JAG, in collaboration with stakeholders representing BSG, ACPGBI and AUGIS, have issued guidance for endoscopy services regularly during the COVID-19 pandemic. We have seen the emergence of highly transmissible variants and the the roll out of vaccination that has reduced mortality and hospital admission significantly. 68% of the UK population aged 12+ have had three doses, 87% 2 doses and 93%, one dose of the vaccination. While there remains a significant risk from COVID-19 infection in someone undergoing GI endoscopy, it is appropriate to modify existing protocols considering the recent changes, whilst also maintaining standards to prevent cross infection.
This guidance for UK endoscopy services is based on work published by our colleagues at ESGE and ESGNA (Endoscopy 2022; 54(02): 211 – 216). See here for the full article Thieme E-Journals – Endoscopy / Full Text (thieme-connect.de). This guidance is also aligned with latest NHS England updates on pre-procedure testing (4 April 2022 see here). Services in Scotland, Wales, Northern Ireland and Republic of Ireland should clarify any local guidance with their respective government administrations.
General infection prevention and control (IPC) measures
The latest UK government guidance (updated April 2022, with links to equivalent information in the devolved nations) should be followed: www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-guidance-for-maintaining-services-within-health-and-care-settings-infection-prevention-and-control-recommendations
- People presenting for day case procedures, who are fully vaccinated, and deemed to be low risk do not require pre-procedure testing. Documentation of full COVID-19 vaccination status should be provided in advance of admission or on the day of admission.
- All people – including those with evidence of recovery from COVID-19 infection within the past six months – whose elective procedure requires at least an overnight stay, and day- case people who are not fully vaccinated should be tested with a lateral flow test (LFT) in advance of admission.
- We recommend that pre-endoscopy viral testing (PCR or isothermic nucleic acid amplification test (INAAT)) be performed immediately in all symptomatic people. Where viral testing is negative, someone may undergo GI endoscopy, thus avoiding postponement of procedures.
- Where appropriate, we strongly encourage all healthcare professionals (HCPs) working in a GI endoscopy unit be fully vaccinated against COVID-19.
- We recommend a return to full GI endoscopy procedure capacity in those areas with an ongoing vaccination policy, while continuing to adhere to IPC measures.
- We recommend that for HCPs who have recovered from COVID-19 infection, proof of natural immunity (up to six months post-infection) may be considered equivalent to vaccine immunity. The HCP may be expected to provide their workplace with documentation of their previous infection (appropriate PCR test result).
- We recommend that people’s fears of contracting COVID-19 infection while visiting a GI endoscopy unit should be properly addressed. This includes having appropriate vaccination policies for HCPs and policies to protect those at high risk of contracting COVID-19 or of having poor outcomes from COVID-19 infection (eg unvaccinated older people, those with multiple health conditions, or those who are immunocompromised).
Aerosol generating procedures (AGP)
Updated definitions of AGPs are awaited from Public Health England (PHE). Current guidance states:
’The available evidence relating to respiratory tract suctioning is associated with ventilation. In line with a precautionary approach, open suctioning of the respiratory tract regardless of association with ventilation has been incorporated into the current (COVID-19) AGP list. It is the consensus view of the UK IPC cell that only open suctioning beyond the oro-pharynx is currently considered an AGP, that is oral/pharyngeal suctioning is not an AGP.’
- We recommend that, as upper GI endoscopic procedures involve endoscopic suctioning beyond the oro-pharynx , and that there may be aerosol dispersal via the instrument buttons, these procedures should still be regarded as AGP.
Social distancing, patient separation, PPE and ventilation
- We do not recommend physical separation of patients based on vaccination status since this does not seem to be logistically feasible nor ethical.
- Where someone has documentation of a negative test or full vaccination status or recovery from COVID-19 infection in the preceding six months, we do not recommend a need for use of enhanced PPE, room fallow time between procedures or 2 metres distancing in recovery areas post-procedure; that is, standard IPC measures are sufficient. Where infectious respiratory illness is suspected or confirmed, transmission-based precautions (TBP) are required, including 2 metres distancing between patients.
- We recommend that during the ongoing COVID-19 pandemic, prioritisation of GI endoscopy procedures, based upon clinical and/or oncological indications, should be optimised in those areas with limited endoscopic capacity. Guidance on this can be found at: www.bsg.org.uk/covid-19-advice/an-update-to-information-and-guidance-for-endoscopy-services-in-the-covid-19-pandemic-2/
- We do not endorse prioritising people awaiting GI endoscopy based on COVID-19 immunity status.
We thank our colleagues at the ESGE and ESGNA and the co-authors of their paper for their work on this evidence-based guidance (Endoscopy 2022; 54(02): 211 – 216), which we have adapted for UK and RoI practice in line with latest guidance.
The situation with COVID is ever-changing and we ask for endoscopy services to continue to refer to guidance issued by their respective devolved administrations or come back to us with any clarifications needed.
Mark Coleman, JAG Chair
Ian Penman, BSG Vice President Endoscopy