Resuming endoscopy in the wake of COVID-19
The COVID-19 pandemic had a vast impact and necessitated a worldwide response. However, getting things back to normal is likely to come on a country-by-country, state-by-state and in some cases, city-by-city basis.
Endoscopy falls squarely into that reality. Non-emergent, endoscopic procedures were among the many “elective” procedures suspended when the pandemic reached full fervor in mid-March and continued well into the next 2 months. That meant the endoscopist’s bread and butter procedures, the screening colonoscopy, had to be put on the shelf until officials had a better grasp on the coronavirus disease and the outlook for society improved.
Although the pandemic is still ongoing, particularly in the U.S., endoscopists are already beginning to resume the urgent and elective procedures that had to be postponed during the worst of COVID-19. To get back to the point of treating their patients, gastroenterologists have had to navigate a network of society guidelines, as well as governmental directives.
Throughout the pandemic, professional societies — including the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy — issued guidance on what GIs needed to know, as well as specific advice on endoscopic procedures.
Neil H. Stollman, MD, chief of the division of gastroenterology at Alta Bates Summit Medical Center in Oakland, served as co-chair for the ACG Endoscopy Resumption Task Force. Speaking to Healio Gastroenterology in mid-May, he said that the process of reopening endoscopy suites was always going to be hyper local.
“In California, the northern and southern regions might as well be different states,” he said. “In New York, upstate and New York City might as well be different countries, as far as COVID interventions are concerned. The answer is that [the plan to resume] has to be micro-determined.”
The task force’s guidance centered on seven categories to focus on for re-opening endoscopy: when to re-open or ramp up; who, our patients; who, our staff; what is needed to safely re-open; where, the physical space and how to most safely use it; and how to succeed safely.
When to Re-open/ramp up
On March 12, Ohio became the first state to close its schools. In Toledo, Costas H. Kefalas, MD, and the rest of his partners at Akron Digestive Disease Consultants had to deal with a halt to elective procedures less than a week later.
“Governor Mike DeWine and the director of the Department of Health, Dr. Amy Acton, were very aggressive in defining measures to flatten the curve,” Kefalas told Healio Gastroenterology. “They put out an order to stop all elective procedures. We have our own ambulatory surgery center and made the decision to also close our practice, not just the ASC.”
With the practice closed, they referred any patients with emergent symptoms to local hospitals to undergo necessary procedures. Kefalas’s experience in Ohio was not unique. According to the ACG, only 33% of GIs were performing endoscopy in an ambulatory surgery center, while 86% reported a reduction of at least 50% in income.
However, not every center closed, and some made other plans to help keep their practices in operation.
At Wichita Falls Gastroenterology in Texas, Louis Wilson, MD, and his private practice colleagues worked out a deal with the local hospital to take on urgent endoscopic procedures at their ASC as the hospital prepared for a patient surge from COVID.
“As many as possible, we continued to do,” Wilson said. “We acted with the hospital to push semi-urgent procedures to the ASC to reduce the burden of hospital service. We were able to continue in our center, which helped us maintain our staff.”
Although they kept busy with those procedures, Wilson and colleagues still experienced a dramatic drop in cases. He said the practice had several weeks where they were only doing about 25% of their normal procedure volume, and at the lowest week, they only did 14% volume.
In its guidance, the ACG task force stressed that re-opening would be location dependent on several factors. In addition to adherence to local government guidelines, they advised physicians to consider several factors before beginning a move toward resuming endoscopy, including local hospital capacity, a 2-week downward trajectory in cases and deaths, weighing whether they were in a high or lower risk community (which was to be determined locally) and the availability of testing.
Who – The Patients
Starting in May, endoscopy centers that closed started letting patients back in a slow trickle, beginning, in many instances, with patients who were displaying symptoms. While elective procedures were stopped and emergent cases continued during the height of the pandemic, urgent procedures were more of a gray area.
“We can talk about the extremes,” Stollman said. “If there’s a fishbone in the esophagus, it has to come out. Emergency procedures get done, and they get done the same day. The other end is also easy. For a 5-year, surveillance colonoscopy, we don’t think there’s a tremendous health risk waiting an extra 3 months, which is the time frame we’re working on now.
“Then we have this middle bucket. How do you triage that middle bucket?”
When Stollman’s center opened in mid-May and started seeing highly symptomatic patients, he diagnosed two new patients with ulcerative colitis and found two strictures that needed dilating in his first day back. He said there wasn’t a single metric to decide which patients need the highest priority for endoscopy, and it needs to be a constant discussion within a practice.
“Generally, doctors are logical humans, and we can figure this out,” he said. “And for the most part, we are figuring it out. You have to decide on a way to do things and do it. No one is going to micro-dissect your decisions.”
Practices are using different tactics to minimize COVID transmission from patients coming into the office. Seth A. Gross, MD, of NYU Langone Health, said the State of New York is recommending that all patients get tested before a procedure to ensure they are negative.
“If there is someone who is asymptomatic and tests positive, we’d postpone that elective procedure for a few weeks before bringing them back” he said.
