key: cord-0875351-z4l3lq39 authors: Tian, Qing; Yan, Xiaodong; Shi, Rui; Wang, Guijie; Xu, Xiaomei; Wang, Hongyan; Wang, Qingqing; Yang, Long; Liu, Zirong; Wang, Lanying; Shrestha, Dhan Bahadur; Zhang, Yamin title: Endoscopic mask innovation and protective measures changes during the COVID‐19 pandemic: experience from a Chinese hepato‐biliary‐pancreatic unit date: 2020-07-23 journal: Dig Endosc DOI: 10.1111/den.13799 sha: 858c21bbc1168bb028cb00756189ccc078f33c13 doc_id: 875351 cord_uid: z4l3lq39 Endoscopy is widely used as a clinical diagnosis and treatment method for certain hepatobiliary and pancreatic diseases. However, due to the distinctive epidemiological characteristics of SARS‐CoV‐2 (the virus causing COVID‐19), healthcare providers are exposed to the patient’s respiratory and gastrointestinal fluids, rendering endoscopy a high risk for transmitting a nosocomial infection. This article introduces preventive measures for endoscopic treatment enacted in our medical center during COVID‐19, including the adjustment of indications, the application of endoscope protective equipment, the design and application of endoscopic masks and splash‐proof films, and novel recommendations for bedside endoscope pre‐sterilization. In December 2019, COVID-19 broke out in Wuhan, Hubei Province, China, and quickly spread to other provinces and countries 1 . According to epidemiological investigations, the main source of infection is patients with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which may also include asymptomatic infection 2, 3 . Droplet transmission and close contact transmission are the main modes of transmitting SARS-CoV-2, but there is a possibility of aerosol transmission in a relatively closed environment, due to long-term exposure to This article is protected by copyright. All rights reserved high concentrations of aerosol. The isolation of SARS-CoV-2 in feces and urine suggests that the virus may be spread by aerosols and close contact transmission caused by fecal and urine pollution in the environment 4, 5 . For some hepatobiliary and pancreatic diseases, conservative treatment often cannot alleviate the patient's symptoms. Endoscopy is widely used as a clinical diagnosis and treatment method. During the COVID-19 pandemic, due to the distinctive epidemiological characteristics of SARS-CoV-2, endoscopy poses a high risk of nosocomial infection, since healthcare providers are exposed to the patient's respiratory and gastrointestinal fluids 6 . Therefore, to minimize infections among patients and medical personnel, identifying an orderly and safe method for emergency endoscopy treatments has become an urgent concern. This article introduces the COVID-19 prevention measures used in our medical center (Department of Hepatobiliary Surgery, Tianjin First Central Hospital). Building on the prevention and treatment experience of other countries or centers 7-10 , we offer several reasonable suggestions for conducting endoscopies during the pandemic, applying endoscope protection articles, and endoscope reprocessing. Based on their possibility of having COVID-19, our patients are categorized as high, medium, or low risk. Patients with different risk levels are classified and treated in different ways ( Table 1) . The specific evaluation criteria are as follows 11, 12 : a) any symptoms caused by SARS-CoV-2 infection, including but not limited to fever, cough, dyspnea, and gastrointestinal symptoms; b) any exposure to patients confirmed or suspected to have COVID-19 in the past 14 days; c) travel history in countries or regions with a high incidence of COVID-19 in the past 14 days; and d) travel history and health condition of family members. This article is protected by copyright. All rights reserved 2) Carry out training on COVID-19 and personal protection through a mobile phone app, a website, and a video presentation. 3) Establish a permanent and experienced endoscopic treatment team to manage outpatient and emergency patients with related diseases. 4) Develop a detailed list of personal protective equipment (PPE), including disposable protective clothing, N95 masks, medical masks, and face shields, to ensure that medical personnel have sufficient PPE to protect them from viruses. 5) Assign special personnel to conduct daily personal health surveys for all medical personnel in the department, including temperature, activities outside the hospital, etc. 6) All medical personnel who a) have fever or respiratory symptoms, b) had contact with suspected or confirmed COVID-19 patients, c) live in or had contact with individuals residing in areas where the disease is prevalent, or d) recently returned from a high-pandemic area or country should undergo self-isolation for 14 days. If necessary, a nucleic acid antibody staining test and related tests and examinations shall be carried out. 7) In the staff restroom or dining room, the separation distance should be increased to at least 1 meter, to avoid cross-infection caused by face-to-face contact. This article is protected by copyright. All rights reserved 8) Develop good hand hygiene habits and reduce the possibility of contact transmission. 