the university endoscopy unit: the standard of...

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The university endoscopy unit: The standard of care?

j l)R11A"- Cit)! L1Rl1\, M L), fRCPC, P,\l IC APA~h. M l ), FRC PC

ABSTRACT: In an attempt to investigate prnuice patterns of the moJem gast ro intest inal e ndoscopy unit, a survey was undertaken in 10 univers ity-affiliated endoscopy units in th ree Ontario cities. T he results showed that there was a wide range of prcmedu.:ations used, a nd that there was variation tn the extent of patient mon itoring, the method of endoscope stcrilizm1on and the degree of safety precautions. This survey provides informa tion on the 'standa rd of care' 111 rhe un1vers1ty endoscopy un it and prnddes a framework for d1scuss1on for rl1e eswblishment of guidelines for the modern gastrointestinal endoscopy un it. Can J Gastroentcrol I 990;4(6 ):255-258

Key W ords: Endosco/)'Y, Monrwrrng, Safecy

L'unite d'endoscopie associee a l' universite: Quelle est la qualite des soins?

RESUME: Une enqucte a etc cffec tuec a upres de 10 unites d'endoscopie ~ssoc ices a ux un1versites dans t rois v1lles ontarienncs, afin de determiner les pmfi b de la prnt1que Jans l' u111te d'endoscopie gastro-intcst ina lc mlxlerne. Les rcsul rats rcvclent qu'i l existe unc vastc gamme de premcdications a insi qu'une variation Jans l'e tcndue J u monimrage des patiencs, la methode de sterilisation de !'endoscope , et le degre des mesures de precaution. C ene etude fourn1 t des J1mnees sur la qua lite J es soins tlispenses dans !es uni tes d 'c ndoscopie des centres hospica liers univcrsirni res; ellc fourn it le cad re des discussio ns conduisan t a l'claborau on J es di rectives destinees au centre d'endoscnp1e gastro-in test male J'aujourd 'hu i.

TIH: ">l' l·t l•\LT\ t)f- t,1\STRIJ.

enterology has hccomc mcreastngly dominated hy end11su1pic procedures performed tn nutp.n1ent and mp,rnent 1ctt1ngs in modern l.'ndoscop1c 11n11s

w1thtn hospitals. T he design and daily func u un of tlw se uni ts varies depend mg on personnel , expen ence, budget and m her fac tors. \V11h the tnc rea-, 111g emphasis on qunlny of care evaluat1cms

Dc/>ar1men1 uf Gcl\lro,'1Hl.'rn/c,/f\, l 1n11•cr111y / fm/lllcrl, l 1111•n111, 11f \X 'c.11em ( )nrarn, , Lmulon . Ommm

Cc,rre,f>tm,bice and n·/)rnlll I )r l'aul ('Adami, I )c/>anmctH of Mrdrcrnr. l nn•enu, 1/11.1/)Hal. L'11m:r1U'\' of W/c11rm O nrarro. P() Bu.\ 'i339. I om.Ion. ( lnwno N6:\ 5A5

Recert•ecl jiJT /mli/1ca11011 March n. I 990 An-c/)1eJ ]1111<' 22, I <NO

CAN J GA~TRtlLNTlRl )J Vt)! 4 Nl l 6 SLl'Tl:1'11\IR/lx Tl ll\l R I 990

.mJ med1coleg;1l issues, the nnus 1s cm the prac.t 1s111g gast roentcmlogbt to provide a level of safety and service wh ich ts compa rable to the 'srandartl of earl.' ' avatlahle 111 the community. In an effort to define this standard further, pracu ce pa tt e rns 111 IO un1verstt y-a ffi l1ated gastro1ntest1nal endoscopy units we re stud ied . T his survey reviewed the procedures tn IO dtffr rent cndmcopy unns wn h rl'gard to pre-endoscopy asse:,sment, patie nt mon noring and safet y, .md e ndoscnpy hyg iene.

METHODS Ten endu~cor y units 111 universtly

te,1c h1ng hospu als 111 three O ntario c11ie~ we re v1s1ted. Data were obtained from senior nurs111g personnel 111 the endoscopy unit us111g a standa rd q uestionna ire. Data, therefore, were based on the d1111ca l imprc~sio n of these personnel , a nd nc1 fo rmal ,1udtt of the facilities o r cltn1u1l omcomes was perfo rmed.

