INFORMATION STATEMENT Guidance and best practices for reestablishment of non-emergent care in nuclear cardiology laboratories during the coronavirus disease 2019 (COVID-19) pandemic: An information statement from ASNC, IAEA, and SNMMI Endorsed by the Infectious Diseases Society of America Hicham Skali,a,b Venkatesh L. Murthy,c Diana Paez,d Elisa M. Choi,e Felix Y. J. Keng,f McGhie A. Iain,g Mouaz Al-Mallah,h Roxana Campisi,i Timothy M. Bateman,g Ignasi Carrio,j Rob Beanlands,k Dennis A. Calnon,l Vasken Dilsizian,m Maurizio Dondi,d Alessia Gimelli,n Robert Pagnanelli,o Donna M. Polk,b Prem Soman,p Andrew J. Einstein,q Sharmila Dorbala,a,b and Randall C. Thompsong a Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA b Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA c Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI d Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria e Atrius Health, Somerville, MA f National Heart Centre, Singapore, Singapore g Saint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO h Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX i Departments of Nuclear Medicine and Cardiovascular Imaging, Diagnostico Maipu, Depart- ment of Nuclear Medicine, Instituto Argentino de Diagnostico y Tratamiento, Buenos Aires, Argentina j Universitat Autonoma de Barcelona, Barcelona, Spain k Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada l OhioHealth Heart and Vascular Physicians, Columbus, OH m Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD n Fondazione Toscana Gabriele Monasterio, Pisa, Italy o Department of Radiology, Duke University Health System, Durham, NC p Division of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA Electronic supplementary material The online version of this Reprint requests: Randall C. Thompson, St. Luke’s Mid America Heart article (https://doi.org/10.1007/s12350-020-02203-3) contains sup- Institute, 4330 Wornall Rd, Suite 2000, Kansas City, MO 64111; plementary material, which is available to authorized users. rthompson@saint-lukes.org This article is being jointly published in The Journal of Nuclear J Nucl Cardiol Medicine (https://doi.org/10.2967/jnumed.120.251355) and the 1071-3581/$34.00 Journal of Nuclear Cardiology (https://doi.org/10.1007/s12350-020- Copyright  2020 Society of Nuclear Medicine & Molecular Imaging 02203-3). and the American Society of Nuclear Cardiology. Skali et al Journal of Nuclear Cardiology Guidance and best practices for reestablishment of non-emergent care in nuclear cardiology q Department of Medicine, Cardiology Division, and Department of Radiology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY Received May 14, 2020; accepted May 14, 2020 doi:10.1007/s12350-020-02203-3 INTRODUCTION 3. In general, we recommend that utilization of nuclear cardiology services parallel opening The Coronavirus Disease 2019 (COVID-19) pan- of upstream and downstream resources such demic is affecting healthcare systems and resources as clinics, catheterization laboratories, oper- around the world in an unprecedented manner. Based on ating rooms and other services, so as to recommendations from the numerous medical specialty facilitate uniform care delivery. societies and governmental agencies such as the United States Centers for Disease Control and Prevention1 and B. COVID-19 testing: Centers for Medicare & Medicaid Services2, non-urgent The diagnosis of COVID-19 is based on the detection procedures and tests were either canceled or postponed and identification of the virus by means of the reverse during the buildup to and decline from the pandemic’s transcription polymerase chain reaction (RT-PCR), a peak. The American Society of Nuclear Cardiology molecular diagnostic technique based on the detection of (ASNC) and the Society of Nuclear Medicine and specific genetic sequences of the virus. Antibody tests Molecular Imaging (SNMMI) issued an Information detect immunoglobulin antibodies from an immune Statement3 with guidance for nuclear cardiology labo- response to SARS-CoV-2 and are not appropriate for ratories during the COVID-19 pandemic in late March diagnosing current COVID-19 infection. Laboratories 2020 that also recommended delaying all non-urgent should rely on molecular tests to diagnose the presence studies. Reestablishment of non-emergent care4 in of SARS-CoV-2 infections. However, a negative molec- nuclear cardiology laboratories will require a careful ular test result does not rule out COVID-19 for several approach to continue to mitigate the risk of viral reasons. Some patients may have negative initial tests due transmission while also providing crucial cardiovascular to low viral load during the early days of infection or assessments for our patients. The current document inadequate sampling of the posterior nasopharynx. Thus, prepared by ASNC, SNMMI, the International Atomic social distancing and PPE are critical to prevention of Energy Agency (IAEA) and the Infectious Disease laboratory transmission of COVID-19. When testing Society of America (ISDA) describes potential practices capacity allows, using a molecular test to test for for this reestablishment, reflecting diverse settings from COVID-19 infection prior to appointments in the nuclear the United