BSG multi-society guidance on further recovery of endoscopy services during the post-pandemic phase of COVID-19

Our advice and guidance around COVID-19 is being regularly reviewed. Visit https://www.bsg.org.uk/covid-19-advice/ to see the latest published guidance.

Introduction

In March 2020, the BSG advised a pause in endoscopic services for all but emergency and essential procedures, to protect patients and the workforce and permit time to plan service reconfiguration (1) Five weeks later, guidance for resuming endoscopy in the early recovery/deceleration phase of the pandemic was published (2), based on consensus opinion and review of the available evidence at the time, acknowledging that some data was inconclusive or conflicting. This received positive feedback from members and endoscopy services but it was clear from this, and from the results of the subsequent JAG-BSG survey of endoscopy services in the UK (4) that there are still aspects of ‘COVID-minimised’ endoscopy that require further clarification if services are to recover further while maintaining patient and staff safety. These include:

• importance of pre-procedure patient testing for SARS-CoV-2
• self-isolation and/or social distancing pre-endoscopy
• levels of PPE required for upper and lower GI endoscopy
• necessity for room downtime between procedures

These are the major limitations to further recovery of endoscopy capacity.

In recent weeks, endoscopy services have recovered to approximately 40-50% of pre-COVID-19 activity levels. After almost 6 months of very low levels of activity, there is a considerable backlog of patients awaiting diagnostic endoscopy in all parts of the UK. Furthermore, there is growing appreciation that the risks of serious unintended harm from delayed diagnosis, particularly of malignancy, likely outweigh the risks of peri-endoscopic transmission of COVID-19.

In view of this, the growing evidence-base and understanding of COVID-19 infection and the declining prevalence of the infection, the BSG, together with partner societies, has developed further guidance. As with previous guidance, the following caveats must be borne in mind:

1) A great deal more is now known about COVID-19 compared to the start of the pandemic but the situation remains dynamic and levels of viral prevalence and infection across the UK will vary across regions and over time.

2) The statements here are recommendations based on the current low prevalence of the virus in the UK. There may be regional ‘hotspots’ of infection over time and all endoscopy units should interpret the guidance in the context of their local situation at any given time, taking advice from Infection Prevention and Control (IPC) teams and Public Health departments. These statements would not apply, for example, in areas with sustained community transmission. Should this be the case, previously issued BSG guidance remains applicable. (2,3)

3) When interpreting this guidance, other factors relevant to risks of severe outcomes from COVID-19 must be taken into account, including the demographics and health of both the local patient population and workforce: safety for all remains paramount.

4) Readers are strongly advised to read the full version of this guidance where discussion of the evidence and rationale for the statements can be found.

This guidance will be kept under review and subject to change as further evidence becomes available.

The aim of this guidance is to focus on infection prevention strategies related to endoscopy and achieve consensus around the best strategies to keep patients and staff safe as endoscopy work flow increases.

Methods

This guidance was developed using a modified Delphi consensus process under the auspices of the BSG Endoscopy committee (BSGE) with involvement of 17 key opinion leaders representing BSG, BSGNA, JAG, AUGIS, ACPGBI and PSGBI. A level of 80% agreement was chosen to represent consensus on a statement. The full list of participants and details of the Delphi process can be found in the extended version of this guidance.

Results

At the end of the Delphi process, consensus was achieved for 14 out of original 19 statements. The statements are divided into three broad domains:

Section 1

Nature of endoscopic procedures and risks of transmission of SARS-CoV-2

1)Upper GI endoscopic procedures carry a risk of transmission of infection when performed in unselected populations and without personal protective equipment (PPE)
Strongly agree (81.3%); agree (6.3%); neither agree nor disagree (0%); disagree (6.3%); strongly disagree (6.3%)

2) Lower GI endoscopic procedures carry a relatively lower risk of transmission of infection given the limited evidence for faecal-oral transmission of the virus
Strongly agree (64.7%); agree (35.3%); neither agree nor disagree (0%); disagree (0%); strongly disagree (0%)

3)  Enhanced PPE is not required for lower GI procedures if the patient has had a negative symptom screen and no history of exposure
Strongly agree (43.8%); agree (37.5%); neither agree nor disagree (0%); disagree (12.5%); strongly disagree (6.3%)

4) Standard PPE may be adequate for all endoscopic procedures if the patient has had a negative symptom screen, no history of exposure and has tested negative for infection in the preceding 48-72 hours
Strongly agree (41.2%); agree (58.8%); neither agree nor disagree (0%); disagree (0%); strongly disagree (0%)

