key: cord-0979989-zlxgs4nq authors: Furuta, Takahisa; Irisawa, Atsushi; Matsumoto, Takayuki; Kawai, Takashi; Inaba, Tomoki; Kanno, Atsushi; Katanuma, Akio; Kawahara, Yoshiro; Matsuda, Koji; Mizukami, Kazuhiro; Otsuka, Takao; Yasuda, Ichiro; Fujishiro, Mitsuhiro; Tanaka, Shinji; Fujimoto, Kazuma; Fukuda, Shinsaku; Iishi, Hiroyasu; Igarashi, Yoshinori; Inui, Kazuo; Ueki, Toshiharu; Ogata, Haruhiko; Kato, Mototsugu; Shiotani, Akiko; Higuchi, Kazuhide; Fujita, Naotaka; Murakami, Kazunari; Yamamoto, Hironori; Ito, Tohru; Okazaki, Kazuichi; Kitagawa, Yuko; Mine, Tetsuya; Tajiri, Hisao; Inoue, Haruhiro title: Clinical Questions and Answers on Gastrointestinal Endoscopy during the Novel COVID‐19 Pandemic date: 2020-05-29 journal: Dig Endosc DOI: 10.1111/den.13757 sha: b789f5f9c865bb8dac3c6e4e54a41c5a52870f2a doc_id: 979989 cord_uid: zlxgs4nq Some situations may require endoscopy during the COVID‐19 (Coronavirus Disease 2019) pandemic. Here, we describe the necessary precautions in the form of clinical questions and answers (Q&A) regarding the safe deployment of gastrointestinal endoscopy in such situations while protecting endoscopy staff and patients from infection. Non‐urgent endoscopy should be postponed. The risk of infection in patients should be evaluated in advance by questionnaire and body temperature. The health of staff must be checked every day. Decisions to employ endoscopy should be based on the institutional conditions and aims of endoscopy. All endoscopic staffs need to wear appropriate personal protective equipment (PPE). The endoscope and other devices should be cleaned and disinfected after procedures in accordance with relevant guidelines. Optimal management of the endoscopy unit is required. Endoscopy for infected patients or those with suspected infection demands exceptional caution. When a patient who undergoes endoscopy is later found to have COVID‐19, the members of staff involved are considered exposed to the virus and must not work for at least 14 days if their PPE is considered insufficient. When PPE resources are limited, some equipment may be used continuously throughout a shift as long as it is not contaminated. Details of the aforementioned protective measures are described. Challenging situations have been continuing worldwide as a result of the COVID-19 (Coronavirus Disease 2019) pandemic. 1, 2 In such circumstances, gastrointestinal endoscopy procedures are sometimes unavoidable. 3 The Japan Gastroenterological Endoscopy Society Answer. Non-urgent endoscopy should be postponed. [5] [6] [7] Similarly, already-scheduled endoscopy This article is protected by copyright. All rights reserved should be postponed by contacting patients via phone, email, or postal service. 8 CQ2. What kinds of endoscopy can be postponed? Answer. The following non-urgent endoscopic examinations can be postponed. 8 #1 Screening and surveillance of asymptomatic individuals. #2 Colonoscopy 1 year after the complete resection of colon polyps. #3 Endoscopy whereby the result will not significantly affect the treatment policy-for example, asymptomatic peptic ulcer after eradication of Helicobacter pylori. CQ3 . What kinds of endoscopy should not be postponed? Answer. Gastrointestinal endoscopy should not be postponed in the following cases. 8, 9 #1 Gastrointestinal bleeding or suspected gastrointestinal bleeding. #2 Swallowing difficulty that may affect oral intake. #3 Cholangitis, obstructive jaundice, or other symptomatic biliary-pancreatic disease that requires treatment using an endoscope. #4 When a malignant disease is strongly suspected. #5 When the treatment plans will change according to the results of endoscopy. #6 Endoscopy procedure that has been decided upon by the head of the facility. CQ4. What are the important precautions in the waiting room? #1 Reception staff should wear masks and gloves 8, 10 and, if possible, face shields or goggles. The This article is protected by copyright. All rights reserved placement of vinyl curtains may also be useful. #2 Hand sterilization and mask wearing in the waiting room is recommended for all patients. 11, 12 Alcohol disinfectant for hand disinfection must be available in the waiting room. 11 #3 Patients should be seated at least 2 meters apart, 13, 14 the chairs being positioned to avoid patients sitting face to face. 13 #4 Endoscopy appointment times must be arranged in such a way as to reduce congestion and waiting time in the waiting room. CQ5. What are the important issues regarding environmental management of the waiting room? #1 Toilet seats and handles of water faucets should be disinfected. 15 Patients should be asked to disinfect the toilet seat before and after use, as well as closing the lid of the toilet before flushing and using a paper towel rather than an air towel. #2 At patient changeover, the chairs, desks, and handrails should be disinfected with alcohol. 8 #3 It is recommended that staff members employed to clean the local environment wear gloves, surgical masks, gowns, face shields or goggles, and a hairnet or cap. 8 CQ6. What should we tell patients who visit for endoscopy? Answer. #1 Based on the results of the questionnaire and body temperature, the endoscopy can be cancelled or postponed. 9, 10 #2 There is a possibility of being exposed to the virus in the endoscopy room and waiting room. 10 This article is protected by copyright. All rights reserved When inquiring directly, maintain a distance of at least 2 meters and wear a mask, face shield, This article is protected by copyright. All rights reserved gown, etc., for protection. 15 It is recommended that patients are asked these questions by telephone or other means before visiting the hospital. 