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Considerations in performing endoscopy during the COVID-19 pandemic

2020; Elsevier BV; Volume: 92; Issue: 1 Linguagem: Inglês

10.1016/j.gie.2020.03.3758

1097-6779

Roy Soetikno, Anthony Yuen Bun Teoh, Tonya Kaltenbach, James Y. Lau, Ravishankar Asokkumar, Patricia Anne Cabral‐Prodigalidad, Amandeep K. Shergill,

Infection Control in Healthcare

Based on experiences and the literature, our objective is to provide practical suggestions for performing endoscopy in the setting of the novel coronavirus-19 (COVID-19) pandemic. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), referred to as COVID-19, has become a global pandemic. Human-to-human transmission occurs through respiratory secretions, aerosols, feces, and contaminated environmental surfaces.1Rio C. del Malani P.N. COVID-19—new insights on a rapidly changing epidemic.JAMA. Epub. 2020 Mar 28; Google Scholar,2Xiao F. Tang M. Zheng X. et al.Evidence for gastrointestinal infection of SARS-CoV-2.Gastroenterology. Epub. 2020 Mar 3; Abstract Full Text Full Text PDF Scopus (1990) Google Scholar Transmission can occur in both symptomatic and asymptomatic individuals.3Bai Y. Yao L. Wei T. et al.Presumed asymptomatic carrier transmission of COVID-19.JAMA. Epub. 2020 Feb 21; Crossref Scopus (3055) Google Scholar Viable virus particles can be detected in aerosols up to 3 hours after aerosolization and up to 3 days on surfaces.4van Doremalen N. Bushmaker T. Morris D.H. et al.Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.N Engl J Med. 2020; (. N Engl J Med. Epub 2020 Mar 17)Crossref Scopus (6645) Google Scholar A recent publication suggests that undocumented infections were the source of a substantial majority of documented cases.5Li R. Pei S. Chen B. et al.Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2).Science. Epub. 2020 Mar 16; Crossref Scopus (2242) Google Scholar The risk of infection to healthcare workers is significant: In one of the earliest documentations of infection in Wuhan, 29% of patients (40/138) were healthcare workers.6Wang D. Hu B. Hu C. et al.Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China.JAMA. 2020; 323: 1061-1069Crossref PubMed Scopus (16040) Google Scholar 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 (HCPs) will be exposed to either respiratory or GI fluids from patients. Thus, adequate protection of HCPs is now critical. The World Endoscopy Organization recently released a recommendation on infection prevention and control in digestive endoscopy based on experiences from China.7Zhang Y. Zhang X. Liu L. et al.Suggestions of infection prevention and control in digestive endoscopy during current 2019-nCoV pneumonia outbreak in Wuhan, Hubei Province, China.http://www.worldendo.org/wp-content/uploads/2020/02/Suggestions-of-Infection-Prevention-and-Control-in-Digestive-Endoscopy-During-Current-2019-nCoV-Pneumonia-Outbreak-in-Wuhan-Hubei-Province-China.pdfDate accessed: March 17, 2020Google Scholar Similarly, an Italian group has provided recommendations regarding the performance of endoscopy during the COVID-19 outbreak.8Repici A. Maselli R. Colombo M. et al.Coronavirus (COVID-19) outbreak: what the department of endoscopy should know.Gastrointest Endosc. Epub. 2020 Mar 14; Abstract Full Text Full Text PDF Scopus (387) Google Scholar Based on their experiences with a similar coronavirus, which caused SARS 17 years ago, Hong Kong adopted measures similar to those aforementioned immediately on receiving the first news of the COVID-19 outbreak in late January.9Muscarella L.F. Recommendations for the prevention of transmission of SARS during GI endoscopy.Gastrointest Endosc. 2004; 60: 792-795Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar With numbers of COVID-19 cases continuing to rise in North America and Europe, we aim to provide practical suggestions to potentially avoid the transmission 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 person-to-person, respiratory droplets, aerosols generated during endoscopy, and contact with contaminated surroundings and bodily fluids.1Rio C. del Malani P.N. COVID-19—new insights on a rapidly changing epidemic.JAMA. Epub. 2020 Mar 28; Google Scholar,10Pan L, Mu M, Ren HG, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastroenterol. Epub 2020 Mar 26.Google Scholar Additional care must be instituted when handling blood samples or specimens because the virus has been detected in the blood of COVID-19 patients. Pan et al10Pan L, Mu M, Ren HG, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastroenterol. Epub 2020 Mar 26.Google Scholar demonstrated that 48.5% of patients presented with GI symptoms, including anorexia (83.8%), diarrhea (29.3%), and vomiting (.8%), with the severity increasing as the disease progressed. With the detection of the virus in feces, the Centers for Disease Control and Prevention (CDC) has suggested the use of separate bathrooms in cases of suspected COVID-19.11Centers for Disease Control and Prevention10 things you can do to manage COVID-19 at home.https://www.youtube.com/watch?v=qPoptbtBjkgDate: 2020Date accessed: March 18, 2020Google Scholar 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. All endoscopic procedures should be considered aerosol-generating procedures (AGPs). 