Personal protective equipment in GI endoscopy

GI endoscopic procedures place operators and personnel at risk for exposure to infectious pathogens, hazardous chemicals, and radiation injury. Accordingly, workplace safety in the GI endoscopy unit is regulated by the Occupational Safety Health Administration (OSHA), whose standards establish the requirements for identification of workplace hazards, employee training, and provision of appropriate personal protective equipment (PPE) to mitigate risk. PPE is defined as any protective barrier, used or worn, to prevent exposure to potential pathogens or hazardous materials. In the setting of GI endoscopy, this includes patient blood or other potentially infectious materials, such as saliva, gastroesophageal and pancreaticobiliary secretions, stool, and colonic effluent; chemical agents (eg, injection of mitomycin C, porfimer sodium, etc); and radiation. Although the OSHA sections of Title 29 of the Code of Federal Regulations, which covers regulations regarding labor, provide minimum standards for general industry, they are not individualized to GI endoscopy or even healthcare settings in general. The American Society for Gastrointestinal Endoscopy commissioned and published guidelines for safety in the endoscopy unit in 2014.1Calderwood A.H. Chapman F.J. Cohen J. et al.Guidelines for safety in the gastrointestinal endoscopy unit.Gastrointest Endosc. 2014; 79: 363-372Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar These guidelines established criteria for low- and high-risk individuals with regard to infectious pathogen exposure in the GI endoscopy unit based on contact with the endoscopy equipment and potential for splash contamination. In this paradigm, low-risk individuals or activities are considered exempt from PPE use. However, research has demonstrated that bacterial exposure can occur in individuals standing as far as 6 feet beyond the endoscope insertion site.2Johnston E.R. Habib-Bein N. Dueker J.M. et al.Risk of bacterial exposure to the endoscopist's face during endoscopy.Gastrointest Endosc. 2019; 89: 818-824Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar Furthermore, the coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rekindled focus and attention to PPE in the endoscopy unit and other healthcare settings, leading to new insights into the infectious risk and protective capacity of current PPE practices. This document serves as an update to the Technology Status Evaluation Report previously published in 2010.3Pedrosa M.C. Farraye F.A. Shergill A.K. et al.Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics.Gastrointest Endosc. 2010; 72: 227-235Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar It aims to provide a comprehensive outline of currently available PPE for those performing and assisting in endoscopic procedures and describe the technology underlying the ability of each PPE accessory to protect the wearer from occupational hazards. Additionally, this document leverages new studies and insights gleaned from the COVID-19 pandemic to optimize the use of PPE for endoscopic procedures. The COVID-19 pandemic has spread to over 200 countries around the world and, at the time of writing, is responsible for over 6 million global deaths.4Medicine JHU. Coronavirus Resource Center, 2021. Available at: https://coronavirus.jhu.edu/. Accessed December 28, 2022.Google Scholar The pandemic served as a flash point for rapid assessment of risk and technologic innovation in PPE for all healthcare settings as the global healthcare community worked to contain the spread of this highly transmissible pathogen. The pandemic has led to many insights that directly impact GI endoscopy PPE practices, not only in the midst of COVID-19 but beyond. Studies assessing the GI infectivity and transmissibility of COVID-19 have found fecal shedding of viral RNA at high copy levels and persisting even past resolution of viral RNA in sputum samples.5Cheung K.S. Hung I.F.N. Chan P.P.Y. et al.Gastrointestinal manifestations of SARS-CoV-2 infection and virus load in fecal samples from a Hong Kong Cohort: systematic review and meta-analysis.Gastroenterology. 