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Setting up a three‐stage pre‐endoscopy triage during the coronavirus disease 2019 pandemic: A multicenter observational study

Authors:

Abstract

Objectives: Between May and July 2021, the coronavirus disease 2019 (COVID-19) pandemic led to a sharp surge in community transmission in Taiwan. We present a three-stage restructuring process of pre-endoscopy triage at the beginning of the pandemic, which can support urgent endoscopic procedures while protecting endoscopy staff. Methods: The pre-endoscopy triage framework was set up with three checkpoints at the hospital entrance, outpatient department, and endoscopy unit, with a specific target patient population and screening methods. Relevant data included the number of endoscopic procedures performed, outpatient department visits, and performing screening methods such as temperature measurement, travel, occupation, contact, and clustering history checking, polymerase chain reaction assay, and rapid antigen test. Results: Forehead temperature measurement and verification of travel, occupation, contact, and clustering history provided rapid, easy, and early mass screening of symptomatic patients at the hospital entrance. During the pandemic, outpatient department visits and endoscopic procedures decreased by 37% and 64%, respectively. The pre-endoscopy screening methods used displayed regional variations in COVID-19 prevalence. Among 16 endoscopy units with a community prevalence of ≥ 31.04 cases per 100,000 residents, 12 (75%) used polymerase chain reaction assay and four (25%) used rapid antigen test to identify asymptomatic patients before endoscopy. Of 6540 pre-endoscopy screening patients, 15 (0.23%) tested positive by laboratory testing. No endoscopy-related nosocomial COVID-19 infections were reported during the pandemic. Conclusions: We present a three-stage pre-endoscopy triage based on the local laboratory capacity, medical resources, and community prevalence. These measures could be useful during the COVID-19 pandemic.
Received:14 April 2022 Revised: 14 June 2022 Accepted: 20 July 2022
DOI: 10.1002/deo2.159
ORIGINAL ARTICLE
Setting up a three-stage pre-endoscopy triage during the
coronavirus disease 2019 pandemic: A multicenter
observational study
Tao-Chieh Liu1Chen-Ling Peng2Fang-Yu Hsu3Li-Chun Chang4
Hsiu-Po Wang4Wei-Kuo Chang1
1Department of Internal Medicine, Division of
Gastroenterology, Tri-Service General
Hospital, National Defense Medical Center,
Taipei,Taiwan
2Department of Integ rated Diagnostics and
Therapeutics National Taiwan University
Hospital, National Taiwan University College
of Medicine, Taipei, Taiwan
3Department of Hepa tology and
Gastroenterology, Chang Gung Memorial
Hospital, Linkou Medical Center, Taipei,
Tai w a n
4Department of Internal Medicine, Division of
Gastroenterology and Hepatology, National
Taiwan University Hospital, National Taiwan
University College of Medicine, Taipei,Taiwan
Correspondence
Wei-Kuo Chang, Department of Internal
Medicine, Division of Gastroenterolo gy,
Tri-Service General Hospital, National
Defense Medical Center,No. 325, Sec. 2,
Chengong Rd., Neihu, Taipei 114, Taiwan.
Email: weikuohome@hotmail.com
Abstract
Objectives: Between May and July 2021, the coronavirus disease 2019
(COVID-19) pandemic led to a sharp surge in community transmission in
Taiwan. We present a three-stage restructuring process of pre-endoscopy
triage at the beginning of the pandemic,which can support urgent endoscopic
procedures while protecting endoscopy staff.
Methods: The pre-endoscopy triage framework was set up with three check-
points at the hospital entrance, outpatient department, and endoscopy unit,
with a specific target patient population and screening methods. Relevant
data included the number of endoscopic procedures performed, outpatient
department visits, and performing screening methods such as temperature
measurement, travel, occupation, contact, and clustering history checking,
polymerase chain reaction assay, and rapid antigen test.
