| Resumption of endoscopy services is critically dependent on the availability of PPE |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| Choice of PPE level should be determined by patient risk stratification, the nature of the proposed procedure and the results of patient testing. |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| Infection Prevention and Control (IPC) interventions must be tailored to the local availability and affordability of resources, while keeping in consideration the local prevalence of COVID-19 and community viral transmission rates. |
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| Given the lack of high-level evidence, the exclusive use of serology or rapid antigen-testing for pre-endoscopy patient triage cannot be recommended at this time. |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| A return to full gastrointestinal endoscopy procedure capacity should be pursued in those areas without evidence of community transmission of COVID-19, while continuing to adhere to IPC measures. |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| Gastrointestinal endoscopy units involved in endoscopy training and research activities may gradually restart their endoscopy training programs and research activities, provided this will not further delay needed gastrointestinal endoscopic procedures. |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| No changes are recommended to established reprocessing procedures for endoscopes and accessories. Standard bedside pre-cleaning, followed by manual cleaning and high-level disinfection in the reprocessing facility should continue. |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| No changes are recommended to ‘terminal cleaning’ procedures for cleaning and disinfecting the endoscopy unit at the end of the day. |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| In areas with limited endoscopic capacity, scheduling of patients should be prioritized reflecting the potential of serious outcomes with delay of procedures. Providers should indicate the patient’s procedural tier in their telehealth visit or telephone encounter note. |
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| Patients’ fears of contracting COVID-19 infection while visiting an endoscopy unit should be properly addressed. |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| In “COVID Minimized” Units: Prioritizing procedures which may be less aerosol generating- flexible sigmoidoscopy and colonoscopy – as the risk of viable, transmissible virus in stool appears to be much lower |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
|
In “COVID Minimized” Units
:
A slower throughput of patients to reduce the risk of positive and negative patients meeting
|
Level I: In case of unavailability of multiple rooms, lower risk procedures may be performed in separate days (“COVID minimized” days) than high-risk procedures. Level II: When two endoscopy suites are available, we suggest to create a “COVID-minimized” area, combined with separated pre- and post-endoscopy waiting areas if available. Level III: No adjustment |
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Practical Recommendations
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| Patient and Staff Protection, PPE use, Infection Prevention and Control |
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| Pre procedure COVID-19 questionnaire within 72 hours of visit on the telephone. Consider using risk stratification questionnaires including questions regarding fever, travel history, occupational exposure, contact history and clustering type). |
Level I: Telephone contact may be unavailable, so we suggest a risk stratification questionnaire physically on the endoscopy day. However, HCP administering the questionnaire should use highest available PPE. Level II: No adjustment, however, in the case of telephone unavailability for patients in rural areas, we suggest to refer to level I suggestion. Level III: No adjustment; however, in the case of telephone unavailability for patients in rural areas, we suggest referring to level I suggestion. |
| Update of questionnaire upon arrival at facility |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| Patients should notify presence of any change in symptoms or condition that may occur between scheduling and procedure date. |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| Daily questionnaire to healthcare personnel (HCP) |
Level I: HCP should be aware of any COVID-like symptoms arising Level II: HCP should be aware of any COVID-like symptoms arising Level III: HCP should be aware of any COVID-like symptoms arising |
| Supplemental use of telehealth services can be considered |
|
| Onsite forehead temperature measurement (patients and HCP) |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| Appropriate social distancing of patients (and staff) needs to be addressed pre- and post-procedure. Possible interventions: markings at 1.5 m for distancing, waiting benches modifications for distancing, staff policing the waiting room and assuring distancing and PPE are implemented, etc. |
Level I: In case of unavailability of enough waiting room space, patients should be asked to wait outside the endoscopy room in designated areas or scheduling should be adapted to accommodate for space needs Level II: Appropriate social distancing of patients (and staff) needs to be addressed pre- and post-procedure. Possible interventions: markings at 1.5 m for distancing, waiting benches modifications for distancing, staff policing the waiting room and assuring distancing and PPE are implemented, etc. Level III: No adjustment |
| Patients should be surveyed 1 to 2 weeks post procedure to record adverse events and assess interval COVID-19 symptoms or positive test results. |
Level I: Due to potential lack of phone and/or testing availability, patients should be educated to report to the center in case of "COVD-like" symptoms development Level II: Due to potential lack of phone and/or testing availability, patients should be educated to report to the center in case of "COVID-like" symptoms development Level III: No adjustment |
| If positive test of staff or patient, contact tracing should be initiated |
