Seth Gross, MD, On Resuming Endoscopy Safely in the Age of COVID-19


In this podcast, Seth Gross, MD, discusses how gastroenterologists can resume semi-elective and elective endoscopies by following key guidelines to protect patients and staff against COVID-19. 



Seth A. Gross, MD, is the clinical chief of the Division of Gastroenterology and Hepatology at NYU Langone Health and associate professor of medicine at NYU Langone Health in New York, New York.



Rebecca Mashaw: Hello and welcome to another installment of Podcasts360, your go‑to resource for medical news and clinical updates. I'm your moderator, Rebecca Mashaw with Consultant360 Specialty Network.

With us today is Dr Seth Gross, clinical chief of the Division of Gastroenterology and Hepatology at NYU Langone Health. He’ll be talking to us about the challenges of reopening endoscopy practice, some steps to take in preparation to protect patients and staff, and where to look for guidelines that can help you make a safe and smooth transition to restarting endoscopy in the age of COVID‑19.

Thank you for being here today, Dr Gross. Would you start off by explaining some of the dangers involved in performing endoscopy when there is a widespread respiratory virus and particularly when patients can present as asymptomatic?

Seth Gross: The good news that we're seeing across the country is a flattening and decreased number of new cases and decreased number of hospitalizations. I work in an area that's high prevalence, in New York City. What I'm experiencing, I think, is probably different than what other areas of the country happened to be seeing in relation to this virus.

However, it's really important that when we have a virus that spreads so easily, that we do have to take proper precautions. We've been doing that for the last couple of months now where we've cut back and postponed elective procedures, and really focusing on patient that needed urgent and emergent endoscopy procedures.

The phase we're moving into now is how do we start doing procedures that have been postponed. Then ultimately, going back to the usual operations in endoscopy, which the majority of our patients are getting screening procedures, like a screening colonoscopy to look for polyps and, of course, for colon cancer.

The first step is to look at where you are in the country and pay attention to the state and federal guidelines specifically from the CDC. In addition, the gastrointestinal societies have really done a nice job in terms of trying to give us guidance of how to safely open up endoscopy.

What we're doing ‑‑ this is a simple approach ‑‑ is when we're starting to move towards doing these semi‑elective cases, so we're past the urgent and emergent. We're doing cases that we had postponed, say for diagnostic and therapeutic purposes, someone with gastrointestinal symptoms.

What we're trying to do to ensure safety of our patients ‑‑ I'm going to break this down a little bit differently a little later where we deal with the prevalence depending on where you are in the country ‑‑ is we're testing all our health care professionals that work in the endoscopy area, the physicians, the nurses, and the technicians.

We also have the ability to test our patients prior to procedure and I know that is not readily available everywhere.

If someone does test COVID negative, they'll be done at an ambulatory facility. If someone should test COVID positive even without symptoms, this is where you have to think about just postponing the procedure and retesting that patient, or if that patient really needs to have the procedure done, transitioning them to the hospital.

RM: We also wanted to ask you about the specific steps gastroenterologist need to take in the planning they need to do before they reopen for endoscopy, and especially how PPE and its adequate supplies might affect that planning?

You mentioned some guidelines that you say are very helpful in going through the process of making these decisions. Could you tell us a bit more about that?

SG: The American College of Gastroenterology has done a really nice job in terms of giving us a decision tree for patients that are undergoing endoscopy and the decision tree is around personal protective equipment.

This has been a hot‑button topic within endoscopy because, of course, we want to keep the patient safe, but we also want to ensure that our staff, the nurses, the technicians, and the physicians are well‑protected, and so the way it's been broken down is low‑prevalence area versus high‑prevalence area.

If you have a low‑prevalence area, you have testing available and it's negative, and you do a symptom screen before the procedure looking for things that are common with the virus, such as cough and fever, and now, we know about gastrointestinal symptoms like diarrhea, loss of taste, and loss of smell, usually consider standard precautions, which is surgical mask, facials, gloves, and gowns.

This is just universal precautions that we've been doing all along. Now, if you have a low‑prevalence area, but you don't have testing available and there's a negative‑symptom screen, then you may consider using different type of mask, N95 masks.

