key: cord-308100-tvk47fd7 authors: Soetikno, Roy; Teoh, Anthony YB.; Kaltenbach, Tonya; Lau, James YW.; Asokkumar, Ravishankar; Cabral-Prodigalidad, Patricia; Shergill, Amandeep title: Considerations in performing endoscopy during the COVID-19 pandemic date: 2020-03-27 journal: Gastrointest Endosc DOI: 10.1016/j.gie.2020.03.3758 sha: doc_id: 308100 cord_uid: tvk47fd7 nan Based on experiences and the literature, our objective is to provide practical suggestions for performing endoscopy in the setting of COVID-19 pandemic. SARS-CoV-2/Novel Coronavirus-19 has become a global pandemic. Human-to-human transmission occurs through respiratory secretions, aerosols, feces, and contaminated environmental surfaces. 1, 2 Transmission can occur in both symptomatic and asymptomatic individuals. 3 Viable virus particles can be detected in aerosols up to 3 hours after aerosolization and up to 3 days on surfaces. 4 A recent publication suggests that undocumented infections were the source of a substantial majority of documented cases. 5 The risk of infection to healthcare workers is significant: in one of the earliest documentations of infection in Wuhan, 29% of patients (40 out of 138) were healthcare workers. 6 It is unknown how much of the risk was related to the direct care of infected patients or to the inadequate use of personal protective equipment (PPE). When performing endoscopy, it seems inevitable that healthcare providers (HCP) will be exposed to either respiratory or gastrointestinal fluids from patients. Thus, adequate protection of HCP is now critical. The World Endoscopy Organization has recently released a recommendation on infection prevention and control in digestive endoscopy based on experiences from China. 7 Similarly, an Italian group has provided recommendations regarding the performance of endoscopy during the COVID -19 outbreak. 8 Based on their experiences with a similar coronavirus, which caused SARS 17 years ago, Hong Kong adopted measures similar to those aforementioned immediately upon the first news of COVID-19 outbreak in late January. 9 With numbers of COVID-19 cases continuing to rise in North America and Europe, we aim to provide practical suggestions to potentially avoid the transmissions of COVID-19 in the endoscopy unit. The virus characteristics and its transmission make endoscopy a potential route for infection. Possible routes of SARS-CoV-2 transmission include (1) person-to-person, (2) respiratory droplets, (3) aerosols generated during endoscopy, and (4) contact with contaminated surroundings and body fluids. 1,10 Additional care must be instituted when handling blood samples or specimens because the virus has been detected in the blood of COVID-19 patients. Lei Pan et al 10 demonstrated that 48.5% of the patients presented with GI symptoms, including anorexia (83.8%), diarrhea (29.3%), and vomiting (0.8%), with the severity increasing as the disease progressed. With the detection of the virus in the feces, the Centers for Disease Control and Prevention (CDC) has suggested the use of separate bathrooms in cases of suspected COVID- 19. 11 In line with these recommendations, extensive precautions need to be adopted to avoid potential oral-fecal transmission. Importantly, staff with a travel history to COVID-19-affected areas or a history of exposure to COVID-19-affected individuals should first self-quarantine for 14 days, to eliminate risk of transmission. Is endoscopy an aerosol-generating procedure? All endoscopic procedures should be considered aerosol-generating procedures (AGP). Coughing and retching can occur during upper endoscopy, generating aerosols. Likewise, patients undergoing colonoscopy may pass flatus, which is also known to disseminate bacteria to nearby surroundings. 12 A prospective study has demonstrated unrecognized endoscopist exposure to infectious particles during GI procedures. 13 Recently, the World Health Organization (WHO) has published an extensive guideline on the rational use of personal protective equipment (PPE) for COVID-19 and provided specific instructions for healthcare workers performing AGP on patients with COVID-19. 14 These include the use of a respirator (N95, FFP2 standard, or equivalent), gown, gloves, eye protection, and apron although aprons are not usually not used in the United States. Their use should be immediately and strictly adopted in practice, if at all possible. 13 Patient-contaminated fluids often splatter when inserting or removing an accessory from the endoscope's working channel, adjusting the air/water button, retrieving tissue from a biopsy bottle, and while performing precleaning. Patients' saliva can contaminate the pillow or the bed, and stool mixed with water often drips to the bed during colonoscopy. Extensive environmental contamination can occur even from patients with mild COVID-19 upper respiratory symptoms. Ong and colleagues 15 The goal is to attain zero percent infection rates among HCP while providing essential services to patients. For the GI community, the key element will be to prevent exposure during any endoscopic procedure. As the outbreaks continue to occur, masks and personal protective equipment (PPE) may become scarce in quantity. An early inventory of what is available to the institute is essential to formulate a plan for PPE usage. Conservation of PPE is important and should be planned. Management 1. Prepare. Plan. Test. Practice. Repeat. Ready the team. Being well prepared is the best we can do to reach our zero-contamination goal. 2. Staff management is an integral part of performing endoscopy during the COVID pandemic. 