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Correspondence| Volume 52, ISSUE 8, P823-828, August 2020

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Planning phase two for endoscopic units in Northern Italy after the COVID-19 lockdown: An exit strategy with a lot of critical issues and a few opportunities

  • Gianpiero Manes
    Correspondence
    Corresponding author.
    Affiliations
    ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Milano, Italy

    ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Milano, Italy
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  • Alessandro Repici
    Affiliations
    Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Rozzano (Milan), Italy

    Humanitas University, Department of Biomedical Sciences, Rozzano (Milan). Italy
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  • Franco Radaelli
    Affiliations
    Valduce Hospital, Gastroenterology Unit, Como, Italy
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  • Cristina Bezzio
    Affiliations
    ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Milano, Italy
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  • Matteo Colombo
    Affiliations
    Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Rozzano (Milan), Italy

    Humanitas University, Department of Biomedical Sciences, Rozzano (Milan). Italy
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  • Author Footnotes
    # The ITALIAN GI-COVID19 Working Group1–2Mario Schettino 1–2Massimo Devani, MD 1–2, Paolo Andreozzi, MD, 1–2Lucienne Pellegrini, MD, 1–2Desirè Picascia, MD, 5Arnaldo Amato, MD, 7Costanza Alvisi, MD, 8Giovanni Aragona, MD, 6Elia Armellini, MD, 9Mohammad Ayoubi, MD, 10Stefano Bargiggia, MD, 11Stefano Benvenuti, MD, 12Paolo Beretta, MD, 13Paola Boarino, MD, 14 Andrea Buda, MD, 15Lorenzo Camellini, MD, 16Sergi Cavenati, MD, 17Vincenzo Cennamo, MD, 18Fabrizio Cereatti, MD, 19Claudio de Angelis, MD, 20Giovanni de Pretis, MD, 21Giuseppe De Roberto, MD, 22Marco Dinelli, MD, 23 Giulio Donato, MD, 24Carlo Fabbri, MD, 25Luca Ferraris, MD, 3–4Alessandro Fugazza, MD, 26Pietro Fusaroli, MD, 27Nicola Gaffuri, MD, 28Salvatore Greco, MD, 29Piera Leoni, MD, 30Gianluigi Longobardi, MD, 31Benedetto Mangiavillano, MD, 32Mauro Manno, MD, 33Alberto Merighi, MD, 34Guido Missale, MD, 35Alessandro Mussetto, MD, 36Massimiliano Mutignani, MD, 23Pietro Occhipinti, MD, 6Fabio Pace, MD, 37 Roberto Penagini, MD, 38Raffaele Salerno, MD, 39Romano Sassatelli, MD, 40Sergio Segato, 6Sandro Sferrazza, MD, 41Teresa Staiano, MD, 42Alberto Tringali, MD, 43Giovanna Venezia, MD, 44 Carlo Verna, MD1ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Italy, 2ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Italy, 3Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Rozzano, Italy, 4>Humanitas University, Department of Biomedical Sciences, Rozzano, Italy, 5Valduce Hospital, Gastroenterology Unit, Como, Italy, 6Bolognini Hospital, Gastroenterology Unit, Seriate, Italy, 7ASST Pavia, Digestive Endoscopy Unit, Pavia, Italy, Italy. 8Guglielmo da Saliceto Hospital, Department of Internal Medicine, Gastroenterology and Hepatology Unit Piacenza, Italy, 9Humanitas, Gastroenterology Unit, Gradenigo, Italy, 10S Clinica San Carlo, Gastroenterology and Digestive Endoscopy Unit, Paderno Dugnano, Italy, 11Ca’ Foncello Hospital, Department of Gastroenterology, Treviso, Italy, 12Città Studi, Gastroenterology and Digestive Endoscopy Unit, Milan, Italy, 13 Policlinico di Modena, Gastroenterology Unit, Modena, Italy, 14Digestive Endoscopy Unit, S.Maria del Prato Hospital, Feltre, Italy, 15Levante Ligure Hospital, Gastroenterology Unit, La Spezia, Italy, 16ASST Bergamo Ovest, Endoscopy Unit, Treviglio, Italy, 17 Bellaria-Maggiore Hospital, Division of Gastroenterology, Bologna, Italy, 18ASST Cremona, Gastroenterology Unit, Cremona, Italy, 19Città della Salute e della Scienza, Endoscopy Unit, Torino, Italy, 20Santa Chiara Hospital, Department of Gastroenterology, Trento, Italy, 21 Institute of Oncology IRCCS, Division of Endoscopy, European Milan, Italy, 22San Gerardo Hospital ASST Monza, Endoscopy Unit, Monza, Italy,23 Department of Gastroenterology, "Maggiore Della Carità" Hospital, Novara, Italy, 24AUSL Bologna Bellaria-Maggiore Hospital, Gastroenterology and Digestive Endoscopy Unit, Bologna, Italy, 25ASST Valleolona PO, Gastroenterology and Digestive Endoscopy, Gallarate, Italy, 26AUSL Imola, Department of Gastroenterology, Imola, Italy, 27Humanitas Gavazzeni, Gastrointestinal Endoscopy Unit, Bergamo, Italy, 28Papa Giovanni XXIII Hospital, Gastroenterology and Digestive Endoscopy Units, Bergamo, Italy, 29AO Lodi, Gastroenterology & Digestive Endoscopy Unit, Lodi, Italy, 30Ospedale degli Infermi, Endoscopy Unit, Biella, Italy, 31Humanitas Mater Domini, Gastrointestinal Endoscopy Unit, Castellanza, Italy, 32AUSL Modena, Endoscopy Unit, Carpi, Italy, 33AUSL Ferrara, Department of Gastroenterology, Ferrara, Italy, 34ASST Spedali Civili, Brescia University, Digestive Endoscopy Unit, Brescia, Italy, 35AUSL Romagna, Department of Gastroenterology, Ravenna, Italy, 36 M Niguarda-Ca' Granda Hospital, Digestive and Operative Endoscopy Unit, Milano, Italy, 37 Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Gastroenterology, Milano, Italy, 38 Fatebenefratelli Sacco, Gastroenterology and Digestive Endoscopy Unit, ASST Milan. Italy, 39>R AUSL Reggio Emila, Arcispedale S. Maria Nuova, Endoscopy Unit, Reggio Emilia, Italy, 40ASST Dei Sette Laghi, Gastroenterology and Gastrointestinal Endoscopic Unit, Varese, Italy, 41Istituto di Candiolo IRCCS, Endoscopy Unit, Candiolo, Italy, 42AULLS2,Conegliano Hospital, Department of Gastroenterology, Conegliano, Italy, 43Ospedale Santa Croce e Carle, Endoscopy Unit, Cuneo, Italy, 44 V SS. Antonio e Biagio e Cesare Arrigo Hospital, Endoscopy Unit, Alessandria, Italy.
