Impact of the COVID-19 pandemic on endoscopic procedures: a single-center study in China

Lai-juan Chen, Xiu-jing Yu, Ting Chen, Mei-feng Wu, Yong-li Ye, Lun-po Wu

1Nursing Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China

2Department of Endoscopy Center, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China

3Department of Gastroenterology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China

4Institution of Gastroenterology, Zhejiang University, Hangzhou 310009, China

Corresponding Author: Lun-po Wu, Email:drwlp@zju.edu.cn

The coronavirus disease 2019 (COVID-19) has aff ected the whole globe since its outbreak in December 2019,and many countries have tried several measures to protect and mitigate against its spread. Although the outbreaks have been effectively controlled in China, COVID-19 is still emerging as a public health crisis worldwide, causing massive panic.Additionally, there are still scattered new cases being reported in China.Therefore, in order to adhere to the policy of preventing imported cases and domestic resurgence, varied strategic countermeasures against COVID-19 have been enforced on a regular basis. As respiratory droplet and contact are the main modes of COVID-19 transmission,all endoscopy centers have a higher risk of exposure to COVID-19 than other areas in a hospital.

As a tertiary center in China, our hospital has two campuses with two endoscopy centers. All endoscopies and invasive operations outside the operating room are performed in these centers. The average daily volume of the procedures in each center is more than 500. The patients are mainly referred from outpatient clinics, inpatient services, and the general health examination department. These patients usually have complex medical conditions carrying higher mobility and mortality. Moreover, the number of patients undergoing painless procedures has increased significantly. The patients are required to have at least one family member to be present, which inevitably brings more challenges during pandemic time.

According to the response measures of COVID-19, different methodologies of the patient screening prior to the procedures are adopted in the endoscopy centers. Also, the information platform and big data technology are used to improve the accuracy and efficiency of screening work. This report presents our experience and strategies on the efficient management of the endoscopy centers during the COVID-19 pandemic.

MANAGEMENT OF THE ENDOSCOPY CENTER Application of Information Technology

Since 2017, our endoscopy centers have implemented the apps and the information platform to deliver the appointment information, real-time dynamic flow information of the centers, precautions for endoscopies, and the instruction videos to the patients who are scheduled an endoscopic procedure. During the COVID-19 pandemic, information technology has been further enhanced. Our department updates the epidemic prevention precautions in real-time, messaging treatment information to the patient’s mobile phone at 8 a.m. one day before the appointment. The messages not only include the important instructions of the endoscopic procedures but also remind patients finishing the nucleic acid and antibody tests prior to arrival. This process has shown to decrease some delays, interruption or cancellations.

In addition, by implementing the information-based appointment system, the number of patients is strictly controlled in each allocated period. The time-based appointments and adequate education to patients and their family members have prevented overcrowding.

COVID-19 designated access

At the beginning of the pandemic, our department conducted various evaluations and measures for patients with confirmed or suspected COVID-19. The specific accesses to endoscopy suites include the specified hallways, elevators, and the negative pressure consultation rooms. This process has been incorporated into the instruction manual of the endoscopy centers. As a result, respiratory infectious diseases control has much improved.

Three-level screening strategy

We implement a three-tier COVID-19 screening strategy for patients who are scheduled to have any endoscopic procedures during the COVID-19 pandemic.

1) Pre-procedure assessment

Primary screening at the gate of the hospital. To avoid overcrowding and speed up the screening process, the endoscopy centers implement different screening methods for the patients from the outpatient and inpatient departments.

Outpatients: At the entrance, volunteers check patients’ body temperature and their health QR codes. Only patients with normal temperature and a green health QR code are allowed to enter the endoscopy centers. The patients with fever are referred to a fever clinic.

Inpatients: Because the hospital patients have been screened for epidemiological history and tested for COVID-19 nucleic acid and antibodies, they can be directly guided to the service desk for endoscopic screening and evaluation.

2) In the endoscopy center

The nurses at the service desk are responsible for epidemiological history screening and pre-treatment assessment of patients. This procedure is divided into the following steps.

Epidemiological history screening. First, the patients have to show the communication big data itinerary card within the past 14 d, and then the nurse will ask them again to confirm and record whether they have left the local area in the past 14 d, and whether they are from a high-risk area, and whether they have contacted with people in a medium-high-risk area. For the elderly who do not have smartphones and health QR codes, an ID card or a residence permit or a citizen card is required. Furthermore, all patients must sign an “Endoscopy Center Outpatient Screening Form”. If a patient’s screening is negative, the nurse will sign the “Surgery/Operation Patient Screening Reconfirmation Form”.

Measurement of vital signs. Body temperature, blood pressure, pulse and symptoms are checked and recorded by the nurses.

For clinic referred patients with body temperature ≥37.5 ℃, a staff will guide them to a fever clinic for further investigation. For hospital patients with body temperature ≥37.5 ℃, the nurse will contact their primary attending if the fever is not related to the epidemic, both the nurse and the patient’s doctor will sign the screening confirmation form.

