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

Table 1 Comparison of guidelines / recommendations / position statements

	United States Joint GI Society	United States (AGA)	United States (ASGE)	Canada (CAG)	Europe (ESGE/ESGENA)	United Kingdom (BSG/JAG)	Australia (GESA)	Asia (APSDE)	Japan (JGES)
Pre-endoscopy
Procedure review and stratification	Urgent: Perform, non-urgent which may need to be performed, non-urgent: Postpone	Time-sensitive (within 24 h-8 wk), not time-sensitive; - defer procedure on case-by-case basis	Urgent/emergent: Perform, elective: Postpone	Essential: Perform, not essential: Postpone	Emergent, elective: Postpone; Evaluate risk of GI disease-related vs COVID-19 related morbidity and mortality	Emergent/essential (continue), needs discussion (case-by-case basis), defer until further notice	Urgent/emergent: Perform, semi-elective: Review, elective: Postpone	Urgent: Perform, semi-urgent: Case-by-case basis, elective: Postpone
Procedures to proceed		Upper GI bleeding; Lower GI bleeding (if SARS-CoV-2 PCR negative)	Upper/lower GI bleeding; Dysphagia causing decreased intake; Time-sensitive diagnosis e.g. evaluation/treatment of cancer/pre; Cancerous conditions;IBD if endoscopy may change management; GI obstruction requiring palliation;Cholangitis	GI bleeding which is life-threatening; GI obstruction (e.g. esophageal obstruction due to food bolus / foreign body); Cholangitis	Upper/lower GI bleeding with haemodynamic instability; Foreign body in esophagus or high-risk foreign body in stomach; Obstructive jaundice; Cholangitis	Upper GI bleeding likely to require therapy; Lower GI bleeding which failed radiological intervention; Foreign body; GI obstruction requiring stenting; Cholangitis, infected peri-pancreatic collection; Nutrition support: Urgent NJT/PEG	Upper GI bleeding, clinically significant;Lower GI bleeding not due to haemorrhoids; Evaluation/treatment of cancer; New diagnosis / flare of IBD in which endoscopy may change management; GI obstruction; Cholangitis, infected/symptomatic peri-pancreatic collection;Nutrition: Urgent NGT/NJT/PEG	GI bleeding; Foreign body; GI obstruction requiring stenting; Management of leakage/perforations; Biliary sepsis; Nutrition: Urgent GI access for feeding
Procedures to consider (case-by-case)	Evaluation of suspected cancer; Evaluation of significant symptoms	Conditions in which delay in diagnosis can have implications on treatment (e.g. cancer, IBD); Treatment of pre-cancerous lesions e.g. high-grade dysplasia in Barrett’s, EMR of large colon polyp	Mild dysphagia; Iron deficiency anaemia		High priority; Upper GI bleeding without instability; Severe anaemia; Dysphagia /dyspepsia with alarm symptoms;Evaluation of suspected cancer e.g. imaging evidence of mass; Treatment of early cancer/pre-cancerous lesions; Pancreatobiliary stent replacement; Low priority; Iron deficiency anaemia; Pancreatic cyst (depends on risk features)	Variceal surveillance in high risk cases (e.g. recent acute bleeding);Evaluation of malignant conditions; EUS for staging/planning of treatment of cancer; Treatment of high-risk lesions e.g. EMR/ESD	Dysphagia; Iron deficiency anaemia (except female < 50 yr) where no other likely cause on clinical exam; Marked weight loss; Evaluation of suspected cancer e.g. abnormal imaging; Treatment of pre-cancerous lesions e.g. resection of large colonic polyp; Pancreatobiliary stent replacement/ removal	High suspicion of cancer; Treatment of cancer/pre-cancerous lesions with EMR/ESD; ERCP for hepatobiliary cancers
Procedures to defer		Screening / surveillance colonoscopy	Screening / surveillance OGD or colonoscopy in asymptomatic patients (including variceal surveillance); Evaluation of non-urgent symptoms or disease states (e.g. intermediate risk pancreatic cysts)	Screening / surveillance OGD or colonoscopy	Screening / surveillance; Evaluation of dyspepsia, reflux or IBS-like symptoms with no alarm symptoms	Screening / surveillance; Assessment of disease in IBD; Low-risk follow-up scopes (e.g. esophagitis or gastric ulcer healing); EUS for biliary dilatation, possible stones, pancreatic cyst (not high risk)	Screening / surveillance; Non-specific symptoms; Evaluation of GERD, probable IBS; EUS for pancreatic cyst (low risk)/chronic pancreatitis; Asymptomatic gallstones	Screening / surveillance; Diagnostic; Therapeutic for benign disease