    Simone Saibeni
    Footnotes
    # The ITALIAN GI-COVID19 Working Group
    # 1–2Mario Schettino 1–2Massimo Devani, MD 1–2, Paolo Andreozzi, MD, 1–2Lucienne Pellegrini, MD, 1–2Desirè Picascia, MD, 5Arnaldo Amato, MD, 7Costanza Alvisi, MD, 8Giovanni Aragona, MD, 6Elia Armellini, MD, 9Mohammad Ayoubi, MD, 10Stefano Bargiggia, MD, 11Stefano Benvenuti, MD, 12Paolo Beretta, MD, 13Paola Boarino, MD, 14 Andrea Buda, MD, 15Lorenzo Camellini, MD, 16Sergi Cavenati, MD, 17Vincenzo Cennamo, MD, 18Fabrizio Cereatti, MD, 19Claudio de Angelis, MD, 20Giovanni de Pretis, MD, 21Giuseppe De Roberto, MD, 22Marco Dinelli, MD, 23 Giulio Donato, MD, 24Carlo Fabbri, MD, 25Luca Ferraris, MD, 3–4Alessandro Fugazza, MD, 26Pietro Fusaroli, MD, 27Nicola Gaffuri, MD, 28Salvatore Greco, MD, 29Piera Leoni, MD, 30Gianluigi Longobardi, MD, 31Benedetto Mangiavillano, MD, 32Mauro Manno, MD, 33Alberto Merighi, MD, 34Guido Missale, MD, 35Alessandro Mussetto, MD, 36Massimiliano Mutignani, MD, 23Pietro Occhipinti, MD, 6Fabio Pace, MD, 37 Roberto Penagini, MD, 38Raffaele Salerno, MD, 39Romano Sassatelli, MD, 40Sergio Segato, 6Sandro Sferrazza, MD, 41Teresa Staiano, MD, 42Alberto Tringali, MD, 43Giovanna Venezia, MD, 44 Carlo Verna, MD
    # 1ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Italy, 2ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Italy, 3Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Rozzano, Italy, 4>Humanitas University, Department of Biomedical Sciences, Rozzano, Italy, 5Valduce Hospital, Gastroenterology Unit, Como, Italy, 6Bolognini Hospital, Gastroenterology Unit, Seriate, Italy, 7ASST Pavia, Digestive Endoscopy Unit, Pavia, Italy, Italy. 8Guglielmo da Saliceto Hospital, Department of Internal Medicine, Gastroenterology and Hepatology Unit Piacenza, Italy, 9Humanitas, Gastroenterology Unit, Gradenigo, Italy, 10S Clinica San Carlo, Gastroenterology and Digestive Endoscopy Unit, Paderno Dugnano, Italy, 11Ca’ Foncello Hospital, Department of Gastroenterology, Treviso, Italy, 12Città Studi, Gastroenterology and Digestive Endoscopy Unit, Milan, Italy, 13 Policlinico di Modena, Gastroenterology Unit, Modena, Italy, 14Digestive Endoscopy Unit, S.Maria del Prato Hospital, Feltre, Italy, 15Levante Ligure Hospital, Gastroenterology Unit, La Spezia, Italy, 16ASST Bergamo Ovest, Endoscopy Unit, Treviglio, Italy, 17 Bellaria-Maggiore Hospital, Division of Gastroenterology, Bologna, Italy, 18ASST Cremona, Gastroenterology Unit, Cremona, Italy, 19Città della Salute e della Scienza, Endoscopy Unit, Torino, Italy, 20Santa Chiara Hospital, Department of Gastroenterology, Trento, Italy, 21 Institute of Oncology IRCCS, Division of Endoscopy, European Milan, Italy, 22San Gerardo Hospital ASST Monza, Endoscopy Unit, Monza, Italy,23 Department of Gastroenterology, "Maggiore Della Carità" Hospital, Novara, Italy, 24AUSL Bologna Bellaria-Maggiore Hospital, Gastroenterology and Digestive Endoscopy Unit, Bologna, Italy, 25ASST Valleolona PO, Gastroenterology and Digestive Endoscopy, Gallarate, Italy, 26AUSL Imola, Department of Gastroenterology, Imola, Italy, 27Humanitas Gavazzeni, Gastrointestinal Endoscopy Unit, Bergamo, Italy, 28Papa Giovanni XXIII Hospital, Gastroenterology and Digestive Endoscopy Units, Bergamo, Italy, 29AO Lodi, Gastroenterology & Digestive Endoscopy Unit, Lodi, Italy, 30Ospedale degli Infermi, Endoscopy Unit, Biella, Italy, 31Humanitas Mater Domini, Gastrointestinal Endoscopy Unit, Castellanza, Italy, 32AUSL Modena, Endoscopy Unit, Carpi, Italy, 33AUSL Ferrara, Department of Gastroenterology, Ferrara, Italy, 34ASST Spedali Civili, Brescia University, Digestive Endoscopy Unit, Brescia, Italy, 35AUSL Romagna, Department of Gastroenterology, Ravenna, Italy, 36 M Niguarda-Ca' Granda Hospital, Digestive and Operative Endoscopy Unit, Milano, Italy, 37 Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Gastroenterology, Milano, Italy, 38 Fatebenefratelli Sacco, Gastroenterology and Digestive Endoscopy Unit, ASST Milan. Italy, 39>R AUSL Reggio Emila, Arcispedale S. Maria Nuova, Endoscopy Unit, Reggio Emilia, Italy, 40ASST Dei Sette Laghi, Gastroenterology and Gastrointestinal Endoscopic Unit, Varese, Italy, 41Istituto di Candiolo IRCCS, Endoscopy Unit, Candiolo, Italy, 42AULLS2,Conegliano Hospital, Department of Gastroenterology, Conegliano, Italy, 43Ospedale Santa Croce e Carle, Endoscopy Unit, Cuneo, Italy, 44 V SS. Antonio e Biagio e Cesare Arrigo Hospital, Endoscopy Unit, Alessandria, Italy.
