The Thai Association for Gastrointestinal Endoscopy published recommendations on safe endoscopy during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to assess the practicality and applicability of the recommendations and the perceptions of endoscopy personnel on them.
A validated questionnaire was sent to 1290 endoscopy personnel globally. Of these, the data of all 330 responders (25.6%) from 15 countries, related to the current recommendations on proper personal protective equipment (PPE), case selection, scope cleaning, and safety perception, were analyzed. Ordinal logistic regression was used to determine the relationships between the variables.
Despite an overwhelming agreement with the recommendations on PPE (94.5%) and case selection (95.5%), their practicality and applicability on PPE recommendations and case selection were significantly lower (
Using appropriate PPE and case selection in endoscopic practice during a pandemic remains a challenge. Resource availability and local prevalence are critical factors influencing the adoption of the current guidelines.
The rapidly evolving coronavirus disease 2019 (COVID-19) pandemic caused by SARS-COV-2 continues to pose unprecedented challenges to global medical communities and it has changed the way medicine is practiced globally. Due to its alarmingly high transmission rate, even among asymptomatic patients [
COVID-19 can manifest with various gastrointestinal symptoms; therefore, gastroenterologists are particularly at risk of inadvertent exposure [
Like other medical societies, the Thai Association for Gastrointestinal Endoscopy (TAGE) strives to provide a safe platform for its members–endoscopists, endoscopy nurses, technical assistants, and all other endoscopy personnel–to deliver safe and effective patient care. TAGE recently published its recommendations on endoscopic practice during the COVID-19 pandemic, focusing on the required PPE, case selection, and scope cleaning process [
However, there are discrepancies in resource supply and institutional capability, which questions whether such recommendations can be implemented in real-world practice. This study aimed to evaluate the practicality of the gastrointestinal society recommendations, as perceived by endoscopy unit staff, using a questionnaire-based survey. The secondary aim was to assess the perceptions of safety related to endoscopic procedures performed during the COVID-19 pandemic among endoscopy personnel.
An international survey was conducted. A web-based online questionnaire consisting of 24 questions was developed to evaluate the perceptions of endoscopy personnel on the TAGE recommendations during the COVID-19 pandemic. The content of the survey was validated by a panel of experts (
The survey was sent to all board-certified physician endoscopists, registered endoscopy nurses, and fellows-in-training according to the TAGE National Membership Office database. In addition, the TAGE recommendations were published on social media platforms (
TAGE recommended (a) PPEs based on patient risk stratification and (b) prioritizing endoscopic procedures as emergent, urgent, and elective for case selection, which were consistent with recommendations from the Asian-Pacific Society of Digestive Endoscopy, Society of American Gastrointestinal and Endoscopic Surgeons, and Center of Disease Control on COVID-19 statements (
Personal demographics and work-related data from the survey respondents were collected. All responses were anonymous. The questionnaire focused on three main aspects of the recommendations: (1) PPE during endoscopy, (2) case selection to be performed during the pandemic, and (3) scope cleaning process (
The web link of the questionnaire was distributed via email, Line® (Line Corporation, Tokyo, Japan), and Facebook® messenger applications. Two reminders were sent to all recipients at weekly intervals to increase the response rate.
Respondents would be considered from a low prevalent country if there were only “sporadic cases” according to the WHO categorization or a “cluster of cases” that did not exceed 10,000 accumulated cases per million population. High prevalence countries were defined as those with “community spread” or >10,000 accumulated cases per million population [
Univariate and bivariate analyses were also performed. Descriptive statistics were used to present continuous, ordinal, and categorical data. Mann-Whitney U and Kruskal Wallis tests were used for Likert-scale ordinal data, while chi-squared and Fisher’s exact tests were used for categorical data. Ordinal logistic regression analysis was performed to identify the relationships among the variables. If there was a statistically significant difference between the analyzed groups, a posthoc analysis was performed using the Mann-Whitney U test. All statistical analyses were performed using SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA).
