key: cord-0891437-devs90kl
authors: Sethi, Amrita; Swaminath, Arun; Latorre, Melissa; Behin, Daniel S.; Jodorkovsky, Daniela; Calo, Delia; Aroniadis, Olga; Mone, Anjali; Mendelsohn, Robin B.; Sharaiha, Reem Z.; Gonda, Tamas A.; Khanna, Lauren G.; Bucobo, Juan Carlos; Nagula, Satish; Ho, Sammy; Carr-Locke, David L.; Robbins, David H.
title: Donning a new approach to the practice of gastroenterology: perspectives from the COVID-19 pandemic epicenter
date: 2020-04-21
journal: Clin Gastroenterol Hepatol
DOI: 10.1016/j.cgh.2020.04.032
sha: 564dc53bc4984dbb8497a1ae9cf5cea01e464fdd
doc_id: 891437
cord_uid: devs90kl

Abstract The COVID-19 pandemic is seemingly peaking now in New York City and has triggered significant changes to the standard management of gastrointestinal diseases. Priorities such as minimizing viral transmission, preserving (personal protective equipment) PPE, and freeing hospital beds have driven unconventional approaches to managing GI patients. Conversion of endoscopy units to COVID units and redeployment of gastroenterology (GI) fellows and faculty has profoundly changed the profile of most GI services. Meanwhile, consult and procedural volumes have been drastically reduced. In this review we share our collective experiences, how we have changed our practice of medicine, in response to the COVID surge. While we will review our management of specific consults and conditions, the overarching theme focuses primarily on non-invasive measures and maximizing medical therapies. Endoscopic procedures have been reserved for those timely interventions that are most likely to be therapeutic. The role of multidisciplinary discussion, while always important, has now become critical. And the support of our faculty and trainees remains essential. Local leadership can encourage well-being by frequent team check-ins and foster trainee development through remote learning. Advancing a clear vision and a transparent process for how to organize and triage care in the recovery phase will allow for a smooth transition to our “new normal.”

By April 10, 2020 the number of COVID-19 cases in New York reached nearly 160,000 (with over 92,000 cases in the metropolitan region alone), a staggering and grim state statistic that alone exceeded that of any country. On March 16, about one week before New York was labeled the epicenter of the pandemic, the New York Society for Gastrointestinal Endoscopy (NYSGE) issued guidelines that built on those from national societies and published narratives from other global epicenters. [1] [2] [3] [4] The urgent communication strongly emphasized prioritization of endoscopic procedures, outlined operational practices of the endoscopy suite, and defined PPE standards to be followed during endoscopy. Yet our growing experience and variability in regional rates of infections, availability of resources, and institutional guidance necessitates tailoring of national recommendations. Most guidelines have yet to address practical changes to management of GI consults and common GI issues in response to the pandemic.

The aim of this review is to describe how GI consultative services and management of some disease specific illnesses such as inflammatory bowel disease (IBD), have been redesigned throughout hospitals in the NY metropolitan area, not unlike how practicing (and in some cases previously retired) gastroenterologists have been redeployed as COVID hospitalists and endoscopy suites repurposed as COVID care units. These modifications follow several guiding principles that are listed in Table 1 and focus on rethinking methods for the assessment of patients with GI diseases, modifying strategies for intervention, and working in tandem with other services to achieve acceptable outcomes. An unexpected consequence of this virus's attack is the hijacking of our standards of excellence and coercion to change our practice in ways that contradict our sensibilities. This narrative review describes some of our proposed solutions to these unfamiliar challenges. By sharing our collective experience we hope that regions of the country yet to endure the full brunt of this contagion will be better informed to implement similar strategies and mitigate what has proven to be a relentless and sustained attack on us all.