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.12Chapman S. Hot air?.BMJ. 2001; 323: 1449Crossref Scopus (9) Google Scholar A prospective study has demonstrated unrecognized endoscopist exposure to infectious particles during GI procedures.13Johnston E.R. Habib-Bein N. Dueker J.M. et al.Risk of bacterial exposure to the endoscopist's face during endoscopy.Gastrointest Endosc. 2019; 89: 818-824Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar Recently, the World Health Organization published an extensive guideline on the rational use of PPE for COVID-19 and provided specific instructions for healthcare workers performing AGPs on patients with COVID-19.14World Health OrganizationRational use of personal protective equipment for coronavirus disease (COVID-19): interim guidance, 27 February 2020. World Health Organization, Geneva2020https://extranet.who.int/iris/restricted/handle/10665/331215Date accessed: March 18, 2020Google Scholar These include the use of a respirator (N95, FFP2 standard, or equivalent), gown, gloves, eye protection, and apron, although aprons are not typically used in the United States. Their use should be immediately and strictly adopted in practice, if at all possible.13Johnston E.R. Habib-Bein N. Dueker J.M. et al.Risk of bacterial exposure to the endoscopist's face during endoscopy.Gastrointest Endosc. 2019; 89: 818-824Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar 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 sample bottle, and 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 et al15Ong S.W.X. Tan Y.K. Chia P.Y. et al.Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient.JAMA. Epub. 2020 Mar 4; Crossref Scopus (1538) Google Scholar detected positive SARS-CoV-2 samples in various locations around patients' rooms, including the bed, sink, bathroom, light switches, and doors. In addition, positive samples were found on the shoes and stethoscopes of staff exiting patient rooms. However, there was no contamination in the anteroom or corridor outside the room. The study illustrates the significant extent of contamination by patients with SARS-CoV-2 through respiratory droplets and fecal shedding.16Knowlton S.D. Boles C.L. Perencevich E.N. et al.Bioaerosol concentrations generated from toilet flushing in a hospital-based patient care setting.Antimicrob Resist Infect Control. 2018; 7: 16Crossref PubMed Scopus (71) Google Scholar The goal is to attain 0% infection rates among HCPs while providing essential services to patients. For the GI community, the key element is to prevent exposure during any endoscopic procedure. As outbreaks continue to occur, masks and 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. 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-19 pandemic.3.It is important to establish a rapid response communication channel using smart phone apps, e-mail, and video conferences to distribute information across the entire unit.4.Administrators, infectious control teams, doctors, and nurses should be updated regularly to stay abreast of infection developments and to discuss a unified plan. 1.Ensure performance of fit testing for N95 respiratory masks for all HCPs. During the course of the outbreak, some masks may run out of stock, and HCPs will need to plan for alternatives. Protection, however, may be achievable even without the N95 mask through the use of medical masks.17Adams J.G. Walls R.M. Supporting the health care workforce during the COVID-19 global epidemic.JAMA. Epub. 2020 Mar 12; Crossref Scopus (1003) Google Scholar Note that as an AGP, endoscopy of persons under investigation (PUIs)/COVID patients requires the use of respiratory protection. The powered air-purifying respirator 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 mask. Most units, however, are not stocked to have an adequate supply of powered air-purifying respirators.2.Familiarize staff with the correct method of hand hygiene. An excellent review has been published.18Longtin Y. Sax H. Allegranzi B. et al.Hand hygiene.N Engl J Med. 2011; 364: e24Crossref PubMed Scopus (50) Google Scholar Compliance with correct hand hygiene practices is low; thus, a practice, review, and compliance check is necessary.3.Follow the World Health Organization recommendations for PPE (Table 1).14World Health OrganizationRational use of personal protective equipment for coronavirus disease (COVID-19): interim guidance, 27 February 2020. World Health Organization, Geneva2020https://extranet.who.int/iris/restricted/handle/10665/331215Date accessed: March 18, 2020Google Scholar Familiarize staff with the correct sequence of gowning up (donning) and down (doffing) through teaching videos and diagrams (Table 1).19Centers for Disease Control and Preventionhttps://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/ppe.htmlGoogle Scholar There is poor correlation between self-perceived proficiency in PPE use and its appropriate use.17Adams J.G. Walls R.M. Supporting the health care workforce during the COVID-19 global epidemic.JAMA. Epub. 2020 Mar 12; Crossref Scopus (1003) Google Scholar 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 HCPs to conserve the use of masks and PPE.Table 1Recommended protocol for putting on and removing PPEAdapted from Centers for Disease Control and Prevention guidelines.19Centers for Disease Control and Preventionhttps://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/ppe.htmlGoogle ScholarHow to put on PPE1. GownFully cover torso from neck to knees, arms, to end of wrists and wrap around the back. 2. MaskSecure ties or elastic bands at the middle of the head and neck. Fit flexible band to nose bridge. Fit snug to face and below chin. Fit-check respirator. 3. GogglesPlace over face and eyes to adjust fit. 4. GlovesExtend to cover the wrist of isolation gown. How to remove PPE (example 1)1. GlovesGrasp 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. 2. GogglesLift headband or earpiece from the back to remove goggles or face shield. 3. GownUnfasten 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. 4. MaskGrasp bottom and top ties of the mask. Remove ties without contacting the front of the mask. How to remove PPE (Example 2)1. Gown and glovesGrasp 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. 2. GogglesLift headband or earpiece from the back to remove goggles or face shield. 3. MaskGrasp bottom and top ties of the mask. Remove ties without contacting the front of the mask. PPE, Personal protective equipment. Open table in a new tab Table 2Recommended PPE to be used in the context of COVID-19 disease, according to setting, personnel, and type of activityAdapted from World Health Organization and Centers for Disease Control and Prevention guidelines.14World Health OrganizationRational use of personal protective equipment for coronavirus disease (COVID-19): interim guidance, 27 February 2020. World Health Organization, Geneva2020https://extranet.who.int/iris/restricted/handle/10665/331215Date accessed: March 18, 2020Google Scholar,19Centers for Disease Control and Preventionhttps://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/ppe.htmlGoogle ScholarSettingTarget personnel or patientsActivityType of PPE or procedureHealthcare facilities, inpatient facilitiesPatient roomHealthcare workersProviding direct care to COVID-19 patientsMedical mask, gown, gloves eye protection (goggles or face shield)∗Use the buddy system to prevent protocol breach and to confirm that PPE is correctly in place.Aerosol-generating procedures performed on COVID-19 patientsRespirator N95 or FFP2 standard or equivalent. Gown, gloves, eye protection, apron∗Use the buddy system to prevent protocol breach and to confirm that PPE is correctly in place.CleanersEntering the room of COVID-19 patientsMedical mask, gown, heavy duty glovesEye protection (if risk of splash from organic material or chemicals)Boots or closed work shoesVisitorsEntering the room of a COVID-19 patientMedical mask, gown, glovesOther areas of patient transit (eg, wards, corridors)All staff, including healthcare workersAny activity that does not involve contact with COVID-19 patientsMedical maskTriageHealthcare workersPreliminary screening not involving direct contactMaintain spatial distance of at least 1 mMedical mask required21Centers for Disease Control and PreventionImplementation of mitigation strategies for communities with local COVID-19 transmission.https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdfDate accessed: March 18, 2020Google ScholarPatients with respiratory symptomsAnyMaintain spatial distance of at least 1 mProvide a medical mask if tolerated by patientsPatients without respiratory symptomsAnyNo PPE requiredOutpatient facilitiesConsultation roomHealthcare workersPhysical examination of patients with respiratory symptomsMedical mask, gown, gloves, eye protection∗Use the buddy system to prevent protocol breach and to confirm that PPE is correctly in place.Healthcare workersPhysical examination of patients without respiratory symptomsPPE according to standard precautions and risk assessmentPatients with respiratory symptomsAnyProvide a medical mask if tolerated.Patients without respiratory symptomsAnyNo PPE requiredCleanersAfter and between