Potential advantages and foreseeable challenges of establishing a TNE service in a COVID-19 era
| Features of a TNE service | Potential benefits applicable to a post-COVID-19 era | Potential challenges | |
| Pre-procedure considerations | Utilisation of space otherwise not used for endoscopic procedures, which may be inside or outside the endoscopy unit footprint (eg, bowel preparation rooms, capsule endoscopy rooms, physiology rooms, outpatient clinics, etc) | Increased capacity for patient procedures without significant restrictions to other services | Not all hospitals will have a suitable area to repurpose. If operating outside the endoscopy unit, a larger inventory of scopes may be required to ensure sufficient equipment to run the list. This financial outlay for this and other resources may be offset by the increased productivity from using previously unused areas for TNE. |
| Twilight/evening endoscopy timings | Extended timings without large staffing requirements | May not fall within the existing job plans of all endoscopy departments. May be met by appropriate restructuring of resources as ultimately less staff are needed for a TNE list. | |
| Shallow learning curve to training of new operators14 | Ability to expand services to both medical and non-medical endoscopists and build resilience in staffing and general departmental skillset | ENT support needed within the training phase. There may be a transient drop-off in procedure completion rates as new endoscopists are trained up that should improve once procedural independence has been achieved. | |
| Intraprocedural considerations | Single nurse assistant | Ability to expand endoscopy services without significant increase in staffing requirement | Nursing staff require initial training to assist with TNE procedures. |
| TNE procedure associated with less coughing/gagging | Theoretical reduction in aerosols7 8 | Reduced ventilation and air exchange in some outpatient areas, although can be counteracted by robust pre-procedural COVID-19 testing; use of face mask to cover the patient’s mouth may provide further aerosol reduction.8 | |
| Unsedated procedure | Total patient interaction time likely to be shorter, thereby improving turnaround time and patient flow | There may be the occasional need to convert a failed nasal intubation to the oral route in a patient who hasn’t received sedation. This is generally more comfortable than c-OGD without sedation, and ENTONOX can be used adjunctively. | |
| Improved patient tolerability when compared with unsedated conventional transoral endoscopy | Theoretical improved lesion detection rate in comfortable patients | Some patients will still find the procedural uncomfortable. This can be ameliorated by adjunctive use of ENTONOX as noted above. | |
| Post-procedure considerations | Better patient tolerability | Improved compliance and attendance for repeat procedures (surveillance, etc) | As above |
| Immediate discharge from endoscopy procedure room | No requirement for social distancing in endoscopy recovery or interference with other endoscopy department patient flow | None significant foreseen |
c-OGD, conventional oesophagogastroduodenoscopy; TNE, transnasal endoscopy.