2020; 159: 81-95Abstract Full Text Full Text PDF PubMed Scopus (1013) Google Scholar, 6van Doorn A.S. Meijer B. Frampton C.M.A. et al.Systematic review with meta-analysis: SARS-CoV-2 stool testing and the potential for faecal-oral transmission.Aliment Pharmacol Ther. 2020; 52: 1276-1288PubMed Google Scholar, 7Zheng S. Fan J. Yu F. et al.Viral load dynamics and disease severity in patients infected with SARS-CoV-2 in Zhejiang province, China, January-March 2020: retrospective cohort study.BMJ. 2020; 369: m1443Crossref PubMed Scopus (990) Google Scholar Given that SARS-CoV-2 is postulated to cause intestinal infection and fecal shedding, the risk of transmissibility during endoscopic procedures was raised early in the COVID-19 pandemic as a significant area of concern, particularly as the PPE scarcity required accurate risk stratification. This increased risk is believed to be because of aerosols that are generated during GI procedures. Although no direct study of endoscopic aerosolization of COVID-19 was conducted, plausibility is enhanced by studies that have established air and surface contamination even in hospitalized patients not undergoing procedures.8Santarpia J.L. Rivera D.N. Herrera V.L. et al.Aerosol and surface contamination of SARS-CoV-2 observed in quarantine and isolation care.Sci Rep. 2020; 1012732Google Scholar Accordingly, GI societies issued joint recommendations that all endoscopic procedures in patients with known or suspected SARS-CoV-2 infection require full PPE with an N95 (or equivalent) respirator to protect from aerosolized transmission.9American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy. Joint GI society message: COVID-19 clinical insights for our community of gastroenterologists and gastroenterology care providers. 2020. Available at: https://www.asge.org/home/joint-gi-society-message-covid-19. Accessed March 14, 2020.Google Scholar Although this is unlikely to remain a universal practice in perpetuity, new insights on the aerosolization and transmissibility of infectious pathogens in GI endoscopy suggest a continuing role for enhanced protective measures and are likely to apply to other highly transmissible respiratory viruses.10Lu R. Zhao X. Li J. et al.Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding.Lancet. 2020; 395: 565-574Abstract Full Text Full Text PDF PubMed Scopus (7475) Google Scholar The Centers for Disease Control and Prevention (CDC) have established what are referred to as standard precautions to be used in all patient care settings. They are predicated on the notion that all patients harbor some risk of potential infection, necessitating a baseline set of practices to reduce transmissibility. These include practices such as hand hygiene, proper training in handling of needles and sharp instruments, and safe cleaning and/or disinfection. Standard precautions are minimum infection prevention practices defined by the CDC and also advocate the use of PPE according to the risk of exposure because of both patient and procedural factors. The specific components of PPE are discussed individually. Face masks are any facial covering designed to reduce exposure to respiratory pathogens or other potentially infectious materials. They can be constructed from various materials, including cloth and synthetic fibers. Their specific construction and fit dictate the degree of protection from various infectious agents. The role of face masks in preventing infectious transmission among the general population or in nonprocedural settings during the COVID-19 pandemic is not discussed here. Face masks can be broadly separated into 3 categories: cloth masks, surgical masks, and respirators. In a healthcare setting, generally only disposable masks should be used with the exception of respirators, which can be reusable. The term “surgical mask” refers to a category of masks created from 3 layers of nonwoven synthetic fabric, most commonly polypropylene. The outer layer is waterproof and provides protection from droplets arising from the external environment. The middle layer is the filter layer, which is specifically calibrated to prevent passage of particles of a certain size in either direction. The inner layer serves as a barrier to absorb the user’s salivary droplets and respiratory moisture to protect adjacent patients and personnel and is also designed for comfort. Surgical masks can be secured by various methods, including ear loops, thread or string ties, and elastic bands. In differentiating between cloth masks and surgical masks, a randomized trial comparing cloth masks with surgical masks for preventing respiratory illness found that all infection outcomes were highest in the cloth mask arm.11MacIntyre C.R. Seale H. Dung T.C. et al.A cluster randomised trial of cloth masks compared with medical masks in healthcare workers.BMJ Open. 2015; 5e006577Crossref PubMed Scopus (283) Google Scholar The performance of face masks is evaluated by the American Society of Testing and Materials (ASTM) standard, which specifies 5 specific performance criteria: particle filtration efficiency, bacterial filtration efficiency, fluid resistance, differential pressure, and flammability. These attributes are reported by each mask manufacturer and allow the user to select the appropriate mask for each application. The ASTM designates 3 levels of safety, increasing from level 1 to 3. ASTM level 1 corresponds to a fluid resistance of 80 mm Hg and a particle and bacterial filtration efficiency of ≥95%, whereas ASTM levels 2 and 3 both provide a particle and bacterial filtration efficiency of ≥98%, differing only in their fluid resistance (120 and 160 mm Hg, respectively).12Chua M.H. Cheng W. Goh S.S. et al.Face masks in the new COVID-19 normal: materials, testing, and perspectives.Research (Wash D C). 