Key points

Editorial Comment: Rationale for including gastrointestinal endoscopy in Plastic Surgery issue:

The author presents safe practice of endoscopy in the outpatient setting, focused primarily on gastrointestinal endoscopy. Why is this of interest to plastic surgeons? Principles for safe endoscopy apply to plastic surgery in the same way that they apply to gastrointestinal surgery. The plastic surgeon will be interested to read the recommendations for and pitfalls of endoscopy in the ambulatory setting that discuss anesthesia, complications, and more .

Introduction to general endoscopy

• •
  

  Endoscopy units have evolved over the past 50 years from small rooms usually placed at the far end of a general medical floor or single multipurpose units as part of the operating room to large, stand-alone suites either in or outside of a hospital, with multiple rooms to accommodate many diagnostic and advanced therapeutic procedures. Indications for endoscopy have also changed over time. Today diagnostic procedures are commonly performed on asymptomatic patients to identify premalignant conditions in those who are at high risk of developing cancer, and more commonly on healthy people for screening. Highly complex therapeutic procedures such as endomucosal resection and biliary interventions have become outpatient procedures performed in specialty units or even in private offices. The movement from a hospital setting to the outpatient facility is the result of multiple factors.

  
  
• •
  

  Scheduling pressures for endoscopy time crowded many hospital endoscopy units so that endoscopists looked to perform procedures in an alternative location, leaving hospital suites available for in-patient care.

  
  
• •
  

  Insurance reimbursement incentivized endoscopy performance outside of the hospital.

  
  
• •
  

  Physicians themselves found they had more control of their time and even the quality of the endoscopy if performed under their direct guidance and leadership rather than in the hospital.

Today, numerous sites of service are available for endoscopy including ambulatory endoscopy centers (AECs), ambulatory surgery centers (ASCs), or a physician’s own private office.

In his review on safe endoscopy published in Gastrointestinal Endoscopy in 1994, the late Emmet Keeffe wrote, “Endoscopy is probably safer in a large hospital endoscopy unit than a small rural hospital procedure room, although this hypothesis has not been studied.” Today, safe office endoscopy has come of age. What are the advantages of endoscopy in the office setting and why do most patients prefer to have their procedures outside of a hospital?

• •
  

  Patients who are generally healthy prefer to remain out of the hospital.

  
  
• •
  

  Patients are more comfortable seeing their physician in the facility where they may be familiar with the location, the personnel, and a routine they have grown accustomed to.

  
  
• •
  

  Patients do not want to share a waiting room with sick inpatients in wheelchairs or on stretchers, or be inconvenienced by delays in the schedule forced on them by unforeseen emergencies.

  
  
• •
  

  In hospital, patients are interviewed by multiple staff in a unit with many asking the same questions. Sometimes more than 1 to 2 hours have elapsed from entry point until the procedure begins.

  
  
• •
  

  Patients are concerned about effects of anesthesia and possible complications, primarily infections and perforation.

Why do physicians want to do procedures outside a hospital?

• •
  

  A physician has better control over time management when working in his or her own office. The surgeon is able to examine a patient in between procedures, maximizing efficiency.

  
  
• •
  

  Procedures can be scheduled in a sequence that conforms to an individual style and patient load.

  
  
• •
  

  In a hospital setting, the endoscopist has limited flexibility because multiple physicians have to be accommodated and time must often be reserved for potential emergencies. Many hospitals host fellowship training programs whereby endoscopic teaching and learning may add extensive time to the procedure. The result is that in-hospital endoscopy time estimates are often inaccurate and delays are normative.

Although there are regional differences, in many parts of North America office endoscopy has become mainstream, with the office a preferred location for common procedures. However, quality endoscopy is more complex than just clean scopes and clean rooms. The purpose of this article is to highlight many issues that serve to make office endoscopy a safe alternative to the hospital-based procedure.

Introduction to general endoscopy

• •
  

  Endoscopy units have evolved over the past 50 years from small rooms usually placed at the far end of a general medical floor or single multipurpose units as part of the operating room to large, stand-alone suites either in or outside of a hospital, with multiple rooms to accommodate many diagnostic and advanced therapeutic procedures. Indications for endoscopy have also changed over time. Today diagnostic procedures are commonly performed on asymptomatic patients to identify premalignant conditions in those who are at high risk of developing cancer, and more commonly on healthy people for screening. Highly complex therapeutic procedures such as endomucosal resection and biliary interventions have become outpatient procedures performed in specialty units or even in private offices. The movement from a hospital setting to the outpatient facility is the result of multiple factors.

  
  
• •
  

  Scheduling pressures for endoscopy time crowded many hospital endoscopy units so that endoscopists looked to perform procedures in an alternative location, leaving hospital suites available for in-patient care.

  
  
• •
  

  Insurance reimbursement incentivized endoscopy performance outside of the hospital.

  
  
• •
  

  Physicians themselves found they had more control of their time and even the quality of the endoscopy if performed under their direct guidance and leadership rather than in the hospital.

Today, numerous sites of service are available for endoscopy including ambulatory endoscopy centers (AECs), ambulatory surgery centers (ASCs), or a physician’s own private office.

In his review on safe endoscopy published in Gastrointestinal Endoscopy in 1994, the late Emmet Keeffe wrote, “Endoscopy is probably safer in a large hospital endoscopy unit than a small rural hospital procedure room, although this hypothesis has not been studied.” Today, safe office endoscopy has come of age. What are the advantages of endoscopy in the office setting and why do most patients prefer to have their procedures outside of a hospital?

• •
  

  Patients who are generally healthy prefer to remain out of the hospital.

  
  
• •
  

  Patients are more comfortable seeing their physician in the facility where they may be familiar with the location, the personnel, and a routine they have grown accustomed to.

