Non-ICU GI-Pulmonary Endoscopy Process

Last update: March 19, 2020

In order to provide consistent care while minimizing the risk of possible infection with COVID19, all endoscopy procedures will be stratified based on UMMC Pandemic Plan for Operating Room/Procedural Areas/Elective Radiology Stage C and D. (See separate document.)

General and interventional bronchoscopy cases

Emergent

• Acute foreign body
• Large amount/massive hemoptysis 
• Central Airway Obstruction with respiratory compromise

Urgent – 24-48 hours

• Immunosuppressed host with new infiltrate tested - COVID neg

Semi-urgent  – 24 hours to 2 weeks

• New lung mass
• Cancer, for staging awaiting treatment decisions
• Known cancer, new lesion or suspected recurrence, where bx will alter management/diagnosis 
• Symptomatic suspected sarcoid
• Symptomatic suspected drug induced pneumonitis
• Central airway obstruction without respiratory compromise
• Lobar atelectasis not responding to conservative management
• Need for T-tube revision
• Revision of stent placed within last 4 weeks
• Small amount hemoptysis

Elective procedures > 4 weeks

• Airway inspection for chronic cough
• BAL for suspected MAC, minimal sx
• Suspected sarcoidosis, minimal sx
• Endobronchial valve for LVS
• Revision of stent placed > 4 weeks (Avoid if absence of symptoms)

General and interventional upper/lower GI endoscopy cases

Emergent

• Foreign body/Food impaction
• GI bleeding 
• Cholangitis
• Liver Transplant patient with biliary obstruction

Urgent - 24 hours

• Esophagus stricture
• Biliary obstruction dues to stones
• Stent placement in esophagus or colon for treatment of obstruction
• Bile leak
• Decompression for colonic pseudo-obstruction
• Transgatric pseudocyst drenage

Semi-urgent – 24 hours to 2 weeks

• Anemia within 2 weeks
• Rectal bleeding
• Abnormal CT scan
• EUS to evaluate for pancreatic or rectal lesion
• Treatment of Varices/variceal screening (MELD>15)
• Removal of high great colonic lesion by ESD/EMR
• Active Inflammatory Bowel Disease
• Abdominal pain with suspected peptic ulcer disease
• Immuno-compromised patients with dysphagia, diarrhea or suspected GVHD
• Treatment of AVM
• ERCP for dominant stricture or stent change

Elective procedures > 4 weeks

• Screening colonoscopy
• Pre-surgical procedures (EGD, bariatrics)
• History of colon polyps
• Variceal screening with MELD<15

• Outpatient mandatory COVID 19 Screening at the following levels:
  • At the time of scheduling of a procedure (to be performed by schedulers of each division)
  • Phone interview 24 hours prior a scheduled procedure (to be performed by designated personnel from the endoscopy lab)
  • Endoscopy RN at admission for a procedure with a temperature check
  • MD while consenting for a procedure

If one of the following is positive, a procedure gets postponed and patient is recommended to get tested for COVID-19: 1. new onset of dry cough 2. Fever 3. Close contact of a patient or a family member with a person who is COVID-19 positive. 4. Sore throat 5. Increased dyspnea from baseline.  

• Re-scheduled cases
  • Each division will maintain a wait list (deferred procedure list). The wait list will require regular review to determine priorities in light of OR, endoscopy suite, and resource availability. 

• Personal Protective Equipment (Applies for all personnel present in the room)
  • PAPR, gown, gloves, shoe covers in emergent procedures
  • Surgical face mask, hairnet/bonnet, eye protection, gown, gloves for urgent procedures tested COVID-19 negative
  • Surgical mask/N95, hairnet/bonnet, eye protection, gown, gloves, and shoe covers for semi-elective procedures

• Patients dress code
  • All patients entering endoscopy unit should wear a surgical mask
  • All patients need to be dressed in hospital gown and their belongings in a plastic bag.
  • All patients should wear a surgical mask also during recovery period (as soon as LMA/ET tube is removed)

• Patients family members/drivers
  • Will follow UMMC Visitor policy.
  • Entering of patient care area of the endoscopy lab won’t be allowed. Physician or RN will come out to the waiting area if a discussion/consent with a family member needs to be performed.

• Endoscopes re-processing
  • Follow standard High-Level Disinfection for re-usable bronchoscope.
  • Cleaning staff will use bonnet, N95 mask, eye protection, gown, gloves, and shoe covers during reprocessing.
• All bronchoscopies without exceptions need to be performed in a negative pressure room. A standard protocol for room cleaning post procedure will be applied. Cleaning of all surfaces with bleach wipes (computer keyboard etc.) will be done after each case.

• Inpatient bronchoscopies
  • Bronchoscopy in COVID-19 suspected patients is not recommended as an initial test for a diagnosis.
  • If bronchoscopy is to be performed to rule-in COVID-19 after initial swab was negative and suspicion is still high, (unexplained radiographic findings and acute respiratory failure) the procedure needs to be done in MICU per ICU Endoscopy Protocol (see separate file).
  • All non-acute elective inpatient bronchoscopies should be postponed and followed up in a provider’s clinic when a determination how to proceed will be discussed with a patient based on a current pandemic situation.
  • All endoscopies in COVID-19 positive patients will be done in MICU per MICU COVID-19 protocol (see a separate file)with an exception of cases needed to be done in OR. Exceptions need to be granted from a divisional chief and chief adult perioperative physician.

References

• Group of Interventional Respiratory Medicine, Chinese Thoracic Society. Expert consensus for bronchoscopy during epidemic of 2019 Novel Coronavirus infection (Trial version). Chin J Tuberc Respir Dis, 2020, 43:Epub ahead of print                                                                                                             
• Repici et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Gastrointest Endosc 2020 (accepted for publication)                                               
• Wahidi et al. American association for bronchology and interventional pulmonology (AABIP) statement on the use of bronchoscopy and respiratory specimen collection in patients with suspected for confirmed COVID-19 infection
• Tran K et al. Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A systematic review.

* Note: This document is a living protocol. Please always check for the latest version. For questions or concerns, please contact Michal Senitko, MD  or Sarah Glover, DO. 

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.