2020; 2020: 1-40Google Scholar The choice of mask is dictated by the degree of anticipated aerosol and/or body fluid levels. Of note, these attributes do not account for the fit and overall seal of the mask to the user’s face. A CDC study demonstrated enhanced reduction of particle exposure when the surgical mask was secured and tied behind the user’s head to facilitate improved fit and seal.13Brooks J.T. Beezhold D.H. Noti J.D. et al.Maximizing fit for cloth and medical procedure masks to improve performance and reduce SARS-CoV-2 transmission and exposure, 2021.MMWR Morb Mortal Wkly Rep. 2021; 70: 254-257Crossref PubMed Scopus (91) Google Scholar Respirators, also known as filtering facepiece respirators, are masks designed to fit tightly against the user’s face and ensure that air passes only through the mask material. They are classified and regulated by the National Institute for Occupational Safety and Health. Each respirator is classified by a letter and number designation. The letter (N, R, or P) signifies the resistance to oil, with N indicating no resistance, R indicating resistance to oil, and P (oil proof) indicating strong resistance. The number indicates the filtration efficiency of a .3-μm test particle. Respirators must achieve at least 95% filtration capacity, and a 100-level respirator filters out at least 99.97% of airborne particles. The most common respirator used in a medical setting is the N95, which filters 95% of airborne particles and is associated with a particle and bacterial filtration efficiency of ≥99.9% and fluid resistance of 160 mm Hg. Respirators must be precisely fitted to the user to achieve their stated filtration parameters. The CDC specifies criteria for fit testing, which must be conducted by qualified occupational health personnel at least annually. Generally, fit testing is conducted by either a qualitative method (smell or taste of a test solution) or quantitative method. Of note, elastomeric half-mask respirators also contain filters with a minimum filtration capacity of 95%. These also require fit testing and largely came into use during the COVID-19 pandemic to combat inconsistent PPE supplies in healthcare settings because they are reusable.14Pompeii L. Hines S.E. Reusable elastomeric respirators in healthcare.Workplace Health Saf. 2021; 69: 291-292Crossref PubMed Scopus (3) Google Scholar Additionally, commonly used respirators, such as the N95 respirator, can be decontaminated and subsequently reused when supplies are limited.15Jiang Z.Y. Huang Z. Schmale I. et al.N95 respirator reuse, decontamination methods, and microbial burden: a randomized controlled trial.Am J Otolaryngol. 2021; 42103017Crossref Scopus (3) Google Scholar Powered air-purifying respirators (PAPRs) contain a high-efficiency particulate-absorbing filter and battery-powered blower that provide clean airflow to the user within a connected hood, mask, or helmet.16McCoy M.A. et al.Board on Health Sciences Policy; Institute of MedicineThe use and effectiveness of powered air purifying respirators in health care: workshop summary. National Academies Press, 2015Google Scholar This system has several important advantages. First, it does not require fit testing and can be reused by multiple operators if cleaned appropriately between uses. Second, it provides superior filtering capacity, reducing the possibility of inhaled airborne contaminant by a factor of 2 to 100 compared with the N95 respirator.16McCoy M.A. et al.Board on Health Sciences Policy; Institute of MedicineThe use and effectiveness of powered air purifying respirators in health care: workshop summary. National Academies Press, 2015Google Scholar The PAPR can also be used by individuals with facial hair or those who have difficulty finding a proper fit with other respirators. Additionally, although PAPR masks can allow for full facial visualization, this must be weighed against issues with audibility, communication, mobility, and dexterity.17Licina A. Silvers A. Stuart R.L. Use of powered air-purifying respirator (PAPR) by healthcare workers for preventing highly infectious viral diseases-a systematic review of evidence.Syst Rev. 2020; 9: 173Crossref PubMed Scopus (30) Google Scholar The principal disadvantages remain higher cost, lack of filtration for expelled air (ie, in sterile fields), and external connections and hoses that can become inadvertently disconnected and disrupt filtration. Despite the superior filtration mechanism, PAPRs have not been demonstrated to be clinically superior to N95 respirators in limiting transmission of infectious particles. In regard to performing endoscopy in patients positive for COVID-19 infection, use of a negative pressure room, although not required, is recommended to help decrease the risk of spreading the disease by preventing airborne particles from escaping the procedure room.18Sinonquel P. Roelandt P. Demedts I. et al.COVID-19 and gastrointestinal endoscopy: What should be taken into account?.Dig Endosc. 