Postpone non-urgent procedure	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Patient pre-screening	Screen for fever, respiratory symptoms and high risk exposure				Screen for symptoms (fever, cough, shortness of breath, diarrhea) and contact history		Screen for symptoms (flu-like symptoms), contact and travel history	Screen for fever, contact history, travel history, occupational exposure	Screen for fever, symptoms (respiratory tract infection symptoms, shortness of breath, diarrhea, dysosmia/dysgeusia, fatigue), contact and travel history
Patient assessment	Check patient's temperature on arrival				Check patient's temperature on arrival				Check patient's temperature on arrival
Patient precautions	Ensure patients maintain an appropriate distance (at least 6 ft) from each other				Patients should use face masks and maintain a distance (at least 1-2 m)			Ensure patients maintain an appropriate distance (2 m) from each other	Ensure patients maintain an appropriate distance from each other
Endoscopy staff screening					Daily assessment of symptoms/signs and risk factors; Isolation and testing if symptomatic				Daily assessment of symptoms/signs and risk factors
Waiting area policy	Avoid bringing patients (or escorts) ≥ 65 or with 1 of the CDC recognised risks				No caregiver/relatives allowed except in special situations			No caregiver/relatives allowed except in special situations
During Endoscopy
Type of PPE	Mask (type not specified), eye shield/goggles, face shield, gown, gloves	N95 mask (or PAPR), double gloves	N95 mask	High risk (include all upper GI procedures): N95 mask or equivalent, double gloves; Low risk: Surgical mask, gloves; Common: Goggles/face shield, gown, hairnet	Confirmed COVID-19 or high risk cases: N95 mask or equivalent, double gloves; Low risk: Surgical mask, gloves; Common: Goggles/face shield, water-proof gown, shoe covers, hairnet	Confirmed COVID-19 or high-risk (upper GI procedures): FFP3 mask, full visor, long-sleeved gown; Low risk: Surgical mask, glasses/visor, disposable apron; Common: Gloves, shoe covers, hairnet	Confirmed/suspected COVID-19 or high risk cases: N95 mask (or FFP2/3); Low risk: Surgical mask; Common: Goggles/face shield, long-sleeved waterproof gown, gloves	Confirmed/suspected COVID-19 cases: N95 mask; Low risk: N95 or surgical mask; Common: Goggles/face shield, water-resistant gown, gloves	Face mask, goggle/face shield, long-sleeved gown, gloves, cap
Members of endoscopy team	Only essential staff should be present in procedures	Minimise number of staff in room during endotracheal intubation (anaesthesia team only); avoid switch in staff during procedures			Only essential staff should be present in procedures	Restrict number of staff in procedures	Confirmed/at high risk of COVID-19 cases: Restrict number of staff in procedures; Low risk: Standard number of staff	1 experienced endoscopist + 2 nurses only
Endoscopy training		Review appropriateness of trainee involvement in procedures			Modify training - encourage use of e-learning	Limit trainee involvement	Confirmed/at high risk of COVID-19 cases: No trainees; Low risk: Trainees can be involved
Location	Confirmed/suspected COVID-19 cases: Do procedure in negative pressure rooms	Confirmed/suspected COVID-19 cases: Do procedure in negative pressure rooms			Confirmed/high-risk of COVID-19 cases: Do procedure in negative pressure rooms		Confirmed/high risk of COVID-19 cases: Do procedure in negative pressure rooms	Confirmed/suspected COVID-19 cases: Do procedure in negative pressure rooms
Post-Endoscopy
Follow-up	Consider phone follow-up at 7 and 14 d to ask about new diagnosis or development of symptoms of COVID-19				Consider contacting patients at 7 and 14 d to ask about new diagnosis or development of symptoms of COVID-19

APSDE: Asian Pacific Society for Digestive Endoscopy; COVID-19: Coronavirus disease 2019; PAPR: Powered air-purifying respirators; IBD: Inflammatory bowel disease; OGD: Oesophagogastroduodenoscopy; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; GI: Gastrointestinal; EUS: Endoscopic ultrasonography.

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.