The survey was distributed to all 339 TAGE members, 488 members of the Endoscopy Nurse Society of Thailand (ENST), and 71 gastroenterology fellows-in-training in Thailand. A total of 927 Facebook® users who shared published TAGE recommendations were screened. The survey was sent to 392 users who were found to be healthcare personnel in endoscopy units outside Thailand.
Of the 1290 surveys sent, 330 endoscopic personnel from 15 countries responded, accounting for a response rate of 25.6%. Using 1290 as the targeted population frame with a 95% confidence interval for Cochrane’s sample size formula, the corresponding correction formula yielded a 4.66% margin of error [
When asked about PPE recommendations for endoscopy (
Regarding the case selection, 95.5% (
Less than half of the respondents (46.1%) felt “moderately safe” working in an endoscopy unit during the COVID-19 pandemic period whereas 21.5% felt a “little safe” or “not safe at all” or unsafe. The main reason for “unsafe” working conditions (80%) was inadequate PPE provided to the endoscopy personnel.
The sense of safety of the respondents in the endoscopy unit significantly differed during the pandemic with age (
Looking at the various professional roles of the respondents, there were no statistically significant differences between the responses of the endoscopists (
Although there were no differences in the agreement with and perceived practicality and applicability of the recommendations among the different levels of hospitals, respondents from private hospitals were more likely to perceive the recommendations for case selection to be less practical than those from governmental hospitals (
Respondents from countries with a high prevalence of COVID-19 (
As COVID-19 continues to ravage the world, endoscopy units are now adapting to the “new normal” of medical practice. Our study has demonstrated that although the recommendations of gastrointestinal societies are generally accepted, their practicality and applicability are still questioned, especially in resource-limited and/or highly prevalent areas. Coverall suit, N95 masks, and leg covers were reported as the most deficient equipment, with 37% of the respondents stating that do-it-yourself equipment and reusing the mask were the most helpful in overcoming the PPE shortage problem [
Even though the majority of the respondents reported being able to implement the recommendations, almost half (46%) responded neutrally to a question on safety while working in an endoscopy unit. The sense of safety did not differ with gender, professional role, institutional level, number of COVID-19 cases in the hospital, or case load of endoscopic procedures for COVID-19 patients; it differed with age, working experience, training status, and the prevalence of COVID-19 in the country. Despite the higher mortality risk associated with COVID-19 infections [
The lower sense of safety of the trainees, compared with their attending counterparts, is a critical observation that should be urgently addressed. Trainees, in spite of their limited experience, constitute a fundamental workforce in the hospital and may inevitably be allocated to the frontline amidst overwhelming medical demand. As opposed to attending physicians, trainees are more vulnerable to coercion and generally receive less training for mass-casualty events [
The TAGE recommendation to postpone all elective cases has an inevitable economic impact on endoscopic practices. The significant disagreement on its practicality among respondents in private practice and governmental counterparts underscored the financial implications of these recommendations. Although there are no strict guidelines on when to resume general practice, the timing should be individualized according to the recommendations of local health authorities while exercising good clinical judgment.
In general, the TAGE recommendations are similar to those by other societies with only a few exceptions, as described in
This study benefited from a relatively large group of multinational respondents. By reaching out to those directly involved in endoscopy management during the COVID-19 pandemic and those who shared the published recommendations via social media platforms, the obtained responses were more likely to reflect the real-world adoption of the recommendations. Given that this was a large multinational survey, the differences in the demographic characteristics of the respondents were inevitable. Despite these differences, the respondents overwhelmingly agreed with nearly all aspects of the recommendations, suggesting that the perceptions of the importance of PPE, the case selection protocol, and the scope cleaning process adjustment during the COVID-19 pandemic were universal among healthcare personnel regardless of their geographical location, level of training, or available resources. However, the perceptions of the practicality and applicability of each recommendation differed with the local COVID-19 prevalence as the pivotal determining factor. Our findings emphasize that the guidelines of societies may not satisfy the “one size fits all” principle. They also demonstrate the crucial need for each endoscopy unit to adapt its practice pattern according to the local prevalence.