    Affiliations
    ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Milano, Italy
    Search for articles by this author
  • Author Footnotes
    # The ITALIAN GI-COVID19 Working Group1–2Mario Schettino 1–2Massimo Devani, MD 1–2, Paolo Andreozzi, MD, 1–2Lucienne Pellegrini, MD, 1–2Desirè Picascia, MD, 5Arnaldo Amato, MD, 7Costanza Alvisi, MD, 8Giovanni Aragona, MD, 6Elia Armellini, MD, 9Mohammad Ayoubi, MD, 10Stefano Bargiggia, MD, 11Stefano Benvenuti, MD, 12Paolo Beretta, MD, 13Paola Boarino, MD, 14 Andrea Buda, MD, 15Lorenzo Camellini, MD, 16Sergi Cavenati, MD, 17Vincenzo Cennamo, MD, 18Fabrizio Cereatti, MD, 19Claudio de Angelis, MD, 20Giovanni de Pretis, MD, 21Giuseppe De Roberto, MD, 22Marco Dinelli, MD, 23 Giulio Donato, MD, 24Carlo Fabbri, MD, 25Luca Ferraris, MD, 3–4Alessandro Fugazza, MD, 26Pietro Fusaroli, MD, 27Nicola Gaffuri, MD, 28Salvatore Greco, MD, 29Piera Leoni, MD, 30Gianluigi Longobardi, MD, 31Benedetto Mangiavillano, MD, 32Mauro Manno, MD, 33Alberto Merighi, MD, 34Guido Missale, MD, 35Alessandro Mussetto, MD, 36Massimiliano Mutignani, MD, 23Pietro Occhipinti, MD, 6Fabio Pace, MD, 37 Roberto Penagini, MD, 38Raffaele Salerno, MD, 39Romano Sassatelli, MD, 40Sergio Segato, 6Sandro Sferrazza, MD, 41Teresa Staiano, MD, 42Alberto Tringali, MD, 43Giovanna Venezia, MD, 44 Carlo Verna, MD1ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Italy, 2ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Italy, 3Humanitas Clinical and Research Center, Digestive Endoscopy Unit, Rozzano, Italy, 4>Humanitas University, Department of Biomedical Sciences, Rozzano, Italy, 5Valduce Hospital, Gastroenterology Unit, Como, Italy, 6Bolognini Hospital, Gastroenterology Unit, Seriate, Italy, 7ASST Pavia, Digestive Endoscopy Unit, Pavia, Italy, Italy. 8Guglielmo da Saliceto Hospital, Department of Internal Medicine, Gastroenterology and Hepatology Unit Piacenza, Italy, 9Humanitas, Gastroenterology Unit, Gradenigo, Italy, 10S Clinica San Carlo, Gastroenterology and Digestive Endoscopy Unit, Paderno Dugnano, Italy, 11Ca’ Foncello Hospital, Department of Gastroenterology, Treviso, Italy, 12Città Studi, Gastroenterology and Digestive Endoscopy Unit, Milan, Italy, 13 Policlinico di Modena, Gastroenterology Unit, Modena, Italy, 14Digestive Endoscopy Unit, S.Maria del Prato Hospital, Feltre, Italy, 15Levante Ligure Hospital, Gastroenterology Unit, La Spezia, Italy, 16ASST Bergamo Ovest, Endoscopy Unit, Treviglio, Italy, 17 Bellaria-Maggiore Hospital, Division of Gastroenterology, Bologna, Italy, 18ASST Cremona, Gastroenterology Unit, Cremona, Italy, 19Città della Salute e della Scienza, Endoscopy Unit, Torino, Italy, 20Santa Chiara Hospital, Department of Gastroenterology, Trento, Italy, 21 Institute of Oncology IRCCS, Division of Endoscopy, European Milan, Italy, 22San Gerardo Hospital ASST Monza, Endoscopy Unit, Monza, Italy,23 Department of Gastroenterology, "Maggiore Della Carità" Hospital, Novara, Italy, 24AUSL Bologna Bellaria-Maggiore Hospital, Gastroenterology and Digestive Endoscopy Unit, Bologna, Italy, 25ASST Valleolona PO, Gastroenterology and Digestive Endoscopy, Gallarate, Italy, 26AUSL Imola, Department of Gastroenterology, Imola, Italy, 27Humanitas Gavazzeni, Gastrointestinal Endoscopy Unit, Bergamo, Italy, 28Papa Giovanni XXIII Hospital, Gastroenterology and Digestive Endoscopy Units, Bergamo, Italy, 29AO Lodi, Gastroenterology & Digestive Endoscopy Unit, Lodi, Italy, 30Ospedale degli Infermi, Endoscopy Unit, Biella, Italy, 31Humanitas Mater Domini, Gastrointestinal Endoscopy Unit, Castellanza, Italy, 32AUSL Modena, Endoscopy Unit, Carpi, Italy, 33AUSL Ferrara, Department of Gastroenterology, Ferrara, Italy, 34ASST Spedali Civili, Brescia University, Digestive Endoscopy Unit, Brescia, Italy, 35AUSL Romagna, Department of Gastroenterology, Ravenna, Italy, 36 M Niguarda-Ca' Granda Hospital, Digestive and Operative Endoscopy Unit, Milano, Italy, 37 Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Gastroenterology, Milano, Italy, 38 Fatebenefratelli Sacco, Gastroenterology and Digestive Endoscopy Unit, ASST Milan. Italy, 39>R AUSL Reggio Emila, Arcispedale S. Maria Nuova, Endoscopy Unit, Reggio Emilia, Italy, 40ASST Dei Sette Laghi, Gastroenterology and Gastrointestinal Endoscopic Unit, Varese, Italy, 41Istituto di Candiolo IRCCS, Endoscopy Unit, Candiolo, Italy, 42AULLS2,Conegliano Hospital, Department of Gastroenterology, Conegliano, Italy, 43Ospedale Santa Croce e Carle, Endoscopy Unit, Cuneo, Italy, 44 V SS. Antonio e Biagio e Cesare Arrigo Hospital, Endoscopy Unit, Alessandria, Italy.
Published:June 19, 2020DOI:https://doi.org/10.1016/j.dld.2020.05.042
Planning phase two for endoscopic units in Northern Italy after the COVID-19 lockdown: An exit strategy with a lot of critical issues and a few opportunities
Previous ArticleImpact of SARS-CoV-2 on a high volume endoscopy center in Italy
Next ArticleWho comes first: Rescheduling endoscopic activity after the acute phase of the Covid 19 pandemic