Nothing about the practice of endoscopy was unscathed as the pandemic inundated the city. By the 3rd week of the pandemic the large hospital systems were 40-80% filled with COVID patients, with up to 25% requiring intensive care unit (ICU) care in some locations. On average, GI services in these hospitals decreased their procedural volume by 80-90% and the consultative volume by 50%. By the time of this writing, repurposing endoscopy suites to COVID care units has occurred in many of the hospital systems in the region. Procedures are now largely relegated to the operating room (OR) or to the bedside in ICUs, and approved indications remain sharply restricted. Anesthesiologists and their equipment are being used to furnish makeshift ICUs while endoscopy staff, including GI faculty and many of New York's 400 fellows, are redeployed throughout the hospital. Many institutions have created central OR committees to review all procedures and surgeries in order to ensure fair provision of resources across the hospital. GI procedures and consults are performed by only 1-2 faculty members, most often a general GI consult attending and an interventionist, who is not typically in the hospitalist redeployment pool. Undeployed fellows play supporting and non-patient contact roles or staff virtual outpatient consults. Finally, some programs have consolidated all GI services, including subspecialty services such as pancreaticobiliary, IBD and transplant hepatology, into one consultative service for all consults.

Updates on guidelines for indications, PPE, and procedural logistics As indicated above, early local guidelines followed national and international recommendations regarding indications of procedures, use of PPE and endoscopy suite etiquette. However, over the few weeks that followed individual institutions went through volatile changes of PPE availability that mandated revised policies. By executive order, ambulatory surgical centers (ASCs) were mandated to stop performing elective procedures and as result many have been forced to close entirely. Some centers, particularly those with hospital affiliations, have been repurposed as COVID care centers while others have redirected staff and equipment resources to assist in the COVID response. Sustained community transmission combined with still limited availability of testing, high false negative rates (~40%), and presumed high prevalence of asymptomatic carriers forced revision of guidelines, including those listed in Table 2 , to be followed for procedures regardless of venue or a patient's COVID status. Changes in indications for procedures will be discussed separately below. Since most procedures now occur off-site, efforts should be made to perform them during the day when more resources and staff are available to manage intra-procedural modifications or complications.

While some specialties report a decrease in their most common emergencies, such as heart attacks, 5 significant GI bleeding remains prevalent and this includes complications from COVID-related illness (Mallory-Weiss tears, profound diarrhea and hypovolemicinduced ischemic colitis). A recent regional survey demonstrated that 70% of consults during this time are for GI bleeding. 6 While overt GI bleeding typically prompts rapid endoscopic evaluation, procedural parsimony is the new rule. Across institutions, our consensus found that urgent upper endoscopies were rarely performed within the first 24 hours. Similarly, procedures for lower GI bleeding were nearly uniformly deferred and have been postponed to the outpatient venue. While these strategies were not driven by pre-pandemic studies regarding the timing of endoscopic intervention, this practice has fortuitously been reflected in emerging literature. 7, 8 Returning to basic principles of resuscitation, optimizing medical management, and exhausting alternative diagnostic modalities allows us to focus only on procedures most likely to be therapeutic. COVID-19 infection can mimic or exacerbate the hemodynamic effects of GI bleeding and an effort should be made to discern between the two by administering acetaminophen, intravenous fluid and blood products as indicated. While aggressive medical management should be individualized, it is worth considering PPI infusions over intermittent IV administration, liberalized octreotide infusions for patients with suspected or known liver disease, scheduled antiemetics, platelets and/or clotting factors to correct iatrogenic or acquired coagulopathies, and reversal agents if appropriate. Emerging experience in critically ill COVID patients suggests they can develop a pro-thrombotic form of disseminated intravascular coagulation (DIC), placing them at a dramatically increased risk of thrombosis. Many of these patients may therefore be receiving newly prescribed anticoagulants which need to be considered when evaluating and managing GI bleeding issues in this cohort.

In hemodynamically stable cases where active upper GI bleeding is in the differential but remains indeterminate, we propose pursuing alternative diagnostic modalities such as CT angiography and bedside real-time viewer capsule endoscopy. Nasogastric tube (NGT) lavage in ventilated patients, a somewhat outdated maneuver, should still be considered a useful test if blood return is revealed. This is not advised, however, in the unsedated patient because of the risk of gagging, vomiting and aerosolization.

Established parameters for assessments of acuity and severity of GI bleeding remain unchanged. These include the volume of visualized blood loss, blood loss based on lab values (both absolute and relative to baseline), rate of blood loss, response to transfusion, and hemodynamics. Physical examination of inpatients is now discouraged unless the findings are expected to impart acute changes in management. We find photo documentation of bleeding (emesis basin, bedsheets, and toilet bowls) by the patient or staff has been increasingly helpful in confirming symptoms and guiding remotely based decisions.