  
  
• •
  

  Patients do not want to share a waiting room with sick inpatients in wheelchairs or on stretchers, or be inconvenienced by delays in the schedule forced on them by unforeseen emergencies.

  
  
• •
  

  In hospital, patients are interviewed by multiple staff in a unit with many asking the same questions. Sometimes more than 1 to 2 hours have elapsed from entry point until the procedure begins.

  
  
• •
  

  Patients are concerned about effects of anesthesia and possible complications, primarily infections and perforation.

Why do physicians want to do procedures outside a hospital?

• •
  

  A physician has better control over time management when working in his or her own office. The surgeon is able to examine a patient in between procedures, maximizing efficiency.

  
  
• •
  

  Procedures can be scheduled in a sequence that conforms to an individual style and patient load.

  
  
• •
  

  In a hospital setting, the endoscopist has limited flexibility because multiple physicians have to be accommodated and time must often be reserved for potential emergencies. Many hospitals host fellowship training programs whereby endoscopic teaching and learning may add extensive time to the procedure. The result is that in-hospital endoscopy time estimates are often inaccurate and delays are normative.

Although there are regional differences, in many parts of North America office endoscopy has become mainstream, with the office a preferred location for common procedures. However, quality endoscopy is more complex than just clean scopes and clean rooms. The purpose of this article is to highlight many issues that serve to make office endoscopy a safe alternative to the hospital-based procedure.

Standards for office endoscopy

The American Society of Gastrointestinal Endoscopy has stated that the standards for out-of-hospital endoscopic practice should be identical to the recognized guidelines followed in the hospital. To achieve this goal many states have adopted mandatory accreditation from national organizations such as the Joint Commission on Accreditation of Health Care Organizations, the American Association of Ambulatory Surgery Facilities, and the Accreditation Association for Ambulatory Health Care. These organizations are dedicated to maintaining a high standard of care in the office setting. Even where those standards are not regulated by law, out-of-hospital endoscopy relies on the physicians’ and staff’s devotion to patient safety and comfort. Rules and forms are important, but an office and its entire staff should strive to establish a goal of excellence, with all personnel made to understand the value and importance of a safe environment.

Personnel

The office staff is usually a patient’s first contact with an endoscopy center. The reliability and caliber of office personnel is second in importance to that of the physician’s. The clarity, compassion, and concern expressed by the staff are a direct reflection of how important the physician values the safety and welfare of the patient. The office personnel and the clinical staff must be able work together to promote a congenial environment with a common goal dedicated to the well-being of the patients served.

The office staff is often the filter between patient and physician. In outpatient endoscopy units it is imperative that the staff understand the procedures performed by the physician. Staff must understand the importance of the preparation and be able to instruct the patients how to prepare for their procedure. The staff may be asked to triage patients and schedule their access to the physician, based on their specific medical problems. Staff must be trained and educated on the basic issues that patients may inquire about and be capable of referring a patient’s telephone inquiry to either nurses or physicians. Failure to recognize a patient’s problem as critical or life-threatening can delay and complicate the patient’s care and access to the physician. For example, a complaint of pain or bleeding should be referred to a nurse or physician to determine the urgency of a visit or need for emergent care.

The staff needs to understand procedure scheduling to allow enough time between procedures for room preparation, equipment processing, and patient setup. Failure to allow appropriate time between procedures will make the physician feel rushed to complete the examination to minimize prolonged waiting time. Every effort should be made to keep waiting time for patients to a minimum. A well-run office will inform a patient if there is an anticipated delay. The patient must be treated with care and dignity by the staff at all times. An office that understands the value of the patient’s time and appreciates their anxiety on the day of the procedure is one that will engender confidence that the technical aspects of the endoscopy will be handled with the utmost care. An office that is habitually running hours behind schedule with a waiting room filled with unhappy, irritated, and anxious patients, by contrast, will likely call into question the competency and reliability of the endoscopist.

Although the physician decides which medications need to be discontinued before the procedure (in collaboration with other treating physicians), the staff often communicates these instructions to the patient directly. Instructions about aspirin and other anticoagulation can often be confusing for a patient who is anxious about his or her upcoming procedure. Anecdotally, the author can recall a patient who came for a procedure and who had assured the interviewing nurses that he took neither coumadin nor aspirin. On observing a gush of blood from the base of the stalk after polypectomy, he explained that he took warfarin, but was not specifically asked about that product. Today there are many new antiplatelet agents and anticoagulants, and it is critical to record the medications taken by a prospective patient and advise on its use or discontinuation. The decision to discontinue anticoagulation is usually made after discussion with other treating physicians.

The endoscopy assistant is another key person whose experience and knowledge will enhance a safe environment. The assistant can be a registered nurse, a licensed practical nurse, or a trained technician. If the assistant is working alone with the endoscopist, he or she may assist in the performance of biopsy or polypectomy. In patients who require more intensive or prolonged endoscopic interventions, a second assistant would be needed to allow the assistant administering moderate sedation to remain focused on patient monitoring rather than technical assistance. Even if the assistant is a nurse, his or her educational background or experience with anesthetized patients may be limited. Teaching and training until the assistant feels comfortable and confident with the responsibilities cannot be overstated. Training an assistant requires time and patience. No one should be thrown into the position and be expected to learn “on the job” while doing procedures. Training may be available at the local hospital, where a new employee might be able to observe the entire outpatient endoscopy routine over several weeks before joining the office endoscopy unit. The assistant’s responsibilities must be clearly delineated. Responsibility may also include care for the equipment, which can be learned from the manufacturer’s representative, who may have a clinical coordinator who will come into the office and provide direct instructions on care of the instruments.