Results: Forehead temperature measurement and verification of travel,
occupation, contact, and clustering history provided rapid, easy, and early
mass screening of symptomatic patients at the hospital entrance. Dur-
ing the pandemic, outpatient department visits and endoscopic procedures
decreased by 37% and 64%, respectively. The pre-endoscopy screening
methods used displayed regional variations in COVID-19 prevalence.Among
16 endoscopy units with a community prevalence of 31.04 cases per
100,000 residents, 12 (75%) used polymerase chain reaction assay and
four (25%) used rapid antigen test to identify asymptomatic patients before
endoscopy. Of 6540 pre-endoscopy screening patients, 15 (0.23%) tested
positive by laboratory testing. No endoscopy-related nosocomial COVID-19
infections were reported during the pandemic.
Conclusions: We present a three-stage pre-endoscopy triage based on
the local laboratory capacity, medical resources, and community prevalence.
These measures could be useful during the COVID-19 pandemic.
KEYWORDS
COVID-19, endoscopy, personal protective equipment, polymerase chain reaction, triage
This is an open access article under the terms of the Creative Commons Attribution License,which permits use, distribution and reproduction in any medium,provided
the original work is properly cited.
© 2022 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.
DEN Open. 2023;3:e159. wileyonlinelibrary.com/denopen 1of10
https://doi.org/10.1002/deo2.159
2of10 LIU ET AL.
FIGURE 1 Number of COVID-19 cases per month reported by Taiwan’s Center for Disease Control. A small number of clusters of
COVID-19 cases were reported in early 2020, and there were no cases/sporadic cases of COVID-19 reported in mid-2020. A sharp surge in the
community transmission was observed during May–July 2021. Abbreviations: COVID-19, coronavirus disease 2019
INTRODUCTION
Since the outbreak of a novel severe acute respira-
tory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan,
China, the disease has spread rapidly.1The World
Health Organization declared coronavirus disease 2019
(COVID-19) a worldwide pandemic on March 11, 2020.2
Digestive endoscopy procedures pose a risk of infec-
tion for healthcare workers due to the potential aerosol
and fecal-oral transmission of microbial agents from
patients. Pombo et al. reported that two-thirds of all
nurses and half of all technicians were infected in the
endoscopy unit during the COVID-19 pandemic.3
The first confirmed case of COVID-19 in Taiwan was
announced on January 21, 2020.4A small number of
clusters of COVID-19 cases were reported in early
2020 in Taiwan (Figure 1).5In May 2021, a sharp surge
began in the community transmission of the disease.
Amid a sudden rise in the number of COVID-19 cases,
endoscopy units faced uncertainty about their func-
tioning during the pandemic and about how the worst
of the pandemic would end. Inefficient functioning of
pre-endoscopy triage can lead to overcrowding in the
endoscopy unit and situations in which the rational use
of personal protective equipment (PPE) is challenged,
jeopardizing the morale of the endoscopy unit staff.6–8
Pre-endoscopy triage screening is already in place
in many medical centers. However, to the best of
our knowledge, there are no published reports on the
three steps of pre-endoscopy triage screening in a
real-world situation. There is a paucity of information
on the pre-endoscopy triage established according to
the local laboratory capacity, medical resources, and
regional variations in the community prevalence of
COVID-19.3,6,9–11
If the triage and management system is not effi-
cient, this can lead to overcrowding in the endoscopy
units,resulting in medical staff exhaustion,missed endo-
scopic procedures for the patient, and situations in
which the use of PPE is challenged.6–8 During the
sharp rise in the number of COVID-19 cases across
Taiwan, endoscopy unit team leaders were required
to take action at the beginning of the pandemic. In
this response, a new, simple, and rapid method for
pre-endoscopy triage screening was developed and
implemented, setting up a community-based systematic
pre-endoscopy triage system, and considering the real-
world situations of laboratory testing capacity, medical
resources, and community prevalence.
This study presents the pre-endoscopy triage imple-
mented in response to the COVID-19 pandemic threat,
which can support the need for urgent endoscopic
procedures while protecting endoscopy staff.
