Protocols, Personal Protective Equipment Use, and Psychological/Financial Stressors in Endoscopy Units During the COVID-19 Pandemic: A Large Survey of Hospital-Based and Ambulatory Endoscopy Centers in the United States.

Endoscopy room personnel are at risk of contracting coronavirus disease 2019 (COVID-19), because gastrointestinal endoscopy is an aerosol-generating procedure; COVID-19 is present in the gastrointestinal tract and in stool, and studies indicate its viability in aerosols. Nonessential procedures have been deferred based on guidance , to preserve hospital resources for patients with COVID-19, limit the spread of the virus within hospitals, and conserve limited supplies of personal protective equipment (PPE). Endoscopy units have undertaken significant but varied additional measures to maximize safety.

Methods

An online survey comprising 50 questions was e-mailed to US gastroenterologists; it was designed to evaluate the COVID-19 pandemic’s impact on endoscopy units/personnel and to determine institutional responses (see Supplementary Methods). The 2-week survey was closed on May 10, 2020.

Results

A summary of survey responses is depicted in Supplementary Table 1.

Supplementary Table 1

Summary of Survey Responses on a Per-Center and Per-Respondent Basis

Survey responses: center based	Centers, n (%)
Total centers	276 (100)
Region of responding centers
Midwest		42 (15.2)
Northeast		61 (22.1)
South		79 (28.6)
West		92 (33.3)
Not reported		2 (0.7)
Practice settinga
University hospital		101 (36.6)
University affiliated		54 (19.6)
Hospital—not university affiliated		91 (33)
Freestanding ambulatory center		79 (28.6)
Other		12 (4.3)
Negative pressure endoscopy rooms
Yes		135 (48.9)
No		113 (40.9)
Do not know		26 (9.4)
Not reported		2 (0.7)
Location of endoscopic procedures for patients positive for or with high suspicion for COVID-19a
Standard endoscopy room		42 (15.2)
Negative pressure endoscopy room		105 (38)
Standard operating room		11 (4)
Negative pressure operating room		82 (29.7)
Don’t know		61 (22.1)
COVID-19 screening and testing
Prescheduling COVID-19 symptom screening
Yes		263 (95.3)
No		6 (2.2)
Don’t know		4 (1.4)
Not reported		3 (1.1)
Onsite COVID-19 testing
Yes		212 (76.8)
No		52 (18.8)
Don’t know		10 (3.6)
Not reported		2 (0.7)
Preprocedure COVID-19 testing
Only in patients with concerning history and/or symptoms		47 (17)
All patients		143 (51.8)
Not performed—symptomatic patients not scheduled		50 (18.1)
Don’t know		8 (2.9)
Other		27 (9.8)
Not reported		1 (0.4)
Criteria to test health care workersa
Any asymptomatic worker on request		48 (17)
Asymptomatic workers with exposure to patients with COVID-19		104 (37.7)
Flu-like symptoms alone are sufficient to be tested		125 (45.3)
Must have cough/SOB + fever		79 (28.6)
N95 and PPE use, mitigation of infection risk
Institutional policy for use of N95 respirators
Approved for all endoscopic procedures		220 (79.7)
Only for known patients with COVID-19 and high-risk patients with pending test		35 (12.7)
Approved for upper endoscopic procedures only		11 (4)
N95 not approved for any endoscopic procedures		6 (2.2)
Not reported		4 (1.4)
Implementation of N95 respirator use for endoscopic procedures
Before March 15		27 (9.8)
March 16–31		120 (43.5)
April 1–15		70 (25.4)
April 16 to present		33 (12)
Other/don’t know		14 (5.1)
Not reported		12 (4.3)
Staff re-education in donning/doffing of PPE
Yes		239 (86.6)
No		23 (8.3)
Don’t know		13 (4.7)
Not reported		1 (0.4)
Frequency of N95 respirator distribution to endoscopy providers/staff
None		7 (2.5)
One per procedure		16 (5.8)
One per day		128 (46.4)
One per week or ∼5 uses		62 (22.5)
Until soiled or damaged		11 (4)
Don’t know		19 (6.9)
Other		18 (6.5)
Not reported		15 (5.4)
N95 respirator preservation strategies considereda
Extended use (use of same mask all day–continued use without removal between procedures)		138 (50)
Reuse (use of same mask all day but donning and doffing between procedures)		150 (54.3)
Reuse after decontamination/sterilization of masks		134 (48.6)
Recycling of masks (recycling of previously used masks after holding them for several days)		79 (28.6)
N/A		15 (5)
Interval between N95 respirator reuses if no decontamination/sterilization undertaken
Less than 4 days		56 (20.3)
4–6 days		49 (17.8)
7 days or more		31 (11.2)
Not applicable		129 (46.7)
Not reported		11 (4)
Method for decontamination/sterilization of N95 respirators for reusea
UV light		57 (20.7)
Hydrogen peroxide		51 (18.5)
Ethylene oxide		9 (3.3)
Moist heat		4 (1.4)
Other		4 (1.4)
Not applicable		70 (25.4)
Don’t know		82 (29.7)
Staff PPE during procedures on patients with low concern for COVID-19a
N95 masks		232 (84.1)
CAPR/PAPR		33 (12)
Surgical masks		176 (63.8)
Eye shields/goggles/face shields		260 (94.2)
Gowns		263 (95.3)
Hazmat suits		5 (1.8)
Double gloving		152 (55.1)
PPE use during procedures on patients with positive COVID-19 result or high concerna
N95 masks		226 (81.9)
CAPR/PAPR		70 (25.4)
Surgical masks		133 (48.2)
Eye shields/goggles/face shields		228 (82.6)
Gowns		220 (79.7)
Hazmat suits		23 (8.3)
Double gloving		173 (62.7)
Minimizing endoscopic irrigation
Yes		48 (17.4)
No		180 (65.2)
Not applicable—Don’t perform procedure		46 (16.7)
Not reported		2 (0.7)
Survey responses: respondent based		Respondents, n (%)
Total respondents		407 (100)
Role 1
Physician		309 (75.9)
General GI fellow		61 (15)
Advanced endoscopy fellow		5 (1.2)
Nurse (ie, RN, APRN, LPN, CGRN)		19 (4.7)
Nurse practitioner or physician’s assistant		10 (2.5)
Other administrative role in endoscopy unit		3 (0.7)
Role 2
Advanced/therapeutic endoscopy		170 (41.8)
General GI endoscopy		202 (49.6)
N/A–not an endoscopist		16 (3.9)
Not reported		19 (4.7)
Region of employment of individual respondents
Midwest		67 (16.5)
Northeast		77 (18.9)
South		93 (22.9)
West		152 (37.3)
Not reported		18 (4.4)
Feel that N95 masks or other PPE are in short supply at institution
Yes		201 (49.4)
No		176 (43.2)
Don’t know		11 (2.7)
Not reported		19 (4.7)
Believe there was a delay in N95 use for endoscopy at center because of limited supply
Yes		177 (43.5)
No		177 (43.5)
Don’t know		31 (7.6)
Not reported		22 (5.4)
Inadvertently exposed to COVID-19–positive patient/s or staff
Yes		65 (16)
No		210 (51.6)
Don’t know		110 (27)
Not reported		22 (5.4)
Developed symptoms that prompted testing for COVID-19
Yes		39 (9.6)
No		345 (84.7)
Not reported		23 (5.7)
Concern about being infected or reinfected with COVID-19 at work?
Low level of concern		116 (28.5)
Moderately concerned		211 (51.8)
Very concerned		74 (18.2)
Not reported		6 (1.5)
Tested positive for COVID-19
Yes		6 (1.5)
No		197 (48.4)
Not tested		197 (48.4)
Prefer not to answer		1 (0.25)
Not reported		6 (1.5)
Concern about inadvertently infecting family members during pandemic
Low level of concern		85 (20.9)
Moderately concerned		169 (41.5)
Very concerned		145 (35.6)
Not reported		8 (2)