Inpatient GI consult services are deferring endoscopic evaluation in patients with anemia without overt bleeding, with reported/observed small volume bleeding, selflimited bleeding, and given the low therapeutic potential this includes almost all lower GI bleeding. Once restrictions begin to lift and as the word 'recovery' begins to appear in our institutional communications, these patients should be considered among the first group to receive endoscopic evaluation while further prioritizing those with ongoing symptoms or the need for anticoagulation and/or antiplatelet therapy.

Inpatients or outpatients with symptoms of dysphagia should be assessed for ability to tolerate sufficient oral intake to maintain proper weight and nutrition. Those with mild to moderate dysphagia may need to defer evaluation and therapy. Data is lacking for testing such as esophageal manometry but given the prevalence of coughing during intranasal placement, NYC centers have postponed testing. Non-invasive radiographic studies like barium esophagram may be useful to triage the need for endoscopy, however local availability of radiology services and department policies will need to be considered as well. We have found very few patients sent for timed contrast studies for any indication. Consensus indications for prompt endoscopy include inability to tolerate sufficient liquid diet with ongoing dehydration/profound weight loss or foreign body or food impaction with inability to tolerate secretions after IV glucagon has failed. 9 Options for nutritional management of patients with dysphagia will be discussed in the following section.

COVID-19 can present with nausea, vomiting, and diarrhea and these can predate respiratory symptoms. In a recent report up to 61% of outpatients who tested positive for COVID-19 experienced these GI symptoms. 10 During peak epidemic, acute nausea, vomiting, or diarrhea should be considered COVID related until proven otherwise. Outpatients should self-quarantine and minimize exposure to household contacts. For all inpatients and ongoing symptoms in outpatients, GI pathogen testing including Clostridium difficile should be considered, particularly in those with signs like leukocytosis or those with risk factors such as recent antibiotic use. In the absence of a bacterial pathogen, medical management with anti-emetics and anti-diarrheals (e.g. loperamide) can be optimized. Careful monitoring of the QTc is essential, as many antiemetics prolong the QT, particularly when combined with other agents being used for COVID-19 that also affect the QTc (hydroxychloroquine and azithromycin). Some institutions have hospital-wide protocols in place to monitor QTc and reduce risk of Torsades de Pointes.

Special circumstances may lower the threshold for endoscopic evaluation for nausea, vomiting, or diarrhea. This includes evaluation for graft versus host disease in bone marrow transplant patients and for immune-mediated colitis in patients receiving checkpoint inhibitors. If an infectious workup is unrevealing and patients remain symptomatic after maximizing medical therapy, patients should proceed to endoscopy in efforts to avoid empiric immunosuppression.

Consults for gastrostomy placement have dramatically declined across institutions in New York, with <1-2 referrals/week for percutaneous endoscopic gastrostomy (PEGs) as per a recent NY-based survey. 6 While prolonged intubation typically warrants gastrostomy placement, it is possible that the high associated mortality rate, and need to decrease invasive, aerosolizing procedures in COVID-19 infected patients, has resulted in infrequent gastrostomy placement.

The timing and method of gastrostomy placement should be largely individualized to the services and resources available at a particular location. It is recommended to bring all of the procedural services that place feeding tubes, along with ICU management, together to establish a workflow. Within the NYC area most gastrostomies in patients testing positive for COVID-19 patients are being placed by IR, especially if the patient already has a NGT in place.

Finding the optimal timing for gastrostomy placement in COVID positive patients is critical and must weigh the safety of staff with the associated potential for serious adverse events, such as bleeding, infection and death. We propose a gastrostomy be considered once the patient has shown clinical improvement and a probable chance of discharge. This implies continuing EN with an NGT until discharge seems likely. For patients requiring ICU level of care, the patient be should afebrile, in no need of pressor support with stable hemodynamics, and all potentially complicating conditions (i.e. DIC, paralytic ileus, etc.) be optimized prior to gastrostomy placement. While we recognize that nutrition is important for recovery, rushing into invasive procedures can potentially hinder recuperation. Parenteral nutrition is not recommended for patients with COVID infection due to risk of infection and/or thrombosis.

