Pre-procedure Testing Research Articles

Simple Risk-Score Model for In-Hospital Major Bleeding Based on Multiple Blood Variables in Patients with Acute Myocardial Infarction

Background: In-hospital bleeding is associated with poor prognosis in patients with acute myocardial infarction (AMI). We sought to investigate whether a combination of pre-procedural blood tests could predict the incidence of in-hospital major bleeding in patients with AMI. Methods and Results: A total of 1684 consecutive AMI patients who underwent primary percutaneous coronary intervention (PCI) were recruited and randomly divided into derivation (n=1010) and validation (n=674) cohorts. A risk-score model was created based on a combination of parameters assessed on routine blood tests on admission. In the derivation cohort, multivariate analysis revealed that the following 5 variables were significantly associated with in-hospital major bleeding: hemoglobin level 10000/μL (OR, 2.58), platelet count < 150000/μL (OR, 2.51), albumin level < 3.8 mg/dL (OR, 2.51), and estimated glomerular filtration rate < 60 mL/min/1.73 m 2 (OR, 2.31). Zero to five points were given according to the number of these factors each patient had. Incremental risk scores were significantly associated with a higher incidence of in-hospital major bleeding in both cohorts ( P < 0.001). Receiver operating characteristic curve analysis of risk models showed adequate discrimination between patients with and without in-hospital major bleeding (derivation cohort: area under the curve [AUC], 0.807; 95% confidence interval [CI], 0.759 – 0.848; validation cohort: AUC, 0.793; 95% CI, 0.725 – 0.847). Conclusions: Our novel laboratory-based bleeding risk model could be useful for simple and objective prediction of in-hospital major bleeding events in patients with AMI

Poor agreement between clinical screening and universal pre-procedure SARS-CoV-2 PCR testing prior to endoscopy.

scientific societies recommend screening for SARS-CoV-2 in patients prior to endoscopy. There is no solid evidence regarding the efficiency of universal screening by PCR testing for SARS-CoV-2. The present study aimed to assess the usefulness of clinical screening and universal pre-procedure PCR testing for the identification of patients capable of transmitting the SARS-CoV-2 infection. Concordance between both strategies was also evaluated. a retrospective review was performed in a consecutive cohort of patients undergoing endoscopy at a tertiary teaching hospital between April 22 and June 22, 2020, following a screening protocol. three hundred and sixty-one patients were included. Clinical screening detected 13 patients with a high risk of infection (3.6 %, 95 % CI: 2.62-4.58) while the pre-procedure PCR test was positive in five patients (1.40 %, 95 % CI: 0.20-2.60). Three patients developed COVID-19 and one died from the disease. Agreement between both strategies was poor, with a kappa value of 0.093 (95 % CI: 0.001-0.185). Clinical screening only identified one of the five patients with a positive PCR test. clinical screening prior to endoscopy has a poor agreement with pre-procedure PCR testing.

Brachytherapy utilization for cervical cancer in Western United States border counties: seeking to understand referral patterns for outcome improvement.

PurposeStandard of care for definitive treatment of locally advanced cervical cancer (LACC) is concurrent chemoradiation followed by a brachytherapy boost. Only 55.8% of women in the United States receive brachytherapy, with even lower proportions in San Diego and Imperial Counties. The purpose of this study was to investigate brachytherapy practice and referral patterns in Western United States border region.Material and methodsA short survey was sent to 28 radiation oncologists in San Diego and Imperial Counties, who treat patients with gynecologic malignancies. Descriptive statistics were used for analysis.ResultsSeventeen (61%) physicians responded to the survey. All physicians reported some training in cervical cancer brachytherapy during residency, with median 6 months. Only two physicians reported personally treating all cervical cancer patients with brachytherapy; however, 92% of remaining physicians would recommend brachytherapy for patients if given time and access. The most common reason for referral (78%) was patients deemed to require hybrid or interstitial brachytherapy implants. Barriers to referral included patients’ preference, insurance status, their resources, or logistics. No changes were reported for brachytherapy practices during the COVID-19 pandemic, except the addition of pre-procedural testing for SARS-CoV-2. Ninety-two percent of physicians identified inadequate maintenance of skills as a barrier to performing brachytherapy, but 77% were not interested in additional training. External beam radiation therapy boosts were rarely recommended in case scenarios describing potentially curable patients.ConclusionsThe importance of brachytherapy is widely recognized for conferring a survival benefit, but barriers to implementation include inadequate training or maintenance of skills, and larger systematic issues related to reimbursement policy, social support, and financial hardship. As most established providers were uninterested in additional brachytherapy training, future approaches to improve patients’ access should be multidimensional and reflect the value of brachytherapy in definitive treatment of patients with LACC.