consultations with patients with respiratory symptomsMedical mask, gown, heavy duty glovesEye protection (if risk of splash from organic material or chemicals)Boots or closed work shoesWaiting roomPatients with respiratory symptomsAnyProvide a medical mask if toleratedImmediately move the patient to an isolation room or separate area away from others; if this is not feasible, ensure spatial distance of at least 1 m from other patientsPatients without respiratory symptomsAnyNo PPE requiredTriageHealthcare workersPreliminary screening not involving direct contactMaintain spatial distance of at least 1 mMedical mask required.21Centers for Disease Control and PreventionImplementation of mitigation strategies for communities with local COVID-19 transmission.https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdfDate accessed: March 18, 2020Google ScholarPatients with respiratory symptomsAnyMaintain spatial distance of at least 1 mProvide medical mask if toleratedPatients without respiratory symptomsAnyNo PPE requiredPPE, Personal protective equipment; COVID-19, coronavirus disease 2019.∗ Use the buddy system to prevent protocol breach and to confirm that PPE is correctly in place. Open table in a new tab 4.Set up a reception bay to screen and stratify the risk of COVID-19 infection of the patient before allowing him or her to enter the waiting area alongside other patients. In the setting of substantial community spread, make efforts to separate all patients by approximately 6 feet.5.Set up a designated procedure and recovery room for suspected (PUIs) and COVID-19–positive patients. Endoscopic procedures should be performed in an Airborne Infection Isolation Room that complies with Level 3 biosafety requirements. Consider alternative sites with enhanced prevention capabilities for performing procedures if an isolation room is not available.6.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.20Ortega R. Bhadelia N. Obanor O. et al.Putting on and removing personal protective equipment.N Engl J Med. 2015; 372: e16Crossref PubMed Scopus (10) Google Scholar7.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.8.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 while the second team is coordinating clinical care off-site, minimizing risk of exposure and providing backup coverage if an on-site provider were to become ill or require quarantine.9.Allow sitting in 1 direction in the staff lounge/eating area, thus preventing infection from face-to-face transmission.10.Treat the bathroom as a potential site of transmission. Ideally separate patient and staff bathrooms and disinfect frequently. PPE, Personal protective equipment. PPE, Personal protective equipment; COVID-19, coronavirus disease 2019. In the epidemic area, indications include management of upper GI bleeding, acute cholangitis, foreign body, and obstructions.7Zhang Y. Zhang X. Liu L. et al.Suggestions of infection prevention and control in digestive endoscopy during current 2019-nCoV pneumonia outbreak in Wuhan, Hubei Province, China.http://www.worldendo.org/wp-content/uploads/2020/02/Suggestions-of-Infection-Prevention-and-Control-in-Digestive-Endoscopy-During-Current-2019-nCoV-Pneumonia-Outbreak-in-Wuhan-Hubei-Province-China.pdfDate accessed: March 17, 2020Google Scholar Care (initial diagnosis, biopsy sampling, 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. 1.Require all staff to have daily measurements of temperature before starting work. All febrile staff should not be allowed to work and 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 HCPs to wear a face mask when in the facility, depending on supply.21Centers for Disease Control and PreventionImplementation of mitigation strategies for communities with local COVID-19 transmission.https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdfDate accessed: March 18, 2020Google Scholar There is a high viral load in the upper respiratory tract and a significant potential for asymptomatic persons to shed and transmit virus.22Woelfel R. Corman V.M. Guggemos W. et al.Clinical presentation and virological assessment of hospitalized cases of coronavirus disease 2019 in a travel-associated transmission cluster.Infect Dis. 2020; Google Scholar Data showing the prolonged stability of the virus on surfaces may have significant potential implications for use of PPE in the general area.23van Doremalen N. Bushmaker T. Morris D. et al.Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1.Infect Dis. Epub. 2020 Mar 8; Google Scholar3.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 HCPs 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 HCPs 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 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-19, point-of-care testing in patients presenting for endoscopy may facilitate a more accurate risk stratification. 