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April 27, 2020

AGA/DHPA joint guidance for resumption of elective endoscopy

Recommendations for resumption of elective endoscopy during the COVID-19 pandemic.
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In response to the COVID-19 pandemic, medical associations and government authorities recommended delaying elective procedures and surgeries, including endoscopic procedures. Subsequent recommendations have addressed appropriate use of personal protective equipment (PPE) to minimize risk of transmission, as well as management of endoscope reprocessing and storage. As new COVID-19 diagnosis rates plateau in certain communities around the U.S. and federal, state and local authorities permit the reopening of health care facilities, resumption of elective endoscopy activity is appropriate.  

This document provides best-practice guidance to help endoscopic facilities evaluate timing for, and approach to, resuming operations. Application of these recommendations by individual facilities will depend on local conditions and will be impacted by further guidance from federal, state, and local authorities. Specific recommendations may evolve as the pandemic progresses and more is learned about COVID-19 prevention and management. 

RECOMMENDATIONS

1. Elective endoscopic procedures may be resumed when there has been a sustained reduction in the rate of new COVID-19 cases in the relevant geographic area for at least 14 days. This decision should take into consideration federal, state, and local directives, availability of local healthcare system resources, and ability to provide a safe environment for staff and patients.

  • Refer to state departments of public health websites for guidance regarding relaxation of prohibitions on elective procedures.
  • Refer to CMS published guidelines, referenced below.

2. Scheduled endoscopies should continue to be prioritized by level of urgency, contingent upon individual patient considerations and physician professional judgement.  

3. All patients should receive PCR-based testing for active COVID-19 infection wherever possible. Ideally, this testing should be performed within 48 hours of the procedure. Such testing is fully covered under Medicare and most commercial plans. If pre-procedure COVID-19 testing cannot be performed, clinicians should consider having patients keep a daily temperature log for 10 days prior to the procedure. A symptom questionnaire and temperature check should be administered to all patients on the day of procedure.

4. Endoscopy center staff should be screened daily with temperature check and surveyed for COVID-19 exposure and symptoms.

5. Endoscopy centers should implement policies to facilitate social distancing for patients, visitors, and staff. Examples of such policies include but are not limited to: 

  • Mask use by all center personnel.
  • Appropriate spacing between intake and recovery beds.
  • Appropriate spacing of waiting room chairs.
  • Restricting accompanying visitors.
  • Required masks for patients and visitors.
  • Staggered procedure start times.
  • Individual workstations for center staff.
  • Organization of workflow patterns and job descriptions to minimize cross-contamination.

6. Mask recommendations are based upon availability of pre-procedure PCR-based COVID-19 testing:

  • If no test is done, all procedure room personnel should use N95 masks or equivalent.
  • If test is positive, either postpone procedure or move to inpatient setting.
  • If test is negative, standard surgical masks are acceptable for use by all endoscopy personnel.
  • If no testing is available and there is no availability of N95 mask or equivalent, consider delaying resumption of endoscopic procedures until resources are available.

7. Facilities should consider implementing similar PPE requirements as for urgent procedures, as previously specified in gastroenterology society recommendations. PPE considerations include but are not limited to:

  • Use of shoe covers.
  • Use of scrubs for endoscopy.
  • Changing street clothes prior to entering or leaving facility.
  • Use of water-resistant gowns.
  • Double-gloving.
  • Use of surgical head coverings.

8. Endoscopes may be reprocessed following standard guidelines for manual cleaning followed by high-level disinfection. Additional gastroenterology society recommendations have been previously published regarding protection of reprocessing staff, room cleaning, and restarting reprocessing equipment following facility shutdown.    

9. Routine endotracheal intubation of patients undergoing elective upper endoscopy is not recommended. Consider supplemental oxygen delivery by mask in order to minimize aerosolization. 

REFERENCES

American Society of Gastrointestinal Endoscopy. Gastroenterology professional society guidance on endoscopic procedures during the COVID-19 pandemic. https://www.asge.org/home/advanced-education-training/covid-19-asge-updates-for-members/gastroenterology-professional-society-guidance-on-endoscopic-procedures-during-the-covid-19-pandemic. Accessed April 23, 2020. 

Centers for Medicare & Medicaid Services. Opening up America again: Centers for Medicare & Medicaid Services (CMS) recommendations. Reopening facilities to provide non-emergent non-COVID-19 healthcare: Phase I. https://www.cms.gov/newsroom/press-releases/cms-issues-recommendations-re-open-health-care-systems-areas-low-incidence-covid-19. Accessed April 23, 2020. 

Joint gastroenterology society message: Covid-19. Use of personal protective equipment in GI endoscopy. https://gastro.org/news/joint-gastroenterology-society-message-covid-19-use-of-personal-protective-equipment-in-gi-endoscopy. Access April 23, 2020.

Joint statement: roadmap for resuming elective surgery after COVID-19 pandemic. https://www.asahq.org/about-asa/newsroom/news-releases/2020/04/joint-statement-on-elective-surgery-after-covid-19-pandemic. Accessed April 23, 2020. 

Management of endoscopes, endoscope reprocessing, and storage areas during the COVID-19 pandemic. https://www.asge.org/docs/default-source/default-document-library/gi-society-management-of-endoscope-fleet.pdf. Accessed April 23, 2020.

Sultan S, Lim JK, Altayar O, Davitkov P, Feuerstein JD, Siddique SM, FalckYtter Y, El-Serag HB, on behalf of the AGA, AGA institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic. Gastroenterology. 2020; [Epub ahead of print]. doi: https://doi.org/10.1053/j.gastro.2020.03.072.

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