Adaptations of the IP Department

Each IP unit must implement infection-control programs and rethink its administrative, environmental, logistic, and procedural circuits [10], as well as the type and timing of procedures to perform and personal protection equipment (PPE).

Administrative andOrganizational Issues

Administrative and organizational measures are crucial to assure safety while maintaining activity [10].

All referrals and requests to the IP unit must be made preferably by telephone or digital means. Patients should be contacted by telephone 24–72 h prior to arrival to the IP unit and submitted to a pre-screening checklist that includes questions about recent symptoms suggestive of COVID-19; contact with suspicious/con rmed SARS-CoV-2 cases; or occupational exposure.

•\ The elective procedure in patients who have recent respiratory and infectious symptoms and/or chest imaging suggestive of COVID-19 should be postponed and rescheduled after all symptoms are solved.

•\ All patients must be asked for respiratory symptoms and temperature checked when arrived at IP unit.

•\ All patients should have at least one negative RT-PCR for SARS-CoV-2 in the hours/days preceding the exam (most hospitals recommend in the previous 24–48 h). In patients with a positive RT-PCR SARS-CoV-2, the decision to proceed with the intervention will be based on the procedure emergence (Flowchart 8.1 and Table 8.1).

•\ The IP unit should keep a record of deferred patients to reschedule their procedures according to the COVID-19 outbreak situation, as proposed in Table 8.2.

It is crucial to plan and correctly prepare the physical space of the IP unit [4].

•\ All areas of the IP unit should separate con-rmed/high-risk patients from negative/ low-­risk ones. This must include reception, administrative, clinical, and waiting rooms. Inpatients and outpatients should be separated, either by time or physical location, to prevent cross infection.

•\ Speci c circuits and written workfow plans must be prepared, covering the pre-proce- dural area, procedural room, post-procedural area, decontamination, and reprocessing. It is recommended the implementation of a fowchart with different areas and walking paths using a color visual zone system: red zone for contaminated areas and green zone for non-­ COVID-­19 safe areas [11] (Fig. 8.1a).

•\ All items required for PPE should be stored in a de ned and separated place inside the unit.

•\ A designated area in the unit should be selected, close to the procedural suite, for wearing and removal of all PPE, according to hospital protocol and standards, to reduce exposure to contaminated particles and droplets. When an anteroom is available, it may be used as an area for donning and dof ng of PPE (Fig. 8.1b).

•\ Stations should be created to facilitate frequent hand hygiene.

•\ Waste containers should be distributed according to local infectious control recommendations.

•\ Posters and other visual aids should be placed at strategic locations around the intervention suite to act as reminders.

•\ Emergent procedures must be, if possible, performed in a negative pressure room environment, preferably under airway-controlled protection (e.g., laryngeal mask, endotracheal tube).

NON-URGENT

Perform SARS-CoV-2 test, assess symptoms and contact exposure

Flowchart 8.1  Proposed triage of IP procedures during the COVID-19 outbreak. (Adapted from F. Guedes et al., Recommendations for interventional pulmonology during

COVID-19 outbreak: a consensus statement from the Portuguese Pulmonology Society)

•\ Elective procedures should be reserved for COVID-19 negative patients (Flowchart 8.1 and Table 8.1).

•\ Even in COVID-19 negative patients, procedures should be performed in a dedicated negative pressure room (see below, ventilation requirement) with strict isolation precautions and adequate ventilation to avoid aerosol contamination [12]. If these requirements are not met in the bronchoscopy suite, they should be then sought in a different venue, such as an operating theatre, isolation room, or ICU with negative pressure, if available.

•\ If negative pressure rooms are unavailable throughout the institution, a speci c and dedicated room with adequate natural ventilation (see requirement below) may be an alternative [6].

•\ Suspicious and con rmed cases of COVID-19 must be placed in an airborne infection isolation room with negative pressure before and after the procedure.

•\ Low-risk and negative patients can remain in the pre-procedural and recovery area, if there is adequate room ventilation, protective equipment (e.g., surgical mask), and physical distance (>2 m) from other negative patients.

•\ Patient source control strategies, such as wearing a mask and keeping a safety distance should be encouraged.

•\ Whenever feasible, it is recommended to perform procedures in a room that meets the ­ventilation requirements for airborne infection isolation (AII), ensuring the dilution and removal of contaminated air. The preferred

system is a negative pressure room with at least 12 air changes per hour (ACH) with airfow direction control (single-pass or recirculation systems with HEPA ltration). Alternatively, natural ventilation with an airfow of at least 160 L/s is an option [11].

•\ Between procedures, it must be ensured that adequate time for air renewal is allowed (depending on ACH and disinfection methods, but at least 30 min). Local adaptations must be considered according to the characteristics of the IP unit.

Concerning cleaning and disinfection of the environment and equipment:

•\ Recommendations from the Centres for Disease Control and Prevention (CDC) on reprocessing equipment should be followed. These include precleaning, leak testing, manual cleaning, and visual inspection followed by disinfection/sterilization. A high-level disinfection, either manually or using an automated endoscope reprocessor is recommended.