States and worldwide. cardiology laboratory is recommended combined with It is important to note that these recommendations screening patients for a fever and symptoms consistent are primarily based on expert opinion, not systematically with COVID-19 infection upon arrival for testing appoint- tested, and may provide guidance to supplement guide- ments. Patients who are known to have an active infection lines, regulations and legislation as well as institutional with the COVID-19 virus should in the vast majority of infection control policies.2 A survey of the authors’ cases have their nuclear cardiology test deferred. opinions regarding several issues outlined this document is available in the online supplement. C. Preventive Measures for COVID-19 Disease: The implementation of preventive and mitigation GENERAL PRINCIPLES measures is essential. The most effective preventive A. Timing of re-opening/resuming activities in measures include performance of proper hand hygiene; stress/nuclear cardiology laboratory: avoidance of touching eyes, nose and mouth; practice respiratory hygiene when coughing or sneezing; wearing 1. Timing should follow national, state and a medical mask and maintenance of physical distancing local regulations and recommendations.4–6 (ideally 2 meters or more).8,9 2. Healthcare facilities should have adequate equipment and personnel and not be in crisis D. Personal Protective Equipment (PPE): management mode or diversion mode. For The goal of PPE use is to protect healthcare inpatient laboratories, there should be available providers and patients and predominantly to minimize hospital beds and intensive care unit beds. spread from asymptomatic individuals and surface Journal of Nuclear Cardiology Skali et al Guidance and best practices for reestablishment of non-emergent care in nuclear cardiology exposure.10 Healthcare workers require additional pre- have recently extended the time period before expi- cautions to protect themselves and prevent transmission ration during the pandemic. in the healthcare environment. Precautions include • Case prioritization can be performed primarily by wearing proper PPE and donning and doffing items laboratory professionals but is most commonly properly. Recommendations for PPE use vary by insti- decided collectively and in collaboration with other tution, region and country and the type of PPE colleagues from cardiology, surgery, and other recommended will usually be based on institutional or disciplines. regional policies. Currently most healthcare centers in • Early during the COVID-19 pandemic, many facili- the United States require universal use of a surgical ties prioritized patients being scheduled and those mask by staff and visitors with selective use of more already scheduled according to the perceived clinical advanced PPEs. As nuclear cardiology and other labo- urgency of the study. Please see an example of a ratories re-expand their operations, a sufficient and prioritization scheme using four categories in increasing quantity of PPE will be required for protec- Table 1. Some laboratories use a 3-category tion for healthcare personnel and patients. PPE use is scheme instead.3 currently recommended throughout the nuclear labora- tory when indicated; this use should follow national, state/regional, and local public health policies and 2. Scheduling a patient: recommendations. Scheduling of patients should take into account a number of parameters including institutional and labo- SPECIFIC PRINCIPLES FOR NUCLEAR ratory resources for safe performance of testing during CARDIOLOGY the COVID-19 pandemic. A. Before the test: • Institutional policies: When increasing patient volume 1. Prioritization of a study request: through the nuclear cardiology laboratory, it is also important that this be coordinated with the affiliated As we move into the next phase of the COVID-19 institution to ensure that service delivery is consistent pandemic, in which newly diagnosed cases have with their overarching plan during the pandemic. declined in many regions, regulations are permitting flexibility and allow facilities to reinstate services for • Staff: Availability of laboratory staff is an equally important consideration, especially if many have been patients needing non-emergent non-COVID-19 care. redeployed, furloughed or become ill as a result of the Urgent patients should continue to be tested first and as pandemic. quickly as prudently possible while ensuring patient and healthcare provider safety. It is important to remember • Operating hours: As utilization increases, laboratories should consider extending to early/late hours and/or that many of the patients with higher priorities are weekend testing to allow the backlog of patient tests typically symptomatic whose risk of a cardiac event is to be completed and to allow more effective social not insignificant. distancing. This approach should be balanced with • For patients of equal urgency, those who have been availability of staff and key equipment, especially waiting the longest for their procedure should be the PPE. first to be undergo testing. • Phased opening: A phased opening with a ramp up • Many patients have had testing delayed for several period