Section 2

Strategies to minimise risk of transmission of SARS-CoV-2 to patients and staff in Endoscopy departments

5) Obtaining a clinical history from patients (symptoms/exposure risk) 3 to 7 days pre-procedure enables risk stratification of patients to focus testing resources and consideration of alternative tests in high risk patients
Strongly agree (43.8%); agree (37.5%); neither agree nor disagree (0%); disagree (12.5%); strongly disagree (6.3%)

6) If patients are screened (3-7 days) and tested (1-3 days) in advance of their procedure, then social distancing for 7-14 days pre-endoscopy is of little additional benefit.
Strongly agree (0%); Agree (87.5%); neither agree nor disagree (0%); disagree (12.5%); strongly disagree (0%)

7) All patients and staff working in clinical areas of the endoscopy department should wear surgical masks at all times
Strongly agree (62.5%); agree (31.3%); neither agree nor disagree (6.3%); disagree (0%); strongly disagree (0%)

8) All endoscopy units should have a system in place to remind staff regularly of symptoms of SARS-CoV-2 infection (to enable self-monitoring) and ensure staff understand the need for testing and self-isolation at the onset of any relevant symptoms
Strongly agree (64.7%); agree (35.3%); neither agree nor disagree (0%); disagree (0%); strongly disagree (0%)

Section 3

Environmental changes in Endoscopy units to minimise the risk of transmission of SARS-CoV-2

9) All patients with suspected or confirmed COVID-19 infection should have their endoscopy procedures in specific areas designated only for high risk patients
Strongly agree (75%); agree (6.3%); neither agree nor disagree (6.3%); disagree (0%); strongly disagree (12.5%)

10) Endoscopy care (admission & recovery) for all patients with suspected or confirmed COVID-19 infection should be separated in time and/or place from non-COVID-19 patients
Strongly agree (81.3%); agree (12.5%); neither agree nor disagree (0%); disagree (0%); strongly disagree (6.3%)

11) Social distancing of 1-2 metres pre and post- procedure is mandatory if patients are not wearing surgical masks and have not been tested prior to endoscopy
Strongly agree (68.8%); agree (12.5%); neither agree nor disagree (6.3%); disagree (6.3%); strongly disagree (6.3%)

12) If patients (1) have tested negative in the 48-72 hours prior to endoscopy, (2) wear surgical masks when attending the unit for their procedure and (3) follow strict infection control measures then the additional value of post-procedure social distancing (1-2 metres) is uncertain in areas of low disease prevalence
Strongly agree (41.2%); agree (47.1%); neither agree nor disagree (5.9%); disagree (5.9%); strongly disagree (0%)

13) Room downtime between procedures is not mandatory for lower GI procedures if patients have been screened negative prior to endoscopy
Strongly agree (56.3%); agree (25%); neither agree nor disagree (6.3%); disagree (6.3%); strongly disagree (6.3%)

14) If patients undergoing upper GI procedures have: (1) had a negative PCR test within 48-72 hours prior to endoscopy (2) been screened negative for symptoms of COVID-19 or exposure history and (3) recommended standard room cleaning procedures are followed, then the added value of room downtime between procedures remains uncertain
Strongly agree (52.9%); agree (35.3%); neither agree nor disagree (0%); disagree (11.8%); strongly disagree (0%)

Areas of contention that failed to achieve consensus

1) Enhanced PPE is required for all upper GI endoscopic procedures

2) Social distancing for 14 days prior to endoscopy is recommended if routine testing is not performed or available

3) Social distancing for 7 days prior to endoscopy is recommended if routine testing is not performed or available

4) Regular (fortnightly) PCR based testing for active infection should be carried out on all endoscopy staff

5) Initial antibody testing should be carried out on all endoscopy staff and subsequently on a monthly basis for all endoscopy staff who are antibody negative

Conclusions

Readers are strongly advised to read the full version of this guidance below where discussion of the evidence and rationale for the statements can be found. This latest BSG guidance draws on currently available evidence regarding Sars-CoV-2 and COVID-19 but recognises the evidence gaps that still exist. It addresses specifically the areas (infection prevention and control) highlighted as causing ongoing uncertainty for endoscopy services and holding back their full recovery to pre-COVID levels. Consensus has been achieved on the best strategies to keep patients and endoscopy staff safe whilst allowing endoscopy services to fully recover.

Ian Penman, Vice-President Endoscopy, BSG
Pradeep Bhandari, Delphi Process Lead

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