COMMENTARY

Practical Advice for Performing Endoscopy in a Pandemic

David A. Johnson, MD

Disclosures

April 08, 2020

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

This transcript has been edited for clarity.

I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

COVID-19 is now well recognized as a world pandemic. That's certainly been underscored in the United States by the explosion of infections and resulting drain on our healthcare resources.

We know that this virus is transmitted through a microdroplet spread of a variety of secretions, in particular, respiratory secretions, as well as through aerosolization of a variety of fluids (eg, saliva, feces). The potential spread of the virus via contaminated environmental surfaces has also gained attention, given that approximately 40% of patients with COVID-19 have had no known direct epidemiologic contact with a reported index case. [Editor's note: Since the recording of this video, the percentage increased to about 80%.] Virus particles keep their integrity for up to 3 hours in microaerosol form and up to 3 days on surface areas. This suggests another key route for infectivity of both asymptomatic and symptomatic patients.

COVID-19 is a particular concern for healthcare providers. During the initial outbreak in Wuhan, China, 29% of the infections were in healthcare providers treating patients. We can't rise to the task of combating COVID-19 without protecting our healthcare providers.

Endoscopies Already Present Risks for Infectious Spread

An endoscopy is an aerosol-generating procedure, with the potential for microscopic spread of infectious particles. A 2019 study conducted prior to the COVID-19 outbreak reported a significant colonization count within 6 feet of the table where the endoscopy was performed, including the surgeon's mask and the endoscopy suite walls, posing a real and potentially unrecognized risk. The coughing and retching that often can accompany upper endoscopy also generates aerosol, especially with the use of a suctioning device. During upper endoscopy, the proximity of the upper gastrointestinal and upper respiratory tracts may also increase the risk.

Colonoscopy can lead to inflation that disseminates bacteria to nearby surroundings. And even after an endoscopy is complete and patients are discharged to the recovery area, contamination can still occur in the form of saliva on their pillow or fecal bacteria on the bed.

A study published this March in JAMA specifically addressed the risk for microaerosolization and colonization in patients who were COVID-19 positive. Researchers were able to demonstrate the virus in the patient's room—not only in the bed but also on the sink, bathroom, light switches, and doors—as well as on the shoes and stethoscopes of the staff caring for them. That presents a real exposure risk.

Prepping Your Facilities for the Worst

Dr Roy Soetikno and a group of international colleagues have just published a literature review offering practical suggestions for performing endoscopy in patients who potentially have or are positive for COVID-19. There are a few take-home messages that I wanted to highlight for you, the first of which have to do with preparing your staff and facilities.

The authors recommend that you familiarize the staff with the appropriate measures for high-level COVID-19 protection as it relates to proficiency in personal protective equipment (PPE), including the use of N95 masks. They note that there is often a disconnect between perceived and appropriate use of PPE in this regard and recommend consulting the World Health Organization's guidelines. The suggestion from the group, which I think is very viable, is to use a buddy system where a colleague observes you when gowning up and, I think most critically, when gowning down.

Second, they recommend setting up a reception bay to screen and evaluate these patients, before they even get to the waiting area alongside other patients. Minimize potential exposure in this setting, obviously, by ensuring that patients are separated by 6 feet or more.

The idea that staff should take additional precautions is a key element of this discussion. They recommend that staff should work at individual workstations using a designated phone, computer, and chair and stay at least 6 feet away from their coworkers when possible. This means not using devices or equipment that were in non-environmentally protected workstations. And then, certainly, create a virucidal cleaning process to be employed in these workstations at particular times.

The group's recommendation for bathrooms is really interesting. I wholeheartedly agree with this given that the bathroom is a site of transmission, particularly now that we recognize the possibility for fecal transmission of the virus. (And, although we don't yet know whether this leads to infectivity, my hunch is that it absolutely does.) Ideally, patient and staff bathrooms should be separated and disinfected frequently.

Putting COVID-19 Protocols Into Practice

The authors also provide some very significant practice recommendations. One is that all staff have daily measurements of temperature before starting work, with febrile staff not allowed to work. The same temperature checks should be given during the screening of patients before they get into the specific endoscopy area.

Second, they recommend employing the Centers for Disease Control and Prevention's COVID-19 mitigation strategies. These require wearing a face mask in the hospital, in particular in the endoscopy lab. This is something that many of us may have not been doing routinely in the past during endoscopy, but is now absolutely essential. This goes for all staff, given that we know this has a transmission potential from its microaerosolization within about 6 feet, maybe even more.

They also recommend that the healthcare provider use appropriate clothing. This includes using hospital-issued scrubs and—one that I think potentially many of us have not been doing—dedicated endoscopy shoes that are left at work. That is certainly justified given the recent epidemiologic report showing that the virus was detected on practitioners' shoes. They do recommend that boot covers be used, during endoscopic retrograde cholangiopancreatography in particular, but also considered across the board in all cases.

The next recommendation revolves around preparation for endoscopy, which I believe is a really critical mandate now. Include verification of the patient's COVID-19 status so you can allow for more accurate risk stratification before you do your procedure. This should be documented as part of the time-out protocol before the procedure starts.

There is also a recommendation for patients who need advanced support from endoscopy anesthesia; we're not talking about typical monitored anesthesia care here but general anesthesia. The endoscopy staff should extract themselves from the room during tracheal intubation, if it is required. The upper and lower respiratory tracts certainly have a higher viral load of infectivity, and you want to protect your staff by keeping them out of the room. The anesthesiologist and their team best understand that risk and how to potentially mitigate it.

The next piece of advice is also very important. We routinely prescreen our patients who require emergent or semi-urgent endoscopy and always call them the day after the procedure to talk about safety. These authors now recommend contacting asymptomatic patients within 14 days after the procedure to check on their progress. At my practice, we now do this at 7 and 14 days after the procedure. If they have some alarming symptoms or signs, you will have to go back and look at who was exposed during that potential case of COVID-19.

The piece of advice I want to share pertains to trainee exposure. Obviously, we're trying to train the trainees, but their involvement does extend the procedure time and odds of exposure during endoscopy. Fellows' involvement in gastrointestinal training programs should really be minimized. Potentially, we can use the fellows more proactively, as they've done in New York, by enlisting them on the intensive care side.

We need to understand that the healthcare providers really are the key resource in combating COVID-19. Gastroenterologists may not be involved in many endoscopy procedures with these patients, but we can be potentially be proactive in our prevention, not only for our staff but also for ourselves. The idea of maintaining a risk-free environment for the healthcare provider and the staff is critical in preserving the resources that we need to deal with this global pandemic.

This is Dr David Johnson. Thanks again for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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