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Canadian Internal Medicine Ultrasound (CIMUS)
Recommendations Regarding Internal Medicine Point-
of-Care Ultrasound (POCUS) use during Coronavirus
(COVID-19) pandemic.
Irene WY Ma, MD, PhD, RDMS, RDCS;
Ranjani Somayaji, MD, MPH; Elissa Rennert-May, MD, MSc; Joseph Minardi, MD;
Michael H. Walsh, MD; Katie Wiskar, MD; Leo M. Smyth, MD; Steven Burgoyne, MD; Barry Chan, MB, BCh, BAO;
Babar A. Haroon, MD, MEd; Janeve Desy, MD, MEHP, RDMS
About the Authors
Irene WY Ma; Ranjani Somayaji; Elissa Rennert-May; Michael H. Walsh; Steven Burgoyne; and Janeve Desy are with the Department
of Medicine, University of Calgary.
Joseph Minardi is with the Department of Emergency Medicine and Medical Education, West Virginia University School of Medicine.
Katie Wiskar and Barry Chan are with the Department of Medicine, University of British Columbia.
Leo M. Smyth is with the Department of Medicine, University of Alberta.
Babar A. Haroon is with the Departments of Critical Care and Medicine, Dalhousie University.
Corresponding Author: ima@ucalgary.ca
Submitted: March 20, 2020. Accepted: March 23, 2020. Published: April 1, 2020 ahead of issue. DOI: 10.22374/cjgim.v15i2.344
With the COVID-19 pandemic, we are in unprecedented
times -- our clinical environment is changing rapidly and may
continue to do so in the future. Over the last decade, there
has been an increase support for the use of internal medicine
point-of-care ultrasound (POCUS) across the country and
worldwide.
1-3
While standard infection control guidelines are
available on device and transducer cleaning and disinfection,
4,5
these recommendations may not apply to the current COVID-19
pandemic. While we anticipate that the experience and need for
POCUS deployment will differ across the country depending
on a number of contextual factors, similar principles will likely
emerge across multiple settings. To that end, in order to enable
POCUS readiness, we recommend that each program/practice
site consider undertaking appropriate measures on a semi-urgent
basis if POCUS use is anticipated.
The objective of this article to provide internists who
currently use POCUS with interim recommendations on
processes that need to be in place prior to its use. This
document refers primarily to the non-critical use of ultrasound
devices, based on the Spaulding classification
6
(see Appendix
for definitions) and does not apply to settings of critical use
where sterilization is required, nor to semi-critical use, where
high level disinfection is required.
7
Each institution must
have its own policy in place on the cleaning and disinfection
procedures for POCUS. This document is meant to serve as
an adjunct to existing protocols.
Recommendation #1: Develop or adapt existing infection
prevention and control (IPC) protocols for ultrasound device(s)
POCUS use under all circumstances must strictly adhere to
appropriate and clearly defined IPC protocols. These protocols
must be developed as early as possible for use in each local setting.
The following recommendations must be taken into consideration:
Appropriate disinfectant products must be:
a. Effective against coronavirus, based on best available
evidence.
For product information, consult documents
from Government of Canada
8
or the United States
Environmental Protection Agency (EPA)
9
b. Compatible with the ultrasound device and
transducers.
Consult manufacturer manuals for a list of compatible
products.
All surfaces on the device should be cleaned after each use
and a minimum of once daily. This includes but not limited
to the monitor, instrument control panel, transducers, cords/
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cables, stand, transducer holders, and disinfectant container,
where applicable.
Note the minimum wet contact time required to achieve
disinfection. This minimum wet contact time is the length
of time that the disinfectant must remain wet on the surface
for it to be effective. The minimum wet contact time required
must be in compliance with the manufacturers specifications
for a given product.
9
Consult the device manual and/or device manufacturer
regarding required cleaning and disinfection procedures.
Adhere to appropriate cleaning and disinfection
principles.
10
Surfaces must be cleaned of any visible
debris prior to disinfection. The sequence of cleaning and
disinfection must be done from the least-soiled to the most-
soiled areas. Following cleaning and disinfection, the device
must be allowed to dry completely before reusing.
Recommendation #2: Optimize the ultrasound device(s)
prior to use
A dedicated device or a limited number of devices, should be
selected on the basis of ease of cleaning and disinfection (i.e. least
number of crevices, small size), portability, imaging capability,
and ability to provide clinically meaningful information/utility.
To prepare the device(s) for use, we recommend minimizing
all unnecessary accessories. For instance, in cart-based systems,
remove all unnecessary trays, baskets, transducer holders, and
brackets. Minimize the number of transducers on the device by
removing transducers unlikely to be of use.
Recommendation #3: Where possible, use single-use gel
packets for patient assessments
Ideally, no multi-dose gel bottles should be used.
Recommendation #4: Integrate IPC protocol into the workflow
Consideration must be given to:
a. where the device will be cleaned (e.g the device should
be disinfected prior to exiting the room, if no anteroom
is available)
b. where the disinfectant product will be accessible (in the
patient room vs. stored on the ultrasound device)
c. how the device cleaning/disinfection will be done in
conjunction to existing donning and doffing of personal
protect equipment of the operator
d. if additional staff/personnel will be present to assist
during any of the above IPC procedures
Working with your local IPC professionals to implement and
monitor proper POCUS use and disinfection processes is highly
recommended. Refer to the most updated and credible sources,
such as the American College of Emergency Physicians ultrasound
cleaning protocol for COVID19.
11
Recommendation #5: Identify a secure clean area for device
storage
Recommendation #6: Ensure necessary training of all POCUS
practitioners
Restrict users of POCUS to only those appropriately trained in
both POCUS and IPC protocols. For the training of IPC protocols,
simulation-based education can be considered.