      Keywords

      Dear Editor,
      Since the beginning of May 2020, Italy will gradually emerge from the novel coronavirus (COVID-19), lockdown [

      Decreto del Presidente del Consiglio dei Ministri - 26 april 2020 - Gazzetta ufficiale della Repubblica Italina in Internet: https://www.gazzettaufficiale.it/eli/id/2020/04/27/20A02352/sg.

      ], which began on March 9. With the deceleration of the pandemic across the country, disease control measures have been eased through a well-structured plan and Italy is now in the so-called “Phase Two” of lockdown, moving toward an eventual return to normalcy. After a pause for all but urgent procedures, Endoscopy Departments (EDs) are converting back to their pre-COVID-19 configurations and are returning to carrying out elective endoscopic procedures [

      Danese S., Ran Z.H., Repici A., et al. Gastroenterology department operational reorganisation at the time of covid-19 outbreak: an Italian and Chinese experience. Gut.2020 Apr 16. pii: gutjnl-2020-321143. doi:10.1136/gutjnl-2020-321143. [Epub ahead of print]

      ,

      Repici A., Pace F., Gabbiadini R., et al.;ITALIAN GI-COVID19 Working Group. Endoscopy units and the COVID-19 Outbreak: a Multi-Center Experience from Italy. Gastroenterology. 2020 Apr 10. pii: S0016-5085(20)30466-2. doi:10.1053/j.gastro.2020.04.003. [Epub ahead of print]

      ,

      ESGE and ESGENA Position Statement on gastrointestinal endoscopy and the COVID-19 pandemic – European Society of Gastrointestinal Endoscopy (ESGE). Im Internet:https://www.esge.com/esge-andesgena-position-statement-on-gastrointestinal-endoscopy-and-the-covid-19-pandemic/.