3) In the operating room

Patients who finish secondary screening are allowed to enter our endoscopy centers, and an endoscopy doctor and a nurse would recheck the information before they starts the procedure.

Disinfection of the environment and endoscopes

Before the endoscopic procedure, chlorinecontaining disinfectant is used to sterilize all surfaces of the equipment and the floor in our centers.

Continuous ventilation is required using a plasma air-sterilizing machine in every operating room during working hours. Secretions are removed immediately, and the areas are wiped immediately with chlorine-containing disinfectant.

After an endoscopic procedure, the patient’s supplies are disinfected separately. The endoscopes are sterilized with peracetic acid and ethylene oxide and a STERRAD NX Sterilizer.

Air samples for cultures are collected in three operating rooms before and after disinfection. The average number of colonies in the air before disinfection was ≥3.0 cfu. The average number of colonies in the air after disinfection was ≤0.0 (Table 1).

MANAGEMENT OF MEDICAL STAFF

During the epidemic, all medical staff are trained to put on and take off isolation gowns, wear masks, use ventilator and defibrillator, and other requirements to cope with unexpected events. In addition, according to the characteristics of the endoscopy center, the department focuses on training the bedside techniques of the cleaning, disinfecting and transporting procedures of the endoscopes to prevent iatrogenic infections.

Therefore, medical staff must be trained in sensory control, work procedures, hand hygiene, standard prevention, and mask removal procedures. Each person must be assessed to ensure that there is nothing wrong in the work procedures. The endoscopy centers conduct a questionnaire survey on the training content periodically.

The endoscopy centers develop a work flow to fulfill daily training, weekly questionnaire assessment, weekly practice assessment (hand hygiene), and supervision and inspection at least 3 times a day.

RESULTS

Comparing the total number of diagnosis and treatment in our endoscopy centers in 2019 and in 2020, the results showed no reduction in endoscopy cases in total. Among them, diagnostic operations (routine gastroscopy, routine colonoscopy, etc.) decreased while therapeutic operations increased. Routine gastroscopy and capsule gastroscopy were the most affected operations. Moreover, bronchoscopists were affected (Table 2).

Table 1. Colony forming units in each operating room

Regarding to the pre-diagnosis assessment, only about 5 min was needed before the pandemic, while at least 10 min was needed during the COVID-19 epidemic period.

After cooperation with supervision and implementation, all medical staff increased their awareness of infection control (Table 3). The training content and frequency have been significantly enhanced compared with those before the epidemic outbreak, and the implementation has been effective. No patients or medical workers were infected with COVID-19 during the pandemic.

DISCUSSION

During the COVID-19 pandemic, our endoscopy centers have functioned normally and efficiently. Using the time of sudden public health incidents occurred in Zhejiang Province as a cut-off point, the number of patients from January 2020 to March 2020 has decreased significantly, compared with that in the same period of 2019. In our hospital, the number of endoscopes showed a 20% increase every year. During the epidemic period, several strategies were applied. For example, to reduce the flow of people in each operating room, we added three operating rooms. We also arranged overtime on weekends. With these strategies, the number of patients increased gradually. Compared with 2019, the workload in 2020 (from January 1 to December 31) showed no reduction.

There are several strategies to be shared to facilitate workflow by implementing regular epidemic prevention and control. First, the mobile app platform plays a critical role in daily practice. Using the platform to deliver the epidemic requirements in advance will help patients obtain sufficient information and respond in a timely manner. Furthermore, as the screening work of the endoscopy centers face challenges, informationbased big data technology can be applied to the epidemic screening. As the epidemic information changes dynamically, the epidemiological history should be updated timely. Big data sharing technology facilitates the accuracy and efficiency of screening. With the information-sharing data, the risk level of living area and recent exposures can be checked quickly, and medical staff can carry out epidemic screening efficiently. More importantly, we have formulated a standard workflow for pandemic protection and control. Diff erent management strategies according to the characteristics of patients from various areas and diff erent ages are adopted in the endoscopy centers. Also, we arrange online and offline epidemic prevention training and monitor the health status of employees. The sterilization and sampling of endoscopic equipment are also strictly performed.

Table 2. Endoscopic operations in endoscopy center during the COVID-19 pandemic

Table 3. Staff management of infection control

CONCLUSIONS

In conclusion, to control and prevent the COVID-19, epidemic screening for endoscopic procedures should be strengthened. Developing the information platform, formulating a standard workflow, excising regular training, and strictly monitoring the infection improve the screening accuracy and protect patients and staff . Our experiences may provide comprehensive management for endoscopy centers within regular epidemic prevention and control.

Funding: This work was supported by the National Natural Science Foundation of China (82103496).

Ethical approval: The study protocol was approved by the Clinical Research Ethics Committee of the Second Affiliated Hospital of Zhejiang University. This study does not involve human participants.

Conflicts of interest: The authors declare that they have no conflict of interest.

Contributors: LPW contributed to the conception and design. All authors contributed to the data collection, analysis, and interpretation of data, manuscript writing and editing and final approval of manuscript.