Q&A: Endoscopists need to prioritize health screenings, procedures during COVID-19 pandemic
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With the COVID-19 pandemic, many patients’ previously scheduled health screenings such as cancer screenings and colonoscopies are now being canceled or postponed until further notice. Many centers are prioritizing patients’ procedures as urgent or not.
Healio Gastroenterology and Liver Disease spoke with Glenn Littenberg, MD, chief medical officer of InSite Digestive Health Care in Pasadena, and health policy chair of the Digestive Health Physicians Association, about what screenings endoscopists are postponing, what procedures are considered priority and what precautions endoscopists need to take to prevent the spread of COVID-19. – by Monica Jaramillo
Healio: What are the concerns of COVID-19 in relation to endoscopy?
Littenberg: There are two perspectives to mention: patient safety and staff safety. With patient safety, we want to keep the numbers of people to a minimum. Besides being restrictive on what procedures we do, we are restricting the number of people at the center. Visitors who drop off patients stay in the car unless they are a caregiver and only one person comes in. It’s important to minimize the people in the endoscopy unit and minimize the exposure. Screen patients by temperature and questioning them before them come into the center. For staff safety, we are screening their temperature and asking questions. We check their temperature as they come in. If they have any suspicious symptoms or temperatures, they are told to go home and isolate. If they get sick enough, we will get them tested. Right now, getting them tested is not an option unless they show up in the hospital dreadfully sick. That is changing quickly, we hope.
There’s a contamination question here. While we’re doing scopes on people, we are considering that patients might be carriers, particularly with upper endoscopy. We are not doing upper GI endoscopy even on the ones we would judge as urgent on an outpatient basis and even in inpatients, if it’s not absolutely a lifesaving necessity. We are doing our best to estimate what’s wrong and how to manage it without endoscopy. We are minimizing procedures even in hospitals for “normal” clinical situations. There are a fair number of symptoms and other reasons we would normally do an endoscopy for on either outpatient or inpatient, but they are not essential. Anesthesiologists are trying to decide if patients should be intubated in all cases during upper endoscopy to prevent coughing and potential aerosol spread. Obviously protective gear is a big problem. They are in short supply in California and many parts of the country. We try to take the extra precautions. Some people are keeping their masks longer than they normally would. We are trying to be proactive as much as we can and minimize the problems.
Healio: What kind of procedures are being postponed?
Littenberg: Our procedure volumes at the outpatient center are down about 85% if not more. There are very few procedures being done. We are only doing procedures for people who have severe gastrointestinal issues, worrisome issues with colon cancer that we feel we can’t wait for, a handful of people with high risk polyps and the occasional colitis patients. We are wary about brand new symptoms; so, we are looking at established patients. We’re not doing screenings or routine surveillance unless there is something urgent about their clinical problem.
Healio: If a procedure cannot wait, what precautions should be taken for the endoscopist?
Littenberg: For any scope, we are using our masks, face shields and the best gowns we have. We are trying to minimize the secretions; viral particles can spread. We need to be very careful washing and sanitizing the procedure room and equipment after each case and more so at the end of the day. The normal scope washing is very adequate for a virus. A virus is not a threat with the endoscopy because of the appropriate scope washing being done is very effective against the virus. The biggest threat to the endoscopist and staff is more from patients who either don’t know they are infected or are infected and have active disease. We are not taking any people with any suspected active disease at the outpatient center. If they have any symptoms that sound like COVID-19 they are sent home.
Healio: What’s the best way to move forward with procedures that had to be postponed? Do certain procedures get priority?
Littenberg: There will be two considerations. One, is the staff going to be available? There will be staff that will leave. How much staff will be available when we want patients to come back? It’s an open question. What we are doing as far as prioritizing is looking over our schedules coming up and basically assigning a priority. A priority one patient is one who we really want to come in for a scope even despite the current situation. It’s urgent. Category 2 priority will be people who ought to have as a scope as soon as it’s reasonably safe. We will be calling them in order and scheduling them into the next available spots. The rest are category 3 in the screening, routine surveillance and patients who won’t be suffering or at risk from being put off a few months. We will get them in as long as open spots (not claimed by category 1, 2; cancellations) and staffing allows. I wouldn’t be surprised if the centers do 6-day work weeks once we are back in action. We have the back log. We will all be hurting severely financially; we’ll probably want to do as much work as we can manage to get done once it is safe.
Some centers may not be able to recover and may have to go bankrupt over this. We are lobbying hard through DHPA and specialty societies to have some help included in the big package being debated right now (March 26) that may give relief to some medical practices and ASCs in terms of supporting payroll, paid leave, and with small business loans. The infrastructure may suffer when we try to go back, and I don’t know who will be there when we do. We are concerned with how many healthcare workers are going to be out sick or quarantined, and that we can’t timely test them to see if they COULD come back to work. There is no significant volume of COVID-19 testing being done in California right now.
Disclosures: Littenberg reports no relevant financial disclosures.
For more information: Patients looking for more information can visit ColonoscopyToday.com to learn more about colorectal cancer screening and warning signs.
Perspective
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Sunguk Jang, MD
In general, I concur with Dr. Littenberg’s opinion and management plan in regards to the endoscopic operation during this COVID-19 pandemic crisis. His concern for the safety of patients as well as caregivers should resonate with all those that are involved in endoscopic operation. Clearly, the importance of prioritizing endoscopic procedures based on the degree of urgency has been a challenge in a time where social distancing plays a central role in controlling the current pandemic. Although the general sentiment of prioritizing endoscopic procedures is shared by gastroenterologists across the country, there remains some gray area and disagreements based on subjective interpretation of what procedures are deemed emergent/urgent versus procedures that can be postponed to near future. While it is relatively easy to recognize life threatening situations that require timely endoscopic intervention, the level of urgency - even in the setting of chronic medical issues – can be challenging to prioritize optimally. In general, patients with on-going symptoms or concern for neoplastic process should not be delayed. In addition, there are varying opinions as to length of delay if the procedures are pushed back. We also must not forget that not all endoscopic procedures are equal in their complexity and weight. Screening colonoscopy, for example, is a preventive procedure by and large with substantial health impact to the patients. Thus, rescheduling screening colonoscopy patients compared to those with diagnostic indication should be viewed with different sets of rules.
As many healthcare systems are looking ahead to re-open their endoscopic practice, it looks more likely that the recovery in procedural volume will take some time. Among several reasons, the concern for maintaining social distancing and financial health of the patients are likely to play a key role in this slow recovery. We must do our best to maintain an effective prevention system as well as deliver continued message of reassurance to our patients that, to the best of our knowledge and in accordance with guidelines, we take all necessary measures to provide a safe environment for their health care.
Cleveland Clinic
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