Our study was also subject to inherent limitations of a survey study that included recall and selection bias. Due to the international design of the study and the changing prevalence of COVID-19 in each country, the responses obtained may be subject to change over time. In addition, as further evidence on the aerosolization risk of endoscopy emerges, the official recommendations on optimal PPE and reprocessing methods for endoscopic procedures may be modified.
We conclude that using appropriate PPE and implementing optimal case selection for endoscopic practice during the COVID-19 pandemic remains a challenge, especially among less experienced endoscopists in highly prevalent countries, although the response of the respondents indicated a general agreement with the recommendations. TAGE recommendations, similar to other guidelines, should be taken only as general guidance, rather than as a compulsory standard. The personal sense of safety of endoscopy personnel is imperative in the management of an endoscopy unit during the pandemic. The optimal response to such an unprecedented public health crisis necessitates knowledge, preparedness, and multidisciplinary coordination to ensure proper resource availability and allocation.
Endoscopy During Covid-19 Pandemic
Conceptualization: Rungsun Rerknimitr and Parit Mekaroonkamol
Data curation: PM, Kasenee Tiankanon, Fariha Shams, Ghias Un Nabi Tayyab, Julia Massaad, Saurabh Chawla, Stanley Khoo, Siriboon Attasaranya, Nonthalee Pausawasdi, Qiang Cai, Thawee Ratanachu-ek, Pradermchai Kongkham
Formal analysis: PM, KT, Rapat Pittayanon Investigation: PM, KT, RP
Methodology: Rungsun Rerknimitr, PK, PM
Project administration: KT, PM
Resources: RR, PK
Supervision: RR
Validation: NP, TR, PK, RR
Writing-original draft: PM
Writing-review & editing: KT, RP, Wiriyaporn Ridtitid, FS, GUNT, JM, SC, SK, SA, NP, QC, TR, PK, RR
The authors would like to thank the Thai Association of Gastrointestinal Endoscopy (TAGE) and the Endoscopy Nurse Society of Thailand (ENST) for the critical revision and support in distributing the questionnaire.
The Thai Association for Gastrointestinal Endoscopy recommendations on the use of personal protective equipment, procedural classification, and scope reprocessing. PUI, patient under investigation.
Responses on the agreement with and the practicality and applicability of personal protective equipment (PPE) and case selection recommendations.
Safety perception of all respondents stratified by age group, work experience, and training status.
Perceptions of the practicality of the recommendations on case selection by personnel in private and non-private practices.
Demographic and Institutional Data of All Respondents
Number of respondents ( |
|
---|---|
Age (years) | |
Under 25 | 3 (0.9) |
25–34 | 93 (28.2) |
35–44 | 156 (47.3) |
45–54 | 57 (17.3) |
Over 55 | 21 (6.4) |
Gender | |
Male | 202 (61.2) |
Female | 128 (38.8) |
Role | |
Endoscopist | 278 (84.2) |
Endoscopy nurse | 44 (13.3) |
Technical assistant | 8 (2.5) |
Work experience | |
Fellow-in-training | 32 (9.7) |
0–5 years | 109 (33.0) |
5–10 years | 92 (27.9) |
10–15 years | 46 (13.9) |
More than 15 years | 51 (15.5) |
Institutional level of care | |
Primary care | 10 (3.0) |
Secondary care | 47 (14.2) |
Tertiary care | 273 (82.7) |
Institutional funding | |
Private practice | 58 (17.6) |
Governmental hospital | 272 (82.4) |
Case volume prior to COVID-19 pandemic per day | |
0–10 | 71 (21.5) |
11–20 | 105 (31.8) |
21–30 | 59 (17.9) |
31–40 | 28 (8.5) |
41–50 | 25 (7.6) |
More than 50 | 42 (12.7) |
Number of COVID-19 cases being treated in the hospital | |
None | 65 (19.7) |
1–10 | 107 (32.4) |
11–20 | 42 (12.7) |
21–30 | 26 (7.9) |
More than 30 | 90 (27.3) |
Region of practice | |
Southeast Asia | 180 (54.5) |
South Asia | 97 (29.4) |
North America | 38 (11.5) |
Europe | 9 (2.7) |
West Asia | 5 (1.5) |
East Asia | 1 (0.3) |
National COVID-19 prevalence | |
High prevalence |
150 (45.5) |
Low prevalence |
180 (54.5) |
Data are presented as number (%).