2020; 32: 723-731Crossref PubMed Scopus (27) Google Scholar, 19Calderwood A.H. Day L.W. Muthusamy V.R. et al.ASGE guideline for infection control during GI endoscopy.Gastrointest Endosc. 2018; 87: 1167-1179Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 20Gralnek I.M. Hassan C. Beilenhoff U. et al.ESGE and ESGENA position statement on gastrointestinal endoscopy and the COVID-19 pandemic.Endoscopy. 2020; 52: 483-490Crossref PubMed Scopus (239) Google Scholar Additionally, although there are no formal recommendations regarding the use of portable air purifiers, purifiers using high-efficiency particulate-absorbing filters (which remove 99.97% of .15- to .2-μm particles) may help decontaminate SARS-CoV-2 aerosols in an endoscopy room as the CDC had previously suggested their use as adjunctive infection control for SARS-CoV-1 during the 2003 SARS epidemic.21Centers for Disease Control and Prevention. Infection control in healthcare facilities: public health guidance for community-level preparedness and response to severe acute respiratory syndrome (SARS). Volume 2021. Available at: https://www.cdc.gov/sars/guidance/index.html. Accessed February 3, 2023.Google Scholar Ocular contamination by body fluids during endoscopy presents a significant risk, because of both direct splashing of aerosolized fluids and hand to eye contamination by the endoscopist. Although GI endoscopy has been associated with visible ocular contamination in only 4.1% of cases, surgical series using fluorescein staining have demonstrated detectable contamination in up to 85% cases.22Mohandas K.M. Gopalakrishnan G. Mucocutaneous exposure to body fluids during digestive endoscopy: the need for universal precautions.Indian J Gastroenterol. 1999; 18: 109-111PubMed Google Scholar,23Taylor J.D. AIDS and hepatitis B and C: contamination risk at transurethral resection. A study using sodium fluorescein as a marker.Med J Aust. 1990; 153: 257-260Crossref PubMed Scopus (10) Google Scholar The use of eye protection has been studied in the context of respiratory infection (SARS and Middle Eastern respiratory syndrome), and a systematic review and meta-analysis revealed an adjusted odds ratio of .22 (95% confidence interval, .12-.39) for reducing infection compared with no eye protection.24Chu D.K. Akl E.A. Duda S. et al.Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis.Lancet. 2020; 395: 1973-1987Abstract Full Text Full Text PDF PubMed Scopus (2380) Google Scholar Therefore, eye protection is a critical aspect of effective PPE. Protective eyewear consists of goggles and face shields of various designs and materials. They are also regulated by OSHA standards and must be appropriate to the specific expected hazard. Both goggles and face shields must be adequately fitted to maximize protection. Protective goggles in endoscopy must provide adequate peripheral protection (covering the front and side of the face). Therefore, neither personal corrective eyewear nor goggles that mimic its design is adequate to provide protection against ocular contamination. Face shields provide protection of the entire face and may enhance the protective function of face masks and respirators. In contrast, face masks that contain an integrated upward-facing face shield often do not provide adequate protection from splashes and contamination and should not be considered as equivalent. Gowns are the second-most used piece of PPE in the healthcare setting and help protect healthcare providers from potentially infectious solid and liquid particles, offering coverage over a large body surface area.25Gruendemann B. Single-use vs. reusable gowns and drapes.Infection Control Today. 