Bedside PEG placement in the ICU is the preferred venue if the room is outfitted with negative pressure. However most patients will have a previously placed NGT (which may impede discharge) and an IR-placed gastrostomy may be preferred for such patients who are not intubated but continue to have respiratory symptoms and high oxygen requirements. Consideration should be given to the increasingly described hypercoagulable state seen in critically ill COVID patients. In patients who fit the criteria for anticoagulation we recommend continuing to follow guidelines such as those outlined by the ASGE in 2016. 11 EN via weight nasogastric tube in the prone position Many intubated patients with pulmonary disease consistent with acute respiratory distress syndromre (ARDS) from COVID are being placed in the prone position. Feeding in the prone position may lead to decreased gastric emptying, vomiting and aspiration but studies have shown mixed results. Voort et al showed that EN can be continued when a patient is turned from supine to prone position (or vice versa) without consequence. The results indicated that patients with a clinically significant gastric residual volume in one position are still likely to have a clinically significant gastric residual volume in the other position. 12 Reignier et al later concluded that early EN is poorly tolerated in the prone position and use of a prokinetic agent should be considered. 13 Subsequent meta-analysis have not suggested a substantial increase in complications when EN is administered in the prone compared with the supine position. 14 We suggest EN via NGT while prone should be used with caution and patients should be watched for signs of intolerance or vomiting.

Management of interventional services leading up to the peak of the crisis has been particularly challenging due to the restrictions in allocated endoscopy space and resources in rooms not properly outfitted for interventional procedures. Within days, indications for interventional procedures dwindled down to those that needed to be performed within 48 hours in order to prevent admission, would enable discharge, or, less uniformly, enable neoadjuvant chemotherapy. Table 3 and 4 On average, the interventional procedures saw a reduction of 30-40%, the majority of which were endoscopic retrograde cholangiography (ERCP).Throughout the region's institutions, interventional procedures are reviewed by either central committees or evaluated (remotely) by two members of the advanced endoscopy team to confirm appropriateness and obtain all endoscopy unit approvals (nursing, anesthesia, scheduling) before proceeding.

The most common indications for emergent interventional procedures have been cholangitis and obstructive jaundice. While emergent ERCP remains the treatment of choice, a lower threshold for percutaneous transhepatic cholangiography (PTC) should be instituted for hemodynamically-unstable patients particularly in which mobilization is difficult, such as ICUs or when endoscopy is performed in shared space and timely intervention cannot be performed. For patients with presumed malignant biliary obstruction, the decision to obtain both a tissue diagnosis via EUS with fine needle aspiration (EUS-FNA) and biliary decompression with ERCP is fairly straightforward.

There are no data defining the urgency of chemoradiotherapy for GI cancers and most centers have a short-term (ie, 4 weeks) deferral plan. If however local resources are robust and curative cancer surgery is similarly deferred or is otherwise not appropriate, select cases have undergone tissue acquisition (TA) with EUS-FNA or ERCP with the intent of initiating systemic therapy. If however there is no immediate plan for medical oncologic treatment or if the patient is COVID+ and cannot yet begin such therapy, the decision to defer TA is reasonable. It is especially important now to recall that interventional procedures should not occur in a silo and decision-making be vetted through a multi-disciplinary process or be presented at a virtual GI tumor board. Finally, some consideration should be given to therapeutic maneuvers performed or types of stents such that there is minimal risk of delayed complications and subsequent need for reintervention in the near future.

Despite the reasonable assumption that alcohol intake has increased during the pandemic, far fewer patients have been admitted with acute pancreatitis during the COVID-19 crisis. Medical management of patients with acute pancreatitis should be optimized with the goal of deferring otherwise indicated procedures, such as ERCP and sphincterotomy in gallstone pancreatitis or drainage of pancreatic fluid collections. Intervention should be reserved for deteriorating clinical status and signs of impending sepsis.

Malignancy-related bowel obstruction is common, is not always amenable to surgical intervention, and can delay chemotherapy. Venting gastrostomies should be considered as urgent procedures for palliation of small bowel obstruction if a patient will not be accepted to hospice with a naso-gastric drainage tube. In the setting of COVID-19 and restricted access by surgeons to the OR, colonic and duodenal stenting for large bowel and gastric outlet obstruction, respectively, should be prioritized as urgent procedures if in line with the patient's goals of care. Partial bowel obstructions should be managed medically for as long as possible.

Complex interventional procedures such as EUS-guided ERCP, third-space endoscopy, or tumor resection have been deferred at this time given the time constraints of available shared anesthesia time, increased risk associated with the procedures, decreased access to resources for management of complications such as surgical intervention, and need for potential post-procedure admission and prolonged hospital stay.