is generally recommended by health agencies2. weeks during the period of sheltering in place; it is For example, 25% of a standard case load might be important for the provider team to maintain contact planned for the first 1-2 weeks, 50% case load in with patients and to encourage them to report changes weeks 3 and 4, and then greater caseloads if in symptoms. conditions permit. Concomitant overlapping cases • Due to the delay in testing, extra caution needs to be should be avoided to provide for appropriate social exercised by clinical staff, including supervising distancing. physicians, as the patient’s clinical status may have • Adequacy of supplies: To reestablish operations it is deteriorated to the point where stress testing may no necessary to ensure the availability of radioisotopes longer be safe or appropriate. which are produced in a limited number of facilities • For some patients requiring prior approval from the worldwide. One of the effects of the pandemic has insurance carrier, the approval may have expired and been the disruption of distribution channels, including need to be reinstated. However, some Radiology international cargo flights. In addition, many radio- Benefit Management companies in the United States pharmacies have either furloughed or laid off staff Skali et al Journal of Nuclear Cardiology Guidance and best practices for reestablishment of non-emergent care in nuclear cardiology Table 1. An example of a prioritization scheme Urgent inpatient or outpatient (to be performed upon request): Inpatient or outpatient with a clinical scenario suggesting a moderate to high likelihood of short-term major adverse cardiac events, in whom the results of testing would have high likelihood of modifying management Higher priority (deferred for 1-2 months): Inpatient or outpatient who meets AUC criteria for testing, but with a clinical scenario suggesting a low likelihood for short-term major adverse cardiac events Lower priority (deferred for 2-4 months): Outpatient, who meets AUC criteria for testing, and who is clinically stable, expected to have normal or low-risk findings that would not be expected to effect short-term management. Some examples are pre-operative testing for elective surgery; surveillance testing such as in asymptomatic patients with prior history of PCI or CABG, a patient already on class 1C antiarrhythmic, a patient post cardiac transplant; asymptomatic patient with an elevated coronary artery calcium score Elective (deferred for 4-6 months): Screening or wellness tests such as coronary artery calcium scans and treadmill exercise tests because of reduced demand over the period of during the stress test to minimize COVID-19 exposure sheltering in place during the pandemic. risk as outlined below. An important principle is to • Resources: In addition, the laboratory needs to ensure minimize the amount of time spent by patients in the that they have adequate resources to safely perform nuclear cardiology laboratory or at the associated testing, keeping in mind that the demand for certain institution to reduce risk both for patients and staff. equipment will grow as other healthcare providers ramp up deferred services. 1. Arrival/Registration: • Communication/Patient concerns: A significant pro- A key goal is to avoid overcrowding of the portion of patients may decline testing because of elevators, waiting rooms, corridors, and scanners while concerns about the risk of contracting COVID-19 by not delaying patient care. The test procedures need to visiting the testing facility. Institutions must provide allow for adequate social distancing between patients referring physicians detailed information about steps before and during the whole testing process. taken by the laboratory to minimize the risk of COVID-19 infection. Referring providers must • Appropriate physical distancing should be maintained remind patients about the real and significant risk of at all stages of patient engagement, including regis- not undergoing testing. Staff scheduling patients tration, waiting areas, and consent. Waiting areas and should have scripting available to screen patients for processes should be arranged to allow appropriate symptoms consistent with COVID-19 to reassure physical distancing. In addition, accompanying visi- patients, including a description of the additional tors and family members should not be allowed or precautions that are being undertaken by the labora- should be limited to one person and only if their tory to minimize COVID-19 infection risk. If a presence is essential. If the facility has significant patient refuses to undergo testing it is of the utmost space constraints, consideration should be to having importance for the nuclear cardiology laboratory to patients wait in their vehicles until contacted by cell- inform the referring physician to let them know of the phone by a member of the nuclear cardiology patient’s decision so that they can contact the patient laboratory staff. The patient would then be met at to discuss this further and make alternate the entrance of the facility by the staff member and arrangements. escorted to the laboratory. • Tracking: Establishment of proper systems to track • The use of