2002; 6: 1-12Google Scholar The U.S. Food and Drug Administration recognizes the consensus standards set forth by the American National Standards Institute/Association of the Advancement of Medical Instrumentation PB70: 2003 for liquid barrier performance of protective apparel and drapes intended for use in healthcare settings.26U.S. Food and Drug Administration. Medical gowns, 2021. Available at: https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/medical-gowns. Accessed July 19, 2022.Google Scholar This terminology sets 4 levels of barrier protection for gowns defined as the following: level 1: minimal risk, to be used during basic care; level 2: low risk, to be used, for example, during blood draw and suturing or in the intensive care unit or pathology laboratory; level 3: moderate risk, to be used, for example, during arterial blood draw, inserting an intravenous line, in the emergency room, or for trauma cases; and level 4: high risk, to be used, for example, during long, fluid-intense procedures and surgeries when pathogen resistance is needed or infectious diseases are suspected. Although no endoscopy-specific recommendation for level of barrier protection exists, use of gowns meeting a level 3 or higher is advisable in accordance with the Association of the Advancement of Medical Instrumentation recommendation for surgical procedures. A variety of gowns are available that offer varying resistance to solid and liquid particles. Because textiles play a significant role in the process of infection from bacteria and viruses, choosing the right gown textile can help prevent exposure to the endoscopist and endoscopy staff.27Borkow G. Gabbay J. Biocidal textiles can help fight nosocomial infections.Med Hypotheses. 2008; 70: 990-994Crossref PubMed Scopus (140) Google Scholar,28Sidwell R.W. Dixon G.J. McNeil E. Quantitative studies on fabrics as disseminators of viruses. 3. Persistence of vaccinia virus on fabrics impregnated with a virucidal agent.Appl Microbiol. 1967; 15: 921-927Crossref PubMed Google Scholar Although single-use disposable gowns and reusable gowns are both commercially available, single-use gowns are more commonly used in the United States.29Kilinc F.S. A review of isolation gowns in healthcare: fabric and gown properties.J Eng Fiber Fabr. 2015; 10: 180-190PubMed Google Scholar Disposable gowns are typically composed of synthetic fibers such as polypropylene, polyester, and polyethylene, whereas reusable gowns are typically made of 100% cotton, 100% polyester, or polyester/cotton blends.29Kilinc F.S. A review of isolation gowns in healthcare: fabric and gown properties.J Eng Fiber Fabr. 2015; 10: 180-190PubMed Google Scholar Regardless of the type of fabric, the fabric should have a density near 100 g/m2, an air permeability of at least 100 L/m2/min, and a moisture transmission rate of 400 to 600 g/m2/day to provide both resistance to liquid penetration and sufficient breathability.30Parthasarathi V. Thilagavathi G. Developing antiviral surgical gown using nonwoven fabrics for health care sector.Afr Health Sci. 2013; 13: 327-332PubMed Google Scholar,31Azam Ali M. Shavandi A. Medical textiles testing and quality assurance.in: Wang L. Performance testing of textiles. Woodhead Publishing, Sawston, United Kingdom2016: 129-153Crossref Scopus (16) Google Scholar Table 1 provides a list of commercially available gowns.Table 1Representative personal protective equipmentType of personal protective equipmentManufacturerFeaturesPrice range per unit (U.S.$)Gowns∗Gown level based on American National Standards Institute/Association of the Advancement of Medical Instrumentation PB70: 2003 standards for liquid barrier performance.Boston Scientific EndoArmor+ (Marlborough, Mass, USA)Nonsterile level 3 barrier2.50-10.00Kimberly-Clark Kimtech A7 (Dallas, Tex, USA)Nonsterile, level 3 barrier4.36-6.37Cardinal Health Surgical Gown (Dublin, Ohio, USA)Nonsterile, level 3 barrier2.41-4.11McKesson Surgical Gown (San Francisco, Calif, USA)Nonsterile, level 3 barrier3.87-4.83Halyard Aero Chrome Surgical Gown (Alpharetta, Ga, USA)Nonsterile, level 4 barrier (reusable)7.71Standard Textile ComPel MLR surgical gownNonsterile, level 3 barrier (reusable)60.25N95 masksHalyard Fluidshield (Halyard, Ga, USA)Duckbill model with bonded straps.88-3.213M 8511 Particulate Respirator (St Paul, Minn, USA)Braided headbands with exhalation valve2.45-3.113M Health Care Particular Respiratory and Surgical Mask 1860SBraided headbands with cushioning nose foam1.27Aero Pro AP0028 (Taipei, Taiwan)Duckbill model1.80-2.99Makrite 9500 (New Taipei City, Taiwan)Preformed cone respirator2.50-4.50Elastomeric half-mask respirators3M Half Facepiece Reusable Respiratory 6000 SeriesAdjustable with 3 sizes14.99-20.20Honeywell 5500 Series Hals Mask (Charlotte, NC, USA)Latex-free headstraps with wide sealing area14.54-23.98GlovesCardinal HealthNitrile gloves.05-.07Kimberly-ClarkPurple nitrile gloves.28-.58MckessonLatex or vinyl gloves.09-.27Medline (Mundelein, Ill, USA)Nitrile or vinyl synthetic gloves.08-.17∗ Gown level based on American National Standards Institute/Association of the Advancement of Medical Instrumentation PB70: 2003 standards for liquid barrier performance. Open table in a new tab Wearing gloves is required while performing all endoscopic procedures including while handling endoscopic accessories and patient care equipment. There are a myriad of gloves made of different materials available to healthcare providers, with the U.S. Food and Drug Administration providing minimum safety requirements for medical gloves, including the banning of all powdered gloves.32Anonymous. Guidance for Industry and FDA Staff Medical Glove Guidance Manual. 