The Utility of Rapid Nucleic Acid Amplification Testing to Triage Symptomatic Patients and to Screen Asymptomatic Preprocedure Patients for SARS-CoV-2

We investigate the utility of the ID Now when compared to RT-PCR to triage patients suspected of having COVID-19 presenting to emergency rooms (ERs) and to screen asymptomatic patients presenting for pre-procedural testing. We find it useful when prevalence of COVID-19 is high in symptomatic patents and potentially useful in asymptomatic patients who are likely to be retested if symptoms emerge.

Gastrointestinal endoscopy during the coronavirus pandemic in the New York area: results from a multi-institutional survey

Background and study aims The coronavirus disease 2019 (COVID-19), and measures taken to mitigate its impact, have profoundly affected the clinical care of gastroenterology patients and the work of endoscopy units. We aimed to describe the clinical care delivered by gastroenterologists and the type of procedures performed during the early to peak period of the pandemic. Methods Endoscopy leaders in the New York region were invited to participate in an electronic survey describing operations and clinical service. Surveys were distributed on April 7, 2020 and responses were collected over the following week. A follow-up survey was distributed on April 20, 2020. Participants were asked to report procedure volumes and patient characteristics, as well protocols for staffing and testing for COVID-19. Results Eleven large academic endoscopy units in the New York City region responded to the survey, representing every major hospital system. COVID patients occupied an average of 54.5 % (18 – 84 %) of hospital beds at the time of survey completion, with 14.5 % (2 %-23 %) of COVID patients requiring intensive care. Endoscopy procedure volume and the number of physicians performing procedures declined by 90 % (66 %-98 %) and 84.5 % (50 %-97 %) respectively following introduction of restricted practice. During this period the most common procedures were EGDs (7.9/unit/week; 88 % for bleeding; the remainder for foreign body and feeding tube placement); ERCPs (5/unit/week; for cholangitis in 67 % and obstructive jaundice in 20 %); Colonoscopies (4/unit/week for bleeding in 77 % or colitis in 23 %) and least common were EUS (3/unit/week for tumor biopsies). Of the sites, 44 % performed pre-procedure COVID testing and the proportion of COVID-positive patients undergoing procedures was 4.6 % in the first 2 weeks and up to 19.6 % in the subsequent 2 weeks. The majority of COVID-positive patients undergoing procedures underwent EGD (30.6 % COVID +) and ERCP (10.2 % COVID +). Conclusions COVID-19 has profoundly impacted the operation of endoscopy units in the New York region. Our data show the impact of a restricted emergency practice on endoscopy volumes and the proportion of expected COVID positive cases during the peak time of the pandemic.

AGA Institute Quality Measure Development for the Diagnosis and Management of COVID-19

AGA Institute Quality Measure Development for the Diagnosis and Management of COVID-19

Abstract 16977: Coronary Chronic Total Occlusions: Insights on Upstream Management