      ].
      However, safely recommencing outpatient activity raises several critical issues, such as the risk of exposure to infection for healthcare personnel and patients, the reduced availability of staff, the presence of infrastructural barriers and the lack of a clear policy regarding the timely rescheduling of cancelled or postponed endoscopies.
      We conducted a survey among the Directors of EDs in high-risk areas of Northern Italy with the aim of investigating the barriers and strategies to safely resume elective endoscopy activity in Phase Two of the lockdown.
      The study was conducted between April 20th - 25th, 2020 (two weeks before the start of “Phase-Two”). A total of 55 EDs, which participated in a previous survey on the COVID-19 outbreak in Italy (3), received by e-mail a structured questionnaire, which consisted of 3 sections (Table 1). The first section focused on the organizational characteristics of EDs before and after the outbreak, in order to assess the impact of the pandemic on EDs. The second section explored the availability of specialist staff and personal protective equipment (PPE) in the EDs at the start of Phase Two. In the third section, the Directors of EDs were asked to foresee the endoscopy workload they would realistically estimate as achievable, according to local resources, in Phase Two (from May to July 2020), and to indicate strategies to optimize endoscopic activity in this reference period.
      Table 1List of questions presented in the survey.
      Characteristics of Endoscopic Units
      1How many procedures do you perform in your Endoscopic Unit every year?
      • A
        < 5000
      • B
        ≥ 5000
      2How many physicians do you have in your Endoscopic Unit?
      3How many nurses do you have in your Endoscopic Unit?
      4How many health assistants do you have in your Endoscopic Unit?
      5When was your Endoscopic Unit built or renovated?
      6Does your Endoscopic Unit allow a differentiated clean/dirty path for the equipment?
      7How many endoscopic rooms do you have in your Unit?
      8Is your Endoscopic Unit provided with negative-pressure rooms?
      • A
        Yes
      • B
        No
      Changes in your Endoscopy Unit related to the COVID-19 outbreak
      9How much has the endoscopic activity of your Unit reduced?
      • A
        100% (stopped)
      • B
        75–99%
      • C
        50–74%
      • D
        25–49%
      • E
        0–24%
      10How many endoscopic rooms are presently not available since converted to another use?
      11How many physicians are presently infected?
      12How many physicians have been relocated to other departments?
      13How many nurses are presently infected?
      14How many nurses have been relocated to other departments?
      15How many heath assistants are presently infected?
      16How many health assistants have been relocated to other departments?
      Modifications in your Endoscopy Unit organization and its suitability for resuming endoscopic activity
      17In your opinion, is your Endoscopic Unit adequate to manage infected and non-infected patients?
      • A
        Yes
      • B
        No
      • C
        Only reducing the number of procedures
      18Is in your Endoscopic Unit possible to have separated paths for infected and non-infected patients?
      • A
        Yes
      • B
        No
      • C
        Only reducing the number of procedures
      19Is the waiting room of your Endoscopic Unit suitable to ensure adequate distance between patients/relatives/caregivers?
      • A
        Yes
      • B
        No
      • C
        Only reducing the number of procedures
      20Is the recovery room of your Endoscopic Unit suitable to ensure adequate distance between patients?
      • A
        Yes
      • B
        No
      • C
        Only reducing the number of procedures
      21Do you fear any shortage of PPEs in your Endoscopic Unit after resuming the endoscopic activity?
      • A
        Yes
      • B
        No
      Perspective and proposal for resuming the endoscopic activity
      22What would you suggest to restart safely and affectively the endoscopic activity?
      23In your opinion, which increase in the endoscopic activity can be achieved in the month of May?
      • A
        0% (the activity remains as today)
      • B
        10%
      • C
        25%
      • D
        33%
      • E
        50%
      • F
        Return to the pre-COVID-19 activity
      24In your opinion, which increase in the endoscopic activity can be achieved in the month of June?
      • A
        0% (the activity remains as today)
      • B
        10%
      • C
        25%
      • D
        33%
      • E
        50%
      • F
        Return to the pre-COVID-19 activity
      25In your opinion, which increase in the endoscopic activity can be achieved in the month of July?
      • A
        0% (the activity remains as today)
      • B
        10%
      • C
        25%
      • D
        33%
      • E
        50%
      • F
        Return to the pre-COVID-19 activity
      26In your opinion, when will your Endoscopic Unit return to the pre-COVID-19 activity?
      27Once completely re-opened, which further increase in the endoscopic activity is achievable to reduce the waiting list?
      • A
        0% (the activity will remain as in the pre-COVID-19 period)
      • B
        10%
      • C
        25%
      • D
        33%
      • E
        50%
      28When could the CRC screening activity restart in your Endoscopic Unit?
      • A
        Immediately (in the month of May) at the pre-COVID-19 vol
      • B
        Immediately (in the month of May) at a reduced rate
      • C
        I would wait to restart the screening activity
      29In your opinion, will the COVID-19 crisis promote a significant evolution in the organization models/mentality of the Endoscopic Units?
      Of the 55 EDs invited, 43 (78.2%) completed the questionnaire. The median interval time from construction or last renovation of EDs was 9.8 (7.2–13.2) (range 1–25) years. The main characteristics of EDs in the pre-COVID-19 period are shown in Table 2. Due to the COVID-19 outbreak, 17 (39.5%) centres had their normal endoscopic activities reduced by 50–74% and the remaining 26 (60.5%) by 75–99%.
      Table 2The main characteristics of the Endoscopic Departments in the pre-COVID-19 period and at the time of questionnaire administration
      Involved Endoscopic Departments (n)43
      EDs performing >5000 exams/year (n, rate)40/43 (93%)
      Time from ED construction or renovation (year; mean ± SD; range)11.9 ± 7.3; 1–25
      EDs >10 year-old (n, rate)20/43 (46.5%)
      Available/non-available endoscopic rooms121/67
      EDs with at least one non-available endoscopic room (n, rate)32/43 (74.4%)
      Available endoscopic rooms/ED (mean ± SD; range)
      • -
        Pre-COVID-19
      • -
        Present time
      		4.44 ± 2.13; 2–11

