All upper GI endoscopy should be considered high risk and enhanced PPE is recommended for all patients, regardless of any risk stratification.
BSG also considers lower GI endoscopies to be aerosol generating procedures (AGP) but the evidence for this is less strong and there is insufficient evidence to consider these as high risk at the present time
Risk stratification of patients by symptoms and temperature is of limited value, given the widespread prevalence and incubation period of up to 14 days
We recognise the limited availability of PPE, especially FFP3 masks, and so case selection is critical, focussing only on emergency and absolutely essential procedures. Minimising the volume of emergency activity will help preserve PPE supply.
Notes on FFP3 masks and enhanced PPE
Proper fitting and testing prior to use
Although ‘single use’ can use for several hours if not removed/contaminated
FFP3 uncomfortable after prolonged wearing, may affect ease of procedure
Cannot e.g. use phone, visit, toilet, eat or drink once enhanced PPE is on
For COVID-positive patients – consider wearing full visor and surgical mask over FFP3 mask. This minimises risk of contamination of FFP3 mask and prolongs use
Further Key points for Optimal Practice
For known COVID-positive patients
Scope in designated, different area of the department
Designated, separate recovery area
Minimal furniture and equipment in room
Minimum essential staff in room
Remember
PPE is only part of the strategy to prevent and control transmission of infection
Team organisation –essential staff only in procedure room
Don’t share PCs, keyboards, phones etc – or clean thoroughly between users
The situation is rapidly evolving and this guidance may be updated regularly
Approaching a coughing patient, for example, even if COVID-19 has not been diagnosed. Protection including eye shield is needed.
Naso-gastric tube placement is an aerosol generating procedure (AGP). AGPSs are high risk. Full PPE is needed. Consider carrying out in a specified location.
Only emergency endoscopic procedures should be performed . No diagnostic work to be done and BSG guidance followed. Upper GI procedures are high risk AGPs and full PPE must be used
GI Endoscopy Activity and COVID-19: Next steps
INTRODUCTION
The BSG has produced recommendations(1,2) based on the best available evidence from China(3), Italy(4) and the USA(5) that show:
The virus causing COVID-19 is potentially present in all GI secretions.
That all endoscopic procedures, but particularly upper GI endoscopy, are aerosol generating procedures (AGP).
That transmission can occur at the time of endoscopy.
We have received reports that some centres are continuing to run booked endoscopy lists, requiring patients:
To travel.
To enter hospitals already treating significant numbers of COVID-19 patients.
To wait in areas that do not meet any of the Government’s social isolating directives.
For these reasons, the BSG has recommended that all but emergency procedures should stop immediately.
The main issues of contention remain whether Urgent 2 Week Wait (2WW) patients, (or Urgent Suspected Cancer (USC) patients in Scotland,) and patients already diagnosed as FIT positive under Bowel Cancer Screening Programs (BCSP), should be “paused” during the current crisis.
How any potential damage from delayed diagnosis can be mitigated.
2WW/USC, and BCSP referrals: Relative Diagnostic Yield. The Risks of Pausing
2WW/USC referrals – yield of cancer = 3%
Bowel cancer screening programmes (BCSP) (FIT+) – yield of cancer = 8-10%
Another, small percentage of patients will have advanced disease at the time of referral and the delay will not alter their prognosis, which unfortunately will already be very poor.
For this group, a delay of 3 months is unlikely to materially alter the risk of an adverse outcome.
Some of those who do not have established malignancy will have benign lesions such as polyps.
In the majority of these cases, progression to malignancy, if it occurs, may take years.
Conclusion: Very few patients are likely to come to harm from a pause of 3 months.
Risks of continuing 2WW/USC, BCSP and urgent referrals.
Removing polyps, particularly those over 1 cm, carries risks of haemorrhage and perforation often requiring admission to hospital.
During the COVID-19 crisis, ICU beds are unlikely to be available and even urgent surgical procedures will be restricted.
The risks of death from polypectomy usually quoted, are based on entry into a hospital operating under normal conditions, but not during a COVID-19 epidemic, where the risks of death will be significantly higher.
Patients who are diagnosed with cancer may not be offered surgery at the height of the epidemic. Their anxiety is likely to be equal to or even greater, than those with a positive FIT test whose colonoscopy is paused.
In addition:
All patients attending for a non-emergency endoscopy now enter a high-risk environment.
The benefit of endoscopy may be offset by the risk of COVID-19 infection to themselves.
The majority will be older than 60 years with higher mortality from COVID-19 if they become infected.
They become a potential risk to their families and contacts.
Patients with asymptomatic COVID-19 infection pose a significant risk to staff. By definition, their infection will not be detected before having a procedure.
