About this case study

Each month JAG publishes a case of the month highlighting a real life clinical scenario which has impacted patient safety. Case studies are contributed by JAG leads and endoscopy services across the UK and are designed to provide an opportunity for discussion and to share learning. 

Download the PDF version here and share this for discussion with your team.

NB. This case was submitted before the emergence of COVID-19 in the UK, however the learning points are a timely reminder relevant in all phases before, during, or after a pandemic. 

Case synopsis

A patient attended an elective, outpatient OGD for dyspepsia which was unremarkable; he was discharged with advice following the procedure. Two weeks later, the patient was admitted with cough and a large cavitating lesion was found on his chest x-ray. A smear/ culture was positive for multi-drug resistant tuberculosis (MDR-TB). It was likely that he was infectious prior to diagnosis. Additionally, the patient was HIV positive and it is unclear whether this was disclosed during pre-assessment. Treatment was commenced.

The endoscopy service was contacted by the national public health body and informed of the MDR-TB diagnosis. Contact tracing was enacted which revealed:

•The patient attended the endoscopy unit twice, once for pre-assessment and then for their appointment.
•The patient sat in the waiting room for approximately 40 minutes.
•There were approximately 40 patients in the waiting room that may have been exposed.

A full investigation was conducted involving the public health body, infection control team, occupational health team, operational director and endoscopy lead nurse. It was decided that all patients and staff were at a low risk of contracting TB, however they would be written to in order to inform them of what had happened.

What are the learning points you took away from this case?
How could things have been improved?

The following patient safety incidents were identified by JAG. They have been categorised for severity (mild, moderate and severe) based on the actual or potential impact to the patient and adherence to clinical guidance, as well as by theme [2]:

Did you identify any other patient safety incidents?

Learning

Following the onset of the COVID-19 pandemic, the strategy to restart endoscopy services supports and strengthens optimal infection control practices. The learning points described are relevant and timely, and a reminder of the risk of infectious disease to staff and patients.

It is important to acknowledge and record all medical co-morbidities and medication as part of pre-assessment, admission and checklist processes. Patients with respiratory symptoms who are immunosuppressed (from medical conditions and/or medication) should raise the suspicion of infectious respiratory pathogens. Services should risk assess patients prior to their procedure; for example, asking specifically about infectious diseases such as TB, HIV, Hepatitis B and Hepatitis C. Screening should now also incorporate the SCOTS criteria (symptoms of infection, close contact with known or suspected cases, occupational exposure, travel history and shielded category) [1].

If patients are suspected or known to have an infectious respiratory pathogen, precautions should be taken such as: [3]

1. Undertaking procedures within an appropriate environment. Clearance of infectious particles after an aerosol-generating procedure (AGP) is dependent on the ventilation and air change within the room.
2. Wearing appropriate personal protection equipment (PPE) including gowns, gloves, masks and eyewear.
3. Cleaning the procedure room as per local standards, often meaning a ‘terminal’ or ‘deep’ clean once aerosols have settled.
4. Placing patients at the end of an endoscopy list to facilitate controlled recovery of patients.

UK regulations require employers to carry out a suitable and sufficient risk assessment to identify precautions and protect people from harm [5]. Provision of appropriate PPE is one such response but should only be applied where other measures to remove, reduce or isolate the hazard are unlikely to be effective [6].

Generally, PPE is reserved for staff with ‘high-risk’ exposure eg direct contact with a contaminated endoscope, device or bodily fluid [4]. COVID-19 has reminded us of the inherent risks of endoscopy as largely aerosol-generating. PPE guidance is updated regularly and should be factored into routine practice [2].

In this case, exposure to patients and staff may have been unavoidable as the diagnosis was made after endoscopy. In the pre-COVID-19 era, it was common for waiting rooms to be relatively full and relatives or carers to enter units. Pre-assessment was largely face-to-face. As a result of COVID-19, the patient pathway has been significantly restructured to reduce the risk of transmission, avoiding unnecessary contact where possible [1, 2]. 

This case is a reminder that infection control principles, although heightened in the current pandemic, should always be an important consideration in reducing the risk of infectious diseases in patients and staff. Vigilance will be required in the longer term following the resolution of this pandemic.

Do you have a case study from your service which you would like to share in the next ISREE case study of the month?

Please contact askjag@rcplondon.ac.uk for more information

References

1.     Hayee, B., et al., Safely restarting GI endoscopy in the era of COVID-19. Gut, 2020: p. gutjnl-2020-321688.
2. Joint Advisory Group on Gastrointestinal Endoscopy. Supplementary environment guidance following the COVID-19 pandemic. 2020  15/05/20]; Available from: https://www.thejag.org.uk/covid-environment-guidance. 
3. Calderwood, A.H., et al., ASGE guideline for infection control during GI endoscopy. Gastrointestinal Endoscopy, 2018. 87(5): p. 1167-1179.
4. ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force, et al., Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointestinal endoscopy, 2014. 79(3): p. 363-372.
5. UK Statutory Instruments. The Management of Health and Safety at Work Regulations. 1999; Available from: http://www.legislation.gov.uk/uksi/1999/3242/contents/made.  
6. UK Statutory Instruments, The Personal Protective Equipment at Work Regulations. 1992.