1.Screen for symptoms, signs, and exposure to SARS-CoV-2 (contact and travel history). Measure patients' temperatures to risk stratify (Fig. 1).2.Test all suspected patients for COVID-19 whenever possible using Reverse Transcription-Polymerase Chain Reaction (RT-PCR).24Centers for Disease Control and Prevention. CDC 2019-novel coronavirus (2019-nCoV) real-time RT-PCR diagnostic panel. Instructions for use.https://www.fda.gov/media/134922/downloadDate accessed: March 18, 2020Google Scholar 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. 1.Evaluate for COVID-19 status and reassess for symptoms suspicious for COVID-19 in all patients referred for endoscopy and triage accordingly.2.PUIs and COVID patients should be provided a mask while awaiting the procedure and should be stationed away from other patients as detailed above. Designated transportation corridors or lifts/elevators should be used to transfer patients to the endoscopy unit. 1.Include verification of the patient's status for COVID-19 in the Time Out protocol.2.Ensure that a PPE supply is available before entering the procedure room.3.Wash your hands according to the recommended hand-washing method.4.Follow the CDC's recommendations for performing AGP: wear a respirator (N95, FFP2 standard, or equivalent), impermeable gown, gloves, apron, and eye protection (Fig. 2).5.Follow the CDC sequence for putting on the PPE. Remove all personal items, such as jewelry, pagers, and badges. Use the buddy system to confirm that the PPE is correctly in place for those who are not familiar with gowning up and down.6.Consider boot covers during ERCP.7.If the patient requires tracheal intubation for the procedure, only the anesthesiologist and the assistant stay in the room during intubation. The remaining team stays outside.8.After the procedure is completed, follow the CDC's recommendations for removing PPE. Use a buddy system to observe for any breach. For a breach, use an alcohol spray to decontaminate the potentially touched area(s).9.Wash your hands according to the recommended hand-washing method. Confirm proficiency.18Longtin Y. Sax H. Allegranzi B. et al.Hand hygiene.N Engl J Med. 2011; 364: e24Crossref PubMed Scopus (50) Google Scholar10.Other HCPs in the clean area can complete the procedure report, thus potentially avoiding contamination.7Zhang Y. Zhang X. Liu L. et al.Suggestions of infection prevention and control in digestive endoscopy during current 2019-nCoV pneumonia outbreak in Wuhan, Hubei Province, China.http://www.worldendo.org/wp-content/uploads/2020/02/Suggestions-of-Infection-Prevention-and-Control-in-Digestive-Endoscopy-During-Current-2019-nCoV-Pneumonia-Outbreak-in-Wuhan-Hubei-Province-China.pdfDate accessed: March 17, 2020Google Scholar 1.Staff: After performing endoscopy in a PUI/COVID-19–positive patient, shower before leaving the hospital.2.Patients:a.Provide patients with a suitable PPE, depending on their risk status, while waiting in the recovery area.b.Toilet flush is known to generate bioaerosols ("toilet plume") and may transmit infection. Advise patients to flush toilets after use with the lids closed.c.Contact asymptomatic patients within 14 days to assess their progress after the procedure. For the reprocessing of reusable medical equipment, we are not aware of a change in the reusable medical equipment protocol. Note that the most significant HCP contamination occurs during precleaning of the endoscope in the procedure room because of 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. Table 2 shows the recommended attire for 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 re-evaluation. 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 trainee involvement during endoscopic procedures.25American Society for Gastrointestinal EndoscopyJoint GI society message: COVID-19 clinical insights for our community of gastroenterologists and gastroenterology care providers.https://www.asge.org/home/joint-gi-society-message-covid-19Date accessed: March 18, 2020Google Scholar 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 Accreditation Council for Graduate Medical Education–required continuity clinics. In the absence of point-of-care testing, we suggest stationing fellows at 1 hospital to avoid inadvertent spread of infection across multiple sites. Our guidance is based on our practical experience, observations, and published literature. Our present understanding of SARS-CoV-2, however, is still rapidly evolving. The success of preventing endoscopy unit transmission of SARS-CoV-2 is contingent on the compliance of every member of the team. We must cooperate and collaborate to comply with the prevention steps the best we can and to prevent transmissions. The following authors disclosed financial relationships: R. Soetikno: Consultant for Olympus and Fujifilm. A. Y. B. Teoh: Consultant for Boston Scientific, Cook Medical, Taewoong and Microtech. T. Kaltenbach: Consultant for Olympus, Aries Pharmaceuticals, and Medtronic. A. Shergill: Research gift from Pentax All other authors disclosed no financial relationships. We would like to thank Tiffany Nguyen-Vu and Carmel Malvar for assistance with manuscript preparation. COVID-19 in endoscopy: Time to do more?Gastrointestinal EndoscopyVol. 