key: cord-0847637-wj0dxicl authors: Guda, Nalini M; Emura, Fabian; Reddy, D. Nageshwar; Rey, Jean ‐Fracois; Seo, Dong‐Wan; Gyokeres, Tibor; Tajiri, Hisao; Faigel, Douglas title: Recommendations for the Operation of Endoscopy Centers in the setting of the COVID19 pandemic – A WEO guidance document date: 2020-06-22 journal: Dig Endosc DOI: 10.1111/den.13777 sha: be39517c7d19303a48e8cb94f674dbf2e1d5d73b doc_id: 847637 cord_uid: wj0dxicl SARS‐CoV‐2 (Severe Acute Respiratory Syndrome Corona Virus 2) is the etiologic agent causing the disease COVID‐19(Corona Virus Disease 19), resulting in a worldwide pandemic. Non emergent endoscopy services have been disrupted as incidence and hospitalizations were rising. It is anticipated that the peak incidence may be leveling off in many parts of the world, but there is a concern for resurgence of the virus activity. Thus, it is important for endoscopy units to have plans in place during peak times of the epidemic and when resuming endoscopic services as the pandemic wanes. The global endoscopy community is faced with the challenge of providing care during this time. The WEO‐COVID guidance task force has provided this resource document based on the current evidence and consensus opinion. These WEO recommendations are meant to guide endoscopists worldwide, should be interpreted in light of specific clinical conditions and resource availability and may not apply in all situations. This guidance document does not supersede the need to check for all local regulations and legislations. In December 2019 the World Health Organization has first reported a cluster of cases caused by a novel strain of corona virus, SARS-CoV-2. Over 6 million people in more than 200 countries have been affected and 371,000 deaths reported to date in what is now considered a global pandemic by the World Health Organization . 1 Although the most common manifestation of SARS-CoV-2 is a respiratory illness, the manifestations of the disease have varied from a completely asymptomatic presentation to respiratory failure, septic shock, organ and coagulation dysfunction with case fatality rates ranging from <1% to 16.4% . 2 Human-human transmission of SARS-CoV-2 mainly occurs through large droplets and contact and less so by aerosols and fomites. [3] [4] [5] The virus can be transmitted at least to a distance of one meter by aerosols although the maximum distance is unclear. 6, 7 Endoscopists are at risk of aerosol infection due to the proximity to patient and the potential aerosol generation during the procedures, although, recent data suggest that the risk is low. [8] [9] [10] In the setting of rapid spread and high fatality rate, all non-emergent procedures including endoscopy were delayed throughout the world. This was to minimize the spread of the disease and decrease resource utilization. Due to stringent social distancing norms and quarantines, most countries seem to have passed their peak of infections (Phase 6 of the 6 phases of the pandemic as defined by WHO) or there has been This article is protected by copyright. All rights reserved "flattening of the curve". 1, 11 Though, many parts of the world are seeing a decreased disease activity level (compared to peak), current models suggest possible resurgence of the disease due to relaxation of social distancing norms. 12, 13 Delays in endoscopic procedures results in backlogs and potential for delay in diagnosis and harm to patients. (10, 11) Delaying colorectal cancer screening and variceal screening in those with cirrhosis for 6 months could result in delayed diagnosis, increased health care costs and mortality. 12, 14 The task force understands that the disease severity might be different in various parts of the world and the resources might be variable. This document deals with 1) the practice of safe endoscopy (peak/resurgence of the disease/phases 4-6) and 2) recommendations during the post peak phase. 15 During the peak phase most units stopped performing routine elective endoscopy. In triaging the care of patients needing endoscopy, it is important to consider the indication and the urgent need for the procedure. Routine procedures (no harm if not done in 4 weeks) should be avoided and urgent ones are to be done (delay harmful to the patient). The principal concept being benefits> harm. Prior to performing endoscopy attempts should be made to identify patients at increased risk for or currently infected with the COVID-19 virus. All patients should be screened by questionnaire for symptoms or exposures . Positive answers should prompt viral testing or delay or cancellation of non-urgent procedures or consider performing / transfer to a COVID-19 dedicated facility. If viral testing is readily available, it is recommended that all patients undergo rapid nucleic acid based (PCR)/antigen testing. 