There are no guidelines for how to integrate radiation protection (lead-equivalent attire with a thyroid shield) into the required level of PPE. We recommend first donning the head and shoe covers before donning radiation protection, and then proceeding with the donning sequence for the remainder of PPE. Radiation protective attire should be wiped down with disinfectant immediately after use.

Considerations for hepatology-related consults, such as elevated liver function tests (LFTs), complications of cirrhosis, and variceal bleeding will not be discussed in this review. Our consensus suggests most hepatology services defer to very recently published clinical insights released by the AASLD. 16 We recommend readers reference this resource as well.

There are a myriad of logistical and clinical challenges that disrupt IBD care during the pandemic. We present some of the most common scenarios encountered.

Fear of exposure to COVID-19 when presenting for hospital based infusions and the concerns associated with using public transportation Practices with a hospital based infusion center should expect to receive a high volume of patient calls. Many patients expressed a great fear of coming to a "hot zone" to receive immunosuppressive therapies. In fact, we shared their concerns and worked with hospital administration to move the infusion center to a sister location that does not receive COVID-19 patients, allaying many fears on the part of the patients and the treating physicians.

Using published guidance from the national gastroenterology societies, we were able to reassure patients of the suggested benefit of continuing maintenance therapy and that staying in remission outweighed the risks of therapy discontinuation. While most centers might reload the medication for the inevitable cases of delayed and deferred treatments, strong consideration should be given to avoiding repeat loading doses during the peak pandemic period. Unless there is suggestion of flare symptoms, we prioritized obtaining and/or maintaining symptomatic control over achieving therapeutic target drug levels.

Expert consensus supports ongoing use of infusion centers, provided a COVID-19 screening protocol is in place. 17, 18 While electively switching to injectable therapies may seem attractive, and in some cases is the only option, this strategy has previously been shown to be associated with relapses. 19 It is appropriate to acknowledge both the patients' fears and the dearth of clear data on the outcomes of COVID-19 infection among a biologic treated population. Using a shared decision making model one can negotiate how long a patient may safely delay infusions.

Establishing access to therapies and choosing alternative therapies Some immunosuppressed patients have fled New York City because it is currently the epicenter of the pandemic. This creates challenges coordinating infusions since many offices are not seeing new patients, or have limited appointments creating a long wait time for patients to see a new provider. Some patients cannot get alternative access to treatments and require remote care. Though potentially suboptimal, this may require switching to subcutaneously administered in-class therapies. In cases where this option does not yet exist (anti-integrin therapy), consider delaying infusions or advocating with local physicians to seamlessly transfer care. Home infusions for patients in other states create new logistical challenges. Unless the patient has established a relationship with a local physician who would be able to manage any complications, we were reluctant to support this strategy. Furthermore, home infusions may introduce a risk that a nurse provider traveling between multiple sites could become a virus vector.

This also gives rise to the question of whether a small molecule therapy may be considered a preferred option for moderate to severe ulcerative colitis (UC) among those seeking an alternative to injection/infusion biological therapy. Current consensus opinion avoids initiating treatment with tofacitinib during the pandemic. 20 There is concern that tofacitinib might inhibit viral immunity in light of a clear association with the reactivation of herpes zoster virus. 18 Furthermore despite a short half-life, studies in the general population found defects in immune function up to one month after the drug was stopped. 18 Initiation of biologics is controversial across the various guidelines. Unlike Renmin hospital in Wuhan, China, which decided to stop all biologics for their IBD patients, 21 United States and European guidelines recommend continuing IBD medication regimens. 18, 20, [22] [23] [24] In the IOIBD guidelines, a patient with a new diagnosis or relapsing disease is recommended to be treated similar to pre-COVID-19 era, though this was not a high consensus recommendation. 18 We agree that delaying initiation of biologics in patients who have manageable symptoms is a preferred strategy. Although some published guidelines recommend avoiding initiation of steroids or monotherapy with biologics during the pandemic, 20 this must be weighed against the need to avoid an emergency room evaluation and hospitalization, locations which have become synonymous with the presence of COVID-19.

It will be increasingly important in IBD care to continually reassess whether patients treated with biologics have worse outcomes with concomitant COVID-19 infection. The SECURE-IBD registry 25 may be best positioned to determine that in real time.

