COVID-19, the highly contagious disease caused by the novel SARS-CoV-2 virus, has
been declared as pandemic by the World Health Organization. Till the time an effective
antiviral treatment or vaccine becomes available, adopting best infection control
practices appear to be the cornerstone of managing this pandemic. Infection control
practice in the endoscopy room should address three important aspects—personnel, equipment,
and environment.
Personnel: Patients and Health Care Personnel
Personnel: Patients and Health Care Personnel
Guidelines from endoscopy societies have outlined appropriate selection for patients
for endoscopy during the pandemic phase. Patients scheduled for endoscopy should be
educated about social distancing, cough etiquette, and wearing of mask. Proper hand
hygiene and appropriate use of personal protective equipment for health care workers
are recommended to decrease the risk of transmission of SARS-CoV-2.
Equipment: Endoscope and Accessories
Equipment: Endoscope and Accessories
Dr. Rai, in his review, has described in detail, the standard disinfection procedures
for endoscopes, which is considered effective for preventing transmission of SARS-CoV-2.[1] Disposable accessories should not be reused. It is reassuring that no reports of
endoscopy-related transmission of COVID-19 has been documented till now.
Environment: Endoscopy Room and Patient Care Equipment in the Room
Environment: Endoscopy Room and Patient Care Equipment in the Room
As viral ribonucleic acid (RNA) has been detected in air samples from intensive care
unit, concerns regarding aerosol transmission of SARS-CoV-2 have been raised.[2] Thus, endoscopy rooms where aerosol-generating procedures are done are potentially
high-risk areas for nosocomial transmission.
As reviewed by Dr. Rai, the American Gastroenterological Association and Asia Pacific
Society of Digestive Endoscopy (APSDE) societies recommend the use of negative pressure
rooms, when available, for endoscopic procedures in patients with presumptive or proven
COVID-19.[3]
[4]
What are the specifications of a negative pressure room? As per the Centers for Disease
Control and Prevention, airborne infection isolation rooms or negative pressure rooms
are defined as single-patient rooms at negative pressure relative to the surrounding
areas with following specifications:
-
≥12 air changes/hour (ACH).
-
Air supply and exhaust rate sufficient to maintain a 2.5 Pa (0.01-inch water gauge)
negative pressure difference with respect to all surrounding spaces with an exhaust
rate of≥50 ft3/min.
-
Air exhausted directly outside away from air intakes and traffic or exhausted after
high-efficiency particulate air (HEPA) filtration prior to recirculation.
-
If an anteroom is not available, use portable, industrial-grade HEPA filters in the
procedure room to provide additional ACH equivalents for removing airborne particulates.
-
Room doors should be kept closed except when entering or leaving the room, and entry
and exit should be minimized.[5]
As most endoscopy units may not have a negative pressure room, the APSDE recommends
that the procedure can be performed in a venue outside the endoscopy center, with
negative pressure in the operation theater, for example, or in a room with better
ventilation.[4]
Interval between Procedures—Impact on Scheduling Procedures
Interval between Procedures—Impact on Scheduling Procedures
It is important to reemphasize the recommendation mentioned in review by Dr. Rai,
that negative pressure rooms be kept empty for 30 minutes, and in the absence of negative
pressure rooms, diluting the air with cleaner air from outdoors and leaving the room
empty for 1 hour.[6] This has to be borne in mind while scheduling procedures.
Disinfection of Surfaces and Patient Care Equipment in Endoscopy Room
Disinfection of Surfaces and Patient Care Equipment in Endoscopy Room
SARS-CoV-2 has been shown to survive on surfaces for hours to days.[6]
[7] All noncritical environmental surfaces, endoscopy furniture, and floor should be
considered heavily contaminated in patients with intermediate or high risk of COVID-19
and should be disinfected at the end of each procedure.[6] Visibly soiled surfaces should be cleaned with detergent and, subsequently, disinfected
with 1% sodium hypochlorite solution.[8]
The following recommendation, adapted from standard operating procedure for transporting
suspected/proven COVID-19 patient issued by the Family Welfare Directorate General
of Health Services, gives practical suggestions that can be implemented in the endoscopy
room:
-
Disinfect (damp wipe) all horizontal, vertical, and contact surfaces with a cotton
cloth saturated (or microfiber) with a 1% sodium hypochlorite solution. These surfaces
include, but are not limited to, stretchers, bed rails, infusion pumps, intravenous
poles, monitor cables, telephone, countertops, sharps container, stethoscopes, blood
pressure cuffs, monitors, backboards, and immobilization devices, laryngoscope blades,
shelves, and door handles.
-
Spot clean walls (when visually soiled) with disinfectant detergent and windows with
glass cleaner. Allow contact time of 30 minutes and allow the air to dry. Damp mop
floor with 1% sodium hypochlorite disinfectant.
-
Discard disposable items and infectious waste in a biohazard bag. The interior is
sprayed with 1% sodium hypochlorite. The bag is tied and the exterior is also decontaminated
with 1% sodium hypochlorite and should be disposed according to hospital policy.[9]
Although viral RNA and live virus have been cultured from stool samples of COVID-19
patients, there is no evidence to date that transmission through sewage has occurred.
Available information suggests that standard municipal wastewater system chlorination
practices are said to be sufficient to inactivate coronaviruses.[8]
Conclusion
COVID-19 pandemic has brought to the fore the need for strict adoption of infection
control practices in endoscopy room to prevent nosocomial transmission. Constructing
negative pressure rooms and meticulous disinfection of surfaces after each procedure
and the need to schedule procedures with adequate interval between them are likely
to alter the way we work in the near future.