Level I: In case of staff or patient positivity, local healthcare authorities should be informed and "intra-unit" contact tracing should be performed Level II: In case of staff or patient positivity, local healthcare authorities should be informed and "intra-unit" contact tracing should be performed Level III: No adjustment |
| All patients and staff should wear ear-loop surgical masks at all times when in the facility. |
|
| When putting on or taking off PPE, proper hand hygiene needs to be practiced. |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| All staff (endoscopy and other) should be trained on unit's COVID-19 protocol (required PPE, don and doff, disposal, etc.) |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
PPE for Pre-admission staff:
Surgical/ear loop masks Nitrile gloves
|
|
Staff PPE in pre- and post-operative area:
Surgical/ear loop masks Nitrile gloves N95 respirator or equivalent can be considered, depending on availability, if direct patient contact, e. g. helping patients gown or dress, conducting patients out of center for discharge
|
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
PPE in operative/procedure room:
N95 respirator or equivalent Nitrile gloves Impervious gowns, if available. Laundered gowns have replaced lightweight disposable gowns in some centers Face shields/eye protection Head covering (hair net, bouffant type or surgical cap)
|
Level I: In case of unavailability of recommended PPE, the highest level of available PPE should be employed, based on local pandemic phase, patient risk status and procedure priority Level II: In case of unavailability of recommended PPE, the highest level of available PPE should be employed, based on local pandemic phase, patient risk status and procedure priority Level III: No adjustment |
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COVID Screening and Testing
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| Where possible, all outpatients being considered for endoscopy should undergo antigen testing based on molecular diagnosis (PCR or iNAAT) 1–3 days prior to their procedure |
Level I: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening Level II: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening Level III: No adjustment |
| A test-and-scope strategy in asymptomatic patients, where testing is negative, might be considered to save PPE. |
Level I: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening Level II: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening Level III: No adjustment |
| A test-and-scope strategy in symptomatic patients, where testing is negative, may identify patients so that gastrointestinal endoscopy procedures are not postponed. |
Level I: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening Level II: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening Level III: No adjustment |
| In the case of limited molecular testing availability, testing should be reserved for those patients considered to be at high-risk for having COVID-19 infection. |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
|
Procedure Scheduling
|
| The high administrative burden of telephone screening ± antigen testing and telephone follow-up is likely to require endoscopy units to have additional administrative and clerical staff to deliver this. |
Level I: In case of unavailability of additional staff, existing staff may be reorganised to undertake pre- and post- endoscopic screening Level II: In case of unavailability of additional staff, existing staff may be reorganised to undertake pre- and post- endoscopic screening Level III: No adjustment |
|
Room Requirements and Cleaning Measures
|
| Reprocessing staff should be donning personal protective equipment (PPE) that includes gloves, gown, face shield, bonnet and mask (N95 if available). |
Level I: If not all recommended PPE are available, reprocessing staff should use the highest grade of PPE available in the center Level II: If not all recommended PPE are available, reprocessing staff should use the highest grade of PPE available in the center Level III: No adjustment |
| EPA-registered hospital-grade disinfectant solutions and wipes should be used in procedure rooms to clean all high-touch and horizontal surfaces |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
|
“COVID Minimized” Units
|
| Linear patient flow through the unit, (no crossing of COVID positive and negative pathways, separate entrance and exit) |
Level I: Due to unavailability of multiple rooms, lower risk procedures may be performed in separate days ("COVID minimized" days) than high-risk procedures. Level II: When two endoscopy suites are available, we suggest to create a "COVID-minimized" area, combined with separated pre- and post-endoscopy waiting areas if available. Level III: No adjustment |
| Keeping known /suspected COVID patients out of “COVID-minimized” units (e. g. scope in theatre or at the bedside) |
Level I: Known or suspected COVID patients should be scoped separately (e. g. end of the day or "hot days"). Level II: Known or suspected COVID patients should be scoped separately (e. g. end of the day or "hot days"). Level III: No adjustment |
| Smaller units, or where there are few units in a region, could have “COVID-minimized” and “hot” days of the week, or could prioritize inpatients and COVID-positive patients in separate rooms, prioritised to the afternoon to allow deep cleaning and settling of the rooms overnight |
Level I: No adjustment Level II: No adjustment Level III: No adjustment |
| Staff will also require enhanced viral screening to maintain “COVID-minimized” units. e. g. pre-work symptoms and fever-free confirmation; staff rotation to work between “hot” and “COVID-minimized” parts of a hospital or sites should be avoided. |
Level I: Due to shortage of trained endoscopy staff, separation between "COVID-minimized" staff and "hot" staff may not be possible. HCP should report any possible exposure or COVID-like symptoms. Level II: Due to shortage of trained endoscopy staff, separation between "COVID minimized" staff and "hot" staff may not be possible. HCP should report any possible exposure or COVID-like symptoms. Level III: No adjustment |
