A team of UC Davis pediatric experts has developed a safety protocol for endoscopy that protects health care providers working with pediatric patients with possible COVID-19 infection. The protocol, published March 31 in Journal of Pediatric Gastroenterology and Nutrition, presented a framework to classify and mitigate the risks of COVID-19 infection by using limited protective resources.
Avoiding COVID019 infection in endoscopy
Endoscopy is a nonsurgical procedure used to examine a person's digestive tract using a flexible tube with an attached light and camera. It is considered an aerosol-generating procedure (AGP) with the potential of spreading airborne and droplet respiratory diseases such as COVID-19.
Pediatric COVID-19 patients requiring endoscopy present a unique challenge. They are disproportionately without symptoms or mildly ill but can still transmit the disease. During upper endoscopy, a patient’s coughing and gagging may generate aerosols, and those undergoing colonoscopy may pass gas or liquid stool that can carry the virus. Health care providers performing the endoscopy can be exposed to respiratory or gastrointestinal fluids from these patients.
As the risk of infection is substantial, adequate protection for health care providers during endoscopic procedures is critical
“We recognize the need to conserve PPE and other needed resources in anticipation of the surge of COVID-19 patients who require hospitalization,” said Daphne Say, assistant clinical professor in the Division of Pediatric Gastroenterology at UC Davis Children’s Hospital and lead author on the report. “The protocol provides a detailed set of recommendations for the use of PPE, with the goal of ensuring the safety of the health care providers and the patients.”
The protocol is specific to pediatric cases, unlike guidelines published March 19 by the World Health Organization (WHO) for rational use of personal protective equipment (PPE), which included specific instructions for health care workers performing AGP on patients with known COVID-19.
Say said the protocol UC Davis Health developed is being shared with colleagues across the country who are using it as framework to make clinical decisions, especially in hospitals that don’t have the ability to conduct in-house COVID-19 testing.
“Ultimately, our goal with this protocol was to balance the need for patients to receive care (in spite of the concerns regarding the pandemic) but also to be safe and responsible,” Say said.
Protocol includes recommendations on protective gear and safety measures
To make appropriate PPE decisions when COVID-19 testing is unavailable, endoscopists classify the patient risk based on symptoms and sick contacts of the patient. They should consider the higher probability that a child with no symptoms or a mildly ill child may be infected.
The report suggests limiting non-essential personnel for all endoscopic procedures, with no more than five individuals in the endoscopy suite at a time. It recommends the use of a negative pressure room to prevent airborne particles from dispersing.
When conducting an endoscopy in a neutral pressure room with a closed door, all personnel should don a powered air-purifying respirator (PAPR), use a water-resistant gown and a double layer of gloves. This room should remain closed for one hour after the procedure is complete to allow enough air exchange to evacuate suspended infectious particles. Appropriate signage should be placed outside the procedure room, indicating to others that an AGP is occurring or has just occurred.
At minimum, those in the pediatric endoscopy suite need to use gloves, water-resistant gowns, surgical face masks, eye protection and hair coverings for all endoscopic procedures. For patients requiring upper endoscopy and high-risk patients requiring colonoscopy, endoscopists need to utilize N95 respirators or equivalent, in addition to the PPE.
Scheduling of endoscopic procedures evaluates risks and benefits
According to the protocol, endoscopists need to prioritize emergent procedures such as foreign body retrieval, evaluation of gastrointestinal bleeding and procedures in hospitalized patients. They should limit outpatient procedures only to “essential” ones – defined as procedures that, if delayed more than eight to 12 weeks, would lead to harm or injury.
However, some children require endoscopy for their ongoing care and evaluation, irrespective of the COVID-19 pandemic. Delaying their procedures may compromise their health and strain future resources. In all cases, the endoscopy team needs to review the risks and benefits of endoscopy with patient families in advance of the procedure. Many patient families may choose to reschedule procedures until physical distancing restrictions have been lifted.
“Final decisions regarding the scheduling and timing of endoscopy will be made through shared decision making between the individual gastroenterologist, patient and the patient’s family,” Say said. “At the start of the shelter-in-place recommendations last month, many institutions locally chose to cancel all scheduled procedures entirely. We didn’t take that approach here at UC Davis, which I know many people in the community thought was unusual. I am so proud that we took a patient-centered approach to this crisis, acknowledging that just because a procedure was scheduled in advance doesn’t necessarily mean that it wasn’t essential.”
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Co-authors of this protocol are Arthur de Lorimier, Cathleen R. Lammers, JoAnne Natale, Satyan Lakshminrusimha, Jean Wiedeman and Elizabeth Partridge, all of UC Davis Health.
Study: Say et al. Risk Stratification and PPE Use in Pediatric Endoscopy During the COVID-19 Outbreak: A Single-Center Protocol. Journal of Pediatric Gastroenterology and Nutrition. DOI:10.1097/MPG.0000000000002731