      2.80 ± 1.38: 1–7
      COVID-19 -related procedure reduction (n, rate)
      • -
        50–74%
      • -
        75–99%
      		17/43 (39.5%)

      26/43 (60.5%)
      Available endoscopists/ED (mean ± SD; range)
      • -
        Pre-COVID-19
      • -
        Present time
      		8.34 ± 4.53; 3–20

      7.27 ± 4.51; 1–19
      Available/non-available endoscopists (n)305/48
      Reason for non-availability
      • -
        COVID-19 infection
      • -
        Reallocation to another unit
      		9

      39
      Available nurses/ED (mean ± SD; range)
      • -
        Pre-COVID-19
      • -
        Present time
      		15.19 ± 10.46; 3–65

      11.34 ± 9.92; 2–62
      Available/non-available nurses481/162
      Reason for non-availability
      • -
        COVID-19 infection
      • -
        Reallocation to another unit
      		25

      137
      Available health assistant/ED (mean ± SD; range)
      • -
        Pre-COVID-19
      • -
        Present time
      		4.24 ± 3.36; 1–15

      3.22 ± 2.17; 0–15
      Available/non-available health assistants154/25
      Reason for non-availability
      • -
        COVID-19 infection
      • -
        Reallocation to another unit
      		4

      21
      Overall, 353 endoscopists (range 3–20/ED), 643 nurses (range 7–65/ED) and 179 health assistants (range 1–15/ED) had been working in EDs in the pre-COVID-19 period. At the end of April, 48/353 (13.6%) endoscopists, 162/643 (25.2%) nurses, and 25/179 (14%) health assistants were not available due to Covid-19 infection (9, 25 and 4 respectively), or reallocated to other units (39, 137 and 21 respectively) (Table 2).
      Of 188 endoscopy rooms used in the pre-COVID period, 67 (35%) in 32 EDs were not available, since they were either converted to COVID-19-care areas (n = 9) or devoted to endoscopic procedures in COVID-19 positive patients (n = 58). Regarding structural characteristics, 29 (67.4%) centres had either the waiting area (22/43, 51.2%) or the recovery area (24/43, 55.8%) or both (17/43, 39.5%) that were too small to guarantee sufficient distancing between patients or caregivers/escorts at the pre-crisis workload; 10 (23.2%) centres could not guarantee a “infected patients pathway” separated by “non-infected” areas; 30 (70%) were lacking at least one negative-pressure room; 10 (23.2%) did not even guarantee the separated dirty/clean pathways for endoscopes. In this phase of the pandemic, PPE shortage represented a critical issue for a minority (5–11.6%-) of centres. In general, only 3 (7%) EDs reported that they were able to immediately resume elective endoscopic activity at the pre-crisis volume, with respect of the safety protocols.
      When asked to foresee which increase in the endoscopic workload would have been bearable in the upcoming months, according to the services resources, the majority of the Directors (34/43, 79%) envisioned as realistic a workload increase up to 33% for the month of May as compared to the actual one. For the month of June, this figure was up to 33% and 50% in 26 centres (60.5%) and in 15 (34.9%), respectively. For the month of July, the majority of centres (30/43, 69.8%) envisioned a workload increase of at least 50% (n = 22). Returning to the pre-crisis workload by the end of July, September and October was judged as a realistic goal by 8 (18.6%), 10 (23.2%), and 14 (32.6%) participants, respectively (Fig. 1).
      Fig 1:
      Fig. 1Hypothesized increase in the endoscopic workload, as compared to the actual one, bearable in the upcoming months after re-opening of the Endoscopic Departments.
      All participants agreed that, once completely returned to elective endoscopy, the chance of overcrowding would be very high, due to the very large number of postponed cases that need to be rescheduled. However, only 10 of them reported they were confident in being able to significantly increase (at least 33%) their activity with respect to the pre-COVID-19 vol; conversely, the majority of participants realistically declared no (14 centres) or minimal (10–25%) increases in their activities to be possible.
      Endoscopists suggested that implementing the application of guidelines (n = 12), organizing a direct-line with general practitioners (GP) for triaging and scheduling/rescheduling patients (n = 21), and promoting telemedicine and virtual visits (n = 10) could be strategies to optimize endoscopic activity and promote a more rational use of resources. Only 10% of those interviewed were pessimistic, fearing that the COVID-19 crisis would have not brought any changes and improvements in ED organization. All centres claimed their availability to immediately restart screening activity at the pre-crisis volumes, but 38 of them suggested to replace pre- and post- colonoscopy visits by telemedicine.
      The present survey demonstrates that there are several barriers preventing EDs in Northern Italy to safely manage elective endoscopy activity in Phase Two of the pandemic. Professional societies have issued guidelines to safely return to elective procedures [

      Sultan S., Lim J.K., Altayar O., et al. AGA Institute Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic. Gastroenterology. 2020 Mar 31. pii: S0016-5085(20)30458-3. doi:10.1053/j.gastro.2020.03.072. [Epub ahead of print]

      ,

      Endoscopy activity and COVID-19: BSG and JAG guidance. 2020 Mar 22. https://www.bsg.org.uk/covid-19-advice/endoscopy-activity-and-covid-19-bsg-and-jag-guidance/.

