This information sheet applies to the medical imaging diagnosis of COVID-19 and the diagnosis of other conditions in patients with suspected, probable or confirmed COVID-19. The imaging strategies and principles for infection prevention and control aim to support staff and patient safety. The document also aims to provide information to assist with the long term sustainability of medical imaging services during COVID-19 pandemic surge periods.
This document outlines the imaging strategies and principles for infection prevention and control. This information sheet aims to ensure staff and patient safety and long-term sustainability of medical imaging services during the COVID-19 pandemic.
The provision of medical imaging services for patients with suspected, probable or confirmed COVID-19 should be based on a risk assessment or laboratory or clinical clearance criteria. This document assumes that during a surge period, resources will be redirected from non-urgent outpatient settings to COVID-19 surge priorities.
All other (non-COVID-19, COVID-19-negative) patients should be treated via normal pathways.
The guidance on infection prevention and control requirements for the management of these patients and the use of personal protective equipment (PPE) in New South Wales (NSW) healthcare settings should be based on the Clinical Excellence Commission (CEC)
Infection Prevention and Control Management of COVID-19 in Healthcare Settings in conjunction with the
NSW Infection and Prevention Control Policy Directive, the COVID-19 Infection Prevention and Control Response and escalation framework and local procedures and guidance.
Medical imaging should be performed at sites with less foot traffic and with fewer critically ill patients in that area to avoid secondary patient and staff exposure.3
Medical imaging departments should seek to reduce the number of patients coming into the department, reduce patient transits through the department and increase the use of mobile examinations.
For example, medical imaging meetings can be conducted using telehealth or videoconferencing, and the number of people present during procedures reduced, to ensure compliance with social distancing parameters of 1.5m distance between individuals.
Many radiologists will be working from home (split team arrangement with team A and team B) with VPN capabilities. It is recommended that a central point of contact for COVID-19 medical imaging enquiries be established at each local health district (LHD).
Signs indicating ‘maximum occupancy’ on relevant rooms such as tea rooms and meeting rooms, should be considered.
Tearooms should allow for social distancing. Consider using larger seminar rooms as lunchrooms with 1.5m social distancing with hand washing facilities (alcoholbased hand rub or soap and water wash) for staff.
Waiting rooms and trolley bays should also use the 1.5m social distancing rule for chairs and beds.
Imaging requests and e-orders for COVID-19 cases should be sent via a locally approved pathway. Rationalisation of cases will occur with relevant senior staff via a centralised communication pathway. Structured advice on the approval pathway should be determined by each LHD or hospital.
Continued demand for urgent procedures must receive optimal care.
Chest imaging is not a screening tool for COVID-19.1,
15 The majority of patients with COVID-19 have mild symptoms and minimal evidence of disease on chest X-ray.15,
If chest imaging is requested for COVID-19 positive or COVID-19 suspected patients, it is recommended that a designated ‘COVID-19 mobile X-ray unit’ stay in specified wards. A two-person team, ‘hot’ and ‘cold’ team, should be rostered wherever possible. Covered (plastic vs linen) detector to the ‘hot’ team member inside the room and ‘cold’ member to stand outside the room, if possible. (See example CXR protocol at the ACI Medical Imaging COP COVID-19 SharePoint).*
RANZCR strongly advises against conducting routine chest CT scans for all individuals undergoing emergency surgery in Australia and New Zealand. They believe the misuse of chest CT and misapplication of results will bring unnecessary and clinically important risks to the surgical team and the patient, given the current status of the COVID-19 pandemic in Australia and New Zealand.4
There is no role for CT scans in determining the management of COVID-19 positive patients or the diagnosis of COVID-19. CT use is not supported by literature.23,25
Chest CT is not superior to RT-PCR for the initial detection of COVID-19 and has more false positives. It is likely to be useful in confirming COVID-19 in patients with a suspicious clinical presentation but who have a false-negative SARS-CoV-2 RT-PCR test.
Advice regarding the use of CT was released by the Royal Australia and New Zealand College of Radiologists (RANZCR) was consistent with position statements released by both the American College of Radiology and the Society of Thoracic Radiology (STR).2
While the STR does not recommend routine CT screening for the diagnosis of patients under investigation for COVID-19, chest CT can be restricted to patients who test positive for COVID-19 and those suspected of having complicating features, such as abscess or empyema.2,3
For CT examinations on COVID-19 or suspected COVID-19 patients, ensure:
At least two radiographers should be present (or one radiographer and a nurse or technical assistant). Healthcare workers within 1.5m of a COVID-19 suspected case should have gloves, apron or gown, and depending on the risk, surgical mask and eye protection. The radiographer in the control room may have less PPE but will still need a face mask, gown and gloves.