9) Ensure sufficient rest time for medical personnel, to prevent low immune function and increased risk of virus infection due to overwork. 1) Open an Internet telemedicine system and telephone consultation service, arranging for doctors to provide consultation service to patients, in order to reduce patients' visit time, frequency, and process, thereby reducing the risk of hospital infection. 2) In order to shorten waiting time, consider adopting an outpatient appointment mode. An isolation waiting area should be set up outside the diagnosis room. The distance between each patient should be at least 1 meter, and a maximum of one accompanying individual is allowed 13, 14 . All patients and their accompanying individuals should wear medical masks and undergo epidemiological investigation. 2) Endoscopy should be carried out in a fixed endoscopy room with the air conditioning and ventilation equipment closed, or in a negative-pressure operating room. In addition, our center recommends that only an experienced endoscopist, an instrument nurse, and if necessary an anesthesiologist be kept in the endoscopic unit 15 . 3) During the treatment process, disposable treatment towels and bed sheets should be selected as much as possible, to prevent contamination caused by gastric juice splashing during the operation and cross-infection among patients. 4) Our center recommends that patients be given no anesthesia or intravenous anesthesia during endoscopic procedures, to reduce the choking caused by intubation, which can cause droplets or aerosol transmission. masks, goggles/face shields, disposable waterproof surgical gowns, medical gloves, headgear, boot covers, etc. For patients with COVID-19, medical personnel should wear N95 masks, goggles/face shields, disposable protective clothing, double gloves, headgear, and boot covers. 6) Our center reconstructed a simple duodenoscopy protective mask using a duodenoscopy bite block and a respiratory mask. Use sterile scissors to cut an appropriate opening in front of the This article is protected by copyright. All rights reserved respiratory mask and place the bite block into the respiratory mask. The patient bites it and wears the mask before the operation. An oxygen catheter can be connected to the upper end of the mask to give oxygen to the patient during endoscopic operations. At the same time, the patient's body surface is covered with a disposable, transparent, waterproof plastic film containing operation holes. The duodenoscope is inserted into the patient's body through the operation hole and the bite block for treatment. This operation can further cut off the transmission path of the virus, and relevant experiments have confirmed that the use of splash film can effectively reduce the spray range 16 . It is important that these items are disposable and easily accessible. This can avoid cross infection between patients and reduce indoor aerosol dissemination range, greatly improving the safety factor and utilization rate of the endoscope unit. 7) After treatment, our center also improved bedside pre-processing. The enzyme cleaning agent we used, which had no sterilization or disinfection effect, was changed to weak alkaline peracetic acid. When the endoscope is removed from the patient's mouth, wipe the endoscope with sterile gauze moistened with weak alkaline peracetic acid disinfectant (2300 mg/L). Put the lens into a This article is protected by copyright. All rights reserved 1) After endoscopic treatment, transfer the patient back to the ward through a fixed route and minimize going out as much as possible. Arrange a fixed escort to care for the patient. 2) For suspected or confirmed COVID-19 patients, our center recommends using double-layer medical garbage bags to seal the patient's excreta, sending the bags to a medical waste treatment center for disinfection, and then discharging them again. 3) Patients should develop good hand hygiene habits to prevent fecal-oral virus transmission. 4) Our patients usually have a fever, cholangitis, and other symptoms before surgery. Therefore, our center recommends using a biliary stent instead of a nasobiliary duct for biliary drainage as much as possible, to avoid the risk of hospital infection caused by the external drainage of bile. After surgery, anti-inflammatory treatment with broad-spectrum antibiotics is necessary for patients at risk of biliary infection. Based on the results of imaging and laboratory examinations, perform differential diagnosis on fever patients again. This article is protected by copyright. All rights reserved 7) Patients who meet the discharge criteria should be discharged as soon as possible, to avoid hospital infection caused by long-term exposure to the hospital environment. At the same time, follow up with the patients and their accompanying individuals for 14 days, to rule out the possibility of asymptomatic infection. 8) The discharged patients can avail remote follow-up consultation services with competent doctors through an Internet telemedicine system, a mobile app, and other methods, to reduce the number of visits and avoid the risk of cross-infection in the hospital. The potent virulence of SARS-CoV-2 has resulted in a worldwide pandemic. 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