telehealth to assess patients for new canceled or postponed studies is very important. symptoms, to register the patient, to provide them Providers should establish a priority score that can with details about the test to be performed, and to include indication for testing and overall CV risk, and obtain verbal consent is generally recommended. COVID-19 risk. Processes should also be automated as much as possible to reduce face to face interaction. Some on- B. Day of testing: site administrative steps can be performed through the Specific precautions are recommended on the day of patient’s smartphone. The healthcare screening ques- the test at the time of arrival, during the imaging test and tionnaire should be thorough. Journal of Nuclear Cardiology Skali et al Guidance and best practices for reestablishment of non-emergent care in nuclear cardiology • Temperature measurements and a screening question- and stress sessions and the camera needing clean- naire for all patients are generally recommended at ing multiple times. A low-dose rest, high-dose arrival to healthcare facility and to nuclear laboratory. stress protocol may enable a more rapid single- • Face covering or Masks are currently mandated at session imaging. most medical centers (surgical/cloth/specific mask b. Imaging time slots may need to be expanded and type as determined by local rules and infection extra time should be allowed for cleaning rooms, control) for all patients, visitors, and healthcare cameras, chairs, and other surfaces between patients. personnel. c. Appropriate cleaning of equipment between cases is • Review indication for testing at registration or essential. immediately upon a patient’s arrival in clinical areas d. For outpatients requiring rest imaging, consideration to ensure that the test is still indicated and urgent. could also be given to performing this on a separate Changes in symptoms and/or health status may either day to give greater control of workflow and minimize render the test not indicated or demand a different time within the department, although this approach test. may be less appropriate in some settings and needs to be balanced by the downside of using more PPE for 2-day imaging. 2. Imaging considerations: e. For laboratories with access to myocardial perfusion The overarching goals are to perform rapid and PET using Rb82, this modality is preferred because hygienic imaging to minimize COVID-19 exposure to of its time efficiency. A complete rest-stress PET healthcare professionals and patients. MPI study can be acquired within 30 to 45 minutes, not only minimizing exposure for patients and staff, a. Protocol selection but also potentially reducing number of rooms and • For SPECT myocardial perfusion imaging studies, spaces which could experience surface contamination elect stress first/stress only imaging when possible and possibly reducing staffing needs. to potentially decrease duration of the study, and f. For patients tested with SPECT-CT or PET-CT consider rapid acquisition protocols when feasible. instrumentation in regions with higher prevalence of • For SPECT myocardial perfusion imaging studies COVID-19 infections, some laboratories recommend in inpatients who are not eligible for stress only a policy of reviewing the chest CT images before the testing, consider performing the rest injection in patient leaves the laboratory. For patients who have the patient’s inpatient room, to avoid completely lung infiltrates seen on chest CT images, they may or minimize waiting time in the laboratory. A require further evaluation for possible COVID-19 typical protocol would begin with a technologist infection.12 bringing a dose of technetium-99m sestamibi or 3. Stress laboratory considerations: tetrofosmin to the patient’s inpatient room, check- ing the intravenous line, and injecting the dose. The goals are to perform a safe test for the patient After a suitable delay, the patient is transported to and minimize droplet exposure to healthcare profes- the laboratory, directly to a waiting open camera, sionals and patients. where rest imaging is performed. After an appro- • If possible, consider pharmacologic testing priate delay, when the patient waits in their preferably using vasodilator stress agents to hospital room, he or she is brought to an open decrease droplet exposure risk,9 especially in stress room where stress testing is performed. patients who are not known to be COVID-19 After stress testing, the patient is transported back negative. Patients breathing heavily during exer- to their room, and returns to a waiting open camera cise may generate droplets and traditionally stress approximately 1-1.5 hours after stress injection. test personnel are in close proximity to patients. • For technetium-99m pyrophosphate (PYP) scans in Pharmacologic testing is not inferior to exercise inpatients, consider injecting the patient and testing in terms of diagnostic performance. allowing him/her to leave the laboratory, returning Regadenoson may be the preferred stress agent for imaging after the laboratory protocol delay. (if available and not contraindicated), since it • For N-13 ammonia PET myocardial perfusion requires a single 10 second infusion, after which imaging studies, consider performing a protocol providers can maintain a safe distance from the facilitating a single rest/stress session on the patient. For adenosine and dipyridamole stress camera with enhanced social distancing, and avoid testing, extra-long tubing can be used to keep the patient leaving the camera room between rest distance between staff and patients. Skali et al Journal of Nuclear Cardiology Guidance and best practices for reestablishment of non-emergent care in nuclear cardiology • If after careful consideration, exercise testing is of operation will depend of the availability of determined to be necessary, it is recommended to laboratory personnel, PPE, and COVID-19 testing. use a higher- level PPE for staff (for example N95/ D. Tracking of total time required for nuclear cardiol- FFP2/P2/DS/KN95/Korea 1st class respirator or ogy procedures is desirable. This includes time equivalent, face shield, gloves and gown) and surgical required to fully clean and disinfect the stress testing mask or face covering for patients, assuming these equipment and the imaging equipment. This infor- supplies are available,11 and extra time should be mation will inform patient scheduling templates. allowed in order to clean the room. • Appropriate cleaning between patients is required. SAFETY AND RISK FOR POTENTIAL SECOND OR SUBSEQUENT WAVES ONGOING CONSIDERATIONS FOR THE LABORATORY While one cannot predict the potential for a second or subsequent waves of COVID-19 pandemic, numerous An important goal of an ongoing monitoring pro- public health authorities are warning that it is possible, cess is to refine policies and procedures as needed in and procedures need to be in place to mitigate the response to the evolution of the COVID-19 pandemic as adverse effects of a second wave. Hence, it is important the laboratory operations resume to include more elec- to follow the steps below: tive procedures. • Providers and institutions should monitor local data A. Additional data collection and monitoring may be and follow national, state, and department of public warranted. The nuclear cardiology laboratory’s pro- health recommendations for possible second COVD- tocols and patient scheduling templates will need to 19 waves that may require decreasing nuclear cardi- be closely monitored and refined multiple times over ology laboratory activities and enhanced protective the coming months as the COVID-19 pandemic measures. slowly recedes, with potential for local or wide- • Physical distancing and masking should be main- spread waves of new COVID-19 infections. Data tained for the foreseeable future. collection and monitoring will be necessary to • Limitations on visitors and accompanying persons inform the need to modify existing laboratory should be continued for the foreseeable future as well. policies. Some suggested parameters for collecting and monitoring and potential responsive changes to laboratory workflow are listed in Table 2. NUCLEAR CARDIOLOGY TRAINING B. Availability of laboratory personnel might be AND EDUCATION impacted by redeployment to other work responsi- bilities in the healthcare system during the COVID- Trainees are an important part of nuclear cardiology 19 pandemic, staff quarantine to home due to programs and laboratories. During the COVID-19 pan- COVID-19 infection of the staff or their close demic, many trainees have been redeployed from their contacts, and other non-COVID-19 related issues. imaging rotations to clinical care of COVID-19 patients C. Laboratory testing hours should be adjusted as in the hospital and intensive care units. If the pandemic needed. continues, trainee education needs to be revised to use novel training methods including web and video-based • Expansion of testing might need to be suspended approaches to learning. New educational procedures completely if essential laboratory personnel are need to be consistent with policies from stakeholders unavailable. Similarly, if the supply of PPE or such as the Accreditation Council for Graduate Medical COVID-19 testing is interrupted, test scheduling Education, American Board of Internal Medicine, would need to be reduced to allow for adequate American Board of Nuclear Medicine, American Board supply of PPE and COVID-19 testing for other of Radiology, and Nuclear Regulatory Commission. patient care areas of higher priority. This is particularly pertinent for hands-on education in • If, however, there is a large backlog of orders for the stress laboratory, hot laboratory, and radiopharmacy, nuclear cardiology procedures as a result of which may need to be adapted to video methods. The deferred testing during the height of the COVID- number of cases required for graduation may need to 19 pandemic, laboratories might need to consider include a larger percentage of virtual educational ses- temporarily extending weekday hours of operation sions, in compliance/collaboration with certifying or weekend testing to accommodate a surge in agencies including the Certification Board of Nuclear patient volume. The feasibility of extending hours Journal of Nuclear Cardiology Skali et al Guidance and best practices for reestablishment of non-emergent care in nuclear cardiology Table 2. Workflow parameters to monitor in the nuclear cardiology laboratory Parameter for monitoring Impact on laboratory policies Decreased laboratory personnel availability Reduce hours of operation Decreased availability of PPE and COVID-19 testing Reduce hours of operation Increased test duration (including cleaning) Adjust the patient scheduling template Increased or pending orders for cardiac imaging procedures Increase hours of operation Cardiology, American Board of Internal Medicine, the in various locations and will change in the coming American Board of Nuclear Medicine, and the American months. An individualized, adaptable, and thoughtful Board or Radiology. approach that coordinates with other providers and public health authorities will be needed for the foresee- able future. ADDITIONAL CONSIDERATIONS • Staff should be monitored for wellbeing during these Disclosures sometimes-stressful times, especially if required to work long hours and if they are redeployed to Dr. Bateman: Activities related to the present article: No unfamiliar areas. relevant relationships. Activities not related to the present article: Research Grants: Bracco, GE Healthcare, Jubilant • In the United States, nuclear cardiology services are DraxImage. Consultant: AIM, AstraZeneca, Curium, GEHC. often impacted by the details of the patient’s health Royalties: SPECT and PET software products. Ownership insurance policy and enforcement by radiology ben- interest: CVIT. Dr. Beanlands: Activities related to the present efits managers. More advocacy effort will be required article: No relevant relationships. Activities not related to the to convince these oversight agencies to allow relax- present article: Grants/Honoraria from Jubilant DraxImage, ation of previous policies on prior authorization and LMI, GE Healthcare. Dr. Dorbala: Activities related to the flexibility for longer approval windows and to resist present article: No relevant relationships. Activities not one-size-fits all prescribed approaches. related to the present article: Grants and Honoraria from • Laboratory leadership should consider redeployment Pfizer and GE Healthcare. Institution has grants/grants of physician and nursing staff away from routine pending from National Institutes of Health and International (elective) office activities until backlog has been Atomic Energy Agency. Dr. Einstein: Activities related to the present article: No relevant relationships. Activities not reduced, especially for higher priority patients. This related to the present article: Consultant for GE Healthcare approach will help get the higher risk patients whose and W. L. Gore and Associates; institution has grants/grants tests have been deferred completed, while not adding pending from National Institutes of Health, International more and more higher priority patients to the Atomic Energy Agency, Canon Medical Systems, Roche schedule. Medical Systems, and W. L. Gore and Associates; received • Nuclear cardiology laboratory operations, of course, travel/accommodations/meeting expenses unrelated to are part of the local healthcare systems and work in activities listed from HeartFlow. Dr. Murthy: Activities conjunction with other departments in the hospital related to the present article: No relevant relationships. and areas of the medical practice. Most of the Activities not related to the present article: Owns stock in suggestions outlined above must be instituted in General Electric and Cardinal Health and stock options in concert and collaboration with other key departments. Ionetix. He has served as a paid advisor to Ionetix and Covidien. He has received research grants from Siemens and non-financial research support from INVIA Medical Imaging Solutions. He has received payment on behalf of Jubilant CONCLUSIONS Draximage for expert witness testimony. Dr. Soman: Activities The unprecedented COVID-19 pandemic has dis- related to the present article: No relevant relationships. rupted healthcare systems, including nuclear cardiology Activities not related to the present article: Serves on the advisory board of Alnylam Pharmaceuticals and is the laboratories around the world, severely reducing their principal investigator of a grant from Astellas services. As the health crisis recedes, nuclear cardiology Pharmaceuticals to the University of Pittsburgh. The laboratories are able to gradually expand operations remaining authors have no relevant relationships. while maintaining appropriate safe practices. This doc- ument lays out guidance about best practices, but it is important to recognize that conditions are quite different Skali et al Journal of Nuclear Cardiology Guidance and best practices for reestablishment of non-emergent care in nuclear cardiology References nt/covid-flexibility-reopen-essential-non-covid-services.pdf. Accessed April 30, 2020. 1. Center for Disease Control and Prevention. Healthcare facilities: 7. COVID-19 testing by laboratories: Q and A. https://www.cdc.g preparing for community transmission. https://www.cdc.gov/coro ov/coronavirus/2019-ncov/lab/testing-laboratories.html. Accessed navirus/2019-ncov/hcp/guidance-hcf.html. Accessed April 30, May 2, 2020. 2020. 8. 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