RESULTS T he survey revealed tha t esophago

gastroduodcnoscopy was the mnst common e ndoscopic procedure performed with a wide range of va riabtltty evident hetween ind iv idual un1b (Table I) . S imil a rl y, there was consid c rah le varia bi l tl y 111 the use of pre-endnswpy sedation (Table 2). A rre-entloscopy history wa, ohwim·d hy the nurse in a ll

255

GOLL Ji{)\ t\Nll All,\t,.t~

TABLE 1 Patterns of care in university hospital endoscopy units

Annual volume of procedures

Procedure EGD

____Mean ± SD Range 1815±339 1018 4758

Colonoscopy 686±71

Flexible 433± 173

347-1094

114-1055 sigmoidoscopy

ERCP 215±52 88-575

EGO Esophogogostroduodenoscopy. ERCP Endoscopic retrograde cholong1opon creotogrophy

units and vital signs were recorded heforc and after the pnKl'dure. Therl' wa:, consiJcrnhle variability in pmien1 monitoring, avai lability of re:,usl 1tat1on equipment, and endoscopic hygiene (Table 3).

DISCUSSION Th,~ :,urvey of univer:.1ty endo:,copy

units was undertaken to provide mformation on the standard llf care that i:. being provided in university affiliated emloscopy unns. WiLh Lhe mcreasing use of endoscopy in community hosp1-1ab it was anricipmed LhaL a survey of the universn y affiliated un its may provide useful information on Lhe currem 'sranJard of care'. No anempt was made to aud it individual units formally and in no way Jo Lhe authors assume Lhat the level of care provided in a uni versity

TABLE 2 Variation in preoperative medication among endoscopy units

Procedure Medication ----EGD Oral benzocaine spray.

diazepam. diazemule. atropine. no systemic medication

Colonoscopy Dlazepam. diazemule. meperidine. pentazocine. morphine. tentanyl. buscopan. glucagon. dlphenhydramine

ERCP Oral benzocaine spray. d1azepam. diazemule. buscopan. glucagon. diphenhydramlne. atropine

EGO Esophogogoslroduodenoscopy ERCP Endoscopic retrograde c ho longiopon creotogrophy

256

affiliaLed cndosu1py untt is more apprupriate th,111 tha t provided 111 a modern cummunity hospital.

In nl1 cndosLOP) unit 1s a mutme as,essmcnL of all paucnts performed by a phys1c1an prim lll ,rn enJoscop1c procedure . In 1111bt cases, th is would seem unnecessary as che physician would have Jone ~n m hb lifficc. l lowever, Mlme husy physicians will meet rhe path:nt for the first time in the cndosuipy unit and a shon history, parti cu l a rl y of concom itant medic.:a l illnesses and medications could enhance lhc safety of the upcoming procedure.

Parenteral meJ1c.at1ons arc ,tJministcrcd lO the majority nf paiiems undergoing endoscopic procedure~. Previous surveys have reported the 1t1-

l 1dcncc of respiratory depression/ hypmension Lo be 0. 19 to 0.64 per I 000 endoscopies ( 1,2) although complicallons tend lo be underesumalcd. Oxygen desmurnLion LO less than 90% has heen shown to occur in up Ln 29% of gasl mscopics, 68°1.1 of colonoscopies and 44°10 of endnscopic retrograde cholangiopancreatogrnphies m some poim during the procedure (3-8). The process of endoscopic intubation alone has been suggested LO contribute to chis desaturation (9). Studies 111 heahhy volunteers and smokers have shown a decrease in PaOz with meperidine and diazepam plus mcperidine hut not with diazepam alone ( 10-12).

The predictive value of pulmonary function studies on oxygen desaturation during endoscopic procedures has been reported in severa l studies. Pmienls with severe chronic obsLrucLive lung disease (FEV1/FVC less than 60'}o) had a grea ter incidence of desaturaLion of more than 7% (4,13). l lowever, even 111 the p,1ticnts w11 h oxygen desaturation there was no demnrn,trahlc mcreased mmh1J1ly or morta liLy. Whmwell cl al (7) claimed th,it the FEV1/FVC was nm preJ1ct1ve of a fo ll in P,l)z but the severity of Lhe undcrly111g ohstrucuve airways disease was not tkicumcnted. L1ehcrrnan Cl al (4) dcnwn.stratcd an increased inlidcncc of .serious cardiac arrhythmias in patients with oxygen Jes,nuralion nf greater than 7'\>; huwevcr. another

