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Helpful Perspective From Italy Regarding GI Endoscopy in Midst of COVID-19 Pandemic

Bret T. Petersen, MD, FASGE

Bret T. Petersen, MD, FASGE, reviewing Repici A, et al. Gastrointest Endosc 2020 Mar 14. 

Italy recorded its first confirmed case of acute respiratory disease due to a new Coronavirus (SARS-CoV-2) on February 18, 2020. Despite aggressive containment measures, the number of infected people has grown exponentially since then, with symptomatic patients overwhelming the capacity for care in some areas.  

Transmission of Coronavirus-Associated Disease 2019 (COVID-19) is primarily airborne and by direct contact, but virions are also present in stool and tissues, though not in urine. Therefore, gastrointestinal endoscopy inherently risks both exposure and transmission among patients and staff. This article presents measures implemented in a major northern Italian medical center to limit risks to patients and staff.  

  • As asymptomatic carriers can shed the virus, standard precautions employing spatial separation, gloves, gowns, and surgical masks are employed by all personnel in the department.   
  • To facilitate individualized infection control measures, patients are stratified by phone the day before and on arrival to the endoscopy unit into low-, medium-, and high-risk groups, based upon history of potential exposure and travel, presence of symptoms (fever, cough, acute respiratory infection, dyspnea), and body temperature. 
  • All staff and patients wear surgical masks at all times within the endoscopy unit. 
  • Personal protective equipment (PPE) for personnel in endoscopy rooms is modified on the basis of stratification of patient risk.
    • Procedures in low-risk patients (asymptomatic, no exposure or travel) and colonoscopy in intermediate-risk patients (asymptomatic with limited exposure or travel; symptomatic with no exposure or travel) prompt staff use of a hair bonnet, single-use gown, standard surgical mask, eye coverage, and 1 pair of gloves. 
    • Those performing or assisting in upper GI endoscopy for intermediate-risk patients and any procedure in high-risk patients (symptomatic and patient exposure or high-risk travel or residence) employ bonnets, close-fitting N95 masks or positive-pressure ventilators, eye coverage, water-resistant gowns, and 2 pairs of gloves.
  • Appropriate, careful, stepwise removal of PPE is emphasized, with repeated cleansing of gloves and then hands with alcohol solutions to avoid self-contamination in the process. 
  • Procedures for high-risk patients should optimally be performed in negative-pressure rooms within the endoscopy suite or elsewhere in the hospital. 
  • Standard endoscope reprocessing should remain diligent. 
  • Room decontamination with increased attention to all potential surfaces of contact or mist settling should be performed after every procedure. 
  • Negative-pressure rooms should have 30-minute intervals between procedures. 
  • Rooms with standard ventilation should receive adequate time for cycled ventilation, ideally from the outside, for at least 1 hour.

COMMENT
T Serious adherence to protection of patients and staff is now required as SARS-CoV-2 disseminates across our country. Many units based in the United States are canceling all routine procedures, which is entirely appropriate as spread becomes community based and therefore entirely unpredictable by the screening measures mentioned above. Conservation of PPE will be important, such that unnecessary personnel or observers should be avoided for most procedures.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Bret T. Petersen, MD, FASGE

CITATION(S)

Repici A, Maselli R, Colombo M, et al.  Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Gastrointest Endosc 2020 Mar 14. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2020.03.019)

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