Introduction: Percutaneous coronary intervention (PCI) of coronary artery chronic total occlusions (CTO) has increased over time, despite representing higher procedural risk than traditional PCI. While guidelines for stable ischemic heart disease recommend antianginal therapy prior to attempted revascularization, the frequency with which this occurs for CTO PCI remain unknown. We propose to assess the frequency and variability in upstream use of antianginal therapy prior to CTO PCI attempt over time. Methods: This study identified all patients who underwent a CTO PCI attempt from January 2012 to September 2018 across the Veterans Affairs Healthcare System using the Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) program. Patients were categorized by upstream management: (A) &lt;2 antianginal medications prescribed in year prior to CTO PCI, (B) ≥ 2 antianginals (C) Stress testing within 3 months of CTO PCI attempt and (D) ≥2 antianginals AND stress testing. Antianginal medications included beta blockers, nitrates, calcium channel blockers, and ranolazine. Multivariable logistic regression was used to estimate the propensity for receiving each category of treatment over time. Results: During the study period, 4250 patients underwent CTO PCI, with 1716 (40%) on ≥2 antianginal medications, 2534 (60%) on &lt;2 antianginals, 1023 (24%) with stress testing, and 338 (8%) on ≥2 antianginals with stress testing. Trends in upstream medical management of patients undergoing CTO PCI were unchanged over each fiscal year (Figure 1A) while odds of preprocedural stress testing decreased across fiscal years (Figure 1B). Conclusions: The majority of patients were on low intensity antianginal medical therapy prior to CTO PCI. Utilization of preprocedural stress testing decreased over time while patterns of upstream medical management remained constant, suggesting an opportunity to improve guideline compliance among patients undergoing attempted CTO PCI.

Severe Acute Respiratory Syndrome Coronavirus 2 Surveillance and Exposure in the Perioperative Setting With Universal Testing and Personal Protective Equipment Policies.

BackgroundNew York City (NYC) experienced a surge of COVID-19 cases in March and April 2020. Since then, universal PCR based surveillance testing and PPE measures are in wide use in procedural settings. There is limited published experience on the utility and sustainability of PCR based surveillance testing in areas with receding and consistently low community COVID-19 rates.MethodsThe study was conducted at a tertiary care cancer center in NYC from March 22, 2020, until August 22, 2020. Asymptomatic patients underwent SARS CoV-2 testing before surgeries, interventional radiology procedures, and endoscopy. Contact tracing in procedural areas was done if a patient with an initial negative screen re-tested positive within 48 hours of the procedure.ResultsFrom March 22 until August 22, 2020, 11,540 unique patients underwent 14,233 tests before surgeries or procedures at MSKCC. Overall, 65 patients were positive, with a peak rate of 4.3% that fell below 0.3 % after April 2020. For the 65 positive cases, three were pre-symptomatic, and 38 were asymptomatic. Among asymptomatic test-positive patients, 76 % had PCR cycle threshold (Ct) > 30 at first detection. Five patients tested newly positive in the immediate post-operative period, exposing 82 employees with one case of probable transmission (1.2%).ConclusionThe prevalence of SARS-CoV-2 infection identified on pre-procedural surveillance was low in our study, which was conducted in an area with limited community spread at the later stage of the study Universal PPE is protective in procedural settings. Optimal and flexible diagnostic strategies are needed to accomplish and sustain the goals of comprehensive pre-procedure surveillance testing.

Cancer Screening During the Coronavirus Disease-2019 Pandemic: A Perspective From the National Cancer Institute’s PROSPR Consortium

Cancer Screening During the Coronavirus Disease-2019 Pandemic: A Perspective From the National Cancer Institute’s PROSPR Consortium

S0532 Pre-Procedure COVID-19 Screening and SARS-CoV-2 Testing in a Large Community-Based Ambulatory Surgical Center (ASC) in SE Michigan

