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1 Corresponding Author's Membership in Professional Societies: Italian Association for Digestive Endoscopy (SIED); Italian Association for Hospital Gastroenterologists and Digestive Endoscopists (AIGO).
Vincenzo Giorgio Mirante
Correspondence
Correspondence to: Department of Oncology and Advanced Technologies, Gastroenterology and Digestive Endoscopy Unit, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento, 80, 42123 Reggio nell'Emilia, Italy.
1 Corresponding Author's Membership in Professional Societies: Italian Association for Digestive Endoscopy (SIED); Italian Association for Hospital Gastroenterologists and Digestive Endoscopists (AIGO).
Affiliations
Gastroenterology and Digestive Endoscopy Unit, Azienda USL-IRCCS Reggio nell'Emilia, Reggio Emilia, Italy
1 Corresponding Author's Membership in Professional Societies: Italian Association for Digestive Endoscopy (SIED); Italian Association for Hospital Gastroenterologists and Digestive Endoscopists (AIGO).
], which reports how the SARS-CoV-2 disease (COVID-19) has impacted on the Gastroenterology Divisions in Italy.
Here we would like to share our experience during the lockdown period, when our Endoscopy Unit was partially converted into an Intensive Care Unit and our activity was limited.
The first case of COVID-19 in Italy was reported on February 21, 2020, after the admission of a 38-year-old man into an intensive care unit (ICU) for severe pneumonia at Codogno Hospital (Lombardy, Italy). Since then, the number of cases identified in Italy has dramatically increased, mainly in some regions of Northern Italy, such as Lombardy and Emilia Romagna. Italy was therefore one of the most affected European countries, accounting for high rates of deaths and confirmed cases requiring hospitalization for COVID-19 [
Starting from March 10 to June, the Italian Government imposed a nationwide state of emergency with lockdown and self-isolation measures to counteract the spread of COVID-19. Simultaneously, to prevent the probable unjustified contagion for healthcare professionals and among patients, hospitals have progressively reduced all ordinary activities. Furthermore, when ICU admissions quickly increased, each regional healthcare system increased the number of ICU beds and reduced the number of beds available for other urgent or elective hospitalizations.
At the time of writing this paper, the province of Reggio Emilia (Emilia Romagna, Italy; 533,000 inhabitants) has had more than 5.000 SARS-CoV-2 infections [
]. The Arcispedale Santa Maria Nuova (ASMN) is a tertiary referral hospital in Reggio Emilia. Our Gastroenterology and Digestive Endoscopy Unit is located inside the new Oncological and Hematological Center (CORE) of the ASMN. The Unit has five endoscopic rooms, including one that is equipped with a mobile X-ray angiography system (Discovery™ IGS 740; GE Healthcare, Chicago, IL, United States), a large recovery area, an endoscope reprocessing and storage area, a reception and waiting zone, different rooms for interview or clinical examination, and support rooms, for a total surface of nearly 1550 m2 (Fig. 1). The recovery area is equipped with wall medical air and wall oxygen supply, wall suction, and a medical gas and vacuum system with a standard comparable to what is defined for an ICU. Moreover, a centralized system to monitor patients’ vital functions is also available in the recovery room.
Fig. 1Map of the Gastrointestinal Endoscopy Unit. The Gastroenterology and Digestive Endoscopy Unit is on the ground floor of the new Oncological and Hematological Center of the Arcispedale Santa Maria Nuova. Here, the map of the Unit is shown inside the red box.
In early March 2020, the ICU of the ASMN hospital required a substantial increase of bed availability. For this purpose, on March 18, our unit was partially converted in that the recovery area and the two facing endoscopic rooms were replaced with 14 ICU beds dedicated to patients who needed tracheal intubation and intensive care support. Inside this new ICU, a negative pressure (−5 Pa) was maintained. The remaining three endoscopic rooms were operative. The room equipped with the Discovery system (Hybrid Operative Room) was dedicated to hepatobiliary diagnostic and therapeutic procedures. Another endoscopic room was converted to a new recovery area. The last one was used for all other non-hepatobiliary endoscopic examinations. A U-shaped pathway with a single entrance/exit door to the structure was created (Fig. 2).
Fig. 2Map of the new Gastrointestinal Endoscopy Unit. The new intensive care unit is shown inside the blue box. The new Endoscopy Unit with a U-shape pathway is shown outside the blue box.
