Providers at endoscopy centers across the United States are not often on the front lines of the COVID-19 pandemic. But that doesn’t mean they’re not busy.
Although the Centers for Medicare & Medicaid Services put elective endoscopy and colonoscopy procedures on hold to conserve equipment and limit exposures to pathogens (bit.ly/39t6AXr), at some point a patient infected with the novel coronavirus SARS-CoV-2 will undergo an endoscopic procedure—either because it’s an emergent situation or the patient is unknowingly infected and asymptomatic. In recent weeks, providers have been scrambling to adopt new policies to protect themselves and their patients for that eventuality.
“Our main concerns are to ensure the well-being of patients and faculty and our endoscopy staff,” Gregory G. Ginsberg, MD, a professor of medicine and the director of endoscopic services at the University of Pennsylvania, in Philadelphia, told Gastroenterology & Endoscopy News.
The Biophysics of Risk
The SARS-CoV-2 virus often is transmitted via respiratory droplets, and endoscopies can generate aerosols (Gastrointest Endosc 2020. doi.org/ 10.1016/ j.gie.2020.03.3758, preproof). Bronchoscopes may be particularly risky, given the close contact with the airways. Even colonoscopies can pose hazards if air is expelled. According to a recent paper in The New England Journal of Medicine, SARS-CoV-2 was viable in aerosols for three hours, which was the duration of an experiment (2020;382[16]:1564-1567). “That’s the one that really woke everybody up to the real concern extending beyond the pulmonary unit,” Michael L. Kochman, MD, the Wilmott Family Professor of Medicine and Surgery at the University of Pennsylvania’s Center for Endoscopic Innovation, Research and Training, told Gastroenterology & Endoscopy News.
Although Penn’s endoscopy facility has rescheduled elective and nonessential procedures, emergent and urgent situations will arise, Dr. Ginsberg said. For instance, endoscopy suites will continue to be used to treat acute gastrointestinal bleeding, food bolus impactions and cholangitis, among many other procedures.
As a result, the University of Pennsylvania is adding N95 masks to its usual protocol for personal protective equipment when treating all patients, not just those diagnosed with COVID-19, Dr. Ginsberg said. “We have emphasized the importance of training, and endorsing the donning and doffing of protective equipment.” Providers also will try to maintain social distancing with colleagues during procedures and throughout the day, he said.
It’s likely that providers will have to perform endoscopies on patients who have been diagnosed with the virus, who may develop GI complications, or have preexisting issues that require treatment, Dr. Ginsberg said. If a patient has been diagnosed with COVID-19, the staff will consider performing the procedure only if it is necessary to prevent death or further deterioration, and they will keep patients in an isolated room, he said. The facility also plans to limit the number of active participants in the procedure room and thoroughly disinfect between patients.
Dr. Kochman, a councilor for innovation and development for the American Gastroenterological Association governing board, predicted that this situation is not likely to occur often. “The volume of endoscopic procedures we’re going perform on these patients is probably pretty low,” he said.
However, that doesn’t mean endoscopy suites have time on their hands, Dr. Kochman said. Some personnel have been redeployed to other areas, such as phone triage or COVID-19 testing; others are providing telehealth services or working on contingency plans, such as ensuring adequate stocks of supplies. “It is also important to recognize that some personnel may also be in isolation themselves due to occupational and nonoccupational exposures,” he said.
The Cleanup
It’s important to ensure reusable equipment, such as GI endoscopes and bronchoscopes, are being thoroughly cleaned and disinfected during this crisis, Lawrence Muscarella, PhD, the president of LFM Healthcare Solutions LLC, in Lansdale, Pa., told Gastroenterology & Endoscopy News. Obviously, sticking with single-use scopes and other disposable equipment is “going to be ideal,” he said. But all signs indicate that current reprocessing practices should be sufficient for any semicritical instrument, he said. “It’s reasonable to conclude, until we see data to the contrary, that what we currently do is sufficient, is safe.”
Coronaviruses are enveloped viruses, Dr. Muscarella said, and enveloped viruses are relatively easy to destroy with many common household disinfectants (bit.ly/2w2qr24). Therefore, a high-level disinfectant that’s part of the standard reprocessing protocol “should be more than adequate” to disable the pathogen, he said. However, even when endoscopes are reprocessed correctly, they still may remain contaminated due to several factors (Am J Infect Control 2015;43[8]:794-801).
For a high-level disinfectant to kill a germ, it must come in contact with it, so any damage to the scope, a faulty design, inaccessible biofilms, or hiccups with maintenance or repairs could pose problems, Dr. Muscarella said. “Preventing transmission of COVID-19, [as with] any pathogen, depends as much on maintaining the integrity of the scope as ensuring the potency of the disinfectant.”
There’s also the question of whether facilities have sufficient inventory to provide adequate protection for reprocessing technicians, Dr. Muscarella said. “If hospitals don’t have enough personal protective equipment for their front-line nurses, they likely are not going to have enough for endoscope cleaning techs either.”
The reuse of otherwise disposable protective gear during this crisis should not create a new “standard” in infection control, he added. “If we become too familiar with the corners we may be cutting now, we could see more lax infection control moving forward, and this we want to avoid.”
Another major concern is that droplets with the virus present on surfaces could contaminate scopes and endanger staff, Dr. Muscarella said. Theoretically, if people can infect one another by coughing on a supermarket cart, a staffer could inadvertently spread the virus by coughing on a disinfected scope. “I don’t know that could happen, but I think we have to think about the worst-case scenario and assume that it might be possible,” he said. Dr. Muscarella stressed the importance of adopting proper hygienic practices to protect staff and maintain the safety of reprocessed endoscopes for patients.
At Penn, infection prevention remains a top priority, Dr. Ginsberg said. “We ensure that we maintain our content experts for these very important jobs.” Remaining staff are continuing to pay “meticulous attention to standard endoscopic reprocessing,” he said, and being especially mindful to reduce the risk for splash during manual cleaning. In addition, because the clinic is performing fewer procedures, staff members are ensuring that all cleaning reagents have not expired, he said.
Eventually, Dr. Kochman said, clinics will have to determine when scheduled endoscopy procedures can safely resume. It likely won’t occur until there is either a vaccine against COVID-19 or a way to perform rapid on-site testing that’s universally applied, he said. That needs to happen sooner rather than later, he said. “You can put off elective procedures for only so long before they become necessary.”
—Alison McCook
Dr. Muscarella is the president of LFM Healthcare Solutions LLC, an independent safety and quality improvement company that has financial relationships with companies that market low-temperature sterilization technologies, instrument cleaning products, disposable endoscopes, reusable equipment and more. Dr. Ginsberg reported no relevant financial conflicts of interest. Dr. Kochman reported financial relationships with BSC, Dark Canyon Labs, Olympus, Pentax and Virgo.
Tweets From a Pandemic
At its worst, social media can be annoying and excessive, but during the COVID-19 pandemic, gastroenterologists and their colleagues have been using the various platforms to praise their colleagues, share critical information, and even lighten the mood. Here are a few recent GI-related posts on Twitter that caught our notice.