COVID-19; coronavirus disease 2019.
Countries with high prevalence of COVID-19 during the study (Year 2020);
Countries with low prevalence of COVID-19 during the study (Year 2020), High prevalence countries were defined as those with “community spread” or >10,000 accumulated cases per million population.
Association between Demographic Parameters and Agreement, Practicality, and Applicability of the Recommendations on Proper Personal Protective Equipment for Endoscopy
PPE recommendation |
|||
---|---|---|---|
Agreement (“Strongly agree” and “Agree”) | Practicality (“A great deal” and “A lot”) | Applicability (“Very easy” and “Easy”) | |
Age | |||
Under 25 | 100.0% | 33.3% | 66.7% |
25–34 | 92.5% | 58.1% | 54.8% |
35–44 | 94.9% | 60.3% | 61.5% |
45–54 | 96.5% | 57.9% | 57.9% |
Over 55 | 95.2% | 66.7% | 57.1% |
Gender | |||
Male | 95.0% | 57.4% | 55.0% |
Female | 94.5% | 62.5% | 64.9% |
Work experience (years) | |||
0–5 | 95.4% | 64.2% | 64.2% |
6–10 | 96.7% | 50.0% | 52.2% |
11–15 | 91.3% | 63.0% | 58.7% |
>15 | 96.1% | 64.7% | 60.8% |
Professional role | |||
Physician | 94.2% | 59.4% | 56.5% |
Nurses | 95.5% | 59.1% | 70.5% |
Institutional level | |||
Primary care | 100% | 60% | 70.0% |
Secondary care | 100% | 70.2% | 70.2% |
Tertiary care | 93.4% | 57.5% | 56.4% |
Private practice status | |||
Private practice | 93.1% | 60.4% | 55.2% |
Governmental hospital | 94.9% | 59.2% | 59.5% |
Number of COVID cases in the hospital (cases/day) | |||
0 | 95.4% | 60.0% | 66.2% |
1–10 | 98.1% | 51.4% | 57.0% |
11–20 | 95.2% | 54.8% | 54.8% |
21–30 | 92.3% | 65.4% | 53.8% |
>30 | 90.0% | 68.9% | 58.9% |
Endoscopic volume on COVID-19 cases (cases/month) | |||
0 | 100.0% | 83.3% | 100.0% |
1–10 | 94.9% | 59.1% | 59.9% |
11–20 | 93.8% | 56.3% | 56.3% |
21–30 | 80.0% | 60.0% | 30.0% |
>30 | 100.0% | 69.2% | 53.8% |
National COVID-19 prevalence | |||
Low prevalent | 96.7% | 68.3% | 72.8% |
High prevalent | 92% | 48.7% | 42.0% |
Trainee status | |||
In-training | 86.6% | 53.4% | 53.3% |
Attending physician | 95.2% | 60.0% | 56.8% |
COVID-19, coronavirus disease 2019; PPE, personal protective equipment.
Statistically significant.