3. Establishment of a rapid response communication channel using smart phone apps, email, and video conferences to distribute information across the entire unit. to stay updated on the development of the infection and discuss a unified plan. 1. Ensure performance of fit testing for N95 respiratory masks for all HCP. During the course of the outbreak, some masks may run out of stock and HCP will need to plan for alternatives. Protection, however, may be achievable even without N95 through the use of medical masks. 17 Note that as an AGP, endoscopy of PUI/COVID patients requires the use of respiratory protection. The powered air purifying respirator (PAPR) is a desirable alternative that does not require fit testing and can be used by employees with facial hair who would otherwise not achieve a good seal with the N95. Most units, however, are not stocked to have an adequate supply of PAPR. 5. Familiarize staff with the correct method of hand hygiene. An excellent review has been published. 18 Compliance with correct hand hygiene practices is low; thus, a practice, review, and compliance check is necessary. 6. Follow the WHO recommendations for PPE (Table 1 ). 14 Familiarize staff with the correct sequence of gowning up (donning) and down (doffing) through teaching videos and diagrams (Table 1) 19 . Note that there is poor correlation between selfperceived proficiency in PPE use and its appropriate use. 17 Repetitive training and demonstrated competency are necessary. Use a buddy system, where another colleague observes the gown up and down procedures to advise on any breach of protocol (Table 2 ). Inform to conserve the use of masks and PPE. 9. Set up a designated area for donning PPE that is easily accessible and near the room. Doffing of PPE ideally occurs in an anteroom or a doffing area that is separate from the procedure room. 20 10 Equally important, staff should take additional precautions to prevent contamination among providers. Work at individual working stations using a designated phone, computer, and chair, and stay at least 6 feet from any other coworkers while at work to the extent possible, recognizing that this will be difficult in some situations. Avoid sharing workstation items and equipment. Wipe workstations before and after use with virucide, following instructions on the virucide exactly as recommended. 11 Create a workflow to provide a clear job description and designation of authority with backup plans. Separate the workflow to minimize cross-contamination. For example, consider dividing the clinical workforce into 2 teams, alternating roles at predefined intervals (such as weekly). One team is on-site and providing direct clinical care. The second team is coordinating clinical care off-site, minimizing risk of exposure and providing back-up coverage if an on-site provider were to become ill or require quarantine. 12 In the staff lounge/eating area, we allow sitting in one direction, thus preventing infection from face-to-face transmission. 13 The bathroom is a potential site of transmission. Ideally patient and staff bathrooms are separated and disinfected frequently. In the epidemic area, the indications include management of upper gastrointestinal bleeding, acute cholangitis, foreign body, and obstructions. 7 Care (initial diagnosis, biopsy, staging, palliation of biliary and luminal obstruction) of cancer patients may also be considered urgent. Reschedule nonurgent endoscopy services. This measure is aimed at reducing the risk of spreading infection from asymptomatic patients, reducing the risk of cross-infection among patients, reducing use of PPE, and reducing unnecessary admissions to free up hospital resources. In the setting of substantial community spread of COVID-19: 1. Require all staff to have daily measurements of temperature before starting work. All febrile staff should not be allowed to work, and they should be evaluated according to local protocols to screen for potential COVID-19 infections. 2. CDC mitigation strategies in the setting of substantial community spread include requiring all HCP to wear a face mask when in the facility, depending on supply. 21 There is a high viral load in the upper respiratory tract, and there is a significant potential for asymptomatic persons to shed and transmit virus. 22 Data showing the prolonged stability of the virus on surfaces may have significant potential implications for use of staff' PPE in the general area. 23 3. Require staff to perform work using individual stations: use the same phone, computer, and chair. Do not share. Do not answer phones elsewhere other than in your own station and disinfect your working space regularly. 4 . Limit the number of HCP in the endoscopy suite to those essential for performance of the procedures (see below regarding trainees). Off-duty workers should stay at home as much as possible. 5. For HCP directly involved in the procedures, use the hospital-issued scrubs and dedicated endoscopy shoes. Leave these at work. 6 . Although these continue to evolve, current COVID-19 screening guidelines include assessing patient's symptoms (such as fever and/or symptoms of acute respiratory illness) and potential contact with a suspected or laboratory-confirmed COVID-19 patient. The decision to quarantine should be made at that time ( Fig. 1 ). 