In early spring 2020, as the COVID-19 pandemic descended, it seemed as if the entire world was consumed by questions. In radiology at The Johns Hopkins Hospital, the department’s frontline technologists and nurses faced many challenges, both expected and unforeseen.

“There was just a lot of anxiety for patients, faculty and staff,” says Pamela Johnson, professor, vice chair of quality and safety and vice president of care transformation. Starting from the earliest days of the crisis, Johnson led a team of technologists, nurses and scheduling staff members charged with navigating ambulatory, Emergency Department and hospital imaging, with no historical precedent to guide them. She was later joined by faculty members Jenny Hoang, Linda Chu, Aylin Tekes and Haris Sair.

The need for care redesign quickly become apparent. Imaging was a mandatory service. The department could not put its work on hold, but neither could it downplay the pandemic’s severity. In those early days of COVID-19, as telemedicine became commonplace for other specializations, radiology remained an in-person endeavor, and chest X-rays became a critical tool for diagnosing patients with COVID-19 who had respiratory symptoms. In the ambulatory setting, this required rapid implementation of dedicated imaging suites where radiology technologists could safely perform imaging on an outpatient who had any of the symptoms of COVID-19 infection.

All the while, radiology’s numerous other patients, many with serious non-COVID-19-related conditions — cancers, high-risk pregnancies, strokes — all continued to flow through. Every one of those patients was like an incoming flight circling in the skies above a busy airport and in need of guidance on where, when and how to land safely. In fact, air traffic control is the analogy the team members used to refer to the ad hoc system of protocols and procedures they would develop over the ensuing weeks and months. Instead of air traffic control, however, they dubbed their system Care Traffic Control.

In the beginning, there were many open, fraught questions to grapple with, recalls Hoang. Hoang and Johnson immediately began an imaging decision tree — a flowchart of relevant questions and responses, though the tree of today bears little resemblance to the one sketched out in those early days. “Rules from the hospital epidemiology team were changing by the week,” Hoang recalls. “We kept adapting through it all.”

With an airborne infectious disease, there was no room for error. Every question had to be asked of every patient. Every rule had to be followed. Every step in the process had to be taken. The protocols did not govern just patient flow but also the donning and doffing procedures for personal protective equipment, as well as equipment cleaning and disinfection measures.

Radiology Care Traffic Control even remade physical spaces. Johnson says the fluoroscopy suite had to be redesigned to accommodate the personal protective equipment requirements involved with treating COVID-19-recovering patients in the ICU who needed swallowing studies after a protracted period on a ventilator. Frontline staff members had to have access to the necessary equipment, which demanded storage, distribution and disposal areas, but this also begot designated areas for staff members to don and doff new gear for every patient.

Over the subsequent months, as the world’s understanding of the disease evolved, Care Traffic Control evolved throughout the health system as well. Early on, the roundabout in front of The Johns Hopkins Hospital’s iconic dome became a drive-through COVID-19 testing center for ambulatory patients, complete with tents and temporary facilities that would make a mobile Army surgical hospital proud.

“No one has used that circle for years, but the hospital turned it into a testing center. We even put an X-ray unit in one of those tents for Emergency Department patients,” Johnson says.

While the precision safety protocols and high-stakes consequences are fitting of real air traffic control centers, there is one key area where the radiology experience diverges from the analogy. While air traffic controllers rely on radar, GPS, closed-circuit radio and any number of sophisticated operational systems to guide each plane home, there were no such tools for radiology. The Care Traffic Control team updated its ever-evolving flowchart on a laptop. Patient orders were communicated and tracked by a simple email form that populated a spreadsheet to make sure that all cases were resolved expeditiously, Johnson says.

The department’s quality lead, Vince Blasko, a former technologist, set up the email forms. Nurses from each Johns Hopkins imaging site would email the CT, MRI or ultrasound team, which enabled the radiologist on the service to review the patient’s electronic record, contact their physician and report disposition to the nurse and technologist on the front line and the scheduling team. Johnson personally handled countless such cases for the first month. After months in operation, Johnson says, it became a well-oiled machine.

“If they didn’t hear back right away, they’d call my cell,” she remembers of the urgency of the most difficult of days. To date, the team has navigated more than 700 potentially infected outpatients who needed a radiology test, with same-day imaging in many cases.

Early in the process, the Care Traffic Control proved itself up to the ultimate challenge. A patient with no apparent COVID-19 symptoms would come in for imaging for another condition — cancer surveillance, perhaps — and the radiologist would spy the distinctive appearance of COVID-19 in the scans. The disease is unmistakable to the trained eye.

“They would have full-blown COVID-19 in the lungs — asymptomatic outpatients,” Johnson remembers. “The first time we saw it, we were at a loss for how to navigate this new twist.” The asymptomatic challenge led to a whole new set of protocols.

“Those were crazy days. Everybody was learning and teaching and sharing together,” Johnson says. “I can tell you I think Care Traffic Control was a critical resource to protect our frontline staff and patients from this deadly disease. It was a real testament to the importance of a strong interdisciplinary team.”