8 If the endoscopy cannot be postponed, the patient should be asked to keep a record of body temperature and various symptoms related to COVID-19 every day until the day of the procedure. #4 Arrange the order of endoscopic procedures so that the suspected patient is seen last, and ensure that the patient with suspected infection does not have contact with other patients. CQ9. When results of the questionnaire and temperature measurements indicate that the risk of COVID-19 is low, how should we proceed? Answer. When the patient still wishes to undergo the endoscopy even explained about the possibility of exposure to SARS-CoV-2, go ahead and perform it. This article is protected by copyright. All rights reserved CQ10. How should we obtain informed consent from patients judged at low or high risk of infection on the day of endoscopy? Answer. When obtaining consent from low-risk patients, wear a mask and keep distance (at least 2 meters). 15 For patients at high risk all staff must wear a mask, face shield, and gloves. 7 The patient should be asked to wear a mask and use a disposable pen to sign the consent form. #2 In addition to the protection already described, an N95 mask should be a basic requirement. #3 Reconsider the necessity of the endoscopy or referral of the patient to another hospital capable of comprehensive infection control. This article is protected by copyright. All rights reserved #4 For prevention of induced cough and generation of aerosol, the use of jelly or viscous solution instead of spray-type pharyngeal anesthesia is recommended. Answer. We recommend the following: #1 When a patient who has or is suspected of having COVID-19 needs to undergo a procedure, the infection control measures described above should be followed closely. This article is protected by copyright. All rights reserved #7 Procedures should be performed in a negative-pressure room. 8, 20 If this is not an option, make sure the endoscopy room is sufficiently ventilated. However, to avoid spreading aerosol, the room should not be opened to other rooms or corridors during the procedure and should be properly ventilated after the procedure. 19, 21 #8 To avoid PPE shortages, the minimum number of staff should take part in procedures. 9 #9 Owing to the risk of instrument contamination and post-procedural cleaning, the number of items in the endoscopy room should be kept to a minimum. This article is protected by copyright. All rights reserved #10 When performing endoscopy under sedation, it may be helpful to adjust the depth of sedation to reduce patient discomfort, including vomiting reflex, which causes aerosolization. CQ19. Should accompanying persons be allowed to enter the examination room? Answer. Accompanying persons should not be put at risk of infection. 18 They require the same level of PPE as the endoscopist. If a patient absolutely needs company, this should be limited to one person. The risk of infection in the recovery room after the procedure also needs to be considered for the accompanying person. CQ20. What are the issues to consider for the endoscopist after emergent endoscopy on patients who have or are suspected of having COVID-19? Answer. Infection prevention measures need to be continued after the procedure. The endoscopist and other staff should discard their PPE when they leave the endoscopy room. Caution must be exercised when discarding PPE to ensure the virus does not spread. Afterward, hands must be washed thoroughly up to the elbow. Scopes and other reusable equipment should be cleaned according to the JGES guidelines. 21 After endoscopy of an infected patient, although the risk of exposure is low if the all the staff participated in the procedure are careful about personal protective measures, we still recommend that the all the staff participated in the procedure leave work for the day. Self-monitoring, ie daily temperature measurement and symptom evaluation, is essential. It is necessary to return to work after confirming that there is no problem in monitoring. This article is protected by copyright. All rights reserved Answer. It is very important to employ strict infection control measures when transporting and cleaning endoscopes after the procedure. Scopes and other items to be cleaned should be placed on a disposable sheet such as a cover cloth on a dolly. 10, 22 The staff in charge of cleaning should also wear complete PPE to prevent contamination or infection from droplets. 19, 23 Cleaning should be performed by experienced staff. 16 CQ23. Is there any special method for cleaning endoscopes/devices after emergent endoscopy on patients who have or are suspected of having COVID-19? Answer. There should be no problem if scopes are cleaned and disinfected according to the JGES guidelines. 21 It is important to keep a history of cleaning. CQ24. What procedures are necessary in the laboratory or elsewhere after an emergency This article is protected by copyright. All rights reserved endoscopy on a patient who has or is suspected of having COVID-19? Answer. After performing the procedure, the room should be ventilated for ample time without opening the doors. Next, the room should be cleaned as usual. Disinfecting the entire room by wiping it down with alcohol or another disinfectant is recommended. 4, 10, 19, [24] [25] [26] CQ25. How should items other than the endoscope be dealt with in the endoscopy room? Answer. Disposable items such as forceps should be placed in the infectious waste containers in the endoscopy room, and care should be taken when opening these containers. 