AGA publishes new COVID-19 recommendations for PPE during gastrointestinal procedures

Today, the American Gastroenterological Association (AGA) published new COVID-19 recommendations in Gastroenterology, the official journal of the AGA: AGA Institute Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic.

This rapid recommendation document was commissioned and approved by the AGA Institute Clinical Guidelines Committee, AGA Institute Clinical Practice Updates Committee, and the AGA Governing Board to provide timely, methodologically rigorous guidance on a topic of high clinical importance to the AGA membership and the public.

Key guidance for gastroenterologists

Treat all patients like they have coronavirus: In the absence of accurate and reliable testing for COVID-19 infection and the prolonged asymptomatic shedding that precedes symptoms, all patients should be considered at risk.

Boost PPE for endoscopic procedures: All health care workers should use N95 (or N99 or PAPR) masks instead of surgical masks and double gloves instead of single gloves as part of personal protective equipment (PPE), regardless of patient's COVID-19 status. There is strong evidence to support this recommendation for upper GI procedures, and lower-certainty evidence for lower GI procedures (i.e., colonoscopy). Also, negative pressure rooms, when available may help mitigate the spread of infection. Data on extended use and re-use of masks was also reviewed with insufficient evidence to comment on the safety of extended use (up to 8 hours) or re-use of masks. Indirect laboratory testing of masks suggests loss of durability and fit of N95 masks after 5 donnings.

Details: Endoscopies can generate aerosolized viral particles that can stay viable for up to 3 hours, depending on airflow dynamics. Furthermore, viral particles can stay viable for 72 hours on plastic surfaces and can easily promote spread through direct contact. SARS-CoV2 RNA can also be shed from stool though the risks associated with exposure are uncertain. Therefore, individuals performing endoscopic procedures are at higher risk of developing infection.

Triage GI procedures: Triaging of GI procedures is necessary to minimize risk to health care providers and patients and to limit the spread of infection during a pandemic. We provide a framework for decision-making that is focused on the impact of the delay on patient-important outcomes. Decisions to defer procedures should be made on a case-by-case basis using telemedicine as an adjunctive tool to help triage.