METHODS
Study
This was a retrospective study of endoscopy units
in referral medical centers that were members of
the Digestive Endoscopy Society of Taiwan. We sur-
veyed the restructuring of the pre-endoscopy triage
infection control process between May and July 2021,
which represented the COVID-19 pandemic period. The
endoscopy units were surveyed between May and July
LIU ET AL.3of10
FIGURE 2 Framework of the three-stage pre-endoscopy triage which was set up using three checkpoints at the hospital entrance,
outpatient department, and endoscopy unit. Abbreviations: COVID-19, coronavirus disease 2019; PCR, polymerase chain reaction; TOCC, travel,
occupation, contact, and cluster; PPE, personal protective equipment
2020 corresponding to the period before the COVID-19
pandemic. This study was approved by the Institu-
tional Review Board of the Tri-Service General Hospital,
Taiwan.
Three-stage pre-endoscopy triage
The framework of the pre-endoscopy triage (Figure 2)
was set up with three checkpoints at the hospital
entrance, outpatient department (OPD), and endoscopy
unit,with a specific target patient population and screen-
ing methods.6–8,12 Patients potentially infected with
COVID-19 were identified and redirected to a separate
area by trained medical staff.
Rationale of the pre-endoscopy triage
First stage of the triage at the hospital
entrance
In a report by the US Centers for Disease Control and
Prevention, 370,000 confirmed COVID-19 cases exhib-
ited known symptoms such as fever (43%),cough (50%),
and headache (34%).13 A study by Guan et al. repor ted
that 1099 laboratory-confirmed COVID-19 cases pre-
sented common manifestations of COVID-19 such as
fever (88.7%), cough (67.8%), and fatigue (38.1%).14
The objective of the first stage of the triage at the hos-
pital entrance was to conduct rapid,easy, and early mass
screening of people, with the aim of targeting the esti-
mated 43%–88.7% of patients infected with COVID-19
with fever and/or relevant travel,occupation, contact,and
clustering (TOCC) history. Forehead temperature mea-
surement and verification of TOCC history using the
National Health Insurance (NHI) card (Figure 3)were
conducted at the hospital entrance (Table 1). These
efforts were undertaken to ensure rapid evaluation, pre-
vent long waiting lines in front of the hospital, and
prevent further nosocomial infections.
Second stage of the triage at the OPD
Forehead temperature measurement and verification of
TOCC history based on the NHI card at the hospital
entrance may not be sufficiently reliable (Table 1). The
second stage of the triage at the OPD targeted symp-
tomatic cases of COVID-19 using ear thermometers
to measure the temperature again, verifying TOCC his-
tory by seeking verbal and written confirmation from the
patient, and assessing patients for clinical signs and
symptoms. These efforts were under taken to minimize
the exposure of hospital staff and patients to COVID-
19, and to identify patients requiring laboratory-based
or non-laboratory-based screening for COVID-19 before
endoscopy.
Third stage of the triage at the endoscopy unit
Patients infected with COVID-19 may be infectious
for 1–3 days before symptom onset. Approximately
40%–50% of COVID-19 cases are caused by trans-
mission from asymptomatic or pre-symptomatic
patients.15,16 The third stage of the triage at the
endoscopy unit aimed to identify 40%–50% of asymp-
tomatic patients with COVID-19 using laboratory-based
screening methods such as the polymerase chain
4of10 LIU ET AL.
