Recovery of endoscopy services in the era of COVID-19: recommendations from an international Delphi consensus

Abstract

The COVID-19 pandemic has had a profound impact on provision of endoscopy services globally as staff and real estate were repurposed. As we begin to recover from the pandemic, a cohesive international approach is needed, and guidance on how to resume endoscopy services safely to avoid unintended harm from diagnostic delays. The aim of these guidelines is to provide consensus recommendations that clinicians can use to facilitate the swift and safe resumption of endoscopy services. An evidence-based literature review was carried out on the various strategies used globally to manage endoscopy during the COVID-19 pandemic and control infection. A modified Delphi process involving international endoscopy experts was used to agree on the consensus statements. A threshold of 80% agreement was used to establish consensus for each statement. 27 of 30 statements achieved consensus after two rounds of voting by 34 experts. The statements were categorised as pre-endoscopy, during endoscopy and postendoscopy addressing relevant areas of practice, such as screening, personal protective equipment, appropriate environments for endoscopy and infection control precautions, particularly in areas of high disease prevalence. Recommendations for testing of patients and for healthcare workers, appropriate locations of donning and doffing areas and social distancing measures before endoscopy are unique and not dealt with by any other guidelines. This international consensus using a modified Delphi method to produce a series of best practice recommendations to aid the safe resumption of endoscopy services globally in the era of COVID-19.

Moving Forward: Gradual Return of Gastroenterology Practice during the COVID-19 Pandemic

“…A recent international consensus study for the resumption of endoscopy services has defined high-prevalence regions as areas with estimated disease prevalence rates of 2% or higher [36]. For these regions, stricter guidelines are required in the practice of endoscopy and use of PPE.…”

“…Current guidelines recommend the use of full PPE for all emergency and urgent procedures, this includes N95/FFP2/FFP3 respirator, hairnet, goggles/face shield, full-sleeve isolation gown, gloves, and shoe covers. In areas with low prevalence, the use of standard PPE is sufficient for low-aerosol-generating procedures such as colonoscopy [36]. A standard PPE encompasses full-sleeved gown, protective eye wear (face shield/goggles), gloves, and a surgical mask.…”

“…The absence of clinical symptoms does not exclude SARS-CoV-2 infection. Evidence has shown possible disease transmission even from asymptomatic individuals; hence, screening patients based on symptoms, travel history, or exposure may be insufficient [36]. The IDSA panel recommends testing asymptomatic individuals scheduled for a time-sensitive procedure as close to the planned procedure as possible [43].…”

COVID-19 and Gastrointestinal Disease: Implications for the Gastroenterologist

“…Upper GI endoscopy procedures with open suctioning, including endoscopic retrograde cholangiopancreatography, endoscopic ultrasound and transnasal endoscopy, are considered aerosol-generating procedures (AGPs) [ 107 ]. The virus-carrying aerosols are not well blocked by the use of standard surgical masks, and all guidelines currently recommend the use of level 2 personal protective equipment (PPE) for such procedures including FFP3 masks, visors, head coverings, long-sleeved fluid-resistant gowns, two pairs of gloves and shoe coverings or cleanable shoes [ 108 , 109 , 110 , 111 ]. It is time consuming to put on, “don,” and remove, “doff,” the latter being especially critical to do in the correct safe sequence to avoid infection from the PPE itself.…”

“…It is critical that we develop mechanisms to find a way to deliver risk messages that allow patients to make rational decisions about their optimal care at a time of high anxiety generated by the press and social media [ 126 ]. Patient concern about catching COVID-19 through attendance for endoscopy has led to some guidance documents to recommend daily symptom checks for endoscopy staff, and one off or even regular retesting in high prevalence areas [ 111 , 122 ]. If staff are infected, recent US CDC guidance has moved from a symptom and test-based strategy to confirm negativity to a time-based strategy for return to work [ 127 ].…”