1. Approach to CMR requests

• Existing CMR bookings: triage requests, perform urgent scans, defer routine scans.
• CMR in COVID-19 patients: not be performed unless absolutely clinically necessary.
• New CMR requests in non-COVID-19 patients: must involve a direct discussion between the ordering physician and a CMR physician.
• Clinically urgent CMR: the study should be focused, and use shortened protocols (check Standardized CMR Protocols, JCMR 2020) to answer the specific clinical question in order to minimize the examination time and staff contact with the patient.
• Inpatient CMR requests (any): should be reviewed by a CMR physician to assess the clinical necessity and determine whether the study can be safely deferred. Direct discussion with the ordering physician is necessary for any case potentially deferred.
• Outpatient CMR studies: urgent orders should be scheduled only after the outpatient study request has been reviewed and approved by an imaging physician.
• Cardiac MRI director and imaging physicians need to make themselves readily available for discussions with ordering physicians and institutional staff for any CMR study questions.
• If you are planning to administer contrast, check the renal function as this can be altered in COVID+ patients.

If possible, establish a COVID-19 dedicated MRI scanner for both cardiac and general radiology. Allow 70min downtime for cleaning after each examination.

2. Staffing levels and reporting

• Ensure sufficient senior physician coverage for the service and timely reporting with a minimal backlog of cases.
• Ensure senior physician back-up is available in case of personnel reallocation to other services.
• Ensure senior physician availability in case of unanticipated staff shortages.
• Consider a confidential master list of senior physician cell phone numbers.
• Fellows/trainees attendance will be decided by individual programs.
• Consider reducing physicians (senior and junior) in house and develop a team schedule that alternates staff attendance at work. (e.g. week on, week off)
• Organize remote reporting both on campus (physician offices) or at home.

3. CMR Technologist’s Roles

• 2 CMR technologists are required to scan each patient.
• 1 technologist will put on full personal protective equipment (PPE).
• Consult how “Putting on (donning) personal protective Equipment (PPE)” and check the World Health Organisation guidance on “Steps to Put on PPE”. Consult your institutional guidelines for required PPE.
• Follow Institutional Hand Hygiene policy before and after patient contact
• The technologist with PPE will go into the scan room with the patient and move the patient into the scanner alone. The second radiographer will stay in the control room to perform the scan.
• Patient identification confirmation and consent must be obtained as per your Institutional CMR Unit Policy before entering the room.
• Once the patient is ready to be scanned, staff in PPE will stand outside the main MRI doors.
• Member of staff in PPE should never enter the control room, or strictly minimize their presence (if entrance to the scanner room is from the control room).
• Once the scan is completed the radiographer in the control room communicates that over the scanner intercom, “Scan Finished”.The technologist wearing PPE can then remove the patient from the scanner and transfer to the MRI bay.
• Any urgent need for assistance will be put out over the intercom also.
• Once the patient has left the scanner the radiographer in PPE will need to sanitize the scanner and all equipment.
• Once the scanner has been sanitized, the technologist in PPE will remove it as per “Removal of (doffing) personal protective Equipment (PPE)” and the World Health Organisation guidance on “Steps to Remove PPE”, and place it in the designated bin bag found in the PPE box in the control room. Finally, they are to thoroughly wash their hands and gel with alcohol gel.

• Any member of staff who is required to enter the MRI scanning room must complete a staff safety questionnaire and ensure they are metal – free as per local rules.
• The above recommendation for Non-Ventilated Covid-1 apply with the caveat that all members of staff with the patient, including the radiographer going into the scanning room, should wear PPE.
• Once the patient has been scanned, the technologist in the control room should contact to arrange a deep clean of the scanner room. When the cleaning team arrive, the technologist should carry out the safety screening questionnaire and test all the equipment to make sure it is MRI safe.
• The scanner is not to be used until a deep clean has been undertaken.

4. Patients’ transfer

• The coordinator must confirm with CMR Unit team that the room is prepared and with the ward that the patient is ready to be transferred.
• Where tolerated, patients should wear a surgical mask to limit the spread of droplets.
• Patients should be taken directly into the examination room and must not wait in communal areas.
• During patient transfers, no individuals without PPE should come within 2 metres of the patient.

5. Post-examination

• Clean technologist should use the appropriate protocol in your Institution to decontaminate the surfaces of the equipment and surrounding environment. Follow manufacturer specific guidance on how to clean the scanner.
• Exposed technologist waits until the room is clean before removing their PPE following the correct doffing technique.
• Consult how “Removal of (doffing personal protective Equipment (PPE)” and check the World Health Organisation guidance on “Steps to Remove PPE”.
• All waste arising out of the procedure room must be treated as clinical infectious waste and disposed of in the correct waste stream (Please see your Institutional Waste policy).
• If a patient is ventilated, extubated or requiring suction during the examination the room, allow time before decontamination to allow for small aerosol particles to be cleared from the air (20-60min, depending on Institutional policy). After this interval the room can be decontaminated as normal and put back into use.

6. Monitoring

• A record will be kept of all staff in contact with a possible or confirmed case. Staff must ensure they complete the post examination page on the radiological system available with the names of all staff involved.
• Use of temporary staff for high risk patients should be avoided.
• Following laboratory diagnosis of a high-risk infection in the patient, all staff should be vigilant for any symptoms in the 14 days following their last exposure to a confirmed case.

7. Scan Interpretation

• No difference in scan interpretation or post processing between COVID-19 and non COVID-19 patients.
• Pay attention to non-cardiac findings, particularly pulmonary infiltrates, in COVID-19 patients. Suggest further evaluation with chest CT if pulmonary abnormalities present.
• Common findings in COVID-19 patients include myocarditis, pericarditis, heart failure and acute coronary syndromes.

This document was prepared with the contribution of the following colleagues (in alphabetical order): Chiara Bucciarelli-Ducci, Jennifer Bryant, James Carr, Christopher Dyke, Michael Elliott, Christopher Benjamin Lawton, Karen Ordovas, Sven Plein, Andrew Powell, Subha Raman from the SCMR Executive Committee, Technologist Section and Clinical Practice Committee.