INTRODUCTION: The role of pre-procedure COVID-19 testing in outpatient endoscopy centers remains unclear, especially in areas with declining incidence and prevalence of infection. We developed a strategy utilizing symptom screening and SARS-CoV-2 viral RT-PCR testing in patients referred for elective endoscopy at a large community-based ASC in SE Michigan. We hypothesize that this dual screening approach will allow better detection of symptomatic and asymptomatic carriers of COVID-19. METHODS: A retrospective review of all patients referred for elective outpatient endoscopy during a 3 week period (May 20–June 12, 2020) was conducted. Patients were initially screened for exposure history and symptoms of COVID-19 at the time of procedure scheduling, again 3 days prior to the procedure, and on the actual day of the procedure. All patients were offered SARS-CoV-2 RT-PCR testing 48 hours prior to the scheduled procedure and then advised to follow CDC guidelines of social distancing, donning a face mask and frequent hand hygiene until endoscopy. Uptake of COVID-19 testing, barriers, and impact on subsequent endoscopy were evaluated. RESULTS: 718 consecutive patients were scheduled for elective outpatient endoscopy. All patients were symptom screened and 642 patients (89%) underwent COVID-19 PCR testing within 48 hours of their scheduled procedures. 2 patients reported fevers within 48 hours of their scheduled endoscopy, leading to cancellation. COVID-19 PCR testing of asymptomatic patients (n = 642) revealed no positive results. A total of 76 patients (11%) did not undergo viral testing. Barriers to COVID-19 testing included limited time interval between scheduling and procedure, patient reported challenges with travel/availability, and negative perceptions about testing. CONCLUSION: This study demonstrates the feasibility and successful implementation of a pre-procedure COVID-19 screening program in a busy endoscopy center. The dual process of clinical screening for symptomatic patients and viral testing of asymptomatic patients optimizes the likelihood of identifying pre-procedure patients with COVID-19. Although there is a low yield of positive viral tests in settings with low disease prevalence, this study forms a framework to expand pre-procedure screening and testing to enhance safety for our patients and staff during the COVID-19 pandemic.

S0529 UTMB Approach to Restarting Outpatient Endoscopy Amid the COVID-19 Pandemic

INTRODUCTION: The COVID-19 pandemic has led to widespread disruptions of outpatient endoscopic procedures. The Division of Gastroenterology and Hepatology at UTMB developed a tiered strategy for risk stratifying pandemic-related cancellations, in an effort to systematically reschedule patients. The Centers for Medicare and Medicaid Services, in concordance with multi-society guidelines, provided a framework for gradual reopening of outpatient procedures. Here we describe the process and outcomes of the tier-based reinstitution of our outpatient endoscopy after flattening of the COVID-19 curve to provide urgent endoscopy services within a reasonable period applying appropriate risk mitigation precautions. METHODS: Patients with pandemic-related cancellations from 3/16/2020 to 4/20/2020 were stratified into tier groups (1-4) in order of urgency (Table 1). During phase 1 of Texas’s reopening, tiers 1 (urgent/emergent) and 2 (semi-urgent) were rescheduled within 1 and 4 weeks, respectively. During phase 2, tiers 3 and 4 were subsequently rescheduled within 3 months. Additional measures taken between phase 1 and 2 included pre-procedural testing of all inpatient and outpatients, employee testing, symptom screenings, surgical mask use, and internal social distancing. Patients who chose not to reschedule were asked to provide their rationale (Table 2). RESULTS: Of the 540 patients awaiting delayed procedures, 14/16 (87.50%) patients in tier 1 and 147/170 (86.47%) patients in tier 2 could be contacted by phone to discuss the possibility for scheduling. Of these, only 57.14% of tier 1 and 48.97% of tier 2 could be scheduled at their goal procedure interval. Despite counseling on the safety measures instituted, the most commonly identified barrier for rescheduling urgent or semi-urgent endoscopy was COVID-19 related concerns in 40%. Reassuringly, our pre-procedure COVID testing of the patients willing to return for their procedures revealed an incidence of 1.3%, as compared to 4.4% in Galveston county. CONCLUSION: Our model describes a tier-based system that can be used to safely reintroduce elective procedures prioritized based on urgency. The majority of patients across all tiers were rescheduled within 4 weeks. We plan to contact patients 2 weeks after endoscopy to inquire about COVID-19 testing and results, which will allow us to evaluate the efficacy of our peri-procedural transmission prevention measures.Table 1.: Tier system to prioritize outpatient endoscopy proceduresTable 2.: Endoscopy rescheduling due to COVID-19 pandemic

S0562 Comparison of Pre-Procedural COVID-19 PCR Testing on Routine Endoscopic Practice Pre- and Post-Societal Reopening

