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How to get UK gastroenterology and liver services back on track

Updated on: 09 Feb 2022   First published on 17 Jan 2022

This webinar, recorded on 14th May 2020, was designed for BSG members and was led by the BSG Executive team. It discussed practical strategies for recovery of gastroenterology and liver services following the peak of the COVID-19 pandemic. It featured:

  • Interactive sessions on service recovery across endoscopy, liver and IBD/luminal
  • Summary results of the BSG COVID-19 member survey & a discussion on the impact on training

Questions from the webinar

Question Answer
The need to leave rooms for up to an hour between procedures, especially upper GI, is greatly reducing our activity. If we screen and test patients, and use level 2 PPE, can we dispense with the need for room rest and terminal cleaning between cases? This is not easy to answer with certainty. All upper GI procedures are aerosol generating and require level 2 PPE at present. Units should follow PHE advice including that on room ventilation, which should be assessed by local Estates management teams. Then a local risk assessment with your infection prevention and control team can help you decide on how long rooms need to be left between procedures. With symptom screening, a negative test, appropriate PPE and effective ventilation it may be possible to shorten safely the room ‘downtime’. More information can be found on the PHE and JAG websites.
Is there any point in testing in the lower GI scope category? There is minimal, if any risk, so why can’t we use level 1 PPE for all colonoscopy/flexible sigmoidoscopy? We do not believe that there is enough evidence to conclude that there is ‘minimal if any risk’ from lower GI procedures (LGI).  PHE guidance states that stool should be considered potentially infectious at present but they do not list LGI scopes as AGP. The question is really: how aerosol-generating are they and what is the infectivity risk? LGI  procedures are probably less AGP than those from the upper respiratory tract; and, while viral RNA can be detected in stool for prolonged periods post-infection, the emerging evidence supports the view that live virus, capable of transmitting infection, is rarely if ever found.  But this has not yet been confirmed beyond reasonable doubt, and so level 2 PPE is required unless patients have a negative screen and negative test: our modelling indicates that the negative predictive value of this approach (NPV) varies according to the local prevalence of the virus, but across a wide prevalence range is always >90%.
How sensitive is the RT-PCR swab test? I’m aware of cases that clearly have COVID-19 but have had false-negative tests. Should we not regard everyone as positive? The sensitivity of the RT-PCR antigen test varies and this partly relates to the local prevalence of the virus and the degree of testing performed locally, but is reported to be between 70-91%. We used a lower sensitivity of 70% when calculating the negative predictive value of a test result, factoring in variable prevalence of the virus and that provides reassuring data that the NPV of a negative test is >90% (see above).
We’re not currently doing many endoscopies and not enough procedures for our nurse endoscopists. How can nurse endoscopists contribute to endoscopy recovery? Good question! Hopefully, the BSG guidance will enable a safe, gradual build-up of endoscopy activity soon. We believe that senior decision-makers play a huge part in retriaging the backlog of planned procedures that were paused and in assessing new referrals, as well as for deciding on procedure priority. Experience shows that many patients may not require a 2-week wait scope or may safely be managed in other ways, removing their need for endoscopy. Nurse endoscopists can play a vital role in this as well as in contacting patients and in performing lists, but it’s essential that those staff who have been redeployed elsewhere can return to work in endoscopy.
Do you have any comments on sessional use of PPE versus single-use per case? PHE has produced updated guidance about the possible sessional use of some PPE and this should be followed, along with a risk assessment involving your local infection prevention and control team, taking all factors into consideration.
Where do you see colon capsule (CCE) fitting into the lower GI investigation algorithm? The role of alternative pathways to care for patients with lower GI symptoms is being actively pursued and there may be a role of CCE in this, but also the use of qFIT and CT colonography. Where each of these can safely and effectively be incorporated into the diagnostic pathway is being actively discussed at present and more information should be available soon. Major changes to existing pathways, however, need to based on evidence-based as much as possible and monitored to ensure they are effective and safe for patients.
Can endoscopists at high risk from COVID-19  and/or from BAME background continue performing aerosol-generating endoscopy procedures? This is a major concern but also a difficult question to give specific advice about. While the measures outlined in the BSG guidance and elsewhere in these FAQ should reduce greatly the risks, each endoscopist should consider their own personal situation and take advice from Occupational Health and their Clinical Director in reaching a decision.

Reviewed by Ian Penman, VP Endoscopy

Useful supporting documents

Below you will find downloads of several documents referenced in the presentation.

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