FIGURE 3 The National Health Insurance card can be used to confirm the TOCC history of the patients. The hospital staf f can quickly
obtain the patient’s recent medical information, travel history such as travel to COVID-19-infected countries or regions,and can screen
suspected warm patients during the COVID-19 pandemic. Abbreviations: COVID-19, coronavirus disease 2019; TOCC, travel, occupation,
contact, and clustering
TABLE 1 Non-laboratory-based coronavirus disease 2019 (COVID-19) screening methods
Screening method Advantages Disadvantages and limitations
Temperature measurement
Forehead temperature Quick measurement
Easy for mass screening of patients
Use of a non-contact infrared
thermometer
Variation in temperature during exercise,
perspiration, wearing a head wrap, presence of
sweat or dirt on the forehead
Ear temperature Accurate measurement
Core temperature can be measured
Disposable probe cover required
Excess earwax or outer ear infection can affect the
measurement
Blood or drainage in the ear
TOCC history checking
NHI card Can quickly obtain pa tients’ medical
information
Visit COVID-19-infected country or
region can be tracked
Does not comply with COVID-19 preventive
measures
Does not report the traveling fingerprint
Survey questionnaire Provides more accurate information Time-consuming and labor-intensive
Evaluation of patients Patient’s signs and symptoms Direct doctor-patient contact
Abbreviations: COVID-19, coronavirus disease 2019; NHI, National Health Insurance; TOCC, travel,occupa tion, contact, and cluster.
reaction (PCR) assay and rapid antigen test. The aim
was to decrease the risk of nosocomial transmission
of COVID-19 and prevent systemic endoscopy unit
shutdown.
Pre-endoscopy triage screening methods for
COVID-19
The pre-endoscopy triage screening methods for
COVID-19 included non-laboratory-based and
laboratory-based methods. The non-laboratory-based
methods included (1) temperature measurement;
(2) TOCC history checking; and (3) clinical evalua-
tion of COVID-19 at the OPD by clinical physicians
(Table 1).17–20 Laboratory-based methods included the
PCR assay and rapid antigen test.6,8,21,22
Questionnaire survey
Two questionnaire surveys were administered to mem-
bers of the Digestive Endoscopy Society of Taiwan.
The first questionnaire survey of three major med-
LIU ET AL.5of10
FIGURE 4 Regional variations in the
pre-endoscopy screening methods for
COVID-19 used by endoscopy units in Taiwan
during the peak phase of the COVID-19
pandemic (June 1, 2021). Nor thern Taiwan
was the most affected during the COVID-19
pandemic outbreak. Middle and Souther n
Taiwan had a low level of COVID-19
community prevalence. The blue triangle ()
denotes the PCR assay, the green cross (X)
denotes the rapid antigen test and the red
circle () denotes the TOCC history checking.
Abbreviations: COVID-19, coronavirus disease
19; PCR, polymerase c hain reaction; TOCC,
travel, occupation, contact, and clustering
ical centers, located in a COVID-19 hot spot area,
included the Tri-Service General Hospital, National Tai-
wan University Hospital, and Chang Gung Memorial
Hospital with 1743, 2097, and 3406 hospital beds,
respectively. The questionnaire survey included the
following three categories: (1) number of digestive
endoscopic procedures performed, including esopha-
gogastroduodenoscopy, colonoscopy, endoscopic ret-
rograde cholangiopancreatography, endoscopic ultra-
sonography, endoscopic mucosal resection, endoscopic
submucosal dissection, and enteroscopy; (2) OPD visit
volumes; and (3) pre-endoscopy COVID-19 screening
methods.
The second questionnaire survey was conducted dur-
ing the COVID-19 pandemic. The questionnaire survey
was delivered to 33 nationwide endoscopy units via e-
mail and a smartphone messaging application. A total of
29 endoscopy units (response rate of 88%) completed
the survey. The questionnaire evaluating pre-endoscopy
screening methods included PCR assay, rapid antigen
test, and verification of TOCC history.
RESULTS
Regional variations in the community
prevalence of COVID-19
In Taiwan, the number of confirmed COVID-19 cases
per 100,000 residents in the township was reported
by the Taiwan Centers for Disease Control during the
peak phase of the pandemic (June 1, 2021;Figure 4).23
During this period, regional variations in the community
prevalence of COVID-19 were observed. Northern Tai-
wan was the most affected part of the country during the
outbreak, with a high community prevalence of 31.04
cases per 100,000 residents. Middle and southern Tai-
wan had a community prevalence of <31.04 confirmed
cases per 100,000 residents.
First stage of the triage at the hospital
entrance
Information technology can improve the efficiency of
triage screening. NHI enrolment is mandatory for all citi-
zens and legal residents of Taiwan.24,25 Patients visiting
hospitals have to display their NHI card (Figure 3).17
Frontline hospital staff confirmed the medical informa-
tion and TOCC history of patients by checking the NHI
card and screened suspected febrile patients by con-
ducting temperature measurements (Figure 2). Patients
with fever or symptoms of COVID-19 were taken care
of in a separate area. No patient or visitor was allowed
to enter the hospital building without wearing a surgical
mask.
Second stage of the triage at the OPD
Gastrointestinal symptoms are common in patients
with COVID-19, and diarrhea, vomiting, abdominal dis-
comfort, and loss of taste or smell occur in 26% of
patients.26–29 Patients who exhibited symptoms sugges-
tive of COVID-19 were redirected to a separate area.
The following were conducted in all patients:repeat tem-
perature measurement by measuring ear temperature,
verification of TOCC history by seeking verbal and writ-
ten confirmation from the patient, and examination of
clinical signs and symptoms by physicians at the OPD.
Compared to the period between May and July 2020
(Figure 5), there was a 37% reduction (n=18,957 vs. n
=12,003) in the OPD visit volumes during the COVID-19
pandemic period between May and July 2021.
6of10 LIU ET AL.
FIGURE 5 Comparison of the OPD visit volumes at the Tri-Service General Hospital, Taiwan between two time periods:before the
COVID-19 pandemic (May–July 2020) versus during the COVID-19 pandemic (May–July 2021).A 37% reduction in the OPD visit volumes was
observed during May–July 2021. Abbreviations: COVID-19, coronavirus disease; OPD, outpatient department
Third stage of the triage at the endoscopy
unit
A sharp rise in the number of COVID-19 cases
caused a temporary postponement of elective endo-
scopic procedures and non-essential gastrointestinal
office activities. During the COVID-19 pandemic period
(May–July 2021), there was a significant 64% reduc-
tion (n=18,363 vs. n=6540) in the total endoscopic
procedure volume compared to the same period in
2020. The following reductions in procedure volumes
were observed: 64% (n=11,127 vs. n=4032)
for esophagogastroduodenoscopy, 71% (n=5017 vs.
n=1480) for colonoscopy, 28% for endoscopic ret-
rograde cholangiopancreatography (n=992 vs. n=
715), 77% for endoscopic ultrasonography (n=998
vs. n=232), 72% for endoscopic mucosal resec-
tion/endoscopic submucosal dissection (n=191 vs.
n=53), and 26% for enteroscopy (n=38 vs. n=28;
Figure 6).
Pre-endoscopy screening methods for
COVID-19
A nationwide survey of endoscopy units was conducted
during the COVID-19 pandemic.We found that the PCR
assay was costly (USD 32–67), time-consuming (repor t
time 6–12 h), and required a specialized laboratory
setting. In contrast, rapid antigen tests present the fol-
lowing benefits to the healthcare system: decreased
costs (USD 12–30) and rapid result turnaround time
(2–4 h).
A total of 29 endoscopy units reported the use of
pre-endoscopy screening methods for COVID-19, of
which 16 (55%) used the PCR assay, 9 (31%) used
the rapid antigen test, and 4 (14%) used the TOCC
history checking (Figure 7a). During the COVID-19 pan-
demic period, the COVID-19 screening methods used
displayed regional variations. The third stage of the
triage using PCR and rapid antigen tests should be per-
formed for all outpatients, particularly for the endoscopy
units located in COVID-19 hotspot areas (Figure 7b).
Among 16 endoscopy units with a community preva-
lence 31.04 confirmed COVID-19 cases per 100,000
residents (Figure 7b), 12 (75%) used the PCR assay
and 4 (25%) used the rapid antigen test. Among 13
endoscopy units with a low-level community prevalence
of <31.04 confirmed COVID-19 cases per 100,000 res-
idents (Figure 7c), 5 (38%) used the rapid antigen test, 4
(31%) used the PCR assay, and 4 (31%) used the TOCC
history checking.