Recommendation #7: Each decision to perform POCUS must
be based on careful consideration of the following factors:
Even with the appropriate IPC protocol in place, the risks and
benefits of undertaking POCUS must be carefully weighed and
considered.
1.
Indications: Do the indications justify the use of
POCUS?
There are currently no known pathognomonic findings
COVID-19 on POCUS.
12
Therefore, its use to diagnose
COVID-19 without an expected change in management
plans is NOT recommended.
However, there may be a role for POCUS in certain
situations:
º To evaluate for the presence of alternative diagnoses
º To help guide management (e.g. volume status),
monitor disease progression, or provide prognostic
information (e.g. evolving ARDS or cardiac
dysfunction)
º To guide necessary bedside procedures (e.g. establish
intravenous access)
In deciding to pursue POCUS, the user must take
into account the likelihood of
POCUS yielding information that can help manage
the patient.
2.
Contraindications: Factors such as patient refusal
and lack of cooperation that may impact the ability to
obtain necessary information should be considered
early, to avoid wasting unnecessary personal protection
equipment and disinfectant products.
3. Operator expertise: Given the clinical context and
patient factors, is the operator sufficiently trained and
skilled for the POCUS examination to yield important
information?
4. Availability of alternative investigations: The operator
will also need to consider the availability of alternative
modalities that can yield comparable or superior
information and the risks/benefits of any necessary
patient transport and transfers that could place
additional health care workers and patients at risk
5. Barriers to patient transport: Availability of local
resources, personnel, equipment, and patient condition
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must be considered in deciding the optimal imaging
modality. Discussion with imaging specialists is
recommended.
6. Burden on resources: Do the use and results from the
POCUS exam justify the use of protective equipment
and disinfectant products, risk of personnel exposure,
costs, and time?
Recommendation #8: Use the minimum number of POCUS
practitioners and equipment necessary to do the task
To avoid unnecessary waste of personal protective equipment and
disinfectant products, minimize the number of POCUS personnel
required at each patient encounter. Consider integrating POCUS
evaluations with concurrent patient care tasks.
Do not take additional unnecessary equipment (e.g. pens or
paper) into the room. Images and cineloops should be recorded.
Necessary patient identifiers should be entered into the machine
outside of the patient room. Storage of patient identifiers and
images/cineloops should be done in compliance with Canadas
healthcare privacy regulations (Personal Information Protection
and Electronic Documents Act).
13
Recommendation #9: Avoid the use of POCUS during aerosol-
generating medical procedures (AGMP)
AGMPs are procedures that are believed to induce the production
of aerosols, such as:
14
1. Nebulized therapy/aerosolized medication
administration
2. Bi-level Positive Airway Pressure (e.g. BiPAP, CPAP)
3. Humidified high flow oxygen systems (e.g. AIRVO,
Optiflow)
4. Induced sputum
5. Tracheostomy care
6. Intubation
7. CPR
8. Bronchoscopy
9. Procedures that stimulate coughing
10. Open tracheal suctioning
11. High frequency oscillatory ventilation
Care should be taken to avoid performing POCUS during AGMPs.
If POCUS must be performed during AGMPs, system drapes and
transducer covers may be beneficial. Appropriate cleaning and
disinfection procedures will still need to be undertaken after each
use, after the removal of system drapes and transducer covers.
Recommendation #10: Recognize the levels of disinfection
required based on use and/or exposure
Surface disinfection procedures will differ between a) low-level
and b) high-level disinfection. While this document pertains to
low-level disinfection recommendations, high level disinfection
protocols are required if any part of the device surfaces have
been contaminated with blood and/or body fluids or have been
in contact with non-intact skin or mucous membranes.
Consult the device manual and local IPC professionals for
recommendations on high level disinfection protocols.
Recommendation #11: Have contingency plans in place for
alternative disinfection strategy
Contingency plans should be set in place for what to do when
cleaning/ disinfectant products are depleted, or alternate devices
need to be used. It is advisable to have available, on hand, a list
of alternative disinfectant products that are both effective and
compatible with your devices. Noting these products’ specified
wet contact time ahead of time may save time in the future.
Recommendation #12: Educational bedside scans should
be suspended
Based on potential infectious risks involved as well as the need for
personal protective equipment and disinfectant products, CIMUS
recommends that all educational bedside scans be suspended
at this time. Educators are encouraged to seek out alternative
educational activities, such as simulation-based training, online
resources, or review of images and cases.
APPENDIX: Definitions
Cleaning refers to the physical removal of debris through the
mechanical action of wiping with a clean wet cloth. Surfaces must
be cleaned of visible soil before they can be disinfected, as soil
and debris interfere with the effectiveness of the disinfectant.
Disinfection refers to the inactivation of disease-producing
microorganisms through wetting of a surface with a disinfectant
wipe saturated with a disinfectant solution, prepared according to
the manufacturer’s instructions for use. To achieve disinfection,
the surface must stay wet for the manufacturer’s recommended
wet contact time.
Spaulding classification is a system used to match the disinfection
and sterilization of equipment with processes and categorizes
equipment as critical, semi-critical, and noncritical, based on the
degree of infectious risks involved in the use of the equipment.
Critical Items pose high risk for infection and includes equipment
used in sterile body tissue or cavities. Sterilization processes
are required.
Semi-critical items contact mucous membranes or nonintact
skin and require high level disinfection processes.
Non-critical items come into contact with intact skin but no
mucous membranes. Intermediate or low-level disinfection
processes are required.
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