      . These guidelines call for a pre-procedure screening of patients to assess risk of transmission, combining it with PCR-based testing prior the procedure, the use of PPE, and policies to facilitate social distancing for patients and visitors in the waiting and recovery rooms, restrictions on accompanying visitors, and distancing the procedure start times [

      Sultan S., Lim J.K., Altayar O., et al. AGA Institute Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic. Gastroenterology. 2020 Mar 31. pii: S0016-5085(20)30458-3. doi:10.1053/j.gastro.2020.03.072. [Epub ahead of print]

      ,

      Endoscopy activity and COVID-19: BSG and JAG guidance. 2020 Mar 22. https://www.bsg.org.uk/covid-19-advice/endoscopy-activity-and-covid-19-bsg-and-jag-guidance/.

      . Presently, PCR testing prior to the procedure is not available in Italy. Thus, social distancing and the appropriate use of PPE remain critical issues. Unfortunately, despite 50% of EDs had been recently (< 10 years) built or renovated, waiting and recovery areas are inadequate in guaranteeing distancing among individuals in several services, and most units are not able to ensure high flows of patients, personnel and equipment.
      Other issues hinder a prompt restart of elective endoscopy: Endoscopy staff is still lacking in many endoscopy services, since physicians and nurses have been either infected or are still reallocated to other departments; some EDs rooms are still unavailable due to their conversion to the management of COVID-19 infected patients. Indeed, most participants agreed that re-opening EDs should be accomplished very slowly, with a limited increase in the number of procedures over the upcoming months and that it was unrealistic to return to pre-crisis workload in the next three months.
      Phase Two will be challenging: effort should be made to avoid overload of EDs, but several procedures that were cancelled or postponed during the outbreak need to be rescheduled. There is, thus, an absolute need to redesign the organization models of EDs and their interaction with territorial services. The Italian “open access” system has several advantages (eliminating unnecessary pre-endoscopic office-based consultations), but it has also generated a high level of inappropriateness and misuse of resources [
      • Hassan C.
      • Bersani G.
      • Buri L.
      • et al.
      Appropriateness of upper-GI endoscopy: an Italian survey on behalf of the Italian Society of Digestive Endoscopy.
      Gastrointest Endosc. 2007; 65: 767-774
      ,
      • Minoli G.
      • Meucci G.
      • Bortoli A.
      • et al.
      The ASGE guidelines for the appropriate use of colonoscopy in an open access system.
      Gastrointest. Endosc. 2000; 52: 39-44
      . From now on, a clear and thoughtful policy regarding the timely scheduling/rescheduling of endoscopy procedures according to their priority will be required. This can be achieved only on a case-by-case basis; priority should be given to patients for whom even a short delay would significantly alter the patient's prognosis. Due to the great uncertainty about the duration of the pandemic [
      • Giordano G.
      • Blanchini F.
      • Bruno R.
      • et al.
      Modelling the COVID-19 pandemic and implementation of population-wide interventions in Italy.
      Nat Med. 2020 Apr 22; ([Epub ahead of print])https://doi.org/10.1038/s41591-020-0883-7
      ], a further category of patients who should not be postponed are those who do not have life-threatening conditions but for whom treatment should not be indefinitely delayed until the end of the pandemic, such as colorectal cancer screenings. EDs should, thus, strongly consider further postponing elective procedures or their cancellation, if inappropriate by reviewing and categorizing the procedure lists by both prescriber physicians and endoscopists. This scenario inevitably implies, at least temporarily, the shift from an open access endoscopy to a filtered access [
      • Amato A.
      • Rondonotti E.
      • Radaelli F.
      Lay-off of Endoscopy services for the COVID-19 pandemic: how can we resume the practice of routine cases?.
      Gastroenterology. 2020 Apr 26; (pii: S0016-5085(20)30568-0[Epub ahead of print])https://doi.org/10.1053/j.gastro.2020.04.049
      ]. A prioritization model for referrals has already been tested in Italy [
      • Meggio A.
      • Mariotti G.
      • Gentilini M.
      • De Pretis G.
      Priority and appropriateness of upper endoscopy out-patient referrals: two-period comparison in an open-access unit.
      Dig Liver Dis. Nov 2019; 51 (doi:10.1053/j.gastro.2020.04.049. Epub 2019 Jun 21): 1562-1566
      ,
      • Mariotti G.
      • Meggio A.
      • de Pretis G.
      • Gentilini M.
      Improving the appropriateness of referrals and waiting times for endoscopic procedures.
      J Health Serv Res Policy. Jul 2008; 13 (doi:10.1258/jhsrp.2008.007170): 146-151
      , but this process implies a close interaction between GPs and specialists and requires a lot of time. Telemedicine, as highlighted by our survey, could represent a useful tool to fill the gap between GPs and specialists. Telemedicine and virtual visits have never been performed in Endoscopy Units in Italy but are advisable to promote the appropriate use of resources.
      Measures for the return to routine endoscopy during the pandemic have been suggested by gastroenterological societies [

      Sultan S., Lim J.K., Altayar O., et al. AGA Institute Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic. Gastroenterology. 2020 Mar 31. pii: S0016-5085(20)30458-3. doi:10.1053/j.gastro.2020.03.072. [Epub ahead of print]