2008. Available at: https://www.hhs.gov/guidance/document/medical-glove-guidance-manual-guidance-industry-and-fda-staff. Accessed December 28, 2022.Google Scholar,33U.S. Food and Drug AdministrationBanned devices; powdered surgeon's gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon's glove.Fed Register. 2016; : 91722-91731PubMed Google Scholar Because sterility is not required for most endoscopic procedures, medical examination gloves, chemotherapy gloves, and surgical gloves are acceptable during endoscopy. Gloves should be chosen by the endoscopist and all support staff based on barrier properties, patient allergies, staff allergies or sensitivities, comfort, and tactile sensitivity. Double gloving remains the recommended method for appropriate PPE during endoscopy within the context of the COVID-19 pandemic.34Sultan S. Lim J.K. Altayar O. et al.AGA rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic.Gastroenterology. 2020; 159: 739-758Abstract Full Text Full Text PDF PubMed Scopus (217) Google Scholar In 1 trial, PPE worn by healthcare providers was contaminated with a bacteriophage, with the study finding significantly more virus transfer to the hands with single gloving compared with double gloving (inner glove underneath the gown sleeve, outer glove over the gown sleeve).35Casanova L.M. Rutala W.A. Weber D.J. et al.Effect of single- versus double-gloving on virus transfer to health care workers' skin and clothing during removal of personal protective equipment.Am J Infect Control. 2012; 40: 369-374Abstract Full Text Full Text PDF PubMed Google Scholar Multiple randomized trials involving surgeons performing different types of procedures have also found double gloving to have a significantly lower rate of skin perforation compared with single gloving.36Makama J.G. Okeme I.M. Makama E.J. et al.Glove perforation rate in surgery: a randomized, controlled study to evaluate the efficacy of double gloving.Surg Infect. 2016; 17: 436-442Crossref PubMed Google Scholar, 37Laine T. Aarnio P. Glove perforation in orthopaedic and trauma surgery. A comparison between single, double indicator gloving and double gloving with two regular gloves.J Bone Joint Surg Br. 2004; 86: 898-900Crossref PubMed Scopus (69) Google Scholar, 38Laine T. Aarnio P. How often does glove perforation occur in surgery? Comparison between single gloves and a double-gloving system.Am J Surg. 2001; 181: 564-566Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar In a randomized trial examining anesthesia trainees, single gloving was found to have a significantly higher rate of contamination after performing an intubation than double gloving.39Birnbach D.J. Rosen L.F. Fitzpatrick M. et al.Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.Anesth Analg. 2015; 120: 848-852Crossref PubMed Scopus (53) Google Scholar This concept applies to ancillary staff as well, as another randomized trial involving operating room nurses found that double gloving had a 0% rate of inner glove perforation.40Guo Y.P. Wong P.M. Li Y. et al.Is double-gloving really protective? A comparison between the glove perforation rate among perioperative nurses with single and double gloves during surgery.Am J Surg. 2012; 204: 210-215Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Although endoscopy-specific studies are lacking, extrapolation from surgical studies suggest that double gloving during procedures may offer greater protection from contamination to the hands. With the advance in therapeutic endoscopy including new techniques in interventional EUS, endoluminal stent placement, and advanced ERCP modalities, radiation safety plays a prominent role in the protection of therapeutic endoscopists. A recent document by the American Society for Gastrointestinal Endoscopy’s Quality Assurance in Endoscopy Committee provided a comprehensive review of this topic and therefore is not a focus here.41Kwok K. Hasan N. Duloy A. et al.American Society for Gastrointestinal Endoscopy radiation and fluoroscopy safety in GI endoscopy.Gastrointest Endosc. 