Supplementary environment guidance following the COVID-19 pandemic
About this document | General Principles | Environment models | Booking, reception & waiting areas | Patient assessment (including consent) and sub-waiting areas | PPE | Waste & linen disposal | Ventilation & heating | Procedure room| Decontamination | Recovery & discharge | Resources
Published 21 May 2020
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About this document
This guidance provides a framework to assist endoscopy services to adapt their environment following the COVID-19 pandemic. It can be used by all endoscopy services in the UK and will be referred to during accreditation assessments. Restoration of services will vary significantly and so this guidance provides practical points for consideration locally.
This guidance should be reviewed alongside the JAG environment guidance, as well as guidance from government, professional societies and other agencies. Links to several resources are provided at the end of this document.
The following definitions are used throughout:
- Red refers to areas or patient pathways with proven or suspected COVID-19.
- Green refers to areas or patient pathways where patients have been tested negative for COVID-19 or have self-isolated before admission.
This document gives recommendations which may apply only to red areas or pathways; services may also want to extend these recommendations to green areas to further reduce risk.
This guidance is likely to change regularly; please refer to the JAG website at www.thejag.org.uk/COVID-19 for the latest version.
General principles
- Patients safety, privacy and respect must always be protected, and this is especially important as services implement new ways of working. Safety is also an important consideration for staff, who may be exposed to risks which were not previously a consideration.
- Service configuration and management may have changed significantly. Staff should be aware of their responsibility for maintaining a safe environment and ensure they are aware of new practices.
- COVID-19 testing/screening should be available for patients pre-procedure (and carers, where essential) and patients should be clinically screened before endoscopy for symptoms of COVID-19 and for contact with affected individuals (see JAG guidance). Patients who cannot be tested should be assumed to be potentially COVID-19 positive.
- There should be clear signage to ensure that anyone entering the endoscopy unit are aware of procedures and restrictions to maintain a safe environment, as well as patient flow. Patients must be informed of this before arrival, as per hospital policy. Relatives and carers should be clear about their responsibilities when dropping off and collecting patients.
- Patient anxiety is likely to be higher and extra time to speak to patients and carers should be factored into workloads.
- Prevention of unauthorised access is an important factor in maintaining a safe clinical environment. The number of people in the facility at one time should be limited to reduce the risk of transmission and encourage social distancing.
- Infection prevention measures should be in place in line with national guidance (3). This should be supported by standard operating procedures (SOPs) and updated as further guidance is published.
- There should be SOPs to include management of environment changes or variation due to limitations to service delivery imposed by COVID-19.
- Estate management and infection control teams should advise on any structural or pathway alterations to environments and risk assess where required.
- Extra attention should be given to reducing the potential for transmission from touching contaminated objects. This includes ensuring the environment is uncluttered and removing non-essential items which are not of a medical grade or wipeable.
- Gender segregation requirements (where relevant) and facilities to support patients with disabilities should continue to be made available.
- As best practice, children should continue to not be admitted or treated alongside adult patients but on a separate and dedicated list.
Environment models
The following section discusses two ‘models’ of delivery that may be used to resume and deliver endoscopy safely. The following points should be considered when reviewing service configuration:
- The priority for endoscopy to be restored, as part of the organisation’s recovery plan.
- The ability to quickly and safely alter the environment to separate green and red areas, and patients with and without COVID-19, including staff training requirements for new practices.
- The availability of COVID-19 testing/screening for staff and patients.
- Whether ventilation and heating are suitable for patients with COVID-19, and the downtime needed between cases to enable deep cleaning. This may affect productivity.
- The availability and location of critical support services including decontamination and pathology, and safe transportation to these areas.
- The availability and location of radiology and other areas to support interventional procedures.
Model one: a facility which operates as a red site or a green site
This could be part of a service with several sites providing endoscopy, where facilities can only safely see either patients with or without COVID-19 or as a regional centre.
Where an organisation has two (or more) facilities within the same site and operates them independently as a red and a green facility (for example an operating department in addition to a dedicated endoscopy facility), consideration should be given to separating staff to reduce transmission within the team.
Model two: a facility which operates with red and green areas / pathways
The facility could be treated as though all patients are a risk of transmission to reduce the need for separate pathways. However, where this unduly restricts productivity or is not possible, consideration should be given to:
- Separation of staff who see patients with COVID-19 within the facility to reduce the risk of transmission within the team.
- Separation of patients with COVID-19 by room, session or day. Where patients are segregated by session, patients without COVID-19 should be seen in the morning and patients with COVID-19 in the afternoon. This minimises cross contamination and allows enough down time for deep cleaning.
- Where multiple rooms are available to see both patients with and without COVID-19, consider undertaking fewer aerosol generating procedures (ie flexible sigmoidoscopy or colonoscopy). There will need to be defined pathways to reduce the risk of transmission with no cross over between patients and separate recovery areas, entrances and exits.
In either model endoscopy may be undertaken alongside another service, for example alongside general surgery in theatre. In this instance consideration should be given to:
- The endoscopic and surgical procedures that will be undertaken (see NHS England guidance on restarting cancer surgery (5)).
- Running a dedicated operating theatre for endoscopy procedures.
- Operating separate sessions/days for surgical and all endoscopy procedures, including non-GI. Where the endoscopy area is used for non-GI procedures, policies and procedures should be shared across all relevant specialties and non-GI patients expected to follow the same processes.
Booking, reception and waiting areas
- Procedures should be staggered and booked as appropriate to maintain social distancing within waiting and sub waiting areas. Patients with COVID-19 should be separated from patients without COVID-19. This may impact the number of patients booked onto a list.
