• conception: BJE FUNDING None.
Digestive manifestations appear to be common in patients with COVID-19. 1 Gastroenterologists will invariably come into contact with infected patients, and the risk of intraprocedural exposure is well established. 2 Recommendations have been issued to guide personal protective equipment (PPE) use 3 and the triage of procedural urgency, 4 among other operational considerations. In response, institutions providing gastroenterology and endoscopy services have taken urgent action to protect patients and staff, but the uptake and extent of these practice changes in North America is unknown. We conducted a survey of gastroenterology and endoscopy practices to assess the response to the COVID-19 pandemic across the continent.
A web-based survey was disseminated to gastroenterologists across North America.
Distribution was achieved via en masse email, social media promotion, and direct contact by 4 authors (NF, ZLS, SBW, BJE). The survey consisted of 42 items, stratified into 6 categories:
institutional demographics, changes in endoscopy practice, changes in clinical practice, changes in training, peri-procedure screening for COVID-19, and changes in PPE practices.
Detailed methodology is provided in the Appendix.
Seventy-three individuals responded on behalf of their institutions, representing 62 U.S. 
At the time of response, most centers (46/71, 65%) were operating at ≤10% of their normal endoscopy volume, with 18 centers (25%) performing approximately 25% of normal volume. Seventy-one of 73 centers (97%) had postponed screening colonoscopy. Of responding centers, 48/71 (68%) stated that they had no defined plan to address the procedural backlog once restrictions are lifted (Figure 1 ). Those that did have a plan favored weekend and after-hours endoscopy or stool-based testing. Twenty of 72 responding centers (27%) had adopted routine endotracheal intubation for upper endoscopic procedures.
Forty of 73 (55%) and 15/73 (21%) institutions reported that clinics were partly or fully closed, respectively. In response, all but three had implemented telemedicine visits (70/73, 96%). Approximately half of centers (33/70, 47%) reported conducting >75% of visits via telemedicine (Figure 1 ). Fifty-four of 73 centers (74%) had adopted modified schedules limiting number of attending physicians in hospital at any given time; a median of 3 staff physicians were expected to be simultaneously present (IQR 2-4).
Fellows continued to evaluate inpatient consults face-to-face in 47 programs (75%) and
via electronic-only assessment in 14 programs (22%). Only 3 programs still had fellows seeing clinic patients in-person, whereas 39 (62%) had them seeing patients virtually. In contrast, 26 programs (41%) had limited fellow involvement in endoscopy to select cases, whereas 31 (49%) had eliminated their involvement altogether. Many (21/47) interventional endoscopy training programs (45%) had stopped training.
The majority of responding centers (63/73, 86%) are screening patients for COVID-19 upon arrival to endoscopy units through symptom and/or exposure assessments (Figure 1 ).
These screening measures had resulted in at least one procedure cancellation at 37/60 (62%) of responding centers. Only 16/57 centers (28%) were contacting patients up to 14 days postprocedure to assess for de novo COVID-19 symptoms.
Expanded PPE (beyond standard gown, gloves, and goggles) was being used in 63/73 covers (χ 2 10.9, p=0.001) in high-risk/positive patients. U.S. centers were also significantly more likely to re-use N95 masks (χ 2 19.3, p<0.001). There were no significant differences in PPE practices between regions within the U.S., or between academic and non-academic centers.
Centers in the West were significantly more likely allow fellow participation in general (χ 2 26.7, p=0.02) and interventional endoscopy (χ 2 15.1, p=0.03).
Our study demonstrates that institutional responses to COVID-19 have been variable, fluid, multifaceted and substantial. Though most study centers reported expanded PPE use in all endoscopic procedures, the use of surgical masks versus N95 respirators varied. Increasing trends in N95 mask use were observed over time, and U.S. centers were more likely to use these masks as well and hairnets and shoe covers. Though early evidence suggests that standard surgical masks may be sufficient in non-high-risk scenarios, 5 it remains critical to elucidate whether endoscopy produces respiratory aerosols fine enough to penetrate standard masks.
Triaging endoscopic procedures during the pandemic is also crucial, and professional societies have issued guidance on this matter. 6 However, the postponement of non-urgent endoscopy will result in a surplus of procedures when clinical operations normalize. Strikingly, nearly two thirds of respondents had no defined plan to address the backlog. Innovative approaches such as revising CRC surveillance intervals for patients awaiting follow-up colonoscopy according to new multi-society guidelines should be considered, 7 keeping in mind that resumptive strategies may be impacted by numerous factors, including new post-pandemic infection control precautions and whether a country has a single-or multiple-payer system.
This study provides a current and comprehensive snapshot of the changes that North
American centers have implemented in response to the pandemic and -by reporting data on clinical, consultative and training practices -expands on recent information by our Italian colleagues 8 . High-quality research is urgently needed to better inform optimal PPE usage and guide the re-expansion of post-pandemic clinical and endoscopic services. Survey instrument with aggregate results: 5-10
This was a multicenter web-based survey study and was exempt from institutional board review. A survey was constructed within the REDCap electronic data capture platform, 5,6 hosted at the Medical University of South Carolina, and was subsequently disseminated to potential respondents. The survey was accessible via a direct web link (https://gi-covid19.org/survey) without any required login credentials. Respondents were instructed to confer with their institutional leadership prior to completing the survey. In the event surveys were completed by multiple respondents from the same institution, the investigators contacted respondents directly and asked them to reconcile their responses. At the institutional level, this was a cross-sectional analysis; however, because institutions responded at various points in time, this was not a cross-sectional study in aggregate.
The survey was developed through a series of electronic communications between the authors. The initial survey was designed by one investigator (BJE) and then iteratively pilot 
Individual survey item responses were reported as the proportion of total respondents engaging the question that answered affirmatively to the individual reply. • Is your division or unit doing anything not covered above that might be helpful to others?* • How can we improve this survey?* *qualitative responses by free text -no aggregate answers reported