Although imaging services are working hard to regain momentum by restoring capacity and regaining patient confidence, it remains clear that fundamental changes can only be made with significant investment to address the chronic underfunding in radiologists, radiographers, and imaging equipment
At the beginning of full lockdown (23 March 2020 in the UK), elective imaging services virtually ceased overnight. Referrals from primary care were hugely reduced. There was a significant reduction in elective referrals from secondary care. Emergency referrals reduced drastically to those either with COVID-19 or those with immediate life-threatening emergencies, especially in surgery.
An unexpected bonus of this was that imaging backlogs were rapidly demolished. The imaging service functioned for the full benefit of patient care with reporting in real time aiding patient discharge and flow through secondary care. Changes in acute service delivery meant a more effective dialogue between senior clinicians with targeting imaging to the problem to be answered rather than the quickest imaging test available. This improved patient experience in that fewer, more relevant tests were done, to enable the patient to move forward on their pathway.
Infection prevention and control (IPC) measures in the form of personal protective equipment (PPE) and social distancing as well as deep cleaning of COVID exposed equipment significantly reduced the capacity and throughput of imaging across all modalities. In some geographies, where excess staff time was available due to reduced throughput, imaging staff were redeployed to medical wards to support acute COVID activity. In other geographies staff sickness rates and the requirement for shielding further reduced patient throughput.
In the UK, the aerosol-generating nature of anaesthesia coupled with perceived poor outcomes for those patients developing COVID post-operatively, resulted in a shift of care from surgery to interventional radiology (IR). This was most marked in those hospitals with dedicated IR beds and/or day case facilities. This improved patient outcomes and experience with a reduced risk of nosocomial exposure to COVID.
With anaesthetic and intensivist time being taken up dealing with patients in intensive care (ITU), IR also provided an invaluable resource to assist in central venous line placement and effusion aspiration for the sickest of our patients. They also trained juniors from other disciplines in these procedural skills.
New protocols and guidelines to protect patients and clinicians
The main protection for patients and clinicians was the introduction of enhanced IPC measures, including social distancing and the use of PPE. Guidance on PPE was at times difficult to tease out for different clinical areas and presence of aerosol generating procedures (AGPs). Many medical special interest groups developed their own guidance, sometimes at odds with Public Health England (PHE) – government – guidance, leading to further confusion. Anecdotally, some hospitals did not feel that the imaging service was sufficiently patient facing to require PPE, which led to higher levels of infection amongst imaging staff than would have been expected, especially those in image acquisition. This was addressed in updated PPE guidance issued during the pandemic. Shortages of PPE were widely reported at the start of the pandemic but, for the health sector, were addressed at a reasonable pace, given global supply chain issues. The social care sector struggled throughout lockdown, but especially during the initial weeks, with PPE supplies.
Individualised risk assessments were introduced for staff groups including those who were pregnant, immunocompromised or had significant medical comorbidities. Generally, adjustments such as remote working were introduced for those high risk groups. The emerging understanding of the excess risk to Black, Asian and other minority ethnic (BAME) groups was wholly unexpected and required reconsideration of what being ‘at risk’ meant. Expansion of risk assessments with a further depletion of patient facing staff was necessary to protect those at highest risk.
Testing infrastructure and therefore capacity was poor initially and took a long time to reach levels able to assist positively with contact tracing and aiding restoration of elective services including imaging. To maintain ‘COVID-lite’ diagnostic spaces patients were requested to self-isolate for two weeks prior to having an imaging test (if possible) and undergo PCR swab testing 72 hours in advance of the test. Swab testing capacity is now at the required level. All NHS staff who wish to undergo antibody testing have been given the opportunity to do this.
Initially there was concern raised by surgical colleagues about poorer outcomes in patients operated on who were, or subsequently became COVID positive. The Royal College of Radiologists (RCR) in conjunction with the surgical colleges developed interim guidance on preoperative chest CT imaging in those with an acute abdominal presentation. We went on to audit the outcomes for patients treated under this protocol, determine that it did not alter clinical judgement or patient outcomes so withdrew the guidance at the earliest opportunity.
Employment/adoption of new/existing technologies
Expansion of home reporting allowed the workforce to socially distance more effectively, reducing risk of COVID transmission. It also allowed those shielding or self-isolating due to viral exposure to contribute to maintenance of the imaging service. Unfortunately, not all NHS staff had access to sufficiently high-quality home reporting equipment or hospitals had sufficient IT bandwith to support a massive increase in the number of remote workers. Home workers sometimes lacked sufficient IT bandwidth to report from home. Many hospitals invested in rapid deployment of equipment. Hospitals also invested in remote solutions for attendance at cancer multi-disciplinary team meetings (MDTs).
Training of junior colleagues has been hugely disrupted. Expanded access to home reporting for trainees has allowed vulnerable doctors to continue to support the service and gain the competencies to progress through their training. This challenge to our traditional model of training can be built upon to deliver high quality training throughout a region, reducing doctors’ time spent travelling. Improved IT connectivity is necessary to fully realise the benefits of this. Networked reporting solutions also help with making maximal use of available radiologist time to report, but need to be supported with high quality IT.