92Issue 2PreviewWe have read with great interest the paired articles on severe acute respiratory syndrome coronavirus 2/novel coronavirus disease 19 (COVID-19) in this issue of Gastrointestinal Endoscopy. The first, entitled "Coronavirus (COVID-19) outbreak: what the department of endoscopy should know" by Repici et al,1 describes the Italian experience and the second, "Considerations in performing endoscopy during the COVID-19 pandemic" by Soetikno et al,2 is drawn largely from the Hong Kong experience. We congratulate the authors for their development and rigorous account of the endoscopic practices they have successfully used to minimize infection of endoscopy staff while providing essential services in this high-risk environment. Full-Text PDF Use of a modified ventilation mask to avoid aerosolizing spread of droplets for short endoscopic procedures during coronavirus COVID-19 outbreakGastrointestinal EndoscopyVol. 92Issue 2PreviewWe read with great interest the work by Repici et al1 reporting detailed procedures for minimizing the risk of infection to both personnel and patients in endoscopic units during the COVID-19 pandemic. Moreover, training the staff is crucial to prevent exposure during any endoscopic procedure.2 Full-Text PDF Preventing the spread of COVID-19 in digestive endoscopy during the resuming period: meticulous execution of screening proceduresGastrointestinal EndoscopyVol. 92Issue 2PreviewThe experience in management of the endoscopy unit during the COVID-19 pandemic shared by Thompson et al,1 Repici et al,2 and Soetikno et al3 deserves recognition. Identifying the risk of fecal–oral transmission4 and subsequently preventing potential nosocomial infections caused by digestive endoscopy are urgent issues. Full-Text PDF Gastrointestinal endoscopy during the COVID-19 pandemic: an updated review of guidelines and statements from international and national societiesGastrointestinal EndoscopyVol. 92Issue 2PreviewWe read with great interest the publications by Repici et al1 and Soetikno et al2 in Gastrointestinal Endoscopy on recommendations for endoscopic examinations during the coronavirus 2019 disease (COVID-19) pandemic. Health care workers (HCWs) are at increased risk for COVID-19 because upper GI endoscopy is a high-risk aerosol-generating procedure,2 and oral–fecal transmission may be a potential route for COVID-19.3 Full-Text PDF Factors associated with the risk of patients and healthcare workers to develop COVID-19 during digestive endoscopy in a high-incidence areaGastrointestinal EndoscopyVol. 93Issue 1PreviewWe read with interest the article by Soetikno et al1 on how to reduce the risk of COVID-19 spread among patients and healthcare workers (HCWs) during GI endoscopy. In a single-center prospective study, conducted with EC approval (Study Code GIE/COVID-19), we investigated (1) the rate of patients who experienced confirmed or probable COVID-19, according to the World Health Organization definition, after undergoing GI endoscopy and factors associated with this risk and (2) whether HCWs who took care of patients in whom COVID-19 eventually developed were at higher risk for infection. Full-Text PDF ERCP during the pandemic of COVID-19 in Wuhan, ChinaGastrointestinal EndoscopyVol. 92Issue 2PreviewWe read with great interest the recent articles by Repici et al1 and Soetikno et al.2 An outbreak of a novel coronavirus pneumonia spread rapidly through the whole country and is now a worldwide pandemic. Up until March 30, the National Health Commission of China reported a total of 82,423 confirmed cases in 31 provinces and 3306 deaths, in addition to 615,699 confirmed cases worldwide.3 With the development of the pandemic, more countries have become involved in this serious battle against the virus. Full-Text PDF Impact of the COVID-19 pandemic on endoscopy practice: results of a cross-sectional survey from the New York metropolitan areaGastrointestinal EndoscopyVol. 92Issue 3PreviewWe read with great interest the recent articles by Repici et al1 and Soetikno et al2 outlining the approaches taken in Italy and Hong Kong to adapting endoscopy practice to meet the new challenges of the COVID-19 pandemic. Because the virus has now moved to our shores, we sought to describe our experience of the impact of COVID-19 on the practice of endoscopy in the New York metropolitan area, which currently has the highest case burden in the world. Full-Text PDF