Endoscopy related risk
The endoscopy unit is a high-risk environment for COVID-19 transmission due to aerosolization and exposure during upper endoscopy procedures. In addition, due to concerns about detectable virus in GI secretions, both upper endoscopy and colonoscopy can exacerbate the risk of transmission. This can result in contamination of surfaces throughout the procedure room, which requires appropriate disinfection. This impacts procedural room turnover and patient flow through the endoscopy unit.
In the COVID-19 containment stage, several GI societies published guidelines suggested focusing on urgent and emergent endoscopy cases while postponing elective cases. In children, endoscopic procedure indications that fit that category include GI bleeding, foreign body ingestion, biliary pancreatitis and obstructive jaundice.
If endoscopy is needed on a suspected or confirmed COVID positive patient, the procedure should be done in a dedicated negative pressure room. Staff should wear proper personal protective equipment (PPE) for airborne, droplets, and contact precautions including N95 masks and water resistance gowns[23,24]. Proper hand hygiene should be practiced, and monitoring protocols should be in place.
Screening by phone for respiratory and GI symptoms associated with COVID-19 infection should be utilized before endoscopic procedures; however, these are not likely to be sensitive enough in children due to lower frequency of reported symptoms. This poses a significant limitation if screening is solely based on reported symptoms. This highlights the need to test all pediatric patients to determine COVID-19 status before endoscopy when possible. There is no data currently to guide stratifying screening by age (infants, vs toddlers vs older children). Screening can potentially occur the day before the endoscopy for non-emergent cases either in local settings or drive-through testing services. If screening is happening on site just before the procedure, the reception area should include screening area before the patient enters the waiting room.
A determination about whether the procedure can be postponed should be undertaken for patients who test positive. It is expected that some positive cases will still require endoscopy and those should be performed with adequate preparation to limit risk for healthcare providers and other patients utilizing the same endoscopy unit.
Processes to minimize risk
Endoscopy unit setup: Some authors proposed creating three zones and two passages in addition to having negative pressure operating room (OR) and endoscopy suites to decrease contamination risk. Use of negative pressure rooms can serve towards the containment of airborne contaminants within the room. Duct systems within endoscopy suites may be reworked to accommodate special air pressure needs in consultation with hospital epidemiology and engineering services.
For suspected or known COVID-19 positive patients, the number of healthcare providers participating in the procedure should be limited to those absolutely necessary. This should include anesthesiology staffs that are frequently utilized in pediatric endoscopy. This will likely limit the presence of trainees and nonessential endoscopy assistants[26-28]. The number of accompanying family members or legal guardians should be minimized whenever possible and, and visitation should not be allowed at this time[29,30]. A dedicated recovery room for COVID-19 patients recovering from endoscopy should be available.
Proper personal protective equipment use: Measures to minimize the transmission risk should be applied including adequate PPE access and use with appropriate don and duff practice[23,26]. Hospitals should take every effort to make sure proper PPE supplies are available for healthcare workers involved in endoscopy procedures. Processes can be implemented to decontaminate and reuse certain PPE (such as N95 masks) to maintain adequate supplies. All staff should go through training and proper education on how to don and doff PPE in designated areas within the endoscopy unit. Respirator fit testing should be in place according to institutional policies.
Cleaning and room turnover: Adequate time for endoscopy room cleaning and disinfecting will be needed for each case suspected or known to be COVID positive so slower room turnover is anticipated. The procedure room should be cleaned right after every case, and that process should include all surfaces including endoscopy tower, trays, bed rails, tables, chairs, computers, phones, and the floor. Alcohol-based or chlorine-based solutions with proven efficacy should be used for cleaning. Disinfection of endoscopes with the current disinfection protocols seems to be adequate based on findings from a study after Middle East respiratory syndrome coronavirus (MERS-CoV) and other SARS-CoV-1 outbreak[33,34]. Training should take place to ensure that the staffs adhere with appropriate disinfection protocols.
Resumption of elective endoscopy procedures: As the rates of new COVID-19 diagnosis plateau, healthcare facilities will expand access to services including elective endoscopy. Accommodating more patients in the endoscopy suites should be done in a thoughtful and safe manner for both patients and healthcare workers. Steps to follow should include:
Patient related: (1) Patients should be evaluated for active COVID-19 infection by PCR-based testing within 48 h of endoscopy (similar to current process with increased testing capability); (2) Patients who cannot undergo PCR-based testing prior to endoscopy, should be treated as presumed positive with proper safety precautions and post procedure disinfection; and (3) Parents or legal guardians who plan to accompany patients on the day of endoscopy should be screened for COVID-19 symptoms (if positive screen noted, they should not attend and be referred to their primary provider for testing).
Endoscopy unit related: (1) Endoscopy suite employees should be screened daily for COVID-19 signs and symptoms including fever and respiratory symptoms; (2) Endoscopy suite employees, patients and accompanying parents or legal guardians should wear masks; (3) Limit number of accompanying parents or legal guardians to a minimum (preferably one per patient); (4) Space out chairs in the waiting room area; (5) Space out beds in endoscopy unit preparation and recovery areas; (6) Space out workstations for employees; and (7) Avoid routine endotracheal intubation when possible.