The aerosol or droplets take up to an hour disperse, so they remain a risk to staff and other patients after they leave the room.
There is, therefore, little evidence that a pause of 3 months will pose a significant risk to the great majority of 2WW/USC or BCSP patients, although it is accepted that a small number of patients may have a delay in their diagnosis.
On the other hand, a much larger number of patients and staff will be put at significant risk of COVID-19 if the 2WW/USC and BCSP is continued even at a scaled-down level.
Conclusions and Actions.
Stop all non-emergency endoscopy immediately.
Triage plan to identify patients who fall into the emergency category. The evidence base for this is laid out in previous BSG documents. (1) and follows experience from China(3), Italy(4) and the USA(5).
List all patients on to a separate Urgent Deferred Waiting List to prioritise their investigation when services resume.
To: Free-up the maximum possible inpatient and critical care capacity.
Prepare for, and respond to, the anticipated large numbers of COVID-19 patients who will need respiratory support.
Support staff, and maximise their availability. Play our part in the wider population measures newly announced by Government.
Stress-test operational readiness.
Remove routine burdens, so as to facilitate the above
2. Letter from CMO Stephen Powis (attached)
Advice concerning those who are or may be at increased risk of severe illness from COVID-19
Please see a letter suitable to be sent to families in annex 3.
Patients on immunosuppression therapies sufficient to significantly increase risk of infection have been outlined in the BSG Guidance which has been updated today 23/3/20.
Our advice today when we called families of children and young people with IBD in the high risk category, (see guidance – while on steroids prednisolone equivalent to or greater than 20mg, or within 6 weeks of starting a biological therapy, or with severe active disease), was to reassure that Covid19 appears not to cause such severe disease in children and young people.
We reinforced that patients should continue their usual treatment, including infusion therapy, and to continue to contact their IBD team by phone if they have symptoms eg fever, typical features of a relapse. The team will assess each patient case by case and advise accordingly.
3. HOMECARE (Home Parenteral nutrition) advice from 23/3/20 issued by Susan Gibert, who is leading on COVID-19 for Homecare
This has been sent to all regional homecare leads who will disseminate to the trusts.
NHSE contract – CCGs (12 week rule)
In TVW I have gained agreement that NHSE and CCGs will not be expecting the homecare activity to have been recorded within the usual time frames. It might be a good idea to do the same in your regions.
Delivery windows – relaxation of expectation I have agreed with NCHA members that the NHS will not be expecting homecare providers to ‘hit’ their 2 hour delivery windows. Deliveries may need to move to all day windows in the near future, and if this is necessary can we agree to be supportive please? Homecare providers and hospitals are asked to be extra vigilant with the delivery address details as patients may no longer be at their usual work or residential addresses.
Emergency deliveries
We may reach a time where same day, next day and emergency deliveries are no longer possible. We may need to consider adjusting buffer stock in patients’ homes. At the moment, we do not have the reassurance that there is stock to do this, but it is something that we need to bear in mind for the coming weeks.
Phone Lines Homecare providers are experiencing high volumes of calls, this has led to longer wait times. Patients are also reporting that their hospital clinical teams are no longer manning some NHS helplines (as specialist nurses are being called to ward and other duties). Please can you ensure that you use the correct line of communication as per local agreements. If the route of contact is via your BDM, RBM etc, please can you refrain from ringing the homecare providers?
Equally if your CNS staff are being called to the front line, please can you ensure that the homecare providers have a contact number or email for an alternative contact? If in doubt, the pharmacy homecare team will be contacted for all enquiries that have not been dealt with in a timely manner. In TVW we will be ensuring that the pharmacy contacts are up to date, if you could do the same, that would be great.
Dr Sue Protheroe, Consultant Paediatric Gastroenterologist, Birmingham Women’s and Children’s Hospital. Birmingham. B4 6NH. U.K. Tel 0044 121 333 8705 Fax 0044 121 333 8701 Chair NHS England Clinical Reference Group, Paediatric Medicine. President of British Society of Paediatric Gastroenterology, Hepatology & Nutrition.
I trust this this finds you, family and colleagues well and bearing up in these difficult times. We find ourselves under exceptional circumstances. I am indebted to members for coming together to support each other. We will need to step forward, share our skills as best and as appropriate as we can and reach out to those professionals who are most stretched.
“…….and there are no more surgeons, urologists, orthopedists, we are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us”. Dr Daniele Macchine, Bergamo, Italy, 9 March 2020”
I would like to draw your attention to the following-
Recommendations to the Regional Homecare Specialists regarding provision Home Parenteral Nutrition services.