TABLE 3 Variations in safety precautions among 1 O university endoscopy units

Procedure Number of units

Pre endoscopy history and 0 physical by physician

Pre-endoscopy history by 10 nurse

Vital signs Pre-endoscopy 10 Post endoscopy 10

Routine patient monitoring during procedure Blood pressure/pulse 0 ECG 0 Continuous intravenous access 2 Pulse oximetry o·

Routine patient monitoring post procedure Blood pressure/pulse 10 Continuous recovery room 7

personnel Resuscitation equipment

CPR equipment on site 4 CPR equipment off site 4

Pulmonary resuscitation 6 equipment on site

Endoscope hygiene and safety Exclusively immersible 2

endoscopes Uniform cleaning methods

tor all endoscopes Immersible 6 Nonimmersible 4

Selective c leaning for high 5 risk procedures

·Pending one unit ECG Electrocardiograph monitor· CPR Cardiopulmonary resuscita tion

study diJ nol demonstrate any Lorrclation between cardiac arrhythmias anJ Pa02 (14). Al1hnugh Lhesc studies, lO

this point, have heen mcondu,1ve about the rclauomhip between sedation -induced resp iratory dcpre~s1on, oxygen desmurauon, and endoscop1t complicauons, they cmphasi: e the pntential for c.ird,opulmonary cnm plications dunng routine cndoscop1t procedures. Therefore, tt ts ,1gn1t1ca111 LhnL over half of the unit s surveyed 111

this stud) did not h,l\'e card1opul monary re~uscita1ion equ1pmcn1 on s1Le; pacienL monllonng during the prn· cedure was uncommon; intravenous access was immed1.1tdy ,1v.1ibhk 111 the minorny of pr<Kl'durcs; and 1hrel' un1h

CAN I l,,\ STRl)f:)',;Tl'.lll)l V l 11 4 Nt) 6 Su ·nMl1L 1(/0cT( l l\l R 1990

haJ no regular perso nnel 111 the recovery area. Thi? use nf rout me pulse oximetry monnmmg 1s gaming wider acceptance 111 rhL· operarmg mom ,rnd the intensive care untt, and (ll1L' endoscopy unit sur\'cyed has plans to use tlw, technique ro monitor patients during endoscopy. This will require further va lidation since no s t udy has <lemonstr,1ted that oximetry or elect nlcnrd1t1graph1L m11111tonng has al rered the mmh1d1ry or mnrta l1ty as~ociatt?d w1th endoscopic pmceJures. Gu 1de Ii nL's on the mon1tori ng of pat1cnrs undcrgomg gastrointestinal endl>scop1c pnKedurcs hy the Amt?ncan Society for Gastrnmtcsunal Endoscopy sta te that in situ.i t ions where the 111d1v1duali:ed needs of the patient 1nd1cate thm more frequent assessment of card1al rhythm, hlnod pre,su re o r oxygL' n saturatinn wil l complt?ment com enr1onal clinical assessment , the use of nnn111vas1,·e lll\1111 · toring equipment 1s apprnpnatc ( 15 ).

Un1vcrs,il preLaurnms whereh) all blood and sccreuons arc regarded as potent mil) 111fcct1ous h,1s heen recom mcnJ!>Ll by mo:c.t hospitals. However. in

ACKNO WLEDGEMENTS: Dr P( Ada1m 1:, ,\ C.1ret'r Sucnt1,1 ,if I he M1111,tr) nf l lea Ith f,ir Ontam1 and a(krw\\ kJgl', the suppon of 1hL· Mcdtlal Rc,c,1rch ( ounul 1>! Canada. The ,1uthm, acknowledge the•"'" t:mcc of thL· personnel llf the cnd1>scnpy unit, ,urvcycd and I he st'c fl't ,1nal ,1,,1,tarKl' ofCaihy Brown.

REFERENCES I. M.mdcl,1,1m P, Sugaw.1 L. Srln, S,

ct al. Complicat inn, a,,ocimcd with e,oph,1goga,tr,xluodcno,copy ,md with e~ophageal dilm.mon. Ga~rro1111cst Endl> c 1976;23 16-9.

Z. Sch,ller K, Cotton PR, S.1lmon PR. The ha:ard, of d1gcst1w hhre-L·ndo,copy: A ,un-cy ,if the Bnt ish C'\pcrrcncc. l;ut 1972;1 U027.

