key: cord-0755521-hvma5edy
authors: Garbe, Jakob; Eisenmann, Stephan; Walter, Steffen; Lammert, Frank; Darwiche, Kaid; Rosendahl, Jonas
title: German endoscopy unit preparations for the COVID-19 pandemic: A nationwide survey
date: 2020-05-01
journal: Gastroenterology
DOI: 10.1053/j.gastro.2020.04.061
sha: ba89e3c8c6569fa2ea7c6b3de896f2d0862703bd
doc_id: 755521
cord_uid: hvma5edy

nan

The on-going Coronavirus disease 2019 (COVID-19) pandemic is a challenge for patients, healthcare professionals and populations worldwide. Endoscopy units and their staff are at high risk to be exposed to and distribute the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Therefore, guidance on endoscopic activity in this pandemic is urgently needed. Recommendations have to balance safety issues and practicability and therefore need to be cross-validated by realworld data and updated as new findings emerge.

To address the need for guidance in this situation, the European Society for Gastrointestinal Endoscopy (ESGE) and the German Respiratory Society (DGP) have published recommendations for endoscopy units to mitigate infection risks. To date it is unclear whether these recommendations can be implemented in the majority of endoscopy units, as data are scarce and limited to few centers 1 .

We conducted this survey to explore the ability to implement these recommendations. As such our data provides a basic framework for future recommendations.

Based on the ESGE and DGP recommendations, we developed 33 questions to assess the adherence to and practicability of the guidelines in an internet-based survey. Completion of the survey was possible for 7 days from April 1 st to April 7 th . Further details of the methodology are described in the Supplementary Material.

Overall, 676 complete questionnaires were retrieved, of which 20 were identified as duplicates or from outside of Germany and excluded. In total, 393 endoscopy units were from hospitals and 263 from outpatient clinics and practices from all parts of Germany (Supplementary Table 1 summarizes the results in detail.

253 endoscopy units (38.6%) cancelled less than 40%, whereas 225 (34.3%) cancelled more than 60% of their procedures (Figure 1) . Interestingly, 45.6% of private practices cancelled less than 40% of their procedures as compared to 33.8% of hospital-based units.

Ideal conditions for separation of infectious patients were achieved in 2.3% of endoscopies only (n = 15), where a complete spatial separation and a negative pressure endoscopy suite were available. A complete or ideal separation was possible in 20.3% of the investigated endoscopy units (Figure 1 ). In general, most units were not capable to separate well, as 47% could only separate partially (periinterventional area or endoscopy room) and 32.8% could not separate high-risk or proven COVID-19 patients at all.

Most endoscopy units (91.6%) identified patients at risk of infection in a structured manner.

To mitigate risk of infection, most endoscopy units issued new instructions on the risk adapted personal protective equipment (PPE) use and trained their staff in the handling of COVID-19 patients (>85%).

Routine swabs for personnel were performed in 5.5% of endoscopy units. Also, the overall rate of pre-interventional swabs for patients was low (15.1%). Bronchoscopy units had a considerably higher rate of pre-interventional swabs (32.4%) compared to GI units (8.4%).

The majority of endoscopy units (81.3%) perceived shortages in PPE as likely or very likely ( Figure 1) . Overall, 68.8% of endoscopy units expected staff shortages during the pandemic. In total, 77.4% of endoscopy units anticipated substantial financial losses that could threaten the economic survival to be likely or very likely.

This is the first nationwide survey to obtain real-world data on how endoscopy units cope with the current COVID-19 pandemic and the measures taken to ensure a continued balanced patient care. The framework of this survey relied on the ESGE and DGP recommendations that both had been published 14 days before the survey was conducted.

In recent reports the prevalence of GI symptoms in SARS-CoV-infected patients was higher than previously estimated ranging from 11.4 to 61.1% in series with a special focus on GI symptoms 2,3 . Moreover, there is emerging evidence that SARS-CoV-2 is excreted in the feces, even after it becomes undetectable in the pharynx and lung 4 . Furthermore, live virus was detected in the stool of patients 5, 6 . As a consequence of the current knowledge, endoscopy societies have recommended to postpone or cancel all but emergency and urgent endoscopic interventions 7 . Our results demonstrate that approximately one third of the participating endoscopy units followed these recommendations as more than 60% of all procedures were cancelled. However, approximately 40% of the endoscopy units still performed more than 60% of their procedures.

Interestingly, units performing >60% of procedures were more likely to be private practices ( Figure   1 ). In their comments, heads of outpatient GI units repeatedly pointed out the ethical dilemma since their economic survival is threatened by cancellations. Therefore, strategies to substitute for financial losses endangering economic survival need to be discussed and implemented particularly for privately owned endoscopy units worldwide. Again, all these measurements need to be evaluated for their effectiveness in the future.

Lastly, fear is evident among many endoscopists that a lack of PPE might further complicate endoscopic activity in the future. Reprocessing of masks is possible and as such warranted in the current situation. While many practices and outpatient clinics do not have the necessary tools to provide safe reprocessing, cooperation with nearby hospitals and laboratories might be an option to reduce the impact of current PPE scarcity. A mean is given for procedural measures consisting of the structured risk assessment for patients (n = 599), risk-adapted use of personal protective equipment (PPE) (n = 558) and training of staff to handle COVID-19 patients (n = 584). Bottom: Expectations of endoscopy unit heads for the future concerning shortages in PPE and staff as well as financial losses threatening economic survival of the unit.

British Society of Gastroenterology. Endoscopy activity and COVID-19: BSG and JAG

Gastroenterology professional society guidance on endoscopic procedures during the COVID-19 pandemic

The authors thank all participating heads of endoscopy units for their responses, trust and insightful comments. The authors especially thank Clara Heidmann, Marko Damm, Sebastian Krug, and Patrick Michl for their substantial support to perform the survey and writing the manuscript.German endoscopy unit preparations for the COVID-19 pandemic: A nationwide survey