To prevent SARS-CoV-2 transmission and according to the above-mentioned structural changes, since early March our activities have been progressively reduced to a minimum. For example, elective endoscopic procedures and colorectal cancer screening have been temporarily suspended. As the British Society of Gastroenterology suggested, only urgent and emergency endoscopies have been performed in order to treat patients with acute upper and lower bleeding, obstructions, foreign bodies ingestion, jaundice, acute suppurative cholangitis, or other not deferrable benign and malignant gastrointestinal diseases [
During the lockdown the access to the endoscopic unit has been limited to healthcare staff and patients. The body temperature of all operators has been checked daily before they entered the hospital. All inpatient-scheduled exams were performed only after screening for COVID-19 or a chest CT scan. All patients undergoing an emergency procedure had at least a chest X-ray. All outpatients were investigated to determine if they or their family members had a fever or respiratory symptoms, or if they have had direct contact with a case of COVID-19. In cases of doubtful clinical or radiological data, the patient was considered positive for COVID-19. In cases of positive or suspicious patients, the indication was always revised and the exam was performed only if it was confirmed as non-postponable. All patients referred to our Unit had to wear a facial mask. Positive or highly suspicious COVID-19 patients had direct access to the endoscopic room; at the end of the examination, patients had to remain in the room until they could return to the ward. For negative patients, the new recovery room was used. In this room, the presence of more than two patients was not allowed in order to avoid close contact (< 2 m).
Our unit includes 13 doctors. During the COVID emergency, endoscopic activity has been performed by 9 gastroenterologists. 4 doctors have been temporarily assigned to medical departments for the management of COVID patients who did not require intensive care. Only anesthesiologists worked in the new intensive care unit. The number of operators in the endoscopic rooms has been reduced to the bare minimum. When tracheal intubation was required, only the anesthesiologist and one nurse could stay inside the endoscopy room during the maneuver. If required, each endoscopic examination could have been assessed remotely in real time by an expert operator. The use of such personal protective equipment (PPE) as waterproof gowns, gloves, hairnet, medical mask, filtering face piece FFP2/3 respirators, and eye protection (i.e. goggles or disposable face shield) was regulated according to the indications released by national and international authorities [
Gruppo di Lavoro ISS Prevenzione e Controllo delle Infezioni. Indicazioni ad interim per un utilizzo razionale delle protezioni per infezione da SARS-COV-2 nelle attività sanitarie e sociosanitarie (assistenza a soggetti affetti da covid-19) nell'attuale scenario emergenziale SARS-COV-2. 2020. https://www.epicentro.iss.it/coronavirus/pdf/rapporto-covid-19-2-2020.pdf.
]. After endoscopy, healthcare professionals had to remove all protective clothing and appropriately clean their hands before leaving the endoscopic room. The surgical mask was required in the remaining area.
Precautions were adopted to prevent contamination among operators. In the Endoscopy Unit, only strictly necessary operators were required, and the others had to remain at home. Outside the endoscopy rooms, it was forbidden to be in close contact with other operators and it was advisable to keep a minimum distance of 2 m. Each workstation, including a computer and chair, had to be exclusively used by a single operator and was disinfected before and after its use with chlorine-based solutions. Each operator could only use the personal phone. Disinfection of the phone was recommended at least at the beginning and end of the day. Finally, the frequent use of alcoholic disinfectant gels and hand hygiene were encouraged. Currently, no healthcare professional in our digestive endoscopy unit has developed symptoms or tested positive for COVID-19.
These structural and organizational changes have been adopted until the middle of May. The return to the original facility and to the routine endoscopic activity was possible at the end of May after a significant reduction in COVID-19 cases and a decline in the need for intensive care beds.
Conflict of interest
None declared.
Funding
The authors of the manuscript receive no funding, grants, or in-kind support in support of the preparation of the manuscript.
Acknowledgments
Apro Onlus, Associazione per lo Studio e la Cura delle Malattie dell'Apparato Digerente – Progetti Radioterapia. Reggio Emilia (Italy).
References
Maida M.
Sferrazza A.
Savarino E.
et al.
Impact of the COVID-19 pandemic on Gastroenterology Divisions in Italy: a national survey.
Gruppo di Lavoro ISS Prevenzione e Controllo delle Infezioni. Indicazioni ad interim per un utilizzo razionale delle protezioni per infezione da SARS-COV-2 nelle attività sanitarie e sociosanitarie (assistenza a soggetti affetti da covid-19) nell'attuale scenario emergenziale SARS-COV-2. 2020. https://www.epicentro.iss.it/coronavirus/pdf/rapporto-covid-19-2-2020.pdf.
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