3. Wuod, Sl), Chung SC, Leung J, c1 al I lypox1,1 .md tachyc.ud1a during cnd,1-,cllptC retrograde lhola11g1opancrcat<>· graphy; dl·tcctron hy pulsL' 1>x1mctr\' Ga,tn>llllL',r Endo,L 1989; 35:'i2 ~-5.

4. L1chcrm.m DA, Wul'rkcr CK. K.11011 RM. Cardh1puhnonar1 risk ,if e,11phag,1g,1,rnxllH xlcn, lsG>py. (~astrn<·nrcrol,>g) I 985;88:468 72

5. Dark DS. C:,1mphcll DR. Wc"cl1us LJ

Standard of care in university endoscopy units

pracucc, the end(iscop, nf a pat11?nr with knnwn ncquired immu1w Jcfk iency syndmme ( •\ID'.--) or hep,lllll~ R le.id, wan 111Lre,1,c 111 anxiety of the endo,uipy mom personnel and often 111 ,ilternati\'e nwthod, of ,tcril1:nt1on nf cquipmt·nt, such as gas steril1:ation. HepatltlS B has hcen rcpurtedly tr.1th· mittcJ by an enJ\l~wpe ( 16), althnugh the risk nf tr,rnsnm,1,m b l(m ( 17-19). No case uf Af l)S has hem L ll':1rly I inkL·J to endoscnprt rrans1111ss1,H1 of the human 1mmunodcfiucncy virus (l llV). Only five of the IO units sur\'eyed employ a un1,·cr,,1l tkanmg rcchn1quc regardless nf diagn,1s1, . Mctrudl1u, physit.il cleaning nf rlw L'ndosu1pL' ,, the mnst 11npnrt,mt part of the stenli:at Hll1 pmu:ss ( 20-22) hut rs nor niuunely performed in I wn nf t lw unit, ,un'L'yed. Nine tenrres use a mm1mum ,it IO 111111,

of chemical d1smfcu 1on hetwecn prncedures. Vanous d1,111ft•ctants, pnman-1 y akl1hl>ls or glut,ir,ildehydt· prcparat 11llh h,l\'C heen dcmnnst rated to inact1\'ate I llV ,md/nr hcpa1111s R , iru~ ( 21-26). The pr,K till'' t?mployed h) sc, en units wnukl sat1:-.h the Brn 1,h Working Part\ reuimmen<latinn, for

I lypl1xcm1.1 during <''<>ph.1gDg,1str<1 dul xknscup) ,md u 1lnnn,,op,. Arn Rl'v Rt·sp1r [)1, 1988; I "l7 161. (Ah,I)

6 Fenncrr) MB. Eanw,1 DI , I lud,, 111 PB, er al. Phy.,rolngK ch.,ngl's ,luring routine cnd1>su1py. ( ,.1srr1>1nrc,r l:ndo.,< 1988; H:214 (Ah,t)

7. Fcnncn\ MB, Earnc,1 [)I, lludsun Pl\ L'I ,11. l'hy,111l.,g1C ch.1ngc, d1mnu c,>lon,1,copy l ,,1,tro1111es1 t.nd,isl 1990; 16:22-5.

'\ Gm" JR. L,,ng WB. .1s,1l oxygen allcv1atcs hypl1xcm1a 111 u1lonn,u>I'\ p,ltlL'nt, ~l'datc,I w1rh m1d,1:ola111 .md mependrne. ( ~a,rrn111re,t Endn,c 1990; 16:26-9.

9. Wllllrwcll PJ. Sm1th ( 'L, his1er KJ ArtL'n,11 hlood g.is 1c1b1l111, during upper ga,tro1nrc,r1nal endoscopy ( ,u1 1976; 17: 797-800.

10. Z:.rgmond EK, Sh1H·ly J(,, rlynn K. Dia:<·pam an,I mcpcn,lmc ,111 ,lrt<'rt,tl hln<.xl ga,c, 111 pattl'lll' 111tl1 <hn1n1, 1>hstnrct1vc· pulmnn.iry dtsL'.tsl'. J l ' Im Ph,irmacnl 1975; 15-464-9

11 2-"gmnn,I EK, Flynn K, M,1rttn<': t')A. lk1:ep,1m and mepend11w 111 hl'althy n1luniL·er,. J Lim Ph.1rm,1u>I 1976:14:177-til.

