopened—leaving many physicians in familiar limbo.
There is no doubt we need to find safe and effective ways to enable nuclear medicine procedures despite the surrounding pandemic, to avert a “new pandemic” of otherwise treatable illnesses in cardiology, oncology and other care areas.
So, for nuclear medicine departments, keeping abreast of the guidelines, codifying new workflow policies, and keeping communication and compassion at the heart of your practice are key for providers, healthcare professionals and patients.
Dr. Moreno is the Head of Medical Affairs of Europe and Dr Hibberd is Chief Medical Officer and Head of Global Medical Services, for the Pharmaceutical Diagnostics business at GE Healthcare.
Article Updated on October 26, 2020