16 This article is protected by copyright. All rights reserved have viral testing to ensure clearance. 18 . It is a reasonable assumption that reactivation, reinfection and viral shedding despite seroconversion are possible. 12 In general, all endoscopic procedures carry some risk of generating aerosols. Upper endoscopic procedures are thought to carry the highest risk. Although SARS-CoV-2 has been isolated from stool, fecal oral transmission of the virus has not been confirmed. Nonetheless, colonoscopy and sigmoidoscopy do carry some risk of aerosol generation. 18 It is recommended to have an algorithm to help triage and make decisions especially in the case of rising COVID-19 infections or peak prevalence (Table 1) . 19 There have been various algorithms proposed based on the experience from areas where the disease prevalence was high and risk stratification was based on either laboratory-based PCR testing or clinical, epidemiological or procedure related risk factors. 12, [20] [21] [22] [23] [24] [25] [26] [27] Ultimately the decision to perform or delay a case should be individualized. It is preferable these procedures are done in hospital-based endoscopy unit preferably in a negative pressure room where available. Portable HEPA filters could be used . Endoscopists and staff should protect themselves with full PPE including respirator mask, water proof disposable gown, gloves (double recommended), protective hairnet, eyewear and shoe cover, using proper donning and doffing techniques. 28 When general endotracheal anesthesia is used only the anesthesiologist/anesthesia staff and a nurse with full PPE be present in the room at the time of intubation and extubation. Post procedure the endoscopist should remove the PPE and ideally outside the room with the help of a second person. PPE should be removed, hand hygiene performed prior to moving to the work area to complete the operative procedure notes. Post procedure the room should remain empty for 6-12 air cycle exchanges and then undergo terminal cleaning (all surfaces, including walls to be wiped down with standard hospital grade disinfectant). The current recommendation is for 6 air exchanges for endoscopy and 12 for bronchoscopy. Increased air exchanges to 12/minute may reduce the time in between procedures to 30 minutes. 29 It This article is protected by copyright. All rights reserved is helpful to post the donning and doffing instructions in the endoscopy room. 20, 28, 30, 31 Some novel barrier shields are in development. 32-34 For asymptomatic and low risk patients (e.g. no history of exposure or travel to high risk area, negative pre-procedure viral testing) standard PPE including surgical mask, eye protection, gown and gloves is recommended. The decision to use a respirator mask should be based on local availability of respirators and SARS-CoV2 prevalence recognizing that asymptomatic patients may shed virus. (Table 2) Other Considerations during the peak/resurgence phase: Only essential personnel should be present in the endoscopy room. Minimize the number of horizontal surfaces in the room. The endoscopy assistant should change gloves to touch or reach any equipment to minimize contamination. Trainee involvement may be restricted. Reuse of the N95 respirator mask is considered reasonable in view of the local shortages and various methods are available to preserve them. Please check the local resources for the optimal method of preserving and reusing the masks 35 Options include using the same mask for a week at a time and storing the mask in a paper bag or container until the end of the week or until it is soiled and is either discarded or sent for cleaning. Similar strategies have been used for face shields. Other barrier equipment including impervious gowns, hair nets, shoe covers, and nitrile gloves seem to be available. Where N95 or equivalent respirator masks are not available a surgical mask may be used. Data regarding efficacy as compared to N95 respirator are conflicting. 16 This article is protected by copyright. All rights reserved Guidance for safe endoscopy services post peak/resurgence of COVID -19 infection: Before opening one should check with the local regulations and authorities regarding the opening of endoscopy services. Any regional/local guidance supersedes any guidance provided here since local conditions may vary. WEO recommends that you notify your local/regional health authorities regarding resumption of services as applicable. Ideally Prior to reopening, assess the endoscopy unit including the pre-procedure and postprocedure areas to maximize safety for patients and staff. This includes appropriate ventilation, negative pressure capabilities, the possibility of using portable HEPA filter equipment, air change rate settings, and adequate spacing or barrier separation of patients in the pre-and post-procedure recovery areas. If pre-procedure COVID-19 testing