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Paragraph: Results: From January 21, 2020 to March 9, 2020, 3,083 people suspected of or confirmed with
COVID-19 underwent fever-CT examinations. Including initial examinations and
reexaminations, the total number of fever-CT examinations numbered 3,340. As a result of our
precautions, none of the staff of the radiology department were infected with COVID-19. Conclusion: Strategic planning and adequate protections can help protect patients and staff
against a highly infectious disease while maintaining function at a high volume capacity. Keywords: Coronavirus, COVID-19, novel coronavirus pneumonia, infection control

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Introduction
The whole world has been closely focusing on an outbreak of respiratory disease caused by a
novel coronavirus that was first reported in Wuhan, China, on December 31, 2019, and that
continues to spread. On February 11, 2020, the World Health Organization (WHO) named the
disease “coronavirus disease 2019” (COVID-19). As of 24:00 on March 11, 2020, the National Health Commission (NHC) had received reports
of 80,793 confirmed cases and 3,169 deaths on the Chinese mainland. There remain 14,831
confirmed cases (including 4,257 in serious condition) and 253 suspected cases still
hospitalized. To date, 677,243 people have been identified as having had close contact with
infected patients of whom13,701 are under medical observation [1]. Outside China, 44,067
laboratory-confirmed cases and 1,440 deaths have occurred in 117 countries /territories/areas
according to the WHO [2]. COVID-19 poses significant threats to international health. Like the
flu, COVID-19 is thought to spread mainly from person-to-person between people who are in
close contact with one another through respiratory droplets produced when an infected person
coughs or sneezes. In light of the infectious nature of this disease, healthcare workers are at
high risk of infection of COVID-19. In China, healthcare workers account for 1,716 confirmed
cases of COVID-19, including six deaths [3]. Computed tomography (CT) can play a role in both diagnosing and categorizing
COVID-19 on the basis of case definitions issued by the WHO and the treatment guidelines
from the NHC [4]. Suspected patients having the virus may undergo chest CT. Isolation and
barrier procedures are necessary to protect both the department staff and other patients in the
hospital. Note should be made that due to overlap of imaging findings with other respiratory
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diseases, CT is not helpful as a screening tool. But it can help identify the degree of pulmonary
involvement and disease course. Our hospital is a national regional medical center with 4,300 beds and a tertiary referral
center in Sichuan province. The initial response started on January 21, 2020, after transmission
of COVID-19 was confirmed to be human-to-human on January 20, 2020. The first suspected
case of COVID-19 in Sichuan province was reported on January 21, 2020. The Sichuan
provincial government immediately launched the first-level response to major public health
emergencies. On the same day, our hospital was designated to care for Sichuan province
patients with COVID-19. This article describes the emergency management procedure of our radiology department
for situations involving severe infectious diseases, such as COVID-19, and the
infection-protection experience of the department staff. Methods
The hospital provided personal protective equipment (medical protective clothing,
surgical cap, N95 mask, gloves, face shields, and goggles) to all its healthcare staff, erected
three medical tents (fever tents) for screening of fever cases in the parking lot of the emergency
department, planned an examination route and examination area for patients suspected of
harboring the virus, and placed confirmed patients in an isolation ward. “Fever” was the
colloquial term used to designate suspected COVID-19 based on symptoms such as a fever or
with an epidemiological history of a potential exposure as well as those with confirmed
COVID-19 referred for treatment. Further, during outbreak, emergency and outpatient patients
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without fever were asked for information such as epidemiological history and sent to fever tents
as long as they met suspected criteria. The radiology department has 65 diagnostic radiologists and 161 other staff members
(trained technologists, nurses, engineers, and support staff). The equipment of the radiology
department includes 12 magnetic resonance (MR) scanners, 14 CT scanners, 15 digital
subtraction angiography (DSA) systems, 32 sets of digital radiography (DR) systems
(including nine mobile bedside DR sets), and 130 imaging diagnostic workstations for picture
archiving and communication systems (PACS). Most of the equipment is distributed among
four buildings at the hospital main campus. 4 CT scanners, 4 MR scanners, 1 DR are located on
the first floor of the first inpatient building, and 9 DR and 8 DSA are located on the second
floor. 1 CT and 1 MR scanner are located in the third inpatient building. 1 CT and 1 MR scanner
