key: cord-0961998-zzernh1d
authors: Ruan, Wenly; Fishman, Douglas S.; Lerner, Diana G.; Engevik, Melinda A.; Elmunzer, B. Joseph; Walsh, Catharine M.
title: Changes in Pediatric Endoscopic Practice during the COVID-19 Pandemic: Results from an International Survey
date: 2020-05-30
journal: Gastroenterology
DOI: 10.1053/j.gastro.2020.05.068
sha: 91828fbd9ed157240d2e964a3c3705cec69d7b25
doc_id: 961998
cord_uid: zzernh1d

nan

The COVID-19 pandemic has altered endoscopic practice significantly since SARS-CoV-2 is present in the gastrointestinal tract and may be aerosolized during upper and lower endoscopy. 1 Societal recommendations have been published to guide screening processes, personal protective equipment (PPE) utilization and procedure prioritization; 2,3 however, their uptake remains unclear. Additionally, pediatric endoscopy has unique considerations, including a higher proportion of mild or asymptomatic COVID-19 disease, preferential usage of anesthesiologistadministered deep sedation or general anesthesia, and more frequent gastrointestinal symptoms at the time of endoscopy. 4 This is the first study to explore the impact of COVID-19 on pediatric endoscopic practice worldwide and to compare differences across regions and between areas with differing COVID-19 case burdens.

An online REDCap survey was distributed to pediatric gastroenterologists in April 2020 via an email listserve targeting pediatric gastroenterologists affiliated with the European and North American Societies for Pediatric Gastroenterology, Hepatology, and Nutrition. The pre-tested survey anonymously recorded information regarding institutional demographics, current pediatric endoscopic practice patterns, and changes in endoscopic practice, including COVID-19 screening processes and PPE utilization. Detailed methodology is provided in the Appendix.

There were 145 responses from distinct institutions worldwide, representing 27 different countries, with 24.1% (n=35) from Europe, 57.9% (n=84) from North America, and 17.9% (n=26) from countries in other continents. Most were free-standing children's hospitals (59.3%, n=86) and in regions regulated by a stay-at-home/quarantine order (90.3%, n=131) for a mean duration of 26±12 days prior to survey completion. Eighty-six institutions (61.4%) were from regions with ≥10,000 cases at time of survey completion, and 70 (48.3%) were from regions with ≥100/100,000 after normalization by population.

Pediatric endoscopy volumes decreased to <10% of normal at most institutions (81.4%, n=118), and 89.6% (129/144) postponed all elective cases ( Figure 1A ). Most were not rescheduling postponed procedures (53.1%, n=77), and 69.7% (n=101) had no defined plan to address the backlog. Emergent/urgent cases were not delayed at 88.3% (n=128) of institutions. Onehundred twelve (78.3%) institutions continued emergent/urgent procedures for patients with suspected or confirmed COVID-19. Notably, triage criteria for procedures were lacking; only half (n=69) reported using guidelines to classify procedural urgency.

Modified staffing for endoscopy was reported by 53.5% (n=77/144) of institutions, and 60.1% (n=86/143) restricted the number of personnel permitted in the endoscopy suite. Only 17.2% (n=25) continued to allow unrestricted fellow participation in procedures; 33.1% (n=48) barred trainee participation completely.

COVID-19 screening practices varied, with 78.5% (n=113/144) screening patients prior to and on the endoscopy day, and 6.25% (n= 9/144) not performing any screening. Only 53.1% (n=77) 

The location of endoscopy did not change at 67.4% (n=97/144) of institutions. Only 44.8%

(64/143) had negative pressure rooms in their endoscopy unit. Thirty-three institutions (23.1%) used them for all procedures, while 21.7% (n=31/143) used them for select cases. Anesthesia practices changed for 37.1% (n=53/143), with more institutions uniformly performing endotracheal intubation for all procedures.

There was variation in use of full airborne, contact, and droplet PPE precautions compared with contact and droplet precautions alone (Appendix). Re-use of surgical masks was reported by 38.5% (n=55/143) of institutions, and 67.8% (n=97/143) re-used N95/N99 masks or FFP2/3 respirators ( Figure 1B) .