- Patients and carers should receive information prior to arrival outlining the precautions and restrictions in place. Patient information should be reviewed to reflect accurately what the patient is likely to experience and should be considerate of potentially increased patient anxiety.
- Hand sanitiser should be available at the entrance to the facility (3).
- Symptomatic and shielded patients may wear a face mask (1,3). Masks are not expected to be available at the main entrance if the facility shares a reception but should be available on entrance to the endoscopy facility itself.
- Where queuing is likely there should be measures to ensure that patients maintain social distancing.
- Waiting room chairs should be reduced to the minimum number necessary to promote social distancing (this should also be observed in second recovery).
- Where possible, staff in reception should be protected with a screen or similar protection.
- A verbal check of viral status should be made on arrival using SCOTs criteria (1).
- Information leaflets and other reading material should be removed (this is a change from normal JAG recommended practice).
- Carers should be restricted within waiting or clinical areas to only those accompanying vulnerable patients. Where necessary for carers to stay with patients, they should be subject to the same screening before arrival.
Patient assessment (including consent) and sub-waiting areas
- Face to face patient assessment is discouraged. If this is not possible, telephone or video conference triaging of patient suitability for the procedure should be undertaken before booking endoscopy, followed by further assessment and pre-assessment 3 days before the procedure (1,2). See also NHS X guidance. Assessment should be limited to confirming the information provided during triaging and pre-assessment.
- Documentation should be minimised to that necessary to safely manage the patient. Infection prevention measures should be followed to prevent contamination of documents.
- Methods for obtaining patient consent should be risk assessed locally and agreed by the organisation.
Personal protective equipment (PPE)
As extensive guidance on PPE exists, this section does not go into detail on PPE.
- PPE must be used in line with national guidance and guidance from the infection control team. This may change regularly and so services should update practice as required. Strict stock control is required to ensure that stock is available to support the anticipated workload.
- Where patients with COVID-19 are treated there must be defined areas for donning and doffing PPE in accordance with national guidance and local infection prevention policy, including a separate red and green pathway.
Waste and linen disposal
- There should be a defined red pathway where necessary and SOP in place for the safe disposal, storage and collection of infected waste. Local policy should be followed. Waste from a possible or a confirmed case must be disposed of as category B waste (4).
- Normal processes for the disposal of infected linen should be followed. Additional pathways for the safe storage and collection of infected linen will be required. Local policy should be followed.
- Where possible, domestic staff should be allocated to endoscopy and not moved between red and green areas (2).
Ventilation and heating
- Ventilation and temperature should be appropriately regulated throughout the site to meet health building regulations for specialist areas, to provide a comfortable environment and to safely eliminate any noxious chemicals or fumes. This is a standard JAG requirement.
- Critical ventilation systems and temperature should have already been inspected, as per Department of Health requirements. An annual verification should be available for all critical ventilation systems ensuring minimum air change standards are correct for endoscopy. This report should be used to inform new requirements regarding ventilation and infection control.
- Ventilation should be appropriately monitored and managed in red areas. This is a critical area requiring close liaison with infection prevention teams and estates management.
- Ventilation within each procedure room must be assessed to ensure it complies with HTM 03 – 01 Heating and ventilation systems:
- Specialised ventilation for healthcare(5). The quality of the system, the number of air changes and method of filtering will determine the downtime required between cases. This is to allow airborne aerosol to settle and the deep clean to occur. If the required air changes are below minimum requirements a risk assessment should be undertaken and the issue referred to the infection control team. This will determine productivity and may be different in different procedure rooms.
- Special environmental controls, such as negative pressure rooms are not necessary to prevent transmission (3). Ventilation in laminar flow and conventionally ventilated rooms (applies to operating theatres) should remain on fully while treating patients with COVID-19 (3).
Procedure room
For red sites, further considerations to the standard JAG environment guidance include:
- Equipment and documentation in the room should be kept to an absolute minimum. All consumables should be kept in clinical grade storage. Only the consumables required for the immediate procedure should be on work surfaces.
- Consider a ‘pre-entry check’ or starting the WHO checklist outside of the room to ensure that the correct consumables are available during the procedure.
- Where the endoscopy reporting system is situated in the procedure room, it should have a wipeable keyboard and there should be a secure printing facility outside of the procedure room (this is a change from normal JAG recommended practice). Services should continue to upload to the National Endoscopy Database (NED).
Decontamination
Best practice within HTMs should be followed especially in red sites. This includes the reprocessing of endoscopic equipment immediately after use with strict adherence to manual cleaning processes.
Recovery and discharge
For red sites, further considerations to the standard JAG environment guidance include:
- All suspected and confirmed patients with COVID-19 should be recovered in single rooms where possible. Where this is not possible then patients should be accommodated with other suspected or confirmed patients with COVID-19 as per current national guidance (2). If not screened but asymptomatic then strict social distancing between recovery spaces should be applied, using curtains between spaces to provide additional screening.
- Patients with COVID-19 should not be together in the same area as patients who do not have COVID-19. A slower throughput of patients may be needed to avoid contact or give adequate downtime to deep clean the recovery area between patients. Alternatively, separate pathways and areas could be used to segregate patient groups.
Relatives and carers should not be allowed into the clinical or discharge areas unless the patient is vulnerable (change from normal JAG recommended practice). Consideration should be given to how bad news can be given. - Consideration should be given as to how results and aftercare are digitally communicated to patients, carers and GPs.
Resources
The following resources support this guidance. These resources are likely to change and should be checked regularly.
Further information
For further information, please see www.thejag.org.uk/support.