In the context of the coronavirus pandemic, a team of clinicians from Milan, Italy, a region that has been severely affected by the virus, has reported the specific measures and precautions that their hospital has implemented to prevent further spread of the COVID-19-causing virus, SARS-CoV-2, during endoscopy procedures.1 The article was recently published online in Gastrointestinal Endoscopy.1

Endoscopy procedures typically require the endoscopist to be in close proximity to the patient, placing healthcare personnel at increased risk for exposure and infection from SARS-CoV-2-positive patients.1

Repici and colleagues highlighted that the risk of exposure is not only to the endoscopist’s face by virus-carrying airborne droplets but also through possible fecal-oral transmission, as SARS-CoV-2 has been detected in biopsy and stool samples, which may be important when working with asymptomatic patients.1,2  

Spread of the virus via an airborne route also places noninfected patients at risk through aspiration of oral and fecal material via endoscopes.1,2   

The authors explained the importance of establishing a definition for SARS-CoV-2 infection, as well as classifying the potential SARS-CoV-2 infection risk in patients undergoing endoscopic examination as low risk, intermediate risk, and high risk according to presentation of symptoms, contact with someone who was known to be infected with SARS-CoV-2, and known to be in high-risk areas during the previous 14 days.1

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After a patient is scheduled for an endoscopic procedure, the team suggests using a nurse-directed triage protocol to survey the patient the day before the procedure by telephone to assess the risk of SARS-CoV-2 infection and potentially reschedule depending on the patient’s disease and condition.1

Once the patient has arrived for a procedure, the team suggests checking the patient’s body temperature. Based on the preliminary screening, the patient should then be classified according to infection risk; the risk classifications translate into different infection control precautions including suggested personal protective equipment (PPE) for each risk category (see Figure 2 in the publication for details).1

The Milan-based hospital now strictly prohibits caregivers and relatives of patients from entering the endoscopy department, with exceptions only for help with specific patient needs.1

The authors recommend telephone follow-up with dedicated triage at 7 and 14 days after any endoscopy procedure for all patients.1

The team also detailed the proper use and removal of PPE and proper hand hygiene in the endoscopy setting, standardized guidelines for reprocessing of flexible endoscopes and endoscopic accessories, and a decontamination policy for endoscopy rooms.1 Of note, they strongly discourage the reuse of any disposable device and suggest a surgical mask as a substitution when filtering respirators are unavailable, and they encourage the use of 2 pairs of gloves, a skin-covering inner pair and an outer “working” pair, especially when the patient is classified as high risk.1

“In general, establishing infection prevention measures and guideline within an endoscopy department is essential for creating a high-quality and extremely safe environment to protect both patients and personnel,” wrote the authors. “In this new era of the COVID-19 outbreak, it is imperative that these measures be implemented and maintained to avoid further unrecognized spread of the disease.”

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References

1.    Repici A, Maselli R, Colombo M, et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Gastrointest Endosc. 2020;0(0). doi:10.1016/j.gie.2020.03.019

2.    Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission [published online February 26, 2020]. Gastroenterology. doi:10.1053/j.gastro.2020.02.054