APRN, advanced practice registered nurse; CAPR, controlled air purifying respirator; CGRN, certified gastroenterology registered nurse; GI, gastrointestinal; LPN, licensed practical nurse; N/A, not applicable; PAPR, powered air purifying respirator; RN, registered nurse; SOB, shortness of breath; UV, ultraviolet.

Results are non-exclusive.

Institutional Characteristics

A total of 407 responses were received from 276 centers in 42 states, the District of Columbia, and Puerto Rico. After excluding duplicate responses from unique centers, 141/276 (51.1%) respondents reported practicing in University/University-affiliated centers while 135/276 (48.9%) reported practicing in facilities without University affiliation.

Institutional Pandemic-Related Responses

Most centers developed a formal COVID-19 mitigation protocol (135/276, 87%) and implemented a tiered, urgency-based scheduling system (243/276, 88%). Redeployment of gastroenterologists to support internal medicine/intensive care units is being considered by 173 of 276 (63%) and 104 of 276 (38%) of centers, respectively; a higher proportion of US Northeast centers are considering redeployment, compared to centers in the US South, Midwest, and West (82% vs 61% vs 57.1% vs 56.5%, respectively; P = .008).

Impact on Procedural Volume

Procedural volumes fell significantly for upper endoscopy, colonoscopy, and deep enteroscopy, with 81%, 82%, and 71% of centers, respectively, reporting a >60% decrease in volume. For endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography, 62% and 51% of centers respectively reported a greater than 60% decrease in procedure volume (Figure 1 A).

Figure 1

(A) Decrease in endoscopy unit volume, by procedure. (B) Institutional cost mitigation strategies. (C) Proportion of respondents experiencing psychological symptoms. (D) Measures adopted by respondents to keep their families safe. ERCP, endoscopic retrograde cholangiopancreatograpy.

Impact on Provider Salary

A total of 97 of 276 centers (35%) indicated that provider salary would be preserved; 55 of 276 (20%) indicated that salary would be preserved at the preceding year’s level. A total of 91 of 407 (22%) respondents from 70 of 276 (25%) institutions reported that faculty would receive pay cuts. Institutional cost mitigation strategies are depicted in Figure 1 B.