INTRODUCTION: Current GI society recommendations on resuming endoscopy in the COVID-19 era are based on expert consensus with limited data Previously, we reported routine COVID-19 PCR testing of asymptomatic patients prior to societal reopening may be low-yield despite theoretically decreasing staff exposure to carriers The impact of societal reopening on pre-procedure testing remains unknown The aim of this study is to compare yield of routine COVID-19 testing of asymptomatic individuals prior to endoscopy pre- and post-societal reopening METHODS: This retrospective cohort study reviewed all patients undergoing endoscopic procedures at our combined inpatient/outpatient facility 4/13/2020 to 6/15/2020 Outpatients were called prior to the planned procedure with a COVID-19 screening questionnaire Patients with flagged responses during this verbal screening were postponed Those with negative verbal screening underwent PCR testing Patients with a negative PCR underwent procedure, whereas positive PCR patients were rescheduled Inpatients requiring procedures received a rapid in-house test Emergent cases were performed regardless of the test result using full barrier personal protective equipment Patients were again screened verbally and temperature checked day of procedure The proportion of positive tests pre and post re-opening were compared with the Fisher's exact test Our data were compared to publicly available population-based test results from our county, Miami-Dade, FL RESULTS: 1,406 PCR swabs were performed of which 4 patients were positive (test positive rate: 0 28%, 95% CI: 0 08-0 72%) During the pre-opening period, 1 of 396 PCR swabs was positive (percent positive: 0 25%, 95% CI: 0 01-1 4%) Post-opening, 3 of 1,010 PCR swabs were positive (percent positive: 0 30%, 95% CI: 0 06-0 87%) There was no difference in the rate of positive tests pre and post societal re-opening (0 25% vs 0 30%, P 0 99) Demographic data qualify our county as intermediate prevalence for COVID-19 There have been no reported COVID-19 cases among our endoscopy staff CONCLUSION: Despite a significant increase in procedural volume post-societal reopening, rates of asymptomatic COVID infections remained stable compared to pre-reopening Verbal screening tools remain effective, but not perfect, in identifying patients who should have their procedure deferred in intermediate prevalence areas PCR testing may play an adjunctive role to prevent exposure from asymptomatic or pre-symptomatic patients

Comparative Trends in Percutaneous Coronary Intervention in Japan and the United States, 2013 to 2017

BackgroundAdoption of the results of large-scale randomized controlled trials in percutaneous coronary intervention (PCI) may differ internationally, yet few studies have described the potential variations in PCI practice patterns. ObjectivesUsing representative national registries, we compared temporal trends in procedural volume, patient characteristics, pre-procedural testing, procedural characteristics, and quality metrics in the United States and Japan. MethodsThe National Cardiovascular Data Registry CathPCI was used to describe care in the United States, and the J-PCI was used to assess practice patterns in Japan (numbers of participating hospitals: 1,752 in the United States and 1,108 in Japan). Both registries were summarized between 2013 and 2017. ResultsPCI volume increased by 15.8% in the United States from 550,872 in 2013 to 637,650 in 2017, primarily because of an increase in nonelective PCIs (p for trend <0.001). In Japan, the volume of PCIs increased by 36%, from 181,750 in 2013 to 247,274 in 2017, primarily because of an increase in elective PCIs (p for trend <0.001). The proportion of PCI cases for elective conditions was >2-fold greater in Japan (72.7%) than in the United States (33.8%; p < 0.001). Overall, the ratio of nonelective PCI (vs. elective PCI; 27.3% vs. 66.2%; p < 0.001) and the performance of noninvasive stress testing in patients with stable disease (15.2% vs. 55.3%; p < 0.001) was lower in Japan than in the United States. Computed tomography angiography was more commonly used in Japan (22.3% vs. 2.0%; p < 0.001). ConclusionsElective PCI is more than twice as common in Japan as in the United States in contemporary practice. Computed tomography angiography is much more frequently used pre-procedurally in Japan than in the United States.

Early experience with universal preprocedural testing for SARS-CoV-2 in a relatively low-prevalence area.

We implemented universal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing of patients undergoing surgical procedures as a means to conserve personal protective equipment (PPE). The rate of asymptomatic coronavirus disease 2019 (COVID-19) was <0.5%, which suggests that early local public health interventions were successful. Although our protocol was resource intensive, it prevented exposures to healthcare team members.

