CONTINUING EDUCATION Reprinted from The Journal of Nuclear Medicine 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 Hicham Skalia,b, Venkatesh L. Murthyc, Diana Paezd, Elisa M. Choie, Felix Y. J. Kengf, McGhie A. Iaing, Mouaz Al-Mallahh, Roxana Campisii, Timothy M. Batemang, Ignasi Carrioj, Rob Beanlandsk, Dennis A. Calnonl, Vasken Dilsizianm, Maurizio Dondid, Alessia Gimellin, Robert Pagnanellio, Donna M. Polkb, Prem Somanp, Andrew J. Einsteinq, Sharmila Dorbalaa,b, and Randall C. Thompsong aDivision of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; bCardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; cFrankel Cardiovascular Center, University of Michigan, Ann Arbor, MI; dNuclear Medicine and Diagnostic Imaging Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria; eAtrius Health, Somerville, MA; fNational Heart Centre, Singapore, Singapore; gSaint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO; hHouston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX; iDepartments of Nuclear Medicine and Cardiovascular Imaging, Diagnostico Maipu, Department of Nuclear Medicine, Instituto Argentino de Diagnostico y Tratamiento, Buenos Aires, Argentina; jUniversitat Autonoma de Barcelona, Barcelona, Spain; kDivision of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada; lOhioHealth Heart and Vascular Physicians, Columbus, OH; mDepartment of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD; nFondazione Toscana Gabriele Monasterio, Pisa, Italy; oDepartment of Radiology, Duke University Health System, Durham, NC; pDivision of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA; and qDepartment of Medicine, Cardiology Division, and Department of Radiology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY CE credit: For CE credit, you can access the test for this article, as well as additional JNMT CE tests, online at https://www.snmmilearningcenter.org. Complete the test online no later than March 2024. Your online test will be scored immediately. You may make 3 attempts to pass the test and must answer 80% of the questions correctly to receive 1.0 CEH (Continuing Education Hour) credit. SNMMI members will have their CEH credit added to their VOICE transcript automatically; nonmembers will be able to print out a CE certificate upon successfully completing the test. The online test is free to SNMMI members; nonmembers must pay $15.00 by credit card when logging onto the website to take the test. INTRODUCTION an Information Statement3 with guidance for nuclear cardiology labo- ratories during the COVID-19 pandemic in late March 2020 that also The Coronavirus Disease 2019 (COVID-19) pandemic is affecting recommended delaying all non-urgent studies. Reestablishment of non- healthcare systems and resources around the world in an unprecedented emergent care4 in nuclear cardiology laboratories will require a careful manner. Based on recommendations from the numerous medical approach to continue to mitigate the risk of viral transmission while specialty societies and governmental agencies such as the United States also providing crucial cardiovascular assessments for our patients. Centers for Disease Control and Prevention1 and Centers for Medicare The current document prepared by ASNC, SNMMI, the International & Medicaid Services2, non-urgent procedures and tests were either can- Atomic Energy Agency (IAEA) and the Infectious Disease Society of celed or postponed during the buildup to and decline from the pandemic’s America (ISDA) describes potential practices for this reestablishment, peak. The American Society of Nuclear Cardiology (ASNC) and the reflecting diverse settings from the United States and worldwide. Society of Nuclear Medicine and Molecular Imaging (SNMMI) issued It is important to note that these recommendations are primarily based on expert opinion, not systematically tested, and may provide guidance to Received Jul. 6, 2020; accepted Jul. 6, 2020. supplement guidelines, regulations and legislation as well as institutional Reprints requests: Randall C. Thompson, St. Luke’s Mid America Heart Institute, infection control policies.2 A survey of the authors’ opinions regarding 4330 Wornall Rd, Suite 2000, Kansas City, MO 64111; rthompson@saint-lukes.org several issues outlined in this document is available in the online supple- Published online Jul. 24, 2020. This article was originally jointly published in The Journal of Nuclear ment (supplemental materials are available at http://jnm.snmjournals.org). Medicine (https://doi.org/10.2967/jnumed.120.251355) and the Journal of Nuclear Cardiology (https://doi.org/10.1007/s12350-020-02203-3). GENERAL PRINCIPLES Immediate Open Access: Creative Commons Attribution 4.0 International License (CC BY) allows users to share and adapt with attribution, excluding A. Timing of Re-Opening/Resuming Activities in materials credited to previous publications. License: https://creativecommons. Stress/Nuclear Cardiology Laboratory: org/licenses/by/4.0/. Details: https://tech.snmjournals.org/content/permissions. COPYRIGHT © 2021 Society of Nuclear Medicine & Molecular Imaging and the American Society of Nuclear Cardiology. 