12 R,1:l·n P, Frmn,m Z, < ,1r.11 T The l,llts<'' llf l11po,em1,1 111 ckk·rh p,111cm,

dt•,ming nun11nmers1hlc cndrn,cope,. although nnl1 li\'C of 10 units soak the entire 1111111er,1hk instrument het ween rn1cedures a:-, rcuimmc·nded hy this group (22). The ll'L' nl prorcct1,·c eycwear, ma:-,b, glm L'' .ind gowm arc ,1,·.1il,1hle 111 mo,c l'ndnscnptc 11n1ts hut arc nnt Lommonly usL·,I. A relent survey of endn,copy room prac lice:-, 111

known All)'.-- case:-, 111 the US reveak-d that onlv 41 'X, of pcr,onncl wnre l'ye pnitL'ltl(ln, 74"n \\"11rc 111,hks, .md H7"u wore gowns (27).

ln ,unun,H), th is stir,·ey ha, demi mst rated that there l'i con,1dcrahle van,1-lll in 111 the s,1fct y procedure, L'mpll 1ycd 111 un1v<:r,ll y-c1ffil ,med endosu ipy un1b. Safet y of rhe pauenr and endosuipy ronm pers(mnd ,hould he of primary Clllllern, hut cnd()sC()py rl>lllll pr,>tou>ls arl' dependcnr on ume het ween proledurL's, endoscopic inventory, h,1sp1tal hmlgL'ts .md mcreascd understanding ol thL· trans1111ss1on p( infcu 1ou, d1scn,l's. It 1,.tn11upated that wllh furthcr ,1\\areness ,if local and international end()· ,o >pie .,.,fct r procedures, guide! mes Liln he l'stahli-.hed for the 'standard nf c.1re' in tht· cndo,cl1py unit.

,lurmg l'lhlo,u,py·. G.1,tn11nccst End,>s( I 9b2;2H:24 'l 6.

l 1 Rn,ryk11, PS, Md\mald GR. Alben RI<. Upper llltL''tmal endoscopy 111-

ll11.:c, hyp,1x<·m1,1mp.111cnt, with .,h,trult1,·e pulmunar) dr,ea,c. Ua,troe11tcrnl11gy 1980; 78:488 91.

14. Rll:en I', llppenherm I). Rat.in J, ct ,d. Ancn.il o,ygL·n ren,mn changl' in ddcrl) pat rent, undergomg upper g,istn>1nt<·st111.il cnJo,c.,py. SL,md J ( ,a,troenterol 1979: 14:577-81

15. Amenc.in Souct y of G:1srro1ntl'strn.1l Fn,lo,cnpv M111111nnng of p,1t1enc, 1111

dergomg g,1,rro111tcsr111al 1:ndmcoptC procedures. ASUE puhlicat1nn 1989, Nu. 1022

16. B1m1c G(,, Quigley FM. ClcmL'nts UB, l't al. En,h>sn1p1L rr,111sm1,,111n uf hc·pa111,~B,m1,(~ut 1983.24:1716.

17. K,,ret: RI. Cam.icho R FadurL• of ,·ndo,u>pll trnnsm1"1"n ,11 hl'p,1t111, B. D,g D1, S,r 1979:24.Z I 4

18 Munc1da RE, l1l'nc, Al:, &·rquisr KR I n,1ch-l'rt l'nt L'\I'< isurl' , ,t end, "ll 1p} panen1, 10, rral hep.it 111, B. l~.Nmrnrc,t End,isc 1978:24:231-2

19 A),111!.1 l:A ll1c n,l.. ol rypc B hepatm, 1nkc11<1n m flL·x1hk· frhr<'llptll l'lldo,-(1 >p\ l ,,tstrotnlL''I End, N . 1981 ;271 :60-2

20. ( 'IX' gu1dcl1nc·, t.,r h,md,1a,hmg and

257

GOLUROV AND ADA1'1S

hospital environmcnral comn,I. Infect Control 1986; 7:2 36-40.

21. lnfccrinn Control Gu1Jclinc,. Healrh Prmecmm Brnnch and l lcalrh Scv1cc, Oircctorarc, 3rd printing. 0 1rnwa: Mm-1,try of National Health and Welfare, 1987:80-9.

22. C leaning and d1sintccuon of equipment for ga,tromtc,tmal flexih lc cndn,copy: I nternn rc:commendations nf a Working P,my of the Bmbh Society of G:htmentcrology. Gur

258

1988;29: l l 34-51. 2 3. Spire B. Monragnier L, Barre-