7 . With the availability of RNA testing against COVID, point-of-care testing in patients presenting for endoscopy may facilitate more accurate risk stratification. Before the procedure: Outpatients 1. Screen for symptoms, signs, and exposure to SARS-CoV-2 (contact and travel history). Measure their temperature to risk stratify (Fig. 1 ). 2. Test all suspected patients for COVID-19 whenever possible using RT-PCR. 24 If possible, wait until the test results have been received before proceeding. 3 . Suspected or confirmed patients should be provided a mask while being triaged, and should be isolated or separated from other patients by at least 6 feet. Alternately, they should be placed in a negative pressure room. 4 . Patients should be advised to minimize movements while waiting for the procedure to minimize facility contamination. In-patients 1. Evaluate for COVID-19 status and reassess for symptoms suspicious for COVID-19 in all patients referred for endoscopy and triage accordingly. 2. Ensure that a PPE supply is available before entering the procedure room. c. Contact asymptomatic patients within 14 days to assess their progress after procedure. Reprocessing reusable medical equipment. We are not aware of a change in the RME protocol. Note that the most significant HCP contamination occurs during precleaning of the endoscope in the procedure room due to splashing from the air/water button. Follow the protocol to turn off the processor when replacing the air/water button with the credit card button. SARS-CoV-2 is deactivated by commonly used disinfectants such as alcohol or chlorine-based solutions. The CDC cleaning and disinfection recommendation can be adopted. Please see Table 2 for the recommended attire for the personnel cleaning the unit. Personnel cleaning the endoscopy unit must also undergo repeated practice and have their proficiency documented. Trainees are an integral part of most academic endoscopic units. With the potential surge in COVID-19 infection, the role of a trainee in endoscopy procedures requires reevaluation. Because there is too much uncertainty with regard to its transmissible potential and associated morbidity and mortality, we recommend the following plan of actions in managing trainees during endoscopy: 1. They master the prevention of transmission described previously through repeated practice and documented proficiency. 2. Fellows' involvement increases procedure time, and thus increases the potential for exposure. Our practice is to preserve critical resources and minimize the risk of exposure; thus, we limit trainees' involvement during endoscopic procedures. 25 As board-certified internists, however, fellows may provide essential physician support in a time of crisis, such as during a surge. They may contribute to the COVID-19 management workforce. 3. At many institutions, fellows cover multiple clinical sites as part of their on-call duties or for ACGME required continuity clinics. In the absence of point-of-care testing, we suggest that fellows be stationed at one hospital to avoid inadvertent spread of infection across multiple sites. Our guidance is based on our practical experience, observations, and published literature. Note that present understanding of SARS-CoV-2, however, is still rapidly evolving. The success of preventing endoscopy unit transmission of SARS-CoV-2 is contingent upon the compliance of every member of the team. We must cooperate and collaborate in order to adhere to the prevention steps the best we can and prevent transmissions. Place over face and eyes to adjust fit. Extend to cover the wrist of isolation gown How to remove PPE (Example 1) Grasp palm area of the other gloved hand and peel off first glove. Hold removed glove in gloved hand. Slide fingers under the glove at the wrist and peel off the second glove over the first. Lift headband or earpiece from the back to remove goggles or face shield. Unfasten gown ties while ensuring the sleeves do not contact your body. Pull the gown away from the neck by touching the inside of the gown only. Turn inside out and roll into a bundle to discard. Grasp bottom and top ties of the mask. Remove ties without contacting the front of the mask. How to remove PPE (Example 2) Grasp gown in the front and pull away from your body so the ties break. Touch outside of the gown only with gloved hands. While removing the gown, roll it inside-out into a bundle and peel your gloves off at the same time. Lift headband or earpiece from the back to remove goggles or face shield. Grasp bottom and top ties of the mask. Remove ties without contacting the front of the mask. Patients without respiratory symptoms. No PPE required COVID-19-New Insights on a Rapidly Changing Epidemic Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology Presumed Asymptomatic Carrier Transmission of COVID-19 Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan Suggestions of Infection Prevention and Control in Digestive Endoscopy During Current 2019-nCoV Pneumonia Outbreak in Wuhan COVID-19) outbreak: what the department of endoscopy should know Recommendations for the prevention of transmission of SARS during GI endoscopy Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. :23. 11. 10 Things You Can Do to Manage COVID-19 at Home. CDC; 2020 Hot air? 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Infectious Diseases (except HIV/AIDS) CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel. Instructions for USe COVID-19 Clinical Insights for Our Community of Gastroenterologists and Gastroenterology Care Providers