Immunosuppressed patients who work in healthcare settings Available guidelines do not resolve whether healthcare workers with known COVID-19 exposures on immune modifying medications should continue working. Given the possibility that immunocompromised patients will develop more severe COVID-19 illness, we are advising immunosuppressed healthcare workers to avoid COVID-19 patient interactions. Ustekinumab is considered to have less biological effect on viral immunity than anti-TNF in the COVID 19 guidelines. 17, 18 However, in the absence of real world data on outcomes of COVID infection among immunocompromised IBD patients, we have provided uniform recommendations to those on maintenance immunomodulators, Anti-TNF therapies, anti-Integrin therapies, anti-12-23 therapies, and prednisone equivalent doses >20mg daily, to avoid the hospital setting and avoid patient facing duties. This simplified decision making also allowed a uniform response from fellows and nurse practitioners who are often the front line in managing the large volume of calls generated.

Is the decision to delay surgery always the right one? The decision to pursue surgery in patients with IBD is already consensus driven. However, during this pandemic, as discussed earlier regarding interventional procedures, there is a preference to delay surgeries and try to stabilize patients with maximal medical management. For example, while not our standard practice, we have been able to manage perianal abscesses with temporizing measures including antibiotics and drainage by our surgical colleagues in the office setting rather than sending them for surgery. Conversely, complications for which we might ordinarily employ conservative management such as TPN and antibiotics for Crohn's related microperforation, have warranted more urgent surgical intervention due to uncertainty regarding access to medications, home care, and time course for deferred surgeries. 26

All of the large academic medical centers in the New York city region have deployed 'surge teams' to meet the demands of the massive influx of COVID-19 patients. Teams consist of attending physicians, fellows, residents and other providers from a variety of specialties, ranging from internal medicine to dermatology. Many physicians, including gastroenterologists express reluctance to take on these new responsibilities given their often long hiatus from internal medicine training. The main areas of care of COVID patients are following institutional protocols for medical management, helping to maintain close communication with patients and families, and navigating a complex and possibly entirely foreign inpatient electronic health record (EHR).

Successful strategies to care for these patients include ensuring there is one physician on each team (usually a resident or advanced care provider) who is adept with the inpatient EHR. Anxiety regarding the medical care of COVID patients is usually alleviated after onboarding, including reviewing protocols for PPE and those for disease management.

The emotional burden of the COVID-19 pandemic has been extraordinary, not only for patients, but also for physicians (including those who have not been deployed to the front lines) and training programs. Work-life balance takes on new meaning and challenges, as physicians have to find ways of crafting telehealth practices and virtual meetings, while creating in-home classrooms and continue to deal with daily household needs. And like our colleagues everywhere, reconciling our commitment to colleagues and patients with our obligation to also protect our families can be distressing. Successful coping strategies include acknowledgement of the true "pandemic" degree of the challenges that now exist, that one is not alone in managing this collateral damage, and practicing a "learned optimism." 27 A renewed focus on communication within families, as well as ensuring proper time for self-care (including many now complementary mindfulness apps like HeadSpace), is central to success.

Since telehealth and physical distancing have compounded the isolation, frequent division 'check ups' through teleconferences and phone calls to trainees is critical. To prevent feelings of isolation, it is paramount to initiate early, sustained messaging that encourages trainees to feel safe sharing emotional and health concerns with faculty members. Early changes in fellows' educational curriculum include conversion to weekly teleconferences and webinars. To help foster a sense of regional community and honor the education goals of our society, the NYSGE quickly created a lecture series for fellows and members as well as informational webinars to assist with deployment to medicine. This connectivity helped boost morale and remind us that we as a community can weather these challenging times together.

It is not surprising that ethical and end-of-life considerations have featured prominently in the management of patients during this pandemic. While we as gastroenterologists may not have historically been the primary teams leading goals of care (GOC) discussions for consulted patients, the difficult decisions need to be addressed by all care team members. We suggest seeking early (likely virtual) palliative care team input, as well getting familiar with institutional policies surround rationing of care. There are well-developed online resources, including sample scripts and video tutorials, to help get GOC conversations started. 28 Navigating the road to recovery As inpatient procedures are deferred and new consults managed with minimized assessments, a dedicated effort should be made to follow these patients closely as outpatients and to complete thorough assessment and treatment as the surge retreats and resources are freed. Strategies include establishing dedicated outpatient clinics (both fellow and faculty, virtual and in-person) for patients seen as consults, fellow maintenance of consult registries to ensure close follow-up, and utilizing a scoring or tiered classification system to help prioritize which patients should be brought back for re-assessment or for procedures, and in what time-frame (2-3 weeks, 1-3 months or 6 months).