are located in the sixth inpatient building. 2 CT scanners, 2 MR scanners and 7 DSA are located
in the technical building. The rest of the equipment is located in the seventh inpatient building
in the branch campus. The first inpatient building, located next to the emergency department, was reconfigured to
handle cases of COVID-19. Fever tents were set up by the emergency department in the
emergency department parking lot to separate normal emergency patients from patients with
symptoms or exposure history suspicious of COVID-19. We established separate means of
access between fever tents and between the fever examination area of the radiology department
to avoid cross-contamination. The emergency management and infection control measures, as described below and
implemented in the radiology department during the outbreak, have been approved by the
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infection control committee of hospital. These measures are in accordance with relevant laws
and regulations, in order to protect patients as well as the staff. Radiology Emergency Management and Infection Control Team (EMICT)
The radiology department director chaired the EMICT. Its members include the deputy
director, chief technologist, head nurse, equipment engineer supervisor, and infection control
nurse of the radiology department. Team responsibilities included (1) coordination between the
hospital’s management and planning of infection control and radiology departments; (2)
collection of the most up-to-date protection-related information to educate and train staff in the
department; (3) reallocation of staff according to the actual situation; (4) establishment of the
CT procedures for patients with COVID-19; and (5) establishment of an emergency
management plan for the radiology department to ensure that the department would run
normally. Suspected patients
The suspected patients were identified according to the Diagnosis and Treatment Program of
the Novel Coronavirus Pneumonia of the NHC [5], mainly based on epidemiological history. Reconfiguration of the radiology department
The radiology department was divided into four areas [6]: contaminated, semicontaminated,
buffer, and clean areas  (Figure 1). The contaminated area is connected to the fever clinic and
includes the fever accessway, the CT examination room, and the DR examination room for
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confirmed and suspected cases. One CT scanner and one DR system closest to the emergency
department are designated the fever-CT and fever-DR to examine patients with suspected and
confirmed COVID-19. There is a separate dedicated access between the contaminated area and
the fever screening tents. The semicontaminated area includes the fever-CT control room,
fever-DR control room, and other patient examination access areas. The buffer zone includes
access areas for medical personnel and a dressing area for technologists. The clean area
includes the administrative office and the diagnostic room. The contaminated area was isolated from other areas using physical barricades. Directional signs were newly installed to guide patients and staff. Personal protection and training of staff
For providing care for patients with confirmed and suspected COVID-19, all hospital staff
are required to wear complete personal protective equipment [7]: medical protective clothing,
surgical cap, N95 mask, gloves, face shields, and goggles. Wearing and removing of the
equipment must be performed in accordance with the procedures and under the supervision of
the infection control nurse. Because staff members working in the contaminated area are under much situational
pressure, periodically taking time off could lower their physical and mental stress levels. The
technologists on fever-CT duty shifts are provided a break once a week for four hours. In
addition, the health of staff in the contaminated area must be monitored closely for the
symptoms of COVID-19. Pregnant staff must be assigned to the clean area. 7
The EMICT formulates and continually updates guidelines and educates all staff for West
China Hospital of Sichuan University. The EMICT training for staff is mainly involves
documents regarding infection control and CT findings of COVID-19 and maintains an EMICT
WeChat group for West China Hospital of Sichuan University. WeChat is the most widely used
social media app in China. The EMICT releases the latest national and hospital-based
information regarding COVID-19, guidance documents, and other notices from the hospital
and radiology department in the WeChat group on a daily basis. Staff can also report to the
EMICT in the WeChat group any time. Protocols for each modality and infection control
instructions are posted on the walls in all examination rooms. The EMICT periodically reminds
staff to undertake personal measures to reduce infection, such as wearing masks at all instances
in the radiology department and N95 masks if working in the contaminated area; not touching
the mask and the eyes; practicing hand hygiene; facing away from colleagues when eating,
drinking, and talking; and not using personal cell phones while on duty. In addition, the chief thoracic radiologist provided lectures on all radiologists and