Impact on Education of Trainees

Gastroenterology/nursing/technician trainees were excluded from participating in procedures in 169 of 276 centers (61%), with 26.4% of centers excluding advanced endoscopy fellows.

Coronavirus Disease 2019 Testing

More than half (143 of 276, 52%) of centers performed COVID-19 testing on all patients before endoscopy. Endoscopy on patients with confirmed/high suspicion for COVID-19 is performed in negative-pressure endoscopy or operating rooms in 187 of 276 (68%) of centers.

Personal Protective Equipment Use

N95 respirators were approved for all endoscopic procedures in 220 of 276 (80%) of institutions. Respondents from 128 of 276 (46%) of centers reported receiving a single N95 respirator per day. N95 respirators are reused after sterilization at 134 of 276 (49%) of centers, with 79 of 276 (29%) reusing respirators after an extended period of holding.

Stressors and Psychological Symptoms Among Respondents

Inadvertent exposure to COVID-19–positive patients/staff was reported by 65 of 407 (16%) respondents and was more likely among trainee than nontrainee physicians (29% vs 14%; odds ratio [OR], 2.5; 95% CI, 1.36–4.63; P = .003). Thirty-nine (10%) respondents developed symptoms that prompted testing for COVID-19; 6 of 407 (1.5%) tested positive.

A large majority of respondents (330/407, 81%) reported psychological symptoms (Figure 1 C). A high level of concern regarding being infected with COVID-19 at work was reported by 74 of 407 (18%) respondents, and 145 of 470 (35%) reported a high level of concern about inadvertently infecting family members. Measures adopted by respondents to keep their family members safe are depicted in Figure 1 D. Feeling that supply issues led to a delay in implementing N95 respirator use was associated with experiencing psychological symptoms (OR, 2.08; 95% CI 1.23–3.53; P = .006), as was planned institutional implementation of cost mitigation strategies (OR, 1.85; 95% CI, 1.11–3.97; P = .017).

Impact of Type of Institution on Infrastructure and Responses

Data are provided in Supplementary Table 2.

Supplementary Table 2

Comparison Between University-Affiliated Centers and Centers Not Affiliated With a University

Survey Responses	University affiliated, n (%)	Not university affiliated, n (%)	P
Total centers, n	141	135	—
Negative pressure room	90 (63.8)	59 (43.7)	.0008
Onsite COVID-19 test	124 (87.9)	79 (58.5)	<.0001
Decontamination of N-95 for reuse	67 (47.5)	63 (46.7)	.89
Test all patients before procedure	82 (58.1)	43 (31.8)	<.0001
Test some or all patients before procedure	106 (75.2)	75 (55.6)	.0006
Institution indicated salary preservation	63 (44.7)	39 (28.9)	.007
Institution indicated faculty furlough	9 (6.4)	14 (10.4)	.23
Institution indicated staff furlough	48 (34)	72 (53.3)	.001

Discussion

The COVID-19 crisis has highlighted the unpreparedness of most countries, including the United States, in responding to pandemics, and the fragility of global supply chains in times of global crisis. Nevertheless, at this stage of the pandemic, the response of the majority of US institutions appears to be robust. The vast majority of endoscopy centers have instituted tier-based endoscopy scheduling and have created formal mitigation protocols for COVID-19, including PPE policies and preprocedural testing of patients for COVID-19.

Striking decreases in procedural volume have been noted, allowing consolidation of endoscopist schedules. This fall in volume has affected endoscopy center revenues, triggering institutional cost-containment strategies.

Education of gastroenterology, nurse, and technician trainees has been affected because of exclusion from endoscopic procedures. Concerningly, a quarter of institutions have excluded advanced endoscopy fellows from procedures. This will have a disproportionate negative impact on their training, given the brevity of the 1-year advanced endoscopy fellowship.

The psychological well-being of endoscopy unit personnel has been buffeted by several stressors, predominantly related to the risk of acquiring infection at the workplace and transmitting this to loved ones at home. PPE shortage, particularly of N95 respirators, has been a source of considerable anxiety. Although approved for use during endoscopy by most institutions by mid-April, limited supply has led institutions to pursue extended use, reuse, recycling, and even reprocessing of N95 respirators, despite concerns regarding the impact of reprocessing on their structural integrity/efficacy. Additional potential sources of distress include institutional plans to deploy gastroenterologists to support internal medicine/intensive care activities and looming salary cuts/furloughs. Overall, a higher proportion of our respondents reported stress and anxiety than documented in a survey of front-line health care workers in Wuhan.

Our midpandemic survey indicates a robust response within the majority of US endoscopy centers; essential elements including N95 respirator use and patient testing for COVID-19 have been implemented that will facilitate re-expansion of procedural indications for endoscopy. , The impact of the pandemic on training, particularly of advanced endoscopy fellows, is concerning and should be addressed. Finally, the impact of the pandemic on the psychological health of endoscopy unit personnel should not be underestimated; in addition to improving access to information, PPE, and COVID-19 testing, institutions should work to support their personnel emotionally, psychologically, and financially.