Director of cardiac imaging shares his experience with using handheld ultrasound to monitor COVID-19 patients.
Heart disease has been the leading cause of death of both men and women in the United States, accounting for approximately one in every four deaths. Now, in a world that is facing a global pandemic with unknown implications, there’s a new risk factor related to the heart: COVID-19
Patients with underlying heart disease or diabetes are at higher risk of severe illness for COVID-19. If they get the virus, these patients require additional heart exams. However, recent research has also suggested that the virus, and some of the medications being tested to help treat it, can cause heart implications in COVID-19 patients, even those with no pre-existing heart conditions.
Because of this, echocardiography, ultrasound of the heart, which can be performed at the bedside, has become a key tool for clinicians when treating and monitoring COVID-19 patients. Ultrasound helps healthcare providers by quickly gathering information on a patient’s heart condition in a consistent, repeatable way. It has proven useful as it is easy to clean and transport in and out of the small, crowded rooms.
With the cardiac implications of COVID-19 coming to the forefront, GE Healthcare interviewed sonographer Bill Shirkey, Director of Cardiac Imaging at Naples Community Hospital System in Florida, to learn more about the use of ultrasound for monitoring COVID-19 patients with cardiac complications and his experience during the pandemic.
How has COVID-19 impacted the facilities that you oversee?
Bill Shirkey: Our operation has three outpatient offices, two office labs (one adult and pediatric). For the outpatient facility, we’ve condensed all testing down to one site and eliminated all non-essential or emergent studies. On the inpatient side, we basically have established a new “echo triage” if you will, to help in determining what type of studies someone needs. With all of our studies, whether they be full, limited or point-of-care, staff are focused on patient care and quality results.
We have also stopped doing studies in the lab, except negative patients. We do all other studies portably. We have sequestered our equipment down to one room, excluding the machine for negative patients. The equipment is designated for what the patient status is. Some equipment does [COVID-19] negative people, some equipment does COVID-19 positive only, etc. And then I have the handheld units that we use for point of care echos, which is for anybody that gets an echo order that is not negative or does not have specific indications such as aortic stenosis, CHF, pulmonary hypertension/pulmonary embolism. We consider patients may be positive unless they’ve been tested with a negative result. We go through the orders every morning. We point the study to certain directions. So, it would either be point-of-care handheld study, a point-of-care study with a very limited Doppler, a limited study, or a full study.
Can you tell us about the “echo triage” process you and your team have developed?
Bill Shirkey: The whole point of it is to limit time in the room. Particularly with patients, we don’t know what their status is. They are pending, called a PUI (person under investigation), or COVID-positive patients. The whole point is to limit our time in the room. That’s why we really put into place the handhelds. Because there’s a certain number of patients that come in that really don’t have any cardiac history or they’ve had previous studies that are normal studies for the most part. Or they are coming in with certain indications: chest pain, palpitations, abnormal EKG, shortness of breath, syncope. We feel that those patients are okay to get a handheld study.
What we do is, we do that study and upload it quickly to have a cardiologist take a quick look at it to make sure that there’s no other further information needed. Because we are in full gear usually, while we are doing the handheld studies, it is markedly easier to do the study with the handheld device. PPE is quite hot and uncomfortable, and it does affect your ability to concentrate well. With the portable exam, and COVID-19 portables, we feel the time to move furniture, position patient, full-size machine boot-up time, and sanitize equipment is very time consuming and exhausting. Oftentimes full-size equipment is not going to give you much more clinically than you could get from a handheld in certain situations. That does not apply to situations where Doppler is imperative, like aortic stenosis.
So, should I do a point-of-care study with a handheld and I come across something like aortic stenosis, I call down to my team while I’m in the gear in the room, and I have them bring up a certain piece of equipment for me to use so I can do the Doppler interrogation. Basically, I finish my study on the point of care, and they hand off the machine to me if I need it, which at this point, that’s only happened 10% of the time. Then I do the specific-focus Doppler interrogation. I’m not doing a full scan again; it’s just because that system does not have Doppler at this point. Then I just bring that system in, so we don’t have to expend more PPE. That’s just how we do it.
We have someone also--a technologist that works in the office here--who is the communication link between the cardiologist and the technologist, if need be. They would let the cardiologist down here know that, “Hey, there was a point-of-care study done by the handheld unit, can you take a look and see if you need any further information?”
With that system [Vscan Extend], I’m in the room 10 minutes max. With the other system, if I had to boot it up, boot it down, clean it all (because we do a clean in the room and a clean out of the room) you’re talking extensive time, like over an hour.
What were you looking for when you put a probe on a cardiac COVID patient?
Bill Shirkey: We are going to be looking for is left ventricular size and function, because myocarditis is a common issue with COVID-19. Then we look at all the valves with color and we are also looking for any kind of effusions, paracardial diffusion.
Describe how you’re using the Vscan Extend™ to evaluate COVID-19 patients.
Bill Shirkey: It provides a good mechanism, particularly for COVID-19 positive patients. I don’t really think on most of these patients, you need to bring in a full-blown unit and do a full Doppler evaluation on patients that are in a critical situation from Covid-19. They usually need to know function or effusion. The whole point is to limit the time in the room. We already know that viral load is an important aspect as to why people do not do well. Anything to lessen the amount time in the room and exposure to viral load is something a system should take a hard look at doing. We have been fortunate to have planning time to implement the Vscan Extend unit as one of our imaging tools.
Do you think using handheld ultrasound makes it easier on the patients?
Bill Shirkey: I do feel it’s easier on the patient. Definitely, it means less time being scanned. They may not perceive it, but I think it’s easier because it’s easier on the technologist. Whenever you make it easier on the person performing it, you make it easier on the person receiving it.
How will you apply these learnings beyond COVID-19?
Bill Shirkey: COVID-19’s going to be here for a while, so in the future, I see this as how we would probably get a lot of observation patients out of the system or discharged more efficiently. Staff could go down to an observation unit in the morning and all the observation patients with the point of care. If doctors feel they need further imaging that’s imperative, they could schedule them as an outpatient and then discharge the patient or we could simply follow up with focused imaging while admitted. I’ve also talked to cardiologists about working with them. If they had any imaging need while they are consulting a patient, we could easily go in with a handheld and do a point of care echo right then and there. It would only take 5 minutes or so. It does open you up a lot more ability to get a look quickly and then determine where you want to go from there.