2021; 94: 685-697Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Donning and doffing PPE remains a critical component of performing safe endoscopy. In line with CDC recommendations, we recommend the following protocol for putting on and removing PPE.42Centers for Disease Control and Prevention. Using personal protective equipment (PPE). Available at: https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf. Accessed December 28, 2022.Google Scholar The steps for donning PPE are as follows: obtain the proper PPE, perform hand hygiene, put on an isolation gown, put on the appropriate mask or respirator, put on a face shield or goggles, put on gloves, and then enter endoscopy room (Fig. 1). Although not displayed in the CDC recommendations, double gloving would entail placing a second set of gloves on top of the first set, making sure that the second set extends at least 1 inch over the first set of gloves. The steps for doffing PPE are as follows: remove gloves, remove gown, exit the endoscopy room, perform hand hygiene, remove face shield or goggles, remove face mask or respirator, and then repeat hand hygiene after removing face mask or respirator (Fig. 2).Figure 2Steps for taking off personal protective equipment as provided by the Centers for Disease Control and Prevention (see https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf).View Large Image Figure ViewerDownload Hi-res image Download (PPT) In light of the recent COVID-19 pandemic, the selection of appropriate PPE for performing endoscopy in patients with specific infections is reviewed. When performing endoscopy in patients with an active COVID-19 infection, the following articles of PPE are recommended: hair protection, N-95 mask or positive-pressure respiratory hood, double gloves (over and under the gown), water-resistant gown, and protective eyewear.34Sultan S. Lim J.K. Altayar O. et al.AGA rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic.Gastroenterology. 2020; 159: 739-758Abstract Full Text Full Text PDF PubMed Scopus (217) Google Scholar,43American Society for Gastrointestinal Endoscopy. COVID-19 use of personal protective equipment in GI endoscopy. Volume 2022, 2022. Available at: https://www.asge.org/home/resources/key-resources/covid-19-asge-updates-for-members/joint-gastroenterology-society-message-covid-19-use-of-personal-protective-equipment-in-gi-endoscopy. Accessed December 28, 2022.Google Scholar Furthermore, it is recommended that endoscopy is performed in a negative-pressure room with a minimum waiting period of 30 minutes before proceeding with the next endoscopy. In performing any endoscopy in patients with an active Clostridiodes difficile infection, standard precautions are recommended as would be required in the management of these patients in a hospitalized setting. Gloves and a gown should be worn when entering the endoscopy room and throughout the endoscopy. After the procedure, hand hygiene with soap and water should be performed when gloves are removed, and the endoscopy room, including any frequently touched surfaces and reusable devices, should be cleaned and disinfected (with any Environmental Protection Agency–registered disinfectant with a sporicidal claim) before the next endoscopy.44Centers for Disease Control and Prevention. C. diff (Clostridioides difficile). Volume 2022, 2022. Available at: https://www.cdc.gov/cdiff/index.html. Accessed December 28, 2022.Google Scholar Droplet precautions should be taken when performing an endoscopy in patients with known or suspected infections with pathogens transmitted by respiratory droplets through coughing, sneezing, or talking. In regard to PPE, this primarily entails using a mask on entry into the endoscopy room and throughout the procedure.45Centers for Disease Control and Prevention. Transmission-based precautions. Volume 2022, 2022. Available at: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html. Accessed December 28, 2022.Google Scholar Airborne precautions are reserved for patients with a known or suspected infection with pathogens transmitted through an airborne manner (eg, tuberculosis, measles, disseminated herpes zoster). In addition to standard PPE (gloves and gown), endoscopy personnel should wear an N95 mask or higher-level respirator, and the endoscopy should be performed in a negative-pressure room.19Calderwood A.H. Day L.W. Muthusamy V.R. et al.ASGE guideline for infection control during GI endoscopy.Gastrointest Endosc. 2018; 87: 1167-1179Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar,45Centers for Disease Control and Prevention. Transmission-based precautions. Volume 2022, 2022. Available at: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html. Accessed December 28, 2022.Google Scholar In light of the COVID-19 pandemic, PPE has recently garnered significant attention as an essential step in protecting healthcare providers from exposures. Data are limited regarding endoscopy-specific measures, but the known risk of transmission of infectious pathogens during endoscopy necessitates the proper use of PPE during all endoscopies. This includes the use of appropriate face masks and/or respirators, eye protection, gloves, and gowns. Further endoscopy-specific research is needed to identify best practices for the personal protection of GI endoscopists.