Endoscopy during COVID-19 pandemic requires extra safety precautions

Last Updated: 2020-04-02

By Will Boggs MD

NEW YORK (Reuters Health) - Extra safety precautions are needed to avoid the transmission of COVID-19 in the endoscopy unit, according to two new reports.

"We need to develop a strategy to prevent cross-contamination in hospital settings," Dr. Roy Soetikno of San Francisco Veterans Affairs Medical Center told Reuters Health by email. "We are not used to the stringent requirements that are necessary to avoid cross-contamination from a very contagious virus like COVID-19. However, we can get there if we work on it. We need to start thinking about how to break the cycle of contamination."

In their report, in Gastrointestinal Endoscopy, Dr. Soetikno and colleagues provide suggestions for performing endoscopy in the setting of the COVID-19 pandemic.

All endoscopic procedures should be considered aerosol-generating procedures, for which the World Health Organization has endorsed the use of personal protective equipment (PPE) for COVID-19, including a respirator, gown, gloves, eye protection and a gown. These should be strictly adopted in practice, the authors suggest.

Moreover, staff need to be reminded of the correct method of hand hygiene, and this should be complemented by compliance checks.

Patient should be screened before entering the endoscopy waiting area, and efforts should be made to keep all patients approximately six feet apart while awaiting their procedures.

There should be a separate, designated procedure and recovery room for patients with suspected or diagnosed COVID-19, and these procedures should be performed in an airborne-infection isolation room that adheres to level-3 biosafety requirements. The patients themselves should be stationed away from other patients.

Nonurgent endoscopy services should be rescheduled, the authors say, and additional screening and mitigation strategies should be undertaken in the setting of substantial community spread of COVID-19.

After the procedure, Centers for Disease Control and Prevention (CDC) cleaning and disinfection recommendations should be adopted.

The report also includes a schematic of the workflow for managing suspected or diagnosed COVID-19 patients in the endoscopy unit.

"We are very concerned that readers are so busy with their day-to-day activities that they do not have an overall strategy to win this war," Dr. Soetikno said. "To win this war, we need to prevent healthcare providers from cross-contamination to healthy patients/bringing it home to their communities. Social isolation is not enough if healthcare providers who develop COVID-19 spread it to healthy patients."

In the other report, in the Journal of Gastroenterology and Hepatology, Dr. Tiing Leong Ang of Changi Duke-NUS Academic Medical Center and Yong Loo Lin School of Medicine, National University of Singapore, addresses similar concerns.

Dr. Ang told Reuters Health by email that the most important points are: "A) the need to prioritize procedures, B) the need to risk stratify the likelihood of patients being asymptomatic carriers and hence deferring their elective nonurgent procedures until we are sure they are not infected, and C) the need to wear proper PPE during endoscopy and practice hand hygiene to avoid disease transmission."

"It is possible to perform GI endoscopy safely if appropriate measures are taken," he concluded. "We must see ourselves not just as endoscopists, but as part of the larger medical community, and we must all work together to deal with the pandemic."

Dr. Alessandro Repici of Humanitas University, in Milan, Italy, who also recently reviewed what the endoscopy department should know about COVID-19, told Reuters Health by email, "I would like to reinforce the concept that removing the PPE must follow a specific protocol that everybody has to know and to respect. This is a time/condition where the hospital personnel may risk to get infected."

The CDC protocol is available at https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf.

"It's not a single measure that works but just a combination of different preventive measures (sometimes very easy like washing hands, proper use of gloves and gowns) that provides the highest level of protection," said Dr. Repici, who is not connected to the new reports.

He added, "It's important to establish a help-line (phone/email) for the patients. This allows us to keep taking care of them, not giving the feeling of being left behind, but is also helpful to triage patients the day before endoscopy and making sure they are not developing symptoms suggestive of viral infection."

SOURCE: https://bit.ly/3aAPMiN Gastrointestinal Endoscopy, online March 27, 2020; and https://bit.ly/2WYLgXd Journal of Gastroenterology and Hepatology, online March 26, 2020.