Association Between Demographic Parameters and Agreement, Practicality, and Applicability of the Recommendations on Endoscopy Case Selection during COVID-19 Pandemic
Case Selection recommendations |
|||
---|---|---|---|
Agreement (“Strongly agree” and “Agree”) | Practicality (“A great deal” and “A lot”) | Applicability (“Very easy” and “Easy”) | |
Age | |||
Under 25 | 100.00% | 66.70% | 66.70% |
25–34 | 92.5% | 45.2% | 58.1% |
35–44 | 96.8% | 41.0% | 72.4% |
45–54 | 94.7% | 40.4% | 66.7% |
Over 55 | 100.0% | 47.6% | 71.4% |
Gender | |||
Male | 95.1% | 72.2% | 63.4% |
Female | 96.2% | 68.8% | 73.5% |
Work experience (years) | |||
0–5 | 67.9% | 75.2% | 95.4% |
6–10 | 66.3% | 66.3% | 95.7% |
11–15 | 67.4% | 73.9% | 93.5% |
>15 | 68.6% | 66.7% | 98.0% |
Professional role | |||
Physician | 95.7% | 71.9% | 66.2% |
Nurses | 95.5% | 63.6% | 70.4% |
Institutional level | |||
Primary care | 100% | 60.0% | 60.0% |
Secondary care | 93.6% | 76.6% | 77.7% |
Tertiary care | 95.6% | 70.3% | 75.5% |
Private practice status | |||
Private practice | 96.6% | 63.8% | 62.1% |
Governmental hospital | 95.2% | 72.5% | 68.3% |
Number of COVID cases in the hospital (cases/day) | |||
0 | 96.9% | 67.60% | 69.2% |
1–10 | 97.2% | 66.30% | 66.4% |
11–20 | 88.1% | 66.70% | 66.7% |
21–30 | 92.3% | 76.90% | 61.5% |
>30 | 96.7% | 78.90% | 68.9% |
Endoscopic volume on COVID-19 cases (cases/month) | |||
0 | 83.3% | 100.0% | 100.0% |
1–10 | 67.5% | 95.8% | 51.5% |
11–20 | 76.6% | 92.2% | 57.8% |
21–30 | 80.0% | 100.0% | 50.0% |
>30 | 92.3% | 100.0% | 30.8% |
National COVID-19 prevalence | |||
Low prevalent | 96.7% | 75.0% | 77.5% |
High prevalent | 94.0% | 66.0% | 48.5% |
Trainee status | |||
In-training | 93.3% | 70.0% | 77.8% |
Attending physician | 95.9% | 62.0% | 54.7% |
COVID-19, coronavirus disease 2019
Statistically significant.
Recommendations for Endoscopy during the COVID-19 Pandemic from International/National Societies of Gastroenterology/Gastro-Intestinal Endoscopy
Society | Published | Postpone non urgent procedures | Urgent procedures | Pre-endoscopy screening tool | Type of PPE recommended | Scope cleaning process |
---|---|---|---|---|---|---|
European Society of Gastrointestinal Endoscopy | 18 March 2020 | yes | -Acute GI bleeding and anemia with hemodynamic instability | Questionnaire | Double gloves, mask (FFP2/3), goggles or face shield, waterproof gown, hairnet, shoe covers | Same as pre-COVID-19 era |
-Foreign body | ||||||
-Obstruction | ||||||
-Acute cholangitis | ||||||
World Endoscopy Organization | 24 March 2020 | yes | -Upper GI bleeding, | Questionnaire | Double gloves, mask (N95/FFP2/FF3/CAPR/PAPR), goggles or face shield, waterproof gown, hairnet, shoe covers | Not mentioned |
-Foreign body | ||||||
-Obstruction | ||||||
-Acute cholangitis | ||||||
American Society for Gastrointestinal Endoscopy | 27 March 2020 | yes | -Upper GI bleeding, | Questionnaire and body temperature measurement | Gloves, mask(N95/FFP2), goggles or face shield, waterproof gown | Same as pre-COVID-19 era |
-Foreign body | ||||||
-Obstruction | ||||||
-Acute cholangitis | ||||||
-Care of cancer | ||||||
Thai Association for Gastrointestinal Endoscopy | 25 March 2020 | yes | -Acute GI bleeding | Questionnaire and body temperature measurement | Double gloves, mask (N95/FFP2/FF3/CAPR/PAPR), goggles or face shield, waterproof gown, hairnet, shoe covers | 3 additional pre-cleaning steps before standard reprocessing |
-Foreign body | ||||||
-Obstruction | ||||||
-Acute cholangitis | ||||||
-Perforation and leakage | ||||||
-Access for urgent feeding |
COVID-19, coronavirus disease 2019; GI: gastrointestinal; PPE, personal protective equipment.