ACEP COVID-19 Field Guide

Author: ACEP Emergency Ultrasound Section

The ACEP Emergency Ultrasound Section wishes to provide guidance for cleaning and disinfection of ultrasound equipment in the context of the COVID-19 pandemic (Figure 9.4). Special guidance regarding COVID-19 includes the following:

• Remove all nonessential equipment prior to entering the room of a suspected COVID-19 patient. 

This prevents unnecessary items from contamination by droplets and may include removal of nonessential transducers or extraneous items (eg, peripheral IV cannulas, plastic film dressing, bags holding towels). 

• Clinicians should follow optimal hand hygiene by washing their hands between patients and wearing single-use gloves. 

We recommend that, before cleaning, clinicians remove gel and debris, and then use one of the EPA recommended products in between each patient encounter to disinfect the probe.¹ Clinicians may find it advantageous to use a double-glove technique to help avoid cross-contamination from bare hands during the cleaning process.

• When scanning patients who are at low risk for COVID-19 or are not on droplet precautions, we recommend disinfecting the probe and surfaces that were touched during the examination (eg, screen, keyboard, cable). 

Due to the recent knowledge that SARS-CoV-2, the causative agent of COVID-19, can be present on surfaces for days, we recommend disinfecting surfaces that either come into contact with the patient (eg, cable, transducer) or are touched by the clinician (eg, keyboard, screen, handlebar).² We recommend that clinicians remove gel and debris, and then use one of the EPA recommended products in between each patient encounter.^1,3

• In situations where aerosolization or high-risk procedures can occur, probes and machines should be covered, if possible, and disinfected with low-level disinfection (LLD) after every use. 

We recognize that many clinicians will not have access to transparent covers for ultrasound systems. In such cases, the entire ultrasound system and frequently touched surfaces should be disinfected with LLD solution between each patient.⁴

When performing an ultrasound examination in critically ill patients requiring active resuscitation where aerosolization is a risk (eg, intubation, medication nebulization, chest compressions, noninvasive ventilation), the machine and its components should be protected as much as possible.^1,5 This includes use of probe covers (sterile and nonsterile) and may involve draping material, such as translucent bags. These covers should be discarded prior to exiting the patient’s room, taking care to avoid cross-contamination, in keeping with local infection control recommendations. 

• High-level disinfection (HLD) is not required when using ultrasound probes on intact skin. 

Refer to the current ACEP “Guideline for Ultrasound Transducer Cleaning and Disinfection” to determine when to use HLD.³ There is no evidence that HLD is beneficial for disinfection from SARS-CoV-2. 

For ultrasound use during procedures such as peripheral or central venous access, a sterile probe cover should be used, followed by LLD in accordance with the ACEP “Guideline for Ultrasound Transducer Cleaning and Disinfection.”

• Handheld devices may be covered with device covers for both the touchscreen and the probe with its cord. All items should be cleaned with LLD after use on each patient.
  
  
• Innovative cleaning solutions should be discussed with local infection control and the vendors supplying the machine. 

The stocking of different solutions and products varies across the country, and some systems are facing shortages of certain products. We recommend that, in conjunction with infection control, physicians and health systems consider common disinfectants for cleaning, if there are no alternatives to commercial health care products. Examples include soap and water, diluted bleach, and ammonium chloride derivatives. This should be discussed with the vendor to prevent inadvertent destruction of machine elements.

Figure 9.4 Cleaning and disinfection of ultrasound equipment during the COVID-19 pandemic.

References

1. Environmental Protection Agency. List N: disinfectants for use against SARS-CoV-2. EPA website. Accessed 2020 Mar 24.
2. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 [published online ahead of print, 2020 Mar 17]. N Engl J Med. 2020;10.1056/NEJMc2004973. doi:10.1056/NEJMc2004973
3. Guideline for ultrasound transducer cleaning and disinfection. Ann Emerg Med. 2018;72(4):e45-e47. doi:10.1016/j.annemergmed.2018.07.035
4. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. CDC website. Accessed 2020 Mar 24.
5. Tellier R, Li Y, Cowling BJ, Tang JW. Recognition of aerosol transmission of infectious agents: a commentary. BMC Infect Dis. 2019;19(1):101. Published 2019 Jan 31. doi:10.1186/s12879-019-3707-y

Additional readings

• FUJIFILM Sonosite. Infection control resources: for the preparation of the 2019 coronavirus disease (COVID-19) North American market. Sonosite website. Accessed 2020 Apr 4.
• Maintenance. In: Butterfly iQ User Manual. Accessed 2020 Apr 4.