Diagnostic performance of
laboratory-based screening methods for
COVID-19
Of 6540 pre-endoscopy screening patients, 15 (0.23%)
tested positive for COVID-19 based on laboratory-based
screening methods at the three participating hospi-
tals. The PCR assay was positive in nine of 4819
patients (0.19%), and the rapid antigen test was posi-
tive in six of 1721 patients (0.35%) before endoscopy.
No endoscopy-related nosocomial COVID-19 patient
infections were reported during the pandemic.
LIU ET AL.7of10
FIGURE 6 Comparison of the endoscopic procedure volumes between two periods: before the COVID-19 pandemic (May–July 2020)
versus during the COVID-19 pandemic (May–July 2021). Data were obtained from the Tri-Service General Hospital, National Taiwan University
Hospital, and Chang Gung Memorial Hospital. Abbreviations: COVID-19, coronavirus disease 2019; EGD,esopha gogastroduodenoscopy; ERCP,
endoscopic retrograde cholangiopancreatography; EUS,endoscopic ultrasonography; EMR,endoscopic mucosal resection; ESD, endoscopic
submucosal dissection
Potential breakthrough by laboratory
false-negative test patients with COVID-19
In case of potential breakthrough infection by lab-
oratory false-negative test patients with COVID-19,
the endoscopy unit staff followed standardized pre-
cautions with the use of PPE for optimal COVID-19
infection control. Furthermore, all staff were vacci-
nated with the first dose of the COVID-19 vaccine
and underwent PCR testing before the end of May
2021.
The staff of all endoscopy units (physicians, fel-
lows, nurses, technicians, and staff) was divided into
two teams. This ensures continued operation of an
endoscopy unit even if one working group becomes
incapacitated, preventing the systemic shutdown of the
endoscopy unit.30 There were no endoscopy-related
COVID-19 nosocomial infections reported during the
COVID-19 pandemic period in Taiwan.
DISCUSSION
During the sharp rise in the number of COVID-19
cases across Taiwan,endoscopy unit team leaders were
required to optimize the protection, safety, and morale
of the endoscopy unit staff, while responding to urgent
endoscopic procedures.
Forehead temperature measurement
Early identification of febrile patients can control the
rapid spread of COVID-19.31 Forehead temperature
measurement was conducted at the hospital entrance
(Table 1and Figure 2). Infrared thermometers provide
an easy, quick, non-invasive, and non-contact method of
mass screening body temperature.32,33
Repeat temperature measurements using
ear temperature
A minority of febrile patients may not be identified by
the forehead thermometer during screening at the hos-
pital entrance.19 Forehead skin temperature can vary
by several degrees depending on exercise, perspira-
tion, wearing a head wrap, presence of sweat or dirt
on the forehead, or direct heat and air conditioning
(Table 1).34 Ear thermometers can provide an accurate
reflection of the patient’s core temperature at the OPD
and endoscopy unit.35
TOCC history based on the NHI card
The NHI administration has contracted with 100%
of hospitals, 92% of primary clinics, and 80% of
8of10 LIU ET AL.
FIGURE 7 Pre-endoscopy screening methods for COVID-19 used at the endoscopy unit during the COVID-19 pandemic. A total of 29
endoscopy units were surveyed (a),of which 16 had a COVID-19 community prevalence 31.04 COVID-19 cases per 100,000 residents (b),
and 13 had a COVID-19 community prevalence <31.04 COVID-19 cases per 100,000 residents (c). Abbreviations: COVID-19, coronavirus
disease 2019; PCR, polymerase chain reaction; TOCC, travel, occupation, contact, and clustering
pharmacies. Checking the NHI card at hospital arrival
assists in obtaining patient medical information and
travel fingerprints to COVID-19-infected countries or
regions, and screening suspected febrile COVID-19
patients (Table 1and Figure 2).20,36
TOCC double-checking by personal verbal
and written confirmation
Patients may not comply with public health preven-
tive measures and may not report their travel history.