1. Timing should follow national, state and local regulations and DOI: 10.2967/jnumed.120.251355 recommendations.4–6 GUIDANCE AND BEST PRACTICES FOR COVID-19 • Skali et al. 13 2. Healthcare facilities should have adequate equipment and per- cases have declined in many regions, regulations are permitting sonnel and not be in crisis management mode or diversion flexibility and allow facilities to reinstate services for patients mode. For inpatient laboratories, there should be available hos- needing non-emergent non-COVID-19 care. Urgent patients should pital beds and intensive care unit beds. continue to be tested first and as quickly as prudently possible 3. In general, we recommend that utilization of nuclear cardiology while ensuring patient and healthcare provider safety. It is services parallel opening of upstream and downstream resources important to remember that many of the patients with higher such as clinics, catheterization laboratories, operating rooms and priorities are typically symptomatic whose risk of a cardiac event other services, so as to facilitate uniform care delivery. is not insignificant. B. COVID-19 Testing: • For patients of equal urgency, those who have been waiting The diagnosis of COVID-19 is based on the detection and iden- the longest for their procedure should be the first to undergo tification of the virus by means of the reverse transcription poly- testing. merase chain reaction (RT-PCR), a molecular diagnostic technique • Many patients have had testing delayed for several weeks based on the detection of specific genetic sequences of the virus. during the period of sheltering in place; it is important for Antibody tests detect immunoglobulin antibodies from an immune the provider team to maintain contact with patients and to response to SARS-CoV-2 and are not appropriate for diagnosing encourage them to report changes in symptoms. current COVID-19 infection. Laboratories should rely on molec- • Due to the delay in testing, extra caution needs to be exer- ular tests to diagnose the presence of SARS-CoV-2 infections. cised by clinical staff, including supervising physicians, as However, a negative molecular test result does not rule out COVID- the patient’s clinical status may have deteriorated to the point 19 for several reasons. Some patients may have negative initial tests where stress testing may no longer be safe or appropriate. due to low viral load during the early days of infection or inadequate • For some patients requiring prior approval from the insurance sampling of the posterior nasopharynx. Thus, social distancing and carrier, the approval may have expired and need to be re- PPE are critical to prevention of laboratory transmission of COVID- instated. However, some Radiology Benefit Management 19. When testing capacity allows, using a molecular test to test for companies in the United States have recently extended the COVID-19 infection prior to appointments in the nuclear cardiology time period before expiration during the pandemic. laboratory is recommended combined with screening patients for a • Case prioritization can be performed primarily by laboratory fever and symptoms consistent with COVID-19 infection upon professionals but is most commonly decided collectively and arrival for testing appointments. Patients who are known to have an in collaboration with other colleagues from cardiology, sur- active infection with the COVID-19 virus should in the vast gery, and other disciplines. majority of cases have their nuclear cardiology test deferred. • Early during the COVID-19 pandemic, many facilities prior- itized patients being scheduled and those already scheduled C. Preventive Measures for COVID-19 Disease: according to the perceived clinical urgency of the study. Please The implementation of preventive and mitigation measures is see an example of a prioritization scheme using four categories essential. The most effective preventive measures include perfor- in Table 1. Some laboratories use a 3-category scheme instead.3 mance of proper hand hygiene; avoidance of touching eyes, nose and mouth; practice respiratory hygiene when coughing or 2. Scheduling a Patient: Scheduling of patients should take into sneezing; wearing a medical mask and maintenance of physical account a number of parameters including institutional and labo- distancing (ideally 2 meters or more).8,9 ratory resources for safe performance of testing during the COVID-19 pandemic. D. Personal Protective Equipment (PPE): • Institutional policies: When increasing patient volume through The goal of PPE use is to protect healthcare providers and patients the nuclear cardiology laboratory, it is also important that this and predominantly to minimize spread from asymptomatic individ- be coordinated with the affiliated institution to ensure that uals and surface exposure.10 Healthcare workers require additional service delivery is consistent with their overarching plan during precautions to protect themselves and prevent transmission in the healthcare environment. Precautions include wearing proper PPE the pandemic. and donning and doffing items properly. Recommendations for PPE • Staff: Availability of laboratory staff is an equally important use vary by institution, region and country and the type of PPE rec- consideration, especially