is to be offered, identify a testing site remote from the endoscopy unit so as to prevent potentially infected patients from entering your facility. We recommend assessing the lobby area rearranging or taping off seats and adding appropriate signage to maintain physical distancing (2m). Consider installation of additional barriers at reception (e.g., Plexiglas). Notify your vendors (supply chain), referring providers and other ancillary services. Ensure This article is protected by copyright. All rights reserved that your affiliated or local hospital has adequate capacity to admit your patients should the need for hospitalization arise. For endoscopy units that were completely shut down it is advisable to contact your scope manufacturer regarding scope cleaning. All procedural areas should undergo terminal cleaning before reopening. For larger units it might be reasonable to delegate teams to look into various aspects of operations such scheduling, screening, room turnover, sedation/anesthesia, infection control and supplies. Team members might include an endoscopist, the nurse manage, anesthesia provider and administrative staff each with a delegated responsibility and perform a periodic team meeting to ensure safe operation of the unit and to ensure patient and staff safety. Check lists are helpful. (Table 3 ) We advise contacting the staff to ensure their availability and that there is adequate staffing while planning return to operations. Ideally, staff should be assigned to one team consisting of one endoscopist with a procedure nurse/assistant per day so that in case of exposure alternate staff are available. This also helps with the flow and minimizes PPE use. During the procedure minimize staff changes to conserve PPE. Staff should be rotated in such a way that there are adequate number of staff should there be any illness or exposure. Consider using one or two teams for the intra procedural area for a few days or weekly and rotate them with the pre/post procedural area staff. All staff should be checked daily for temperature, symptoms, and exposure. Staff rest areas should also be maintained in such a way that there is social distancing. All staff should wear a mask on entry to the unit until they exit except when eating, drinking beverages or when they are in their private offices. Staggered breaks are advised to minimize crowding in the rest areas. Trainee participation during the peak phase was restricted to minimize exposure and conserve PPE. Balance educational needs with the clinical needs of the patient and the operational issues. Similar restrictions apply for observers and industry representatives. This article is protected by copyright. All rights reserved The preprocedural check in area should be minimally occupied. Avoid any unnecessary furniture or decorations to minimize cleaning requirements. Rearrange furniture to maintain 2m distance between each patient/visitor. Staff should be advised to wear gloves or use 70% alcohol-based sanitizer between each contact. Any electronic equipment used should be cleaned after every use and use disposable pens are encouraged. Avoid reading materials, uncovered food or unbottled beverages. Ensure hand sanitizers or hand wash areas are available. This article is protected by copyright. All rights reserved All staff should follow the proper protocol for doffing the PPE. Once PPE is removed and hand hygiene is performed the endoscopist should wear a regular mask before returning to the work area to complete the procedure note and discharge instructions. 28 Based on the unit policy the post procedure findings and instructions may be conveyed to the patient/visitor or family in person or by a telephone/video visit. Each provider should be provided only one workstation, telephone, and equipment. Use of surgical scrubs in the work area when feasible might limit infection. The endoscopy unit floor should be mopped regularly at least 2-3 times a day. All procedure rooms should be cleaned after each procedure. All horizontal surfaces should be cleaned. Consider terminal cleaning after each high-risk patient procedure or at least once a day at the end of each day. Consider cleaning all door handles/knobs or frequently touched surfaces. All toilets should be cleaned regularly. This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved document provides guidance to endoscopists and endoscopy units to continue to provide needed care to patients both during a pandemic surge and the subsequent recovery. These recommendations are meant to guide endoscopists may not apply in all situations, and do not supersede local advisories and institutional guidelines. Marchese Legends for Tables: Table 1 : Prioritization of endoscopic procedures during peak pandemic prevalence This article is protected by copyright. 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