AGA Institute Rapid Review and Recommendations on the Role of Pre-Procedure SARS-CoV-2 Testing and Endoscopy

AGA Institute Rapid Review and Recommendations on the Role of Pre-Procedure SARS-CoV-2 Testing and Endoscopy

The Impact of the Coronavirus Disease-19 Pandemic on Access to Endoscopy Procedures in the VA Healthcare System

The Impact of the Coronavirus Disease-19 Pandemic on Access to Endoscopy Procedures in the VA Healthcare System

Outcomes of Universal Preprocedure Coronavirus Disease 2019 Testing Before Endoscopy in a Tertiary Care Center in New York City

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The Epidemiology of Severe Acute Respiratory Syndrome Coronavirus 2 in a Pediatric Healthcare Network in the United States.

BackgroundUnderstanding the prevalence and clinical presentation of coronavirus disease 2019 in pediatric patients can help healthcare providers and systems prepare and respond to this emerging pandemic.MethodsThis was a retrospective case series of patients tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) across a pediatric healthcare network, including clinical features and outcomes of those with positive test results.ResultsOf 7256 unique children tested for SARS-CoV-2, 424 (5.8%) tested positive. Patients aged 18–21 years had the highest test positive rate (11.2%), while those aged 1–5 years had the lowest (3.9%). By race, 10.6% (226/2132) of black children tested positive vs 3.3% (117/3592) of white children. By indication for testing, 21.1% (371/1756) of patients with reported exposures or clinical symptoms tested positive vs 3.8% (53/1410) of those undergoing preprocedural or preadmission testing. Of 424 patients who tested positive for SARS-CoV-2, 182 (42.9%) had no comorbidities, 87 (20.5%) had asthma, and 55 (13.0%) were obese. Overall, 52.1% had cough, 51.2% fever, and 14.6% shortness of breath. Seventy-seven (18.2%) SARS-CoV-2–positive patients were hospitalized, of whom 24 (31.2%) required respiratory support. SARS-CoV-2-targeted antiviral therapy was given to 9 patients, and immunomodulatory therapy to 18 patients. Twelve (2.8%) SARS-CoV-2-positive patients required mechanical ventilation, and 2 patients required extracorporeal membrane oxygenation. Two patients died.ConclusionsIn this large cohort of pediatric patients tested for SARS-CoV-2, the rate of infection was low but varied by testing indication. The majority of cases were mild and few children had critical illness.

Implementation and Impact of Universal Preprocedure Testing of Patients for COVID-19 Before Endoscopy

Implementation and Impact of Universal Preprocedure Testing of Patients for COVID-19 Before Endoscopy

Impact of the COVID-19 pandemic on the workflow of an ambulatory endoscopy center: an assessment by discrete event simulation

Background and AimsAs community-based ambulatory endoscopy centers (AECs) across the nation are trying to reopen and safely resume outpatient endoscopic procedures after the unprecedented lockdown related to the coronavirus disease 2019 (COVID-19) pandemic, guidelines recommend pretesting and screening for COVID-19 along with other mitigation measures for the safety of patients and staff. The impact of such changes in the workflow of AECs on throughput and other performance indicators is largely unknown, although a significant reduction in revenue stream is expected.MethodsA discrete event simulation–based model was developed in the setting of a small to medium community-based single-specialty AEC to quantify the impact of COVID-19–related workflow changes on performance indicators and cost per case compared with the pre–COVID-19 baseline.ResultsIn the simulation model, post–COVID-19 recommended workflow changes significantly impacted the operational and productivity metrics and, in turn, adversely affected financial metrics. Overall, there was a significant decrease in staff utilization and consequent increase in total facility time, waiting time for patients, and cost per case because of a bottleneck at the time of preprocedure COVID-19 screening and testing while practicing social distancing. Strategies to minimize this adverse impact on productivity were assessed.ConclusionsPretesting and screening for COVID-19 as recommended by current guidelines will significantly impact the productivity and revenue stream of AECs. Urgent measures by payors are needed to adjust the facility reimbursement of endoscopy centers to ensure successful reopening and ramping up outpatient endoscopy services in these facilities already hit hard by the pandemic.