if many have been redeployed, fur- ommended will usually be based on institutional or regional policies. loughed or become ill as a result of the pandemic. Currently most healthcare centers in the United States require uni- • Operating hours: As utilization increases, laboratories should versal use of a surgical mask by staff and visitors with selective use of consider extending to early/late hours and/or weekend testing more advanced PPEs. As nuclear cardiology and other laboratories to allow the backlog of patient tests to be completed and to re-expand their operations, a sufficient and increasing quantity of PPE allow more effective social distancing. This approach should will be required for protection for healthcare personnel and patients. be balanced with availability of staff and key equipment, espe- PPE use is currently recommended throughout the nuclear laboratory cially PPE. when indicated; this use should follow national, state/regional, and • Phased opening: A phased opening with a ramp up period is local public health policies and recommendations. generally recommended by health agencies2. For example, 25% of a standard case load might be planned for the first 1–2 weeks, 50% case load in weeks 3 and 4, and then greater SPECIFIC PRINCIPLES FOR NUCLEAR CARDIOLOGY caseloads if conditions permit. Concomitant overlapping cases A. Before the Test: should be avoided to provide for appropriate social distancing. 1. Prioritization of a Study Request: As we move into the next • Adequacy of supplies: To reestablish operations it is neces- phase of the COVID-19 pandemic, in which newly diagnosed sary to ensure the availability of radioisotopes which are 14 JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 49 • No. 1 • March 2021 TABLE 1 important principle is to minimize the amount of time spent by An Example of a Prioritization Scheme patients in the nuclear cardiology laboratory or at the associated institution to reduce risk both for patients and staff. Urgent inpatient or outpatient (to be performed upon 1. Arrival/Registration: A key goal is to avoid overcrowding of request): Inpatient or outpatient with a clinical scenario the elevators, waiting rooms, corridors, and scanners while not suggesting a moderate to high likelihood of short-term major adverse cardiac events, in whom the results of delaying patient care. The test procedures need to allow for adequate testing would have high likelihood of modifying social distancing between patients before and during the whole management testing process. Higher priority (deferred for 1–2 months): Inpatient or • Appropriate physical distancing should be maintained at all outpatient who meets AUC criteria for testing, but with a stages of patient engagement, including registration, waiting clinical scenario suggesting a low likelihood for short-term areas, and consent. Waiting areas and processes should be major adverse cardiac events arranged to allow appropriate physical distancing. In addi- Lower priority (deferred for 2–4 months): Outpatient, who tion, accompanying visitors and family members should not meets AUC criteria for testing, and who is clinically stable, expected to have normal or low-risk findings that would be allowed or should be limited to one person and only if not be expected to affect short-term management. Some their presence is essential. If the facility has significant space examples are pre-operative testing for elective surgery; constraints, consideration should be to having patients wait in surveillance testing such as in asymptomatic patients with their vehicles until contacted by cellphone by a member of prior history of PCI or CABG, a patient already on class the nuclear cardiology laboratory staff. The patient would 1C antiarrhythmic, a patient post cardiac transplant; then be met at the entrance of the facility by the staff member asymptomatic patient with an elevated coronary artery and escorted to the laboratory. calcium score • The use of telehealth to assess patients for new symptoms, to Elective (deferred for 4–6 months): Screening or wellness register the patient, to provide them with details about the test tests such as coronary artery calcium scans and treadmill to be performed, and to obtain verbal consent is generally exercise tests recommended. Processes should also be automated as much as possible to reduce face to face interaction. Some onsite produced in a limited number of facilities worldwide. One of administrative steps can be performed through the patient’s the effects of the pandemic has been the disruption of distri- smartphone. The healthcare screening questionnaire should bution channels, including international cargo flights. In addi- be thorough. tion, many radiopharmacies have either furloughed or laid off • Temperature measurements and a screening questionnaire for staff because of reduced demand over the period of sheltering all patients are generally recommended at arrival to health- in place during the pandemic. care facility and to nuclear laboratory. • Resources: In addition, the laboratory needs to ensure that • Face covering or masks are currently mandated at most med- they have adequate resources to safely perform testing, keep- ical