      ,

      Endoscopy activity and COVID-19: BSG and JAG guidance. 2020 Mar 22. https://www.bsg.org.uk/covid-19-advice/endoscopy-activity-and-covid-19-bsg-and-jag-guidance/.

      and experts [
      • Han J.
      • Wang Y.
      • Zhu L.
      • et al.
      Preventing the spread of COVID-19 in digestive endoscopy during the resuming period: meticulous execution of screening procedures.
      Gastrointest Endosc. 5 Apr 2020; (pii: S0016-5107(20)34133-X doi:10.1016/j.gie.2020.03.3855. [Epub ahead of print])
      ,
      • Thompson C.C.
      • Shen L.
      • Lee L.S.
      COVID-19 in endoscopy: time to do more?.
      Gastrointest Endosc. 29 Mar 2020; (pii: S0016-5107(20)34126-2 doi:10.1016/j.gie.2020.03.3848. [Epub ahead of print])
      ,
      • Ponchon T.
      • Chaussade S.
      COVID-19: how to select patients for endoscopy and how to reschedule the procedures?.
      Endosc Int Open. May 2020; 8 (doi:10.1055/a-1154-8768. Epub 2020 Apr 17): E699-E700
      ,
      • Gupta S.
      • Shahidi N.
      • Gilroy N.
      • Rex D.K.
      • Burgess N.G.
      • Bourke M.J.
      A proposal for the return to routine endoscopy during the COVID-19 pandemic.
      Gastrointest Endosc. 28 Apr 2020; (doi:10.1016/j.gie.2020.04.050. [Epub ahead of print])
      ], but local applicability has never been evaluated. The present survey has been conducted in Italy, but has provided data that are likely generalizable to most EDs in the Western countries.
      Crisis periods, like wars, are usually followed by great technological and social evolution. Nearly all endoscopists have agreed that the COVID-19 pandemic may represent a great opportunity to re-model and rationalize the EDs processes. Nothing will be the same again and what we are organizing, planning and changing today will likely represent the basis of our work tomorrow: this opportunity has to be exploited to the best of our possibilities.

      Declaration of Competing Interest

      Authors declare that they do not have any conflict of interest

      Acknowledgements

      GM, AR, and FR planned and designed the survey; GM and MC collected and analyzed data; GM, AR, and RF drafted the manuscript and figures. SS and CB, provided critical appraisal of the manuscript. SS and CB revised the manuscript.

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        View in Article
        • Giordano G.
        • Blanchini F.
        • Bruno R.
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        Modelling the COVID-19 pandemic and implementation of population-wide interventions in Italy.
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        View in Article
        • Amato A.
        • Rondonotti E.
        • Radaelli F.
        Lay-off of Endoscopy services for the COVID-19 pandemic: how can we resume the practice of routine cases?.
        Gastroenterology. 2020 Apr 26; (pii: S0016-5085(20)30568-0[Epub ahead of print])https://doi.org/10.1053/j.gastro.2020.04.049
        View in Article
        • Meggio A.
        • Mariotti G.
        • Gentilini M.
        • De Pretis G.
        Priority and appropriateness of upper endoscopy out-patient referrals: two-period comparison in an open-access unit.
        Dig Liver Dis. Nov 2019; 51 (doi:10.1053/j.gastro.2020.04.049. Epub 2019 Jun 21): 1562-1566
        View in Article
        • Mariotti G.
        • Meggio A.
        • de Pretis G.
        • Gentilini M.
        Improving the appropriateness of referrals and waiting times for endoscopic procedures.
        J Health Serv Res Policy. Jul 2008; 13 (doi:10.1258/jhsrp.2008.007170): 146-151
        View in Article
        • Han J.
        • Wang Y.
        • Zhu L.
        • et al.
        Preventing the spread of COVID-19 in digestive endoscopy during the resuming period: meticulous execution of screening procedures.
        Gastrointest Endosc. 5 Apr 2020; (pii: S0016-5107(20)34133-X doi:10.1016/j.gie.2020.03.3855. [Epub ahead of print])
        View in Article
        • Thompson C.C.
        • Shen L.
        • Lee L.S.
        COVID-19 in endoscopy: time to do more?.
        Gastrointest Endosc. 29 Mar 2020; (pii: S0016-5107(20)34126-2 doi:10.1016/j.gie.2020.03.3848. [Epub ahead of print])
        View in Article
        • Ponchon T.
        • Chaussade S.
        COVID-19: how to select patients for endoscopy and how to reschedule the procedures?.
        Endosc Int Open. May 2020; 8 (doi:10.1055/a-1154-8768. Epub 2020 Apr 17): E699-E700
        View in Article
        • Gupta S.
        • Shahidi N.
        • Gilroy N.
        • Rex D.K.
        • Burgess N.G.
        • Bourke M.J.
        A proposal for the return to routine endoscopy during the COVID-19 pandemic.
        Gastrointest Endosc. 28 Apr 2020; (doi:10.1016/j.gie.2020.04.050. [Epub ahead of print])
        View in Article

      Article info

      Publication history

      Published online: June 19, 2020
      Accepted: May 24, 2020
      Received: May 12, 2020

      Identification

      DOI: https://doi.org/10.1016/j.dld.2020.05.042

      Copyright

      © 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

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