As we pass through the peak of the pandemic, non COVID-19 clinical activity is tentatively returning. Alongside cancer services, cardiology activity has been recognised as a NHS priority.
Many of us are keen to return to normality, anxious that several patients with serious modifiable pathologies currently remain in a holding pattern in the community. However, given that COVID-19 continues to be endemic with the probability of a second wave of infections later in the year, it will not be possible to return to the previous model of delivery of care for the foreseeable future.
This interim guidance provides a framework for tailoring departmental echo activity at this time. The ideas presented focus predominantly on transthoracic echo (TTE); whilst specific details for transoesophageal echo (TOE) and stress echo (SE) services are also discussed. Particular thanks is given to Wendy Gamlin, Expert Cardiac Physiologist from Manchester University NHS Foundation Trust, for her extensive input.
Who can/should attend for an outpatient echo?
This will need to be decided in line with the changes in government restrictions and any local initiatives but is likely to begin with more urgent referrals and younger patient groups. A list of conditions which have been identified as a “higher risk for COVID-19” can be found in Appendix One. A senior member of the echo team should identify potential patients. If the patient has referrals for multiple tests these should be performed on the same day to avoid repeat attendances.
A member of the echo team should contact the patient by telephone to discuss their planned attendance. A structured questionnaire should be followed, for example:
Question 1: Have you or anyone you live with had a letter from the NHS informing you that you are at higher risk of COVID-19 and should not leave your home?
If the patient answers Yes, they should not attend for their appointment at this time. If they are concerned about worsening symptoms, they should consult NHS 111 or their GP for advice.
If the patient answers No, proceed to question 2.
Question 2: Have you or anyone you live with had a persistent cough, temperature or tested positive for COVID-19 within the last 14 days?
If the patient answers Yes, they cannot be appointed at this time. They should be advised to follow the government guidance regarding self-isolation. They should be asked to re-contact the department following this period of isolation.
If the patient answers No, proceed to question 3,
Question 3: Are you able to get yourself to the department for an appointment?
If the patient answers No, It may be necessary to wait until further relaxation of lockdown measures to proceed with their appointment.
If the patient answers Yes, offer them the next available appointment and inform them that only they will be able to attend the department. If applicable, advise the patient to attend via the non-COVID entrance to the hospital/department. Before ending the call inform them that if they or a person they live with develop symptoms between now and the appointment time they must phone the department to re-schedule.
Echo appointments should be scheduled to allow sufficient time to clean all equipment and surfaces appropriately after each patient and the donning/doffing of personal protective equipment (PPE).
Day of the appointment
The patient should be met at the door by a member of the team who should be wearing appropriate PPE. The patient’s temperature should be recorded:
If it is equal to or greater than 37.8°C:
They should be advised to return home and consult NHS 111 if concerned.
If it is less than 37.8°C:
The patient should be asked “Have you or anyone you live with had a persistent cough, temperature or tested positive for COVID-19 within the last 14 days?”
If the patient answers Yes, they should be advised to return home, self-isolate as per guidelines and consult NHS 111 if concerned.
If the patient answers No, the patient should apply alcohol gel to their hands and then put on a surgical mask and gloves prior to entering the department. Seats in the waiting area should maintain social distancing and be cleaned down with disinfectant wipes after the patient has been called in for their appointment.
The echo appointment
The aim should be to minimise the time the patient spends waiting in the department. If the patient is early and the physiologist is ready for them, they should be taken through for the echo immediately rather than delaying until their appointment time. The physiologist should wear appropriate PPE to collect the patient from the waiting room. The patient should be asked if they know their height and weight to avoid any unnecessary repeat measurements.
As focused a study as the referral allows should be undertaken, accepting that a patient with no previous study will need to have a full dataset obtained.
At the end of the study the patient should be shown where to dispose of their PPE before leaving the department. The physiologist’s PPE should then be removed appropriately, and the room cleaned immediately in preparation for the next appointment.
The echo report
In addition to a normal echo report it is helpful to record any change in the patient symptoms or clinical status (e.g. burden of peripheral oedema). This will allow the referring clinician to minimise any unnecessary repeat hospital attendance following the scan.