24 Equipment that involves contact with the patient, such as stethoscopes, thermometers, blood pressure gauges, and pulse oximeters, should be wiped with alcohol or a cloth containing an antiviral agent. The paper sheets, pillowcases, and trolley sheets on the examination table must be changed for every patient. Sheets should be treated as infectious contaminants. CQ26. A patient who is thought to be at low risk of infection and who underwent examination was later found to have COVID-19. How should this be dealt with? Answer. If staff have adopted personal protective measures and post-procedural handwashing, there should be low risk. However, considering that someone may have been exposed without realizing it, the staff should self-monitor by recording their temperature every day and assessing their symptoms. They can return to work after confirming they are asymptomatic. Risk is elevated if there are even small lapses in personal protective measures (e.g., touching the eyes, nose, or mouth when not wearing a face shield or a gown with sleeves) or if hands are not washed properly. If this happens, the staff in question should not work for at least 14 days after the last This article is protected by copyright. All rights reserved exposure. Of course, thorough disinfection of the endoscopy room is necessary. CQ27. Should inexperienced endoscopists be allowed to perform examinations of patients who have or are suspected of having COVID-19? Answer. If the endoscopist is inexperienced, he or she may not be able to insert the scope smoothly during a transoral examination, which can cause aspiration or a reflexive cough that increases the risk of droplet infection. Inexperienced endoscopists also have a tendency to use too much air in performing colonoscopy, which increases the frequency of gas emission, also raising the risk of droplet infection. 18 It is also presumed that the overall examination time will be longer, which will increase the risk of infection in all aspects. Therefore, we recommend that inexperienced endoscopists do not perform examinations. 21 CQ28. Changing aprons and other equipment for each patient will quickly deplete stocks. Is it really necessary to change PPE between each patient? Answer. Yes, it is necessary because PPE can be a source of infection. However, if this is difficult because of inventory issues, consider reuse as a last resort. Note that equipment should not be used continuously beyond each shift, even if it is not contaminated. 8 Nevertheless, be sure to change masks that may be contaminated or after endoscopy for a patient who has or is suspected of having COVID-19. 8 Please refer to the following instructions: #1 Gloves should be changed between each patient. #2 Gowns should be replaced for each patient but, if this is impossible, judgments on successive Accepted Article use should be made based on the degree of contamination. #3 Masks should also be changed for each patient, if possible; if not possible, a single mask can be used for the entire shift (i.e., morning or afternoon) if it is not contaminated. #4 Face shields should also be changed after each patient, but if this is impossible they can be disinfected with alcohol. #5 Hairnets and shoe covers should also be changed after each patient, if possible; if not possible, they can be used for a whole shift if they are not contaminated. CQ29. Can we reuse an N95 mask? Answer. Because endoscopy is likely to generate aerosol and it is desirable to use an N95 mask, such masks will be used frequently. Disposable is preferable, but given that the supply of N95 masks is currently uncertain, the Ministry of Health, Labor and Welfare in Japan has suggested that an N95 mask can be reused under the following protocol. "Sterilization method": replace once a day, and after use sterilize the N95 mask using hydrogen peroxide water plasma sterilizer, which is also used for surgical instruments. Because mask performance deteriorates when sterilized three times, an N95 mask can be used "up to twice." CQ30. What are the measures/inventions for PPE shortage? Answer. The following options are available. #1 Face shields can be wiped with alcohol after examining each patient. The transparency of some materials decreases when wiped with alcohol. Hence, these materials must be washed with a neutral detergent before being reused. This article is protected by copyright. All rights reserved #2 Reusing masks by disinfecting them is not recommended. In addition, while self-made masks are half as effective as medical masks, they do have some effect. These may be considered if absolutely necessary and depending on the risk level. CQ31. Which endoscopic procedure has a higher risk of COVID-19, transnasal or transoral? The answer is not clear. Transnasal endoscopy produces less coughing and vomiting reflex than oral endoscopy, and the risk of infection resulting from aerosolization may be kept low. However, the virus has been established in the sinuses and nasal cavities since the early phase of infection, 25 which is why swabs from the nasal cavity are being tested. In addition, for transnasal endoscopy it is necessary to pay sufficient attention to pretreatment sneezing and coughing caused by reflexes. We also recognize that the endoscope used is likely to be contaminated, and it is thus necessary to give due consideration to the handling (especially transportation) of the endoscope. If postponement of the endoscopic procedure is difficult, it is necessary to pay attention to the symptoms of the nasal cavity other than the clinical signs of infection such as odor abnormality. In addition, one must be aware that there is a risk of infection both nasally and orally. In any case, appropriate protective measures must be undertaken as a matter of course. 27 Authors, Atsushi Irisawa and Akio Katanuma are an Associate Editor of Digestive Endoscopy, and Takayuki Matsumoto is an Editor-in-Chief of Digestive Endoscopy. Other authors declare no Conflict of Interests for this article. 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