If the CT room is sealed off and staff are able to stay in a clean or green separated zone, then no PPE is required due to no COVID-19 contact. A change of gloves is required if contact is made with the patient during the scan.
neuroradiology Interventional radiology and interventional neuroradiology examinations should be screened for COVID-19 transmission risk and a radiologist consulted prior to booking. The clinical need, risk of delay and assessment of feasibility, should all inform the decision to cancel, postpone or proceed with an elective intervention. These decisions will be specific to the local health district or facility. Consider whether any procedural cases will require access to ICU beds, general anaesthesia/sedation and airway manipulation etc.
Where possible, all ultrasound examination requests on COVID-19 (suspected or positive) patients, mobile imaging should be performed to minimise the chances of cross infection.
It should be recognised that each examination requires close proximity for an extensive time. For these examinations, accurate clinical history and specific region of interest would help minimise the time the sonographer is in close proximity to the patient.
When requesting an ultrasound examination, the risks and benefits should be considered. Where possible, another modality may be more appropriate, e.g. CT.
Use a portable unit that stays in a designated location where possible. The unit must be cleaned and disinfected after use.Please refer to the Australasian Society of Ultrasound in Medicine (ASUM) guidelines for mobile ultrasound in the ICU and fixed units.16
Ultrasound probes can be cleaned as per current practices for high level disinfection (HLD) via a trophon or approved HLD device. Probes should undergo HLD after touching infected patients.18
For point of care (POC) units, the following recommendations have been published, which are similar to medical imaging units.20
Some LHDs have referred ultrasound cases to local private facilities or used BreastScreen sites for non- COVID-19 cases.
MRI use should be based on risk assessment and other modalities substituted for COVID-19 positive or suspected cases, if appropriate, because deep cleaning of MRI units is not achievable. Where there is a lag time in eMR infectious status, LHDs are asking for a statement in the clinical information indicating, COVID-19 negative, not suspected COVID-19 status or wait until COVID-19 results are available.
New eMR/Cerner Millenium software for COVID-19 flagging in e-Orders and requests are being progressed.
International MRI COVID-19 evidence states:
PPE in MRI has a risk of mask dislodgement on patients and staff in the magnetic field.
There is also an increased risk of artefact and heating for patients wearing masks during MRI. If the patient is symptomatic, then the procedure may be delayed or postponed based on the clinical condition. If the procedure is necessary, then there are only two masks that have been tested at 1.5 T. After testing, only one P2/N95 mask (Halyard Fluidshield) and one surgical mask (Primed PM4-306) have been passed as being MR safe with no artefact at 1.5 T. These must be used by both staff and patients entering the MRI room. The mask/face shield combo unit currently being used by the anaesthetists are weakly attracted to the magnet.
The ACI MRI Scans in COVID-19 Pandemic Surge and MRI Protocols is also available at the ACI Medical Imaging SharePoint.*
For advice on resumption of Outpatient clinics, please see the
NSW Health risk assessment and mitigation processes. For patients who were previously COVID-19 positive see the
NSW Health fact sheet for confirmed cases.
Outpatient services will be reprioritised, and in some instances be sent to local private practices. Outpatient cases should be restricted in accordance with pandemic conditions.
In particular, ultrasound services have been referred to local private radiology facilities or to BreastScreen sites in some LHDs.
(See OP criteria examples at the ACI Medical Imaging COVID-19 resources on SharePoint.)*
There is a growing need to preserve workforce capacity by providing appropriate PPE and COVID-19 flagging in e-orders and medical imaging requests to support the health service during the COVID-19 response.
In most situations, when caring for patients with suspected or confirmed COVID-19 and contact and droplet precautions are needed, best practice is a single-use surgical mask, along with eye protection, apron or gowns and gloves. P2/N95 masks are reserved for aerosol generating procedures, such as intubation, to help reduce the wearer’s respiratory exposure to contaminants, such as airborne particles.
Frontline staff should be educated in the donning and doffing PPE. Staff should be encouraged to adopt the same ‘time-distance-shielding’ philosophy for COVID-19 cases, i.e. reduce time of imaging, increase distance from patient and shield themselves with careful adherence to PPE.
The CEC’s video on PPE outlines combined contact and droplet precautions and combined contact, droplet and airborne precautions.11 This resource provides specialised training on the correct application and removal of PPE for frontline staff.
The covering of medical equipment with plastic should be done with caution because of the potential of electronics overheating. There must always be a cooling passageway for instrumentation, as required by service maintenance contracts.
Approved guides have been developed by the Clinical Excellence Commission (CEC).
If using a surgical mask for other patients, a new mask is not required for every patient. In consideration of mask burn rates, they can be worn for up to four hours if due care is taken to avoid touching the mask or face.
* To request access to the ACI Medical Imaging COVID-19 resources on SharePoint, email
ACI Medical Imaging.
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Medical Imaging CoP, ACI
ACI Medical Imaging Community of Practice, CEC/IPAC, ED COP, Derek Glenn, Gloria Olivieri, Ellen Rawstron, Susan Jain, Sue-Anne Redmond.
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning