Adapting Your Nuclear Medicine Practice Amid COVID-19

As medical practices plan their post-shutdown reboot, hospital systems have a long road ahead. Clinicians of every specialty will long reckon with the challenges imposed by COVID-19, from infection control and financial effects to backlogs, the lingering risk of staff burnout, and the anxieties that patients express about returning to healthcare facilities for safe testing. Nuclear medicine shares these challenges, and nuclear medicine departments are also confronting barriers unique to their own field of medicine.

These barriers will fundamentally transform the intensity with which they work, adding new responsibilities for the sake of public health and safety. How physicians respond will in part determine how they make it on the other side of the pandemic - and more immediately, how well they serve patients and providers in the meantime.

So what are those pressing challenges and how can they be addressed? Here’s what we see for the next few months and beyond:

Ongoing Training for Infection Control in Nuclear Medicine

Medical organizations worldwide have issued new guidelines to help practitioners navigate COVID-19. In the months since, many have also released new iterations for the resumption of services. Some of these include:

• Statement on Safe Resumption of Non-Urgent Radiology Care During the 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 share key areas of logistical consensus for infection control, including 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 will need to learn applicable guidelines and double down on those knowledge gaps in the months ahead.

Rethinking the Risk/Benefit Assessment in a COVID-19 World

The coronavirus has recalibrated the risk/benefit ratio for clinical imaging. On one hand, the risks from healthcare-acquired COVID-19 are very real and depend on many factors, including local transmission rates, access to testing, and PPE availability. On the other, postponing imaging can lead to a lack of appropriate treatment and disease progression. Recent publications have remarked on the large numbers of potentially treatable conditions that are not coming to medical attention due to limitations in hospital throughput or patient fear of contagion at healthcare facilities. Medical societies are now having to take action to address these concerns and fears.

This balance creates a sliding scale of indication priorities that can help triage medical diagnostic examinations during the recovery from the worst of the pandemic as hospitals ramp up [imaging] services. The Radiological Society of North America (RSNA), for example, designates three categories:

• Elective/Nonurgent: If the examination is delayed it will not harm patients in the next 2-6 months
• Time-Sensitive: A short delay of 2-4 weeks is acceptable
• Critical: The examination cannot be delayed and should be scheduled right away.

Applying these guidelines to the nuclear medicine world - as reported by the British Nuclear Medicine Society -  suggests that PET for diagnosis of cancer, sepsis or myocardial perfusion imaging for acute chest pain should not be delayed, PET for follow up or routine MPI could be delayed after discussions with the referring physician, and other examinations such as diagnosis of neurodegenerative diseases could be postponed for a longer period of time.

Similarly, the UK Royal College of Radiology translates this tiered concept to a set of five priority levels based on the degree of urgency whether imaging can facilitate immediate treatment and the potential outcomes of the latter being delayed. 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 will be 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 risks and benefits, and most of all, they need to be heard.

Optimizing Existing Staff and Resources in Nuclear Medicine Practices

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. Generally, imaging modalities should be selected based on those that give the most information with the least time of exposure, required staff, and the probability of repeated exams. Switching to time-efficient imaging protocols and procedures and leaning on AI technologies for scheduling and other workflows can also help.

All the while, 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. Now, as they work long hours, relearn 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.

Reevaluate Nuclear Medicine Procedures 

It’s not just operational workflows; procedures are adapting 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 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.

Confirm the Radiopharmaceutical Supply Chain

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 half-life nature of decaying radioactive material, providers always had to be good stewards of time management and resource allocation.

All of those factors have since been impacted by the pandemic, making an already complicated process doubly so. 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.

Getting Back to Practice

Nobody knows when, or if nuclear medicine will go back to the way it was. A recent GE Healthcare survey among European practitioners found that more than half of respondents expected to return to normalcy by June or July. Another third thought it wouldn’t be until fall, with a lingering 10 percent expecting a resumption in 2021.

Whether these expectations play out will depend on the evolutions of the pandemic and the geopolitical climate from region to region.  Infection spikes in parts of the U.S., for example, have re-shuttered some elective procedures—months after they reopened—leaving many physicians in familiar limbo.

No matter what your timetable looks like, reopening still comes with a lot of redoing: There’s reevaluation, retraining, rethinking, reassessing. These measures matter and getting back to practice without a thoughtful and documented protocol can confuse patients and staff while inviting the risk of transmission. Most of all, we need to find safe and effective ways to encourage patients back for needed care despite the surrounding pandemic, to avert a “second pandemic” of otherwise treatable illnesses in cardiology, oncology and other care areas. 

So, learn the new guidelines, codify new policies, and keep communication and compassion at the heart of your practice. Those are indeed the makings of a successful reboot.