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Three facilities share what is working best as they begin to screen more patients.
After taking a nearly 70-percent hit to imaging volume during the COVID-19 pandemic, mammography service lines are beginning to churn toward full volume again. It is a process that will look different for each practice or facility based upon their continued local infection rates, as well as their size. But, according to industry leaders, there are a set of best practices that will help groups hit their post-COVID stride quicker.
To this point during the outbreak, the mammography landscape has looked very little like the traditional environment with all screening services halted and many appointments postponed. And, there is scant indication that the return to “normalcy” will, indeed, be a re-start of business as usual.
“During this unprecedented time, we know that nothing is as it used to be,” said Monica Saini, M.D., chief medical officer of Volpara Solutions, a breast imaging analytics company. “Facilities that have seen limited scheduling and significant drops in patient volume must now prepare for higher-than-normal volumes to resolve backlog.”
Successfully managing the imaging study surge – and processing patients safely – will require a multi-pronged plan tailored to individual needs. Fortunately, some industry leadership organizations and several groups that offer mammography services have identified tactics and steps that can put others solidly on a safe path to re-opening and recovery.
According to the U.S. Food & Drug Administration’s Division of Mammography Quality Standards data, every day of delayed mammography services has added another 100,000 studies to the imaging backlog, drastically reducing imaging volume and revenue levels. Despite these precipitous declines, however, mammography has proven to be resilient in the past few weeks.
A June 9 analysis of 20 million anonymized mammography images contained in a Volpara Solutions database showed more than three-quarters – 78 percent – of hospitals and imaging centers that provide mammography services are already operating at levels within 10 percent of their pre-COVID-19 volume. In fact, a handful are already seeing a 5-percent increase over their pre-COVID levels.
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Given this rapid rebound, the Society of Breast Imaging (SBI) has published some guidance on what mammography practices can do to streamline and safeguard their re-opening efforts. These tactics, designed to be a starting point, can maximize patient and provider safety when implemented correctly, as well as facilitate the quickest and most efficient processing of the existing backlog of imaging studies.
As facilities offering breast imaging services are creating plans to bring patients back in for screening mammography and other studies, incorporating these strategies can augment their efforts, SBI officials said.
Screening: Every patient must be screened at the point of re-scheduling their appointment. But, that alone is not enough – they must be re-screened when they arrive and prior to their entering the facility. Ask specific questions about any COVID-19 exposure or symptoms of infection, including fever, shortness of breath, cough, and fatigue. Only allow patients who do not present with symptoms and who pass the screening process to come inside.
Reduce patient density: Even though the screening process is designed to keep facilities as COVID-19-free as possible, it is critical that providers control the number of patients in their building. Practices can either reduce the number of appointments offered or spread them further apart to control the number of patients in each facility as much as possible. Once the risk of a recurrent outbreak sufficiently diminishes in a practice’s area, a return to pre-COVID-19 scheduling protocols can be considered.
Follow social distancing: The recommendations released by the Centers for Disease Control & Prevention still apply. Space any chairs in waiting rooms at least 6 feet apart, and implement other feasible modifications to minimize the risk of viral transmission between patients, as well as between patients and staff. And, streamline the registration, check-in, and check-out processes to limit interactions and the patient’s time in the office.
Monitor staff: Analyze the needs of each procedure, and limit the number of staff involved to those who are absolutely necessary. This limits exposure both for patients and staff. Also, require staff (and patients) to wear masks at all times while in the facility.
In several locations less affected by the viral outbreak, mammography practices have already opened their doors to more patients. Based on the various steps they have tried to improve patient and staff safety and more efficiently work through postponed appointments, they have identified several grass-roots best practices.
Leigh Loughran, operations manager for medical imaging, at Rome Hospital in New York, Robyn Cole, mammography supervisor for Oregon Imaging Center, and Linda Warren, M.D., clinical professor in the radiology department at the University of British Columbia in Vancouver, shared their experiences on what is working well to bring their practices back on track.
1. Contact patients personally: Turn off any automatic patient reminder systems, Loughran advised. Instead, assess each patient’s risk level, and, then, have a nurse or other staff member reach out individually to re-schedule appointments, starting with those patients who are at the greatest breast cancer risk.
2. Alter work hours: Loughran also echoed the existing advice within the industry to extend service hours later into the day or the weekend. But, she also offered an additional suggestion – schedule slightly fewer weekend appointment slots, and reserve that time for the highest-risk patients. Doing so further limits their chances of being unintentionally exposed to the virus.
3. Patient screening: Conduct two levels of screening, Warren recommended. First, ask patients questions about their symptoms and travel history on the phone during scheduling, and have a second screener at the door to check for fever and other COVID-19-related symptoms, she said. Loughran seconded this practice, particularly in the hospital setting. Staff members who serve as gatekeepers can double-check patients sent by referring physicians, adding an extra protective layer to the mammography suite and radiology department overall.
4. Patient belongings: In addition to providing gloves and a mask for patients – if they do not have their own – give them a personal belongings bag so they can carry their clothes with them throughout the mammography process. This eliminates the need to store their personal effects in a locker that could be used by multiple people. Oregon Imaging Center took this precaution a step further, Cole said. They now offer a privacy area in the exam room itself, giving the patient the opportunity to disrobe and have the exam completed without switching locations.
5. Limit visitors: Ask patients to come to their appointments alone whenever possible, Warren said. Visitors should only be allowed if they are needed for interpretive services.
6. Personal protective equipment (PPE): Because a socially distanced mammogram is not possible, all providers involved must wear sufficient PPE, Warren stressed. Reusable, washable face shields, face masks, and goggles are mandatory to limit viral spread during close contact. This can be particularly vital, she said, for screening services where the patient is prone and could expel viral particles under a provider’s face shield.
7. Install barriers: Double down on the effect of face masks and gloves by installing physical barriers between patients and staff whenever possible, Warren suggested. Her department has put these plexiglass shields in place as a separation between patients and front desk employees. The barriers do not impede conversation, and any needed paperwork can be passed across the desk under the shield. Other practices have installed plexiglass between afixed waiting room chairs, as well as on some patient exam beds.
8. Start slow: Do not re-open with the same pre-COVID-19 scanning pace, Warren advised. Take a few weeks to learn exactly how long it will take to clean equipment between patients and to get comfortable with following all the safety protocols. After mastering the new process, add in more scans. For example, she said, her technologists are currently scanning five patients hourly with the plan to add a sixth once they feel confident they can do so without any negative impacts on the quality of services provided.
9. Discuss investments: Consider making equipment changes to protect your patients long-term from a second viral wave, Loughran said. These switches, including installing self-check-in kiosks, purchasing waiting room furniture with no fabric, and installing new engineering panel controls, will likely require unforeseen monetary investments. Begin the necessary conversations with your facility’s financial leaders as soon as possible, she recommended.
Alongside all of these strategies, Loughran said, there is one practice that is key to successfully re-engaging patients and re-opening a practice -- communication. Take the time to discuss disinfection protocols with patients, staff, and other providers. Doing so will increase confidence in a facility’s ability to protect all parties involved from viral infection as best as possible.
“You can’t communicate enough. People take it for granted that their staff knows what’s going on – that the patients and the community know what’s going on,” she said. “But, the more information that you can put out there, the more cleaning you can do in front of the patient, the safer everyone, including your staff, will feel.”