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Gastrointestinal endoscopy during COVID-19: when less is more
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  1. Cathryn Edwards1,
  2. Ian D Penman1,
  3. Mark Coleman2
  1. 1 British Society of Gastroenterology, London, UK
  2. 2 Joint Advisory Group, Endoscopy, London, UK
  1. Correspondence to Dr Ian D Penman, Centre for Liver & Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK; ian.penman{at}nhslothian.scot.nhs.uk

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Writing and publishing in these fast-moving times necessitates continuous vigilance against perverse consequences. For this reason, the British Society of Gastroenterology-Joint Advisory Group (BSG-JAG) documents circulated as best consensus guidance for UK Endoscopy,1–3 dating from 20th March 2020, have been subject to repeat scrutiny over the last 13 days. The latest iterations of these documents are available at https://www.bsg.org.uk/covid-19-advice.

Newton’s Third Law states that for every action there is an equal and opposite reaction.4 The time sequence of various advice documents from the devolved health administrations followed after the BSG-JAG principles of practice were published. For the most part, governments have endorsed these principles at face value.5 There are, inevitably, nuances (eg, the timing of the continued implementation of cancer diagnostics and screening),6 but as a professional membership society in touch with the realities of the UK workforce on the ground, the importance of the primary BSG-JAG message of pausing to regroup, articulated in the early guidance, cannot be overstated; acknowledging that we remain a professional advisory group not a regulatory body.

All but emergency and absolutely essential endoscopy* must stop, in order that service provision for the symptomatic and screening populations can be reviewed and replanned.1 Explaining the rationale for this position was the purpose of the second BSG-JAG document2 which owes much to the published experiences of colleagues in China and Italy. Furthermore, while mathematical models of exponential growth may help explain why some areas of the UK are not currently at crisis levels in terms of service provision, over time they predict a state of equilibrium—the effects of the epidemic will be felt equally, everywhere. This means that the endoscopy workforce in all regions will soon be decimated by the inevitable transfer of human resources to frontline services, or the loss of human resource to sickness or self-isolating; only the exact timing of this eventuality is uncertain.

The call for a pause therefore, in all other than emergency and essential activity, gives us appropriate time to resource and refine the triage systems which will be needed for subgroups requiring essential but non-emergency procedures. BSG-JAG have been clear about how this might be achieved and why it needs to happen now to help flatten the curve of the epidemic. Data from the National Endoscopy Database show that total numbers of endoscopic procedures have fallen in 2 weeks from 33 000 to 7000 (personal communication), but they need to fall further. Complacency must be avoided and notice taken of early international signals from the analysis of non-pharmaceutical interventions on COVID-19 transmission rates and deaths.7 These suggest a reduction in mortality following the adoption and maintenance of social distancing and lockdown strategies.

Finally, and not least of the reasons for holding to our strong statement on pausing, is the need to preserve the supply chain of personal protective equipment (PPE), including FFP3/N95 masks for all aerosol generating procedures.3 8

This is not so much a recognition of Adam Smith’s ‘invisible hand’—the unobservable market force that helps the demand and supply of goods in a free market to reach equilibrium automatically9—but a common-sense, ethical approach to help ensure that all frontline staff have a chance of access to protective equipment by reducing the overall volume of interventions requiring mandatory PPE.

Alongside rapid COVID-19 testing, which must be made available for all staff before we resume increased endoscopy service provision, it is this sequenced decision-making, described by the BSG-JAG guidance, which will best protect our ability to continue service provision long-term. The unknown risk, becomes a known variable.

Moreover the values on which BSG-JAG decision-making is based speak to those articulated by the Royal College of Physicians in their document Ethical Dimensions of Covid-19 for front line staff: accountability, inclusivity, transparency, reasonableness and responsiveness.10

Holding to this clear, sensible and collegiate message of pausing, protects us all: public, patients and staff. It allows action taken now, to impact the outcome, which government social distancing and isolation measures are designed to achieve—a significant reduction in COVID-19-related fatalities.

We believe that this pause is the least damaging approach in a time of crisis, where choice is limited and unpalatable options are the reality.

*Essential endoscopy is defined in the updated BSG-JAG document as those which are ‘not immediate emergencies but which, after full risk assessment on a case-by-case basis, are judged necessary during the ‘pause’ period’.

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Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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