Fewer North American institutions admitted patients for emergent/urgent cases compared to Europe (p=0.00001) or other countries (p=0.0171). Compared to North America, countries in other continents were less likely to classify procedural urgency using guidelines (p=0.0065), and to postpone emergent/urgent cases (p=0.0129) and advanced endoscopic procedures (p=0.0059).

North American institutions rescheduled fewer postponed cases compared with Europe (p=0.0060). Fellows were less likely to be involved in endoscopic procedures in Europe compared to North America (p=0.0037) and other countries (p=0.0005).

Screening questions differed across regions, with European centers asking significantly more gastrointestinal symptom questions (p<0.001). PPE utilization also varied, with European countries using fewer N95/N99 masks in high risk or confirmed COVID-19 patients (p=0.002) compared with North America.

Regions with ≥10,000 COVID-19 cases were more likely to utilize full PPE precautions for all upper (p=0.039) and lower endoscopies (p=0.0418), less likely to postpone emergent/urgent cases (p=0.0094), and more likely to have established protocols pertaining to endoscopy-related COVID-19 exposure (p=0.0461) (Appendix). Institutions with ≥100/100,000 COVID-19 cases more frequently inquired about gastrointestinal symptoms (diarrhea p=0.0385, vomiting p=0.0091).

Institutions in regions with ≥10,000 COVID-19 cases were also more likely to diagnose celiac disease using ESPGHAN non-endoscopic diagnostic criteria (p=0.0327) and inflammatory bowel disease without endoscopy (p=0.00362). Most institutions reported still using endoscopy to guide management of eosinophilic esophagitis.

Our study demonstrates significant pediatric endoscopic practice variation across institutions worldwide and highlights relevant differences in practice across geographic regions and differential COVID-19 case burdens. European institutions were more likely to inquire about gastrointestinal symptoms and recent travel compared to North America, likely reflecting earlier experience with COVID-19. Additionally, areas with a higher case burden were more likely to use full PPE precautions. Only 59.2% of institutions reported utilizing full precautions for all procedures, demonstrating continued variation among institutions despite societal guidelines. 2, 3 Re-use of masks was high, and most institutions reported concerns about PPE supply, underscoring the implications of PPE scarcity. 5 Pediatric endoscopy volumes have been impacted significantly in line with adult practice [6] [7] [8] , with over 80% of pediatric institutions operating at <10% of normal procedural volumes and 98.6% of institutions postponing elective procedures. Most institutions had no defined plans for rescheduling, highlighting the need for guidance as regions start to re-open. Future study of rebooking processes and outcomes of patients affected by these cancellations will be important to re-evaluate which indications for pediatric endoscopy are pertinent.

This study provides real-world data highlighting the drastic impact COVID-19 has had on pediatric endoscopic practice worldwide. As the pandemic evolves, this information will be useful to help inform practices and streamline guidelines in a manner which balances safety issues and practicability and to inform strategies for resumption of endoscopic services. 

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This survey-based descriptive study of pediatric endoscopic practices worldwide was conducted in April 2020. The study received ethical approval of the Baylor College of Medicine Institutional

Review Board.

The target population for the study was pediatric gastroenterologists at various institutions worldwide. The PedsGI email listserve was used which primarily includes pediatric gastroenterologists who are members of the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) and/or the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN).

The survey was developed by study team members and beta-tested by 24 members of the NASPGHAN Endoscopy and Procedures Committee to ensure ease of use and relevance. Feedback was incorporated into the final instrument which consisted of five major sections (Appendix, Table   2 ). The first section collected institutional demographics. 

Data was analyzed using descriptive statistics, with continuous variables summarized using means and standard deviations and categorical variables summarized using proportions. Where relevant, responses were stratified by geographic region (North America, Europe, and countries in other continents) and total case burden (<10,000 or ≥10,000) per country/state (if in the United States).

COVID-19 cases in each country/state were also normalized to number of cases per 100,000 people based on the census data. 5 Responses were then stratified into countries/states with <100/100,000

persons or ≥100/100,000 persons. Differences in survey responses across geographical regions and case burdens were analyzed by chi square analysis. A P-value of <0.05 was considered statistically significant. GraphPad Prism 8 (GraphPad Software Inc., San Diego, CA) was used for statistical analysis. 

World Health Organization. Coronavirus disease 2019 (COVID-19): Situation report