Endoscopy during COVID-19 pandemic: An overview of infection control measures and practical application

Table 2 Infection control measures in the endoscopy unit

Issues	Steps
Pre-procedure
Risk assessment; Patient/ Procedure; Patient precautions	Inpatient urgent cases are done on a case-to-case basis; Outpatient elective non-urgent cases are reviewed by physician in charge – proceed with cases with suspected significant or time-specific diagnosis, reschedule all other cases; Direct access endoscopy is suspended; Prior to endoscopy: Pre-screen patients for history of fever or upper respiratory tract symptoms (cough, sore throat, rhinorrhea), significant contact and travel history, or if they have been issued a home quarantine order or stay home notice; This includes patients who have family members or close contact with suspected or confirmed COVID-19 case, and patients with recent travel to high risk countries in the past 14 d. On day of endoscopy: Check patient’s body temperature on arrival and ensure patients are at least 2 m apart in the endoscopy centre. All patients and staff wear surgical masks while in the endoscopy centre. Hand hygiene is performed before and after patient contact; Only 1 visitor per patient will be allowed to enter the endoscopy centre.
Procedure
Personal protection equipment (PPE)	All members of the endoscopy team wear PPE consisting of N95 mask, face shield, eye shield/goggles, long-sleeved surgical gown and gloves; For confirmed COVID-19 cases; The transfer team will wear PPE while transporting patients to and from the ward; The endoscopist and assisting nurses will wear PPE with powered air-purifying respirators (PAPR) (eye shield/goggles are not required with a PAPR) before entering the room; All endoscopy staff are trained to don and remove PPE accurately; Hand hygiene is performed before wearing and after removing PPE. Wearing of PPE follows these steps: Gown is worn first, followed by N95 mask and eye shield/goggles, then face shield, and finally gloves. Removal of PPE follows these steps: Remove gloves and gown first inside the room, then remove PAPR and N95 mask outside the room or in ante-room (if available).
Members of endoscopy team	Endoscopy staff are grouped into teams and segregated into separate endoscopy rooms. Endoscopy staff are advised to minimise personal contact and interaction with staff from other groups.
Logistics	For confirmed or suspected patients with COVID-19, endoscopic procedures are done in negative pressure rooms. If fluoroscopy is not required, endoscopy is done at bedside in negative pressure isolation room in the ward. If fluoroscopy is required, endoscopy is done in a designated major operating theatre room. The endoscopy team prepares all necessary equipment and scopes on a clean trolley before proceeding to the location. All other inpatient cases are consolidated in a specified room in the endoscopy centre. If this is not possible, the inpatient case will be scheduled as last case in the room. Outpatient elective cases are performed in other available rooms.
Post procedure
Cleaning and disinfection	Standard cleaning and disinfection of endoscopy rooms continue. All surfaces in endoscopy rooms are cleaned, followed by disinfection. For confirmed COVID-19 cases. Used equipment will be wiped down on site with disinfectant, placed in a labeled “dirty” trolley and brought back to endoscopy centre for further cleaning and disinfection. Used scopes will be wiped down on site with disinfectant, placed in a biohazard bag (double bagged), and placed in a rigid container with lid for transportation back to the endoscopy centre for reprocessing.

PPE: Personal protection equipment; COVID-19: Coronavirus disease 2019; PAPR: Powered air-purifying respirators; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2.