Guidance and workflow of endoscopy reopening during COVID-19 pandemic.

Abstract

On March 19, 2020 the WHO declared coronavirus disease (COVID-19), caused by SARS-CoV-2, as a pandemic and it was crucial during the rapid spread of COVID-19 to postpone all elective and non-emergency endoscopic procedures.[1] In April 2020 the Saudi Gastroenterology Association published a position statement to guide gastroenterologists in Saudi Arabia on endoscopy services during the COVID-19 pandemic,[2] similar to other international societies worldwide.[34] The pandemic has led to a challenge for endoscopists as many urgent cases were deferred. In order to care for our patients, it was a must to resume endoscopic services gradually for those cases as soon as it is feasible with the least possible risk of exposing staff, patients, and healthcare providers. The decision of reopening ultimately depends on each endoscopy unit and the capacity of healthcare institution in terms of testing and tracing as well as staffing. The endoscopy unit at King Saud University Medical City (KSUMC) decided to start the process of reopening especially with substantial decrease in the number of COVID-19 cases requiring ventilators. A task-force was formed to provide a roadmap for safe reopening, which in turn could facilitate and guide other units towards restarting outpatient and routine procedures, with a phased approach based upon categories.[2] Nevertheless, the suggested protocol should be updated based on best available local public health information from the Ministry of Health. The main purpose of this commentary is to present recommendations during the gradual reopening of endoscopy units, where indeed it is anticipated that readiness to resume endoscopic procedures will vary based on the status of each endoscopy unit and the guidance from the concerned health authorities. Our unit, which performs around 6000 procedures annually, had more than 800 requests pending since the start of the pandemic, with numerous inquiries from patients seeking information about the risk of infection or the precautions to be taken when attending the unit. Currently, there are no formal evidence-based recommendations from clinical societies or healthcare authorities on resuming endoscopy procedures although, a few reports from international societies are emerging[56] highlighting the potential rearrangements of care and resetting of the endoscopy flow. During the preparation we faced multiple layers of complexity on the reopening scenario, however, this is a novel situation with limited options and we tried our best to keep the process simple and applicable. Table 1 shows the general information which addresses the staff's, patients, and caregivers, safety recommendations pre-procedure and on the day of the procedure. Scheduling the procedures was prioritized based on its urgency and the potential of serious outcomes if the procedure was delayed. The reopening was divided into three phases and Table 2 shows the details of each phase along with the workflow. A significant number of COVID-19 infections are being transmitted from asymptomatic individuals[7] thus requiring all patients to be tested for SARS-CoV-2 within 48-72 hours of a scheduled procedure. Flowcharts 1 and 2 demonstrate the specific steps for pre-procedure protocols for phases 1 and 2 respectively, and the role of individual endoscopy staff as shown in Figure 1a and b.Table 1: General Information for the endoscopy staff and patients prior to and on the day of the procedureTable 2: Definition and workflow of the re-opening phasesFigure 1: (a). Flowchart 1 demonstrate the specific steps for pre-procedure protocols for phase one. (b). Flowchart 2 demonstrate the specific steps for pre-procedure protocols for phase twoIn conclusion, the COVID-19 pandemic will continue to be a burden on our healthcare systems. The decision to reopen endoscopy units should be taken based on the locally available resources respecting infection control recommendations. Finally reopening endoscopic activity should be made in phases with clear guidance for each phase. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.