Verification of the TOCC history by verbal and written
confirmation from the patient is warranted (Figure 2).
TOCC screening forms were integrated into the elec-
tronic health record for TOCC standardized screening.
This study demonstrated a 37% reduction in OPD visits
(Figure 5) and a 64% reduction in endoscopic proce-
dures during the COVID-19 pandemic period (May–July
2021; Figure 6).
Laboratory-based screening methods for
COVID-19
Non-laboratory-based screening methods will fail to
detect at least 50% of asymptomatic patients with
COVID-19.With the development of laboratory technol-
ogy, pooling samples for the PCR assay is a cost- and
time-saving approach.37 Many endoscopy units could
increase their laboratory capacity,improve the feasibility
of testing, decrease patient burden, and avoid delays in
time-sensitive procedures.37
Rapid antigen tests can contribute to the overall
COVID-19 testing capacity, offering advantages in terms
of shorter turnaround times and reduced costs, par-
ticularly in situations in which PCR testing capacity
is limited.21,22 The rapid antigen test is easily usable
as a screening strategy prior to endoscopic proce-
dures for the prevention of COVID-19 transmission.11
The rapid antigen test may suffice because PCR test-
ing for all patients involves a considerable cost burden
and may delay endoscopy if PCR test results are
pending.
Endoscopy staff vaccination and PPE use
Approximately 0.1%–0.3% of laboratory false-negative
test asymptomatic patients with COVID-19 may enter
the endoscopy unit, resulting in potential nosocomial
infection of COVID-19 during the COVID-19 pandemic.8
Endoscopy practice is conducted and supported by
multiple endoscopy staff including physicians, nurses,
technicians, assistants, secretaries, receptionists, jani-
tors, and cleaners. Endoscopy staff were prioritized for
COVID-19 vaccine access and underwent PCR testing
before the end of May 2021. It is compulsory for all staff
members to undergo a body temperature measurement
at the hospital entrance before work and to be monitored
LIU ET AL.9of10
for COVID-19-associated symptoms every day. The
endoscopy unit staff members wore a disposable water-
proof surgical gown, gloves, shoe cover, face shield, and
an N95 mask during endoscopic procedures.38,39 High-
level PPE was preserved and used if the patient was
COVID-19 positive.39
Limitations
This study has several limitations. First, a low number
of patients tested positive (n=15) for COVID-19 by
laboratory-based screening methods. Second, our data
could not determine the relative contribution of each
component of the pre-endoscopy triage in reducing the
risk of endoscopy-related transmission of infection. The
combined effect of all these measures was beneficial
and should be continued throughout the COVID-19 pan-
demic. Third, the survey was conducted among local
endoscopy units, and could not be distributed to all
endoscopy units across the country. Hence, this study’s
findings may not be generalizable to all endoscopy
units. The number of hospital beds at the Tri-Service
General Hospital, National Taiwan University Hospital,
and Chang Gung Memorial Hospital was 1743, 2097,
and 3406, respectively. Figures 5and 6show endo-
scopic practice-derived high-volume institutions located
in a COVID-19 hotspot area.This study did not evaluate
the endoscopic practice obtained from the low-volume
institutions.
CONCLUSIONS
This study was conducted among local endoscopy units
and could not be distributed to all endoscopy units
across the country. Modification and implementation of
the pre-endoscopy triage should be based on local lab-
oratory infrastructure, test feasibility, medical resources,
perceived burden on patients, and community preva-
lence of COVID-19. These measures can be useful in
preparing for future pandemics, as well as for a possible
second wave of COVID-19.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
FUNDING INFORMATION
We are grateful for the financial support provided by the
Ministry of National Defense Medical Affairs Bureau,Tri-
Service General Hospital, Taiwan (TSGH-D-111080 and
TSGH-D-111081) for this study.
ORCID
Wei-Kuo Chang
https://orcid.org/0000-0002-5738-2797
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