technologists on typical CT findings of COVID-19 infection using materials developed in
Wuhan, the epicenter of the outbreak in China. CT examination procedures
There are two sets of procedures for CT examination: the fever-CT procedure and routine CT
procedure for those not suspected of COVID-19. The fever-CT procedure for suspected or confirmed COVID-19 (Figure 2)
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Before the fever-CT technologist operates the equipment, he or she should wear personal
protective equipment according to three-level protection standard [8]. Before the CT
examination of patients with suspected and confirmed COVID-19 begins, the fever tent or
isolation ward notifies the radiologist in advance. The fever-CT technologist checks the
equipment and prepares to disinfect the imaging equipment immediately after the examination. The patient enters the fever-CT waiting area through the fever access area. If the patient
can get onto and off the examination table by themselves, the patient is allowed to do so. If the
patient cannot get onto or off the examination table independently, the person accompanying
the patient assists the patient, rather than the technologist. The technologist checks the patient
information and, using an intercom system in the examination room, asks the patient to remove
any metal ornaments on the neck and chest. Also, by intercom, the technologist trains the
patient to hold his or her breath during the examination. The technologist uses a low-dose chest CT protocol to scan the patient. After scanning, the
original images are reconstructed as 1 mm-thick layers. The technologist browses the images to
ensure that their quality meets the diagnostic requirements and then guides the patient to leave
through the fever access area. The disposable sheets for patient examination are changed after
each patient. The equipment is disinfected according to the procedure below. To protect themselves, the technologists assigned to the fever-CT wear N95 mask and
other personal protection as established by the EMICT. The CT procedure for regular patients (figure.3)
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Some patients with COVID-19 have no symptoms, and they may call at the general clinic for
other reasons. The following CT procedure is applicable under these circumstances:
When the patient makes an appointment for examination, the staff asks the patient about
their epidemiological history, symptoms, and signs. If suspected criteria are met, the patient
will be sent to the fever tent for further screening. When a patient presents to the radiology
department entrance, his/her temperature is measured. If the temperature is higher than 37.2 , ℃
the patient is sent to the fever tent for further investigation. Those with no exposure history, suspicious symptoms or fever are screened in one of the
non-contaminated CT scanners. The technologists assigned to these scanners wear surgical
masks. All patients and the person accompanying them are required to wear surgical masks. After the CT examination, the technologist browses the images quickly. If the CT appearance is
typical of lung infection, the technologist immediately reports it to the chest radiologist on duty
and asks the patient to wait in the CT examination room. If the chest radiologist does not
suspect COVID-19 infection, the patient can leave the CT examination room. If the chest
radiologist does suspect COVID-19 infection, the technologist immediately reports it to the
EMICT and sends the patient to the fever tent. The floor and equipment in the CT examination
room are disinfected according to regulations, and air disinfection is conducted for 30 min
before examining other patients. These CT scanners are considered noncontaminated (not
fever-CTs) after these sterilization procedures. Fever-DR examination procedure
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The COVID-19 guideline of the NHC does not recommend chest DR because its ability in
diagnosing COVID-19 is limited. At our hospital, we only use mobile DR units to provide
bedside examination for critically ill patients. The technologist operating the mobile DR
wears personal protective equipment according to the three-level protection standard and
sterilizes the mobile DR according to the ward management requirements as described below. Equipment and environment disinfection procedures
Routine disinfection procedure [9]
1) Object surface disinfection: Object surface is wiped with 1000mg/L chlorine-containing
disinfectant, wipe twice with 75% ethanol for non-corrosion resistance, once /4 hours. 2) Equipment disinfection: The equipment in the contaminated area are wiped with
2000mg/L chlorine-containing disinfectant. The DR and CT gantry in the contaminated
area are wiped with 75% ethanol. The equipment in the buffer area is wiped with
500-1000mg/L chlorine-containing disinfectant or alcohol-containing disposable
disinfectant wipes twice a day. 3) Air disinfection: Turning off all central air conditioners to prevent air contamination with
each other.

Question: How were the radiology department areas divided?
contaminated, semicontaminated,
buffer, and clean areas