In addition, hospital systems are considering utilizing their ASCs or partnering with external ASCs to begin to address those patients discussed above, particularly whose evaluation was deferred during hospitalization or due to active infection. The role, availability and accuracy of federal drug administration (FDA) approved point-of-care testing will vary regionally and practices should follow institutional or regional guidance regarding the eligibility of patients to be treated. Ascertainment of convalescent antibodies may permit safe development of care teams to be deployed in the highest risk environments. While we will need institutional guidance regarding PPE during the recovery phase, we should be reminded that, while not adopted by all, universal precautions had previously been established as the standard of care during endoscopies, and that we should be returning to these principles as our new baseline. 29 The potential legal implications of minimized and delayed care have yet to be defined but will be another area where physicians will need to work closely with local leadership to ensure establishment of effective policies.

The COVID-19 pandemic may arguably be the most difficult challenge many of us will face in our professional careers. For New Yorkers, the need to adapt quickly with fluidity, ingenuity and resiliency is well ingrained due to the events of the past two decades. This pandemic is unique and has forced all of us to abandon our learned responses and standards of care to better protect our patients and ourselves. We need to defend ourselves from the "moral injury" that this contagion causes with a strategy that focuses on communication, collaboration, innovation, and humility. Early planning and implementation of these strategies can help minimize the collateral damage that may result and in fact may help to establish new norms going forward.

First consider non-invasive testing (i.e., radiography)

Maximize medical therapies prior to procedural intervention Consider interventional radiology (IR), if resources allow Prioritize procedures that reduce length of stay (PEGs, but favor IR G-tube over PEG)

Encourage procedures that avoid surgery (i.e., colonic stenting) 

COVID-19) outbreak: what the department of endoscopy should know

COVID-19 Clinical Insights for Our Community of Gastroenterologists and Gastroenterology Care Providers

Guidelines for Endoscopy Units during the COVID-19 Pandemic

Considerations in performing endoscopy during the COVID-19 pandemic

Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding

Colonoscopy Does Not Improve Outcomes of Patients With Lower Gastrointestinal Bleeding: Systematic Review of Randomized Trials Clin Gastroenterol Hepatol

Management of Ingested Foreign Bodies and Food Impactions

Gastrointestinal Symptoms and COVID-19: Case-Control Study from the United States

The management of antithrombotic agents for patients undergoing GI endoscopy

Enteral feeding in the critically ill: comparison between the supine and prone positions: a prospective crossover study in mechanically ventilated patients

Early enteral nutrition in mechanically ventilated patients in the prone position

Administration of enteral nutrition to adult patients in the prone position. Intensive and Critical Care Nursing

ERCP for acute cholangitis: timing is everything

AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary

International Organization for the Study of Inflammatory Bowel D. Management of Patients with Crohn's Disease and Ulcerative Colitis During the COVID-19 Pandemic: Results of an International Meeting

Switch to adalimumab in patients with Crohn's disease controlled by maintenance infliximab: prospective randomised SWITCH trial

Implications of COVID-19 for patients with preexisting digestive diseases. The Lancet

Protection of 318 inflammatory bowel disease patients from the outbreak and rapid spred of COVID-19 infection in Wuhan

BSG expanded consensus advice for the management of IBD during the COVID-19 pandemic

Joint Society Message on COVID-19)

Clinical Insights for Our Community of Gastroenterologists and Gastroenterology Care Providers

Crohns and Colitis Foundation. Resources for IBD Healthcare Professionals: 2019 Novel Coronavirus

Coronavirus and IBD Reporting Database: Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE-IBD)

Whatever happened to universal/standard precautions?

ERCP (endoscopic retrograde cholangio-pancreatography), EUS (endoscopic ultrasound), EMR (endoscopic mucosal resection), ESD (endoscopic submucosal dissection)

LGD (low grade dysplasia), HGD (high grade dysplasia)