How the Endoscopy Service Was Reorganized during the COVID-19 Pandemic
Before performing any type of endoluminal procedure, a general assessment of the urgency and need of the procedure was assessed. The healthcare workers were trained on the correct use of protective personal equipment (PPE), on donning and doffing procedures, and on the ways to access the dedicated premises where the endoscopy was performed. A dedicated disposable kit was set up (headgear, face shield, long-sleeved water-resistant gown or medical protecting coverall, double long nitrile gloves, waterproof leg covers, and class 2 or 3 filtering face-piece respirators FFP2 or FFP3).
The endoscopy procedures were carried out at the patient’s bed in the inpatient areas, intensive care units, and operating rooms identified as “COVID-19 areas”. Special measures were taken, such as lowering the atmospheric pressure, where possible. In the operating room, endoscopies were often performed on patients in which pathologies of the digestive tract were found, such as perforation or obstruction of the esophagus. Patients from the emergency room had direct access to the endoscopy service only if the result of molecular screening for SARS-CoV-2 was negative and/or they required procedures that could not be postponed; in the event of an ongoing outcome, the patient was considered as possibly COVID-19 positive and the same protective measures were applied as for a confirmed COVID-19 patient. In this case, the patient accessed the service following a telephone agreement with the healthcare workers such that upon their arrival, the dedicated staff of the reception carried out the COVID-19 pre-endoscopy triage and could guarantee that the dedicated outpatient area was available. All patients were questioned about contact with COVID-19-positive individuals and recent or present symptoms, such as fever, cough and dyspnoea, rhinitis, and sudden loss of smell and/or taste. Before entering the waiting room, the patient had to wear a surgical mask and gloves and undergo a temperature measurement and rapid molecular testing to determine whether COVID-19 was present. As recommended by ESGE/ESGENA [1
], risk stratification of the patients for possible COVID-19 infection should be done 1 day prior to the GI endoscopy and then again on the day of the endoscopy by questioning for symptoms and contacts, or through tests for virus infection or immunity. Although many of the COVID-19 symptoms are similar to those of other respiratory diseases, fever (body temperature > 37.5° or 38 °C) is one of the quite frequent symptoms of COVID-19 and the temperature check on arrival in the unit may help to identify COVID-19 patients. To test for virus infection, the nasopharyngeal swab for viral genome detection remains the gold standard for diagnosing COVID-19 [24
In the case of a patient that cannot be transported to the emergency room, the healthcare workers (one doctor and two nurses) were activated to carry out the endoscopy in the dedicated operating room. In the COVID-19 area, each workstation for endoscopy was equipped with dedicated single and reusable material, from the endoscopy column to the endoscopes, up to the containers for the safe transport of the contaminated device.
The Thoracic Endoscopy Unit and intensive care units were equipped with disposable bronchoscopes for bronchial inspection and for performing BAL when necessary.
Disinfection of the endoscopy room surfaces was performed after each procedure using a disinfectant that is effective against viruses. In this hospital, housekeeping staff applied a chlorine-based disinfectant (0.5% sodium hypochlorite, 5000 mg/L) with a 10 min contact time for the disinfection of compatible surfaces [25
], whereas on electromedical non-invasive devices, ready to use wipes pre-moistened with 70% isopropyl alcohol were used with 15 s of contact time.
Regarding the reprocessing of endoscopes, the analysis of the procedure identified critical issues for which improvement actions were taken to reduce the risk of transmitting SARS-CoV-2 infection. The interventions concerned:
Finally, to ensure that the endoscope reprocessing procedures were carried out correctly, audits were conducted in the two endoscopy units.
Endoscopes that were used on SARS-CoV-2-positive patients who met the selection criteria and were hospitalized in the COVID-19 area, namely, 4 bronchoscopes and 10 digestive endoscopes (5 gastroscopes and 5 colonoscopes), were sampled within three days of reprocessing (Table 1
One column and two washer-disinfectors dedicated to COVID-19 patients were also sampled.
In contrast, before the reprocessing, the virological analysis carried out on the Olympus BF1T180 bronchoscope revealed the presence of SARS-CoV-2 RNA in the sampling liquid collected from the endoscope, with a Ct value of 30.5, while the eSwab COPAN swabs collected from the outer surface and valve port of the biopsy channel were negative.
On the Olympus GIF800 gastroscope, SARS-CoV-2 RNA was detected in the sampling liquid with a Ct value of 32. In this case, the surface swabs also gave negative results for the RT-PCR tests.
The virological analysis carried out on both the swabs and the liquids collected from endoscopes gave negative results on all the analyzed samples; therefore, no sample required isolation on cell cultures. Furthermore, no traces of SARS-Cov-2 RNA were found on samples collected on the endoscopy column surfaces or on the two washer-disinfectors dedicated to COVID-19 patients. None of the results obtained were classified as “invalid” based on the compliance of the amplification of controls.
Throughout COVID-19 pandemic phase one, no endoscopy healthcare workers were tested positive for SARS-COV-2.