In other regions, testing is not a requirement. Stollman, Kefalas and Wilson all said their centers did not require patients to get tested before coming in for a procedure. Instead, they use temperature checks and symptom questionnaires to do clinical screening before and at patient arrival.
“When we contact a patient, we ask them a six-question questionnaire about symptoms, recent travel or contract with individuals who have tested positive,” Kefalas said. “We also ask them the day before, and when they come in, we take their temperature and ask the questionnaire again. Subsequent to that, we do a follow-up on day 7 and day 14 after the procedure to check in to see if they have any symptoms.”
The benefit of pre-procedure testing still unclear. However, in study published in Gastroenterology, research found that despite having a low yield, particularly in low-prevalence areas, testing can have benefits, including peace of mind for patients and conservation of PPE.
Who – The Staff
The ACG also advised on best practices for staff in an endoscopy center, which included guidance on minimizing the number of staff present and limiting contact during patient handoffs. Another option was an A/B teams system designed to compartmentalize groups of staff and reduce exposure.
Guidance for staff from the ACG also interacts with the societies suggestions on how to succeed safely once a center reopens. The task force called for groups to come into the office on a day before patients returned to practice every aspect of the day from patient arrival to disinfection and retraining. Kefalas said seeing how well and how quickly the staff responded to their new normal was one of the more surprising but rewarding aspects of reopening.
“When we had our mock run, the staff learned the new protocols quickly,” he said. “Cleaning, patient handoffs, etc., these are not all easy tasks, and it was very heartening to see how well the staff adapted.”
The task force also advised physicians to maintain open communications with staff and show support to reduce burnout.
“The medical center has done an outstanding job making sure everyone is maintaining the highest level of safety,” Gross said. “We really planned around for when things would resume, and we’ve been ready and able to meet the needs of our patients.”
What is Needed?
When the ACG conducted its initial survey of GI practices, they found there was a widespread shortage of facial personal protective equipment. Less than 24% of responders reported that they had an adequate supply of N95 masks. Securing enough PPE, as well as medications, anesthesia supplies and cleaning supplies was a critical part of any plan to reopen endoscopy centers.
Although they have enough PPE to get by, Stollman said their practice is stretching their supply by using masks and other PPE beyond what they would have done normally before the pandemic. With a supply that is still limited in some areas, he said physicians might have to use their judgement to decide how to make their supply last for the most critical procedures.
“In a perfect world, every case would be with new PPE,” he said. “We’re starting to define the fringes of where you might not have to use universal PPE, and in our guidance, we’ve been open to that. We’re suggesting that if there is a low-endemic area with a low-risk procedure, that might be a safe place where doctors can use their judgement to save PPE for higher risk areas and procedures.”
In New York, Gross said they currently have the PPE they need. In Ohio, Kefalas said they partnered with the local hospital to procure the necessary N95 masks. As they began seeing patients, Kefalas said the concern was not the masks, but their gowns.
“We use cloth gowns, and the company we use to clean them had furloughed so many staff that they were not able to deliver clean gowns that we needed,” he said. “They have since brought their employees back and our supply chain was restored.”
Where - the Physical Space and how to Safely use it
The way office space is used has been one of the major differences GI practices have experienced since reopening for endoscopy. Patients are asked to wait in their cars until they are texted to come inside. No family or escorts are allowed inside the building. Practices are also cutting down on the number of rooms where the actual procedures take place.
Kefalas said they re-opened with diminished capacity due to a cutback on the number of endoscopy suites, as well as an increase in allotted procedure time. His practice went from three rooms with 30-minute exam slots to just one room and 1-hour exams when they first resumed endoscopic procedures to accommodate additional safety and cleaning protocols.
“Now, we’re using two rooms and spending 45 minutes per case,” he said in early June. “We will probably get to three rooms next week. Two rooms have been working well, but in terms of the case load, before COVID we performed 45 to 50 procedures a day in three rooms. With two rooms we now perform 24 cases. Right now, we’re at about 50% capacity, and even when we add the third room, it will probably only be about 65% to 70%.”
Although they are not back to normal volume, Gross said they are seeing a significant improvement week by week.
“This area continued to open up as we go through the different phases laid out by the governor,” he said. “Patients are being made aware of what medical centers are doing to maintain safety for them and the people that work here. ... We’re hoping that patients don’t ignore symptoms they have, especially around digestive symptoms, because we like to intervene and make them feel better early.”
However, patient demand is still down. Wilson remains concerned about the unintended health consequence that patients might experience because of the shutdown of endoscopy.
“We’re concerned about delaying access to our patients,” he said. “Everywhere private practice factors are opening. They’re overcoming any obstacles that they need to, but patients are still scared. No-show rates are still high. But we’re going to keep working to overcome it.”
- The ACG Endoscopy Resumption Task Force: Guidance on Safely Reopening Your Endoscopy Center.
- ASGE Guidance for Resuming GI Endoscopy and Practice Operations After the COVID-19 Pandemic.
- Podboy A, et al. Gastroenterology. 2020;doi:10.1053/j.gastro.2020.06.022.