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BSG rationale around current advice to all Endoscopy Units

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In the light of the current uncertainty and before further government announcements, the BSG would like to share the rationale around their current advice to all Endoscopy Units. I hope you find this useful and practical in presenting the case for immediate cessation of all but emergency endoscopy to your managers and colleagues. A further document outlining both advised practice and practical ways forward to maintain emergency service will follow shortly.


Executive Summary UK wide Endoscopy Services COVID-19

  • The rapidly evolving COVID-19 situation needs urgent action immediately to standardise endoscopy service provision in the UK avoiding increased risk of COVID-19 transmission to staff and patients
  • BSG after consultation and based on the experiences of both China and Italy are making available this document to explain the rationale for the advice given
  • A further document recommending next steps action based on this advice will follow

BSG: Immediate advice for Endoscopy Services

  • The advice from the BSG regarding Gastro-Intestinal Endoscopy (GIE) procedures and the risks relating to COVID-19, is updated regularly and can be found here
  • The aim of our advice is to prevent cross contamination of patients, to limit spread of the infection, to protect staff, and limit the demand for PPE to all but the most essential procedures
  • Current advice in COVID-19 Guidance for Infection Prevention and Control in Healthcare Settings (GIPCHS)(1) and the National Infection Prevention and Control Manual (NIPCM)(2) in Scotland, whilst containing information on COVID-19, contain inconsistencies regarding Aerosol Generating Procedures (AGP), particularly relating to GIE. In particular, the advice based on the transmission of Influenza cannot be generalized to COVID-19, unless modified to take account of significant differences between the infections

Key Information

GIE procedures involve exposure to COVID-19

  • Unlike Influenza A, COVID-19 is present in all secretions with the exception of sweat. These include respiratory secretions, saliva and diarrhoeal stools
  • Risks in GIE arise from touch, aerosol, conjunctival contact and faeces. Peri-endoscopic transmission has been reported from China(3) and Italy(4)
  • The NICPM(2) states that:
    Full body gowns/Fluid repellent coveralls must be worn when there is a risk of extensive splashing of blood and/or other body fluids e.g. in the operating theatre; and when a disposable apron provides inadequate cover for the procedure/task being performed
  • The current advice clearly applies to all GIE procedures

GIE procedures are Aerosol Generating

  • GIPCHS(1) and NIPCM(2) state that COVID-19 is droplet spread and that FFP3 or hoods should be worn during AGPs and at all times in high risk units (ICU/ITU/HDU)
  • Upper GI Endoscopy involves continuous suction through the scope and continuous- suction through the oral route. This inevitably includes respiratory secretions as well as GI secretions
  • The suction takes place at face level. Endoscopy Nurses lean over the patient to hold the mouth guard
  • Continuous suction through the scope is occurring at around 30cm distance from the mouth, nasopharynx and eyes of the operator
  • The endoscope continuously blows air, under pressure, into the oropharynx and GI tract producing bubbles and spray
  • The same considerations also apply to colonoscopy and ERCP
  • The procedures are clearly Aerosol Generating Procedures (5)
  • GIE procedures last longer than bronchoscopy. Operative procedures and colonoscopy can easily take up to 40 minutes, 3 times longer than the average bronchoscopy and up to 8 times longer than the placement of an endotracheal tube.  The cumulative exposure to COVID-19 is therefore potentially much higher for each procedure
  • It is, therefore, illogical to accept bronchoscopy as an AGP, without also accepting that GIE procedures confer the same or higher risks
  • GIE teams must, therefore, be offered the same protection in terms of clothing and masks as are offered to bronchoscopy teams

Consistent advice is urgently required from the devolved administrations

  • Inconsistent advice is being given by infection control teams across the UK
  • BSG advice is based on the best evidence from China(3) and Italy(4) which indicate that GIE procedures pose a risk of cross contamination to patients and to staff
  • Our advice is entirely consistent with other expert groups including the European Society for Gastrointestinal Endoscopy (ESGE)(6), the American Society for Gastrointestinal Endoscopy(7) and the World Endoscopy Organisation (8)

Immediate Advisory

  1. All non-emergency GIE procedures should stop immediately, including Bowel Cancer Screening. This will drastically reduce the number of procedures and reduce requirement for PPE and FFP3 masks to the absolute essential
  2. All emergency upper GIE procedures are classified as AGPs, irrespective of the COVID-19 status of the patient, because the virus can be shed before any symptoms are present.
  3. ALL staff in the room wear Personal Protective Equipment and masks designed for AGP situations for emergency procedures
  4. Case by case triage for cancer and other groups (see advice to units on service provision) maintaining core minimal service

Ian Penman, BSG VP Endoscopy

Cathryn Edwards, BSG President

Mark Coleman, Chair JAG Endoscopy

Alastair McKinlay, BSG President Elect

View latest endoscopy guidance

References

(1) UK Government. COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.0. 2020; Available at: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control. Accessed 22,03,20, 2020

(2) Scottish Government. National Infection Prevention and Control Manual, NHS Scotland. 2020; Available at: http://www.nipcm.scot.nhs.uk/. Accessed 3/22, 2020

(3) Zhang Y, Zhang X, Liu L, Wang H, Zhao Q. Suggestions of Infection Prevention and Control in Digestive Endoscopy During Current 2019-nCoV Pneumonia Outbreak in Wuhan, Hubei Province, China. February 2020. 20; Available at: http://www.worldendo.org/wpcontent/uploads/2020/02/Suggestions-of-Infection-Prevention-and-Control-in-Digestive-Endoscopy-During-Current-2019-nCoV-Pneumonia-Outbreak-in-Wuhan-Hubei-Province-China.pdf. Accessed 3/22, 2020

(4) Repici A, Maselli R, Comobo M, et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. 2020; Available at: https://doi.org/10.1016/j.gie.2020.03.019. Accessed 3/22, 2020

(5) Soetikno R, Teoh AY, Kaltenbach T, et al. Considerations in performing endoscopy during the COVID-19 pandemic. 2020. (ASGE Press release, Personal Communication, Dr Ian Penman)

(6) European Society for Gastrointestinal Endoscopy. ESGE-and-ESGENA-position-statement-on-gastrointestinal-endoscopy-and-the-covid-19-pandemic. 20; Available at: https://www.esge.com/esge-and-esgena-position-statement-on-gastrointestinal-endoscopy-and-the-covid-19-pandemic/. Accessed 3/22, 2020

(7) American Society for Gastrointestinal Endoscopy. Covid-19-asge-updates-for-members. 20; Available at: https://www.asge.org/home/advanced-education-training/covid-19-asge-updates-for-members/. Accessed 3/20, 2020

(8) World Endoscopy Organisation recommendations on digestive endoscopy and the COVID-19 pandemic. Available at:
http://www.worldendo.org/2020/03/24/weo-advice-on-digestive-endoscopy-and-the-covid-19-pandemic/