High fidelity simulation has allowed IR, as well as other practical procedural training, to continue with risk to patients, staff and trainees mitigated to the fullest extent.
Artificial intelligence solutions looking to spot classical characteristics of COVID on chest CT scans are being accelerated through NHSX, including the necessary image sharing protocols. A national chest imaging database has been set up, with input from the British Society of Thoracic Imaging (BSTI), hosted by NHSX, to allow training and validation of COVID related algorithms.
Summary of impact and key learning points
As with everywhere and everything else, the impact of COVID on imaging services has been massive. Time needs to pass for the full impact to be demonstrated. Improved access to home reporting coupled with better IT connectivity allow best use of limited radiologist time. Coupled with an acceptance of increasingly flexible working patterns, this should promote retention of the workforce, especially towards retirement age. With the current workforce shortage of at least 20%, the UK desperately needs to retain all competent radiologists within the workforce. All measures which assist this need to be supported by all employers as well as government.
New ways of working remotely, including providing training, have been rapidly adopted proving the flexibility and adaptability of the workforce.
The impact on patient care and outcomes from IR procedures has been demonstrated. The ability to treat patients under mild sedation, avoiding the risk of anaesthesia, with same day discharge have proven that investment in a sustainable IR workforce is both clinically and cost effective.
As with all aspects of life, turning off a service is much easier than turning it back on. The chronic under-investment and subsequent lack of capacity in UK imaging services has been revealed, especially in the relative slowness of service recovery.
Regaining momentum post-pandemic
In the UK, there has been a significant amount of discussion around how best to regain momentum. Nationally, this work has been titled “service restoration”. Restoration of imaging services is complex and multi-factorial covering issues related to baseline demand for imaging as well as the necessary “catch-up” of imaging requests paused during the pandemic.
Prior to the pandemic imaging services in the UK suffered from chronic underinvestment with a lack of capacity in both image acquisition and reporting. These were related to significant workforce, but also equipment shortages. Coupled with new IPC measures, especially social distancing of 2m in all healthcare settings, these shortages have meant current CT capacity at the time of writing is 40 – 70% of pre-COVID levels. MRI is slightly better at 80%. Prior to the pandemic, timely image reporting was a greater problem than image acquisition. Post-pandemic image acquisition is the main bottleneck in the imaging pathway. An investment in extra equipment would aid restoration but not without matched funding to support workforce expansion in both radiographer and radiology staff.
Patient attendances to primary care (the main route into diagnostic pathways) remain below the expected pre-pandemic level. The urgent suspected cancer referral pathway has recovered to 75% of expected in July (compared with 30% nadir in April), but there is still a cohort of patients who have worrying symptoms who are not utilising the health service as expected. The outcomes for patients, for cancer and other potentially life-threatening conditions such as cardiovascular disease, are likely to be negatively impacted for some time to come. There was a media campaign running to assure the public that NHS services are ‘open for business’ and to encourage those with worrying symptoms to seek healthcare advice.
At the end of July, the shielding restrictions on the most vulnerable patients – the elderly and those with significant underlying health problems – were lifted. These patients had been encouraged to stay at home since March, with allowance of outside exercise not being recommended until June. Some patients, especially the elderly and most clinically vulnerable, remain worried about attending hospital to undergo imaging tests. In the UK, the majority of imaging equipment is located in acute hospital settings. A media campaign on the safe practices adopted by imaging departments to ensure patient safety is also running in the UK at present.
The NHS has retained (at time of writing) extra independent (private) sector capacity in some areas of the country. This is enabling development of ‘COVID-lite’ or ‘COVID minimal’ hubs for diagnostic procedures, including imaging, endoscopy, and low risk elective surgery. In some hospitals, mobile CT scanners are being deployed to support on-site ‘COVID-lite’ areas, maximising image acquisition capacity.
Reduced capacity has shone a light on appropriateness of imaging investigations. This has become more, not less of a problem, as remote consultations for patients in both primary as well as secondary care become the accepted default position. The relative difficulty in examining (or in some cases just seeing) a patient has meant clinicians are anecdotally more likely to request imaging as a result of a consultation. RCR has, for many years, been encouraging the NHS to deploy iRefer, a web tool, which highlights the evidence base for requesting imaging. We have, with partners, launched a clinical decision support software version of iRefer, which is inter-operable with electronic imaging order comms, enabling best use of limited resources. The RCR have also supported the national Evidence Based Interventions programme looking at, amongst other procedures, which imaging tests were of no or limited clinical utility for various clinical presentations.
Prior to the pandemic, the NHS was looking at establishing rapid diagnostic centres (RDCs). The need for ‘COVID-lite’ diagnostic spaces to maximise available capacity has shifted this toward the development of Community Diagnostic Hubs. These require extra funding in terms of buildings and equipment as well as staffing but are an attractive solution to expand capacity in a way that maximises patient safety and confidence in the COVID endemic era.
Although imaging services are working hard to regain momentum by restoring capacity and regaining patient confidence, it remains clear that fundamental changes can only be made with significant investment to address the chronic underfunding in radiologists, radiographers, and imaging equipment.
Jeanette Dickson MB ChB MRCP(UK) FRCR MSc MD
Mount Vernon Cancer Centre, UK; President, Royal College of Radiologists, UK