Then of course, face shields or goggles, and then allowing time for you and your team to properly put on the personal protective equipment and take it off.

Now, when you move to the high‑prevalence areas, the test is negative and the symptom screen is negative ‑‑ high prevalence would be where I am, in New York ‑‑ you would use an N95 mask if available and that's the key. It's based on availability and of course, the face shields or the goggles and proper time to don and doff equipment.

If you're in a higher low‑prevalence area, and the test is positive or the patient has a positive‑symptom screen, if this is something that could get postponed, it's very reasonable to just postpone it a couple of weeks and reassess the patient.

If this was something that was very time‑sensitive, this would be a procedure that you would then move away from an offsite ambulatory location and move that patient back to the hospital.

The need of different types of personal protective equipment is variable because there are some parts of the country that have minimal cases of this virus. If you work for a hospital system, they have good leadership teams to help look at all this and give recommendations.

The other thing that's starting to improve is getting access to PPE. It's becoming a little bit more readily available. It's going to allow gastroenterologist to start to go back to the endoscopy. Depending on whether you're a hospital‑based or within a hospital system versus an independent ASC, it's important to get a sense of what you would need to start ramping back up and doing procedures.

Do you need an N95 or one of its equivalents, or are you in a very low‑prevalence area and the patient that tests negative? You don't have the testing available, but they don't have symptoms, you could safely get by with a surgical map. Of course, you wear face shields and we all wear gloves, shoe covers, and a hairnet is something that ought to be optional.

RM: What about follow‑up visits? We've talked about the things that you need to do to reopen safely, the things that you need to plan for and consider, and of course, the steps that you take during endoscopy, but are there things that gastroenterologist need to do to prepare for seeing patients after they perform this procedure?

SG: That's such a good question. It depends on the physician and the practice. Many times the results are just given over the phone because the endoscopist has already talked to the patient afterwards given initial impression and it may just be a follow‑up phone call.

We still have the availability of telehealth and virtual visits, so if you needed to have a follow‑up visit and the office side of your practice is not fully up and running, you could do a virtual visit to go over results and also, you could see how the patient's doing because you may catch some patients that subsequently developed symptoms of the virus.

That's important because then you could identify those individuals, recommend quarantine, and also crease back to see if anybody at your facility has been exposed and you could recommend testing for those individuals. Then of course, you need face‑to‑face office visits.

What's happening now is, as the endoscopy volume increases on the office side, there is still a strong amount of telehealth still being done. As we learn more about which direction we're going in terms of the new cases of this virus or we're just continuing on the downward trend, we'll know more as the country starts to open up in your specific area of what you mean to do or not do going forward.

RM: What is your experience been in working with your patients via telehealth and how have they responded? Have they been positive, negative, or neutral about it?

SG: In terms of the telehealth interaction, it's been quite positive because it still allows patients that are having gastrointestinal issues to be in touch with their physician, to discuss them. We could do very minimal physical exam with the help of the patient, but at least, we're able to continue their care in that.

That's valuable because the last thing we'd want is for our patients to push off their symptoms and ignore something that is preventable if picked up early. Overall, for both the providers and the patients, it's been a positive experience.

RM: Are there specific milestones you want to see before we starting endoscopy, such as a drop‑off in diagnosed cases or reductions in hospitalizations, relaxation of government restrictions? What are you looking for as your cues?

SG: We're waiting on the state government to give us guidance. What we're doing is we're just [inaudible 10:00] up with the infrastructure and planning to make the adjustments to accommodate social distancing, making sure that our staff have the appropriate personal protective equipment which we have, but it's going to be a state‑by‑state following for physicians.

We know that you can't get it to zero, but to try to be in as much of a COVID‑free zone as possible, making sure that they have the right personal protective equipment for them and their staff.

In terms of what we're going to use to dictate when we're going to start to resume the different phases of endoscopy practice moving from urgent and emergent to semi‑elective and then elective procedures, it's going to be a state‑by‑state recommendation to physicians.

RM: Thank you so much for your time. We appreciate your insights into this issue.

SG: Thank you very much for having me.