Advice is being prepared for us to manage the most vulnerable patient groups and for families of children on hone PN that should be available tomorrow.
Specialty guides for patient management during the coronavirus pandemic
Whilst demand may be more felt in adult services, given current understanding of the virus, paediatric services have a key role to play. Children’s hospitals, working with District General Hospitals, will need to provide a regional and national response to pressures on the NHS. The elective component of our work may be curtailed, and resources diverted to areas of greater need. However, non-elective patients will continue to need high quality care and we need to ensure that they receive the care that is appropriate. We should seek the best local solutions to continue the proper management of unwell neonates and children while protecting resources for the response to coronavirus.
The following principles should guide how we run our services during the outbreak:
Follow Public Health England guidance.
Keep children out of the healthcare system, unless essential.
Use telemedicine and other non-direct care, when appropriate.
Plan for stopping elective procedures and treatments that may consume critical care and ward resources.
We should advise patients with specific conditions such as IBD and those on home PN to still make sure that they seek advice in from their speciality nursing /medical teams in the event of fever or typical symptoms of relapse of their condition.
If you find that parents are not seeking advice, it would be good to know, and I can ask the RCPCH and NHS E to help reinforce this message for parents?
As the situation is changing very rapidly, with different resource strains in the adult sector, and events may overtake our advice with paediatric anaesthetists being pulled to work in the adult sector. Any guidance regarding endoscopy should acknowledge the principles above, e.g. that our patients should continue to receive the best care that is appropriate; that we may need to seek best solutions locally and to divert resources to areas of greater need so that they are used equitably, fairly and effectively.
Advice for Planning Endoscopy Activity during COVID-19: Consensus document prepared by Dr Christine Spray and Dr Babu Vadamalayan on behalf of BSPGHAN with advice also taken from BSG guidance (20/03/2020).
It is clear proactive planning for hospital services is essential over the coming weeks and months.
All Trusts are taking measures to reduce in & out-patient activity to reduce risk of exposure to COVID – 19 for patients and staff, especially from asymptomatic carriers
It is also recognised resources including staff, theatre supplies and PPE are limited and need to be available for patients and staff who require them as a priority
Endoscopy Teams are advised to follow both national guidance for reducing transmission of infection with COVID19 (websites above) but also agree their own local protocols and policies in collaboration with senior management, Infectious Disease or Infection Control teams. There are both general measure that should be followed and specific measures around personal protective equipment (PPE).
PPE for endoscopy procedures – advice is that standard infection control measures should be followed except for aerosol generating procedures (AGP) in patients at high risk of or with confirmed COVID19 infection. AGP in this context means upper GI procedures and for patients who fall into this category, enhanced PPE is recommended including FFP3 masks. Endoscopy teams should also consider enhanced PPE for emergency and out-of-hours procedures and also consider arrangements for the most appropriate location to perform these within their hospital. Units are encouraged to ensure staff know how to be fitted for the appropriate size of FFP3 mask and how to put on PPE correctly.
Official advice is that enhanced PPE is not currently felt to be necessary for upper endoscopy in patients at low risk or for lower GI procedures. Concerns have been raised that the virus may be faecally transmitted but there is presently insufficient evidence to recommend the use of enhanced PPE measures for lower GI procedures. Stocks of FFP3 masks are also limited and their use needs to be carefully prioritised. This is; however, a rapidly changing situation and teams should check regularly for updates to both local and national guidance
BSPGHAN suggest these principles and guidance are considered for patients considered to require endoscopy by their Consultants. Requirement for endoscopy should be risk assessed and deferred or delayed if possible.
categories are suggested:
Need to continue:
Newly presenting acutely unwell patients with likely IBD
Unstable known IBD patients who require urgent endoscopic assessment to understand appropriate change in treatment, when all other measures have been assessed as an alternative & failed
Seriously unwell children who require endoscopy for diagnosis and therapeutic endoscopy for treatment, including significant acute UGI bleed, acute oesophageal obstruction including food bolus obstruction & stricture & gastrointestinal obstruction needing urgent decompression/stenting
Urgent inpatient nutrition support – PEG/NJ tube
Upper GI endoscopies for portal hypertension for patients who bled within the last 6 months and still in the eradication process.
Defer until further notice
All non-urgent routine symptomatic patients and those for routine planned endoscopic review including planned dilatation for stricture or achalasia & polyp surveillance
Known IBD patients planned to undergo routine reassessment
Needs discussion
Patients positive for COVID – 19 to be considered for diagnosis and treatment based on clinical grounds rather than tissue diagnosis after discussion with parents
Unwell patients with possible Coeliac disease who do not fit the criteria for non-biopsy diagnosis pathway
Newly presenting patients with likely IBD
Important Notes
This list is neither exhaustive nor prescriptive and is meant to serve as a guide to clinical teams when planning during the current emergency.
The situation continues to evolve rapidly, and this advice may change from day-to-day, so clinicians and managers need to check regularly and look for updates and briefings from the relevant Government agencies in the four nations.
Teams need to consider resources- both staff and equipment (PPE and endoscopy kit) – when planning and think well ahead as we get closer to the peak of the outbreak.
Systems need to be in place to keep records of patients who have been deferred or cancelled so that either alternative arrangements (e.g. clinic follow up, radiological imaging) can be made or rebooking can occur when it is safe to resume normal activities. Local discussions with colleagues in Radiology may also be helpful when considering this.
More general and operational considerations
Restricting numbers of staff in rooms for all procedures –e.g. limit trainees (may be redeployed anyway)
Assessing stocks of consumables and devices daily – without panic buying. Keep in touch with suppliers and local representatives regarding the supply chain in the coming weeks
Considering alternatives for diagnostic testing – Calprotectin; radiology (already hard-pressed); telephone triage of e.g. 2WW referrals.
Free car parking
NCP are offering NHS staff free parking at over 150 car parks across the UK, in support of efforts at this current time. NHS staff should pre-book online and is valid for bookings and exits until end of April, when they’ll review the situation
The following information has been provided by Susan Gibert, chair of NHMC.
Changing ordering (PONs) and clinical validation
If hospitals are planning on planning on changing any of the aspects of their prescribing, please can they liaise with their homecare providers before doing so, this includes:
Changing prescription length – the length of prescription validity must be clear on each prescription
Changing clinical validation (stopping clinical validation in the case of staff shortages)
Changing Purchase Order Numbers (PONs) or not adding PONs to prescriptions due to staff shortages
If hospitals do not inform their homecare provider in advance, there is a risk that prescriptions / documents with queries will be placed in the Document Under Investigation (DUI) files and will not be acted upon. Please instruct your hospitals to check the DUIs carefully. Homecare providers have agreed to pro-actively manage DUIs to reduce the risk.
E-prescribing
It is essential that the process for adding ‘wet’ indelible ink signatures continues as per the current agreed process with the individual homecare providers.
Some hospitals have asked homecare providers to increase the notice given for repeat prescription requests. All hospitals / clinical areas that receive 5 to 6 weeks’ notice for repeat prescription requests will move to 8 weeks. The prescription due date will not change, and hospitals that do not need advanced notice will need to ‘ignore’ the requests that they do not need. Please note this measure only relates to prescriptions that are already requested 5 to 6 weeks ahead, no changes are anticipated for other therapies at this stage. The homecare providers agreed that a consistent approach is essential to maintain patient safety so please encourage your hospitals to comply with the above. This is a temporary measure that will be reviewed on an ongoing basis and after a return to business as usual (BAU) in due course.
Changing / increasing quantities of medicines supplied
This needs to be managed carefully and there needs to be national oversight of any proposed changes to existing prescribing and / or supply. Manufacturers of pharma funded schemes are being asked on an individual basis, whether there is sufficient stock in the supply chain to increase stock of medicines in patients’ homes. Only if there is sufficient stock guaranteed for all patients to receive more buffer stock, will homecare providers be permitted to increase delivery quantities and reduce delivery frequency.
Homecare providers and manufacturers are in the information gathering phase. Once there is a clearer picture of stock availability and which patients will benefit from increased buffer stock in their homes, more information will follow.
At the moment clinicians are asked to kindly maintain current prescribing patterns.
HPN prescribing
Prescriptions for HPN, should include a prescription for fluids and / or multi chamber bags as agreed by the HPN stakeholder group. Please refer to specific guidance from the HPN stakeholder group for further information. It has been confirmed that where multiple prescribers usually sign HPN prescriptions, one signature will be sufficient, as this is the legal requirement.
Mitigation / Risk Management
Hospitals and patients being cared for in secondary care, may benefit from increased access to homecare medicines services. Any ‘extra’ resource needs to be managed carefully and there needs to be national oversight. If hospitals wish to commence new services, this could be managed in a variety of ways:
Hospitals may contact their chosen / preferred homecare provider directly
Hospitals may contact their regional homecare specialist
It would be helpful to have oversight of which patient cohorts would benefit from accessing homecare services and which services hospitals have asked homecare providers to start providing (OPD services and other secondary care services). Please could you liaise with your regional homecare specialist and / or your regional pharmacy procurement specialist for more support and local information.
Expanded BSG consensus advice on management of IBD plus guidance on IBD