centers (surgical/cloth/specific mask type as determined ing in mind that the demand for certain equipment will grow by local rules and infection control) for all patients, visitors, as other healthcare providers ramp up deferred services. and healthcare personnel. • Communication/patient concerns: A significant proportion of • Review indication for testing at registration or immediately patients may decline testing because of concerns about the upon a patient’s arrival in clinical areas to ensure that the test risk of contracting COVID-19 by visiting the testing facility. is still indicated and urgent. Changes in symptoms and/or Institutions must provide referring physicians detailed infor- health status may either render the test not indicated or de- mation about steps taken by the laboratory to minimize the mand a different test. risk of COVID-19 infection. Referring providers must remind patients about the real and significant risk of not undergoing 2. Imaging Considerations: The overarching goals are to per- testing. Staff scheduling patients should have scripting available form rapid and hygienic imaging to minimize COVID-19 expo- to screen patients for symptoms consistent with COVID-19 to sure to healthcare professionals and patients. reassure patients, including a description of the additional pre- a. Protocol selection cautions that are being undertaken by the laboratory to mini- mize COVID-19 infection risk. If a patient refuses to undergo • For SPECT myocardial perfusion imaging studies, elect testing it is of the utmost importance for the nuclear cardiology stress first/stress only imaging when possible to potentially laboratory to inform the referring physician to let them know of decrease duration of the study, and consider rapid acquisition the patient’s decision so that they can contact the patient to protocols when feasible. discuss this further and make alternate arrangements. • For SPECT myocardial perfusion imaging studies in inpa- • Tracking: Establishment of proper systems to track canceled tients who are not eligible for stress only testing, consider or postponed studies is very important. Providers should es- performing the rest injection in the patient’s inpatient room, tablish a priority score that can include indication for testing to avoid completely or minimize waiting time in the labora- and overall CV risk, and COVID-19 risk. tory. A typical protocol would begin with a technologist bringing a dose of technetium-99m sestamibi or tetrofosmin B. Day of Testing: to the patient’s inpatient room, checking the intravenous line, Specific precautions are recommended on the day of the test at and injecting the dose. After a suitable delay, the patient is the time of arrival, during the imaging test and during the stress transported to the laboratory, directly to a waiting open cam- test to minimize COVID-19 exposure risk as outlined below. An era, where rest imaging is performed. After an appropriate GUIDANCE AND BEST PRACTICES FOR COVID-19 • Skali et al. 15 delay, when the patient waits in their hospital room, he or she proximity to patients. Pharmacologic testing is not inferior to is brought to an open stress room where stress testing is exercise testing in terms of diagnostic performance. Regadeno- performed. After stress testing, the patient is transported back son may be the preferred stress agent (if available and not con- to their room, and returns to a waiting open camera approxi- traindicated), since it requires a single 10 second infusion, after mately 1–1.5 hours after stress injection. which providers can maintain a safe distance from the patient. • For technetium-99m pyrophosphate (PYP) scans in inpa- For adenosine and dipyridamole stress testing, extra-long tubing tients, consider injecting the patient and allowing him/her can be used to keep distance between staff and patients. to leave the laboratory, returning for imaging after the labo- • If after careful consideration, exercise testing is determined ratory protocol delay. to be necessary, it is recommended to use a higher-level PPE • For N-13 ammonia PET myocardial perfusion imaging stud- for staff (for example N95/FFP2/P2/DS/KN95/Korea 1st class ies, consider performing a protocol facilitating a single rest/ respirator or equivalent, face shield, gloves and gown) and stress session on the camera with enhanced social distancing, surgical mask or face covering for patients, assuming these and avoid the patient leaving the camera room between rest supplies are available,11 and extra time should be allowed in and stress sessions and the camera needing cleaning multiple order to clean the room. times. A low-dose rest, high-dose stress protocol may enable • Appropriate cleaning between patients is required. a more rapid single-session imaging. b. Imaging time slots may need to be expanded and extra time ONGOING CONSIDERATIONS FOR THE LABORATORY should be allowed for cleaning rooms, cameras, chairs, and other surfaces between patients. An important goal of an ongoing monitoring process is to refine c. Appropriate cleaning of equipment between cases is essential. policies and procedures as needed in response to the evolution of d. For outpatients requiring rest imaging, consideration could the COVID-19 pandemic as the laboratory operations resume to also be given to performing this on a separate day to give include more elective procedures. greater control of workflow and minimize time within the A. Additional data collection and monitoring may be warranted. department, although this approach may be less appropriate The nuclear cardiology laboratory’s protocols and patient in some settings and needs to be balanced by the downside of scheduling templates will need to be closely monitored and using more PPE for 2-day imaging. refined multiple times over the coming months as the COVID- e. For laboratories with access to myocardial perfusion PET 19 pandemic slowly recedes, with potential for local or wide- using Rb82, this modality is preferred because of its time spread waves of new COVID-19 infections. Data collection and efficiency. A complete rest-stress PET MPI study can be monitoring will be necessary to inform the need to modify acquired within 30 to 45 minutes, not only minimizing ex- existing laboratory policies. Some suggested parameters for posure for patients and staff, but also potentially reducing collecting and monitoring and potential responsive changes to number of rooms and spaces which could experience surface laboratory workflow are listed in Table 2. contamination and possibly reducing staffing needs. B. Availability of laboratory personnel might be impacted by f. For patients tested with SPECT-CT or PET-CT instrumenta- redeployment to other work responsibilities in the healthcare tion in regions with higher prevalence of COVID-19 infec- system during the COVID-19 pandemic, staff quarantine to tions, some laboratories recommend a policy of reviewing home due to COVID-19 infection of the staff or their close the chest CT images before the patient leaves the laboratory. contacts, and other non-COVID-19 related issues. For patients who have lung infiltrates seen on chest CT C. Laboratory testing hours should be adjusted as needed. images, they may require further evaluation for possible COVID-19 infection.12 • Expansion of testing might need to be suspended completely if essential laboratory personnel are unavailable. Similarly, if 3. Stress Laboratory Considerations: The goals are to perform the supply of PPE or COVID-19 testing is interrupted, test a safe test for the patient and minimize droplet exposure to scheduling would need to be reduced to allow for adequate healthcare professionals and patients. supply of PPE and COVID-19 testing for other patient care • If possible, consider pharmacologic testing preferably using areas of higher priority. vasodilator stress agents to decrease droplet exposure risk,9 • If, however, there is a large backlog of orders for nuclear especially in patients who are not known to be COVID-19 cardiology procedures as a result of deferred testing during negative. Patients breathing heavily during exercise may gener- the height of the COVID-19 pandemic, laboratories might ate droplets and traditionally stress test personnel are in close need to consider temporarily extending weekday hours of 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 16 JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 49 • No. 1 • March 2021 operation or weekend testing to accommodate a surge in authorization and flexibility for longer approval windows patient volume. The feasibility of extending hours of op- and to resist one-size-fits-all prescribed approaches. eration will depend of the availability of laboratory person- • Laboratory leadership should consider redeployment of phy- nel, PPE, and COVID-19 testing. sician and nursing staff away from routine (elective) office D. Tracking of total time required for nuclear cardiology activities until backlog has been reduced, especially for procedures is desirable. This includes time required to higher priority patients. This approach will help get the fully clean and disinfect the stress testing equipment higher risk patients whose tests have been deferred com- and the imaging equipment. This information will in- pleted, while not adding more and more higher priority pa- form patient scheduling templates. tients to the schedule. • Nuclear cardiology laboratory operations, of course, are part SAFETY AND RISK FOR POTENTIAL SECOND OR of the local healthcare systems and work in conjunction SUBSEQUENT WAVES with other departments in the hospital and areas of the medical practice. Most of the suggestions outlined above While one cannot predict the potential for a second or subse- must be instituted in concert and collaboration with other quent waves of COVID-19 pandemic, numerous public health key departments. authorities are warning that it is possible, and procedures need to be in place to mitigate the adverse effects of a second wave. CONCLUSIONS Hence, it is important to follow the steps below: The unprecedented COVID-19 pandemic has disrupted health- • Providers and institutions should monitor local data and fol- care systems, including nuclear cardiology laboratories around the low national, state, and department of public health recom- world, severely reducing their services. As the health crisis recedes, mendations for possible second COVID-19 waves that may nuclear cardiology laboratories are able to gradually expand opera- require decreasing nuclear cardiology laboratory activities tions while maintaining appropriate safe practices. This document and enhanced protective measures. lays out guidance about best practices, but it is important to recognize • Physical distancing and masking should be maintained for the that conditions are quite different in various locations and will change foreseeable future. in the coming months. An individualized, adaptable, and thoughtful • Limitations on visitors and accompanying persons should be approach that coordinates with other providers and public health continued for the foreseeable future as well. authorities will be needed for the foreseeable future. NUCLEAR CARDIOLOGY TRAINING AND EDUCATION DISCLOSURES Trainees are an important part of nuclear cardiology programs and Dr. Bateman: Activities related to the present article: No laboratories. During the COVID-19 pandemic, many trainees have relevant relationships. Activities not related to the present article: been redeployed from their imaging rotations to clinical care of Research Grants: Bracco, GE Healthcare, Jubilant DraxImage. COVID-19 patients in the hospital and intensive care units. If the Consultant: AIM, AstraZeneca, Curium, GEHC. Royalties: pandemic continues, trainee education needs to be revised to use SPECT and PET software products. Ownership interest: CVIT. novel training methods including web and video-based approaches Dr. Beanlands: Activities related to the present article: No relevant relationships. Activities not related to the present article: Grants/ to learning. New educational procedures need to be consistent with Honoraria from Jubilant DraxImage, LMI, GE Healthcare. Dr. policies from stakeholders such as the Accreditation Council for Dorbala: Activities related to the present article: No relevant Graduate Medical Education, American Board of Internal Medicine, relationships. Activities not related to the present article: Grants American Board of Nuclear Medicine, American Board of Radiol- and Honoraria from Pfizer and GE Healthcare. Institution has ogy, and Nuclear Regulatory Commission. This is particularly grants/grants pending from National Institutes of Health and pertinent for hands-on education in the stress laboratory, hot International Atomic Energy Agency. Dr. Einstein: Activities laboratory, and radiopharmacy, which may need to be adapted to related to the present article: No relevant relationships. Activities video methods. The number of cases required for graduation may not related to the present article: Consultant for GE Healthcare need to include a larger percentage of virtual educational sessions, in and W. L. Gore and Associates; institution has grants/grants compliance/collaboration with certifying agencies including the pending from National Institutes of Health, International Atomic Certification Board of Nuclear Cardiology, American Board of Energy Agency, Canon Medical Systems, Roche Medical Sys- Internal Medicine, the American Board of Nuclear Medicine, and tems, and W. L. Gore and Associates; received travel/accommo- the American Board or Radiology. dations/meeting expenses unrelated to activities listed from HeartFlow. Dr. Murthy: Activities related to the present article: ADDITIONAL CONSIDERATIONS No relevant relationships. Activities not related to the present article: Owns stock in General Electric and Cardinal Health and • Staff should be monitored for wellbeing during these some- stock options in Ionetix. He has served as a paid advisor to Ionetix times-stressful times, especially if required to work long hours and Covidien. He has received research grants from Siemens and and if they are redeployed to unfamiliar areas. non-financial research support from INVIA Medical Imaging • In the United States, nuclear cardiology services are often Solutions. He has received payment on behalf of Jubilant Drax- impacted by the details of the patient’s health insurance pol- image for expert witness testimony. Dr. Soman: Activities related icy and enforcement by radiology benefits managers. More to the present article: No relevant relationships. Activities not advocacy effort will be required to convince these oversight related to the present article: Serves on the advisory board of agencies to allow relaxation of previous policies on prior Alnylam Pharmaceuticals and is the principal investigator of a GUIDANCE AND BEST PRACTICES FOR COVID-19 • Skali et al. 17 grant from Astellas Pharmaceuticals to the University of Pitts- 6. Center for Medicare and Medicaid Services. Opening Up America Again. Cen- burgh. The remaining authors have no relevant relationships. ters for Medicare & Medicaid Services (CMS) recommendations: re-opening facilities to provide non-emergent non-COVID-19 healthcare: Phase I. https:// www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services. pdf. Accessed April 30, 2020. REFERENCES 7. COVID-19 testing by laboratories: Q and A. https://www.cdc.gov/coronavirus/ 1. Center for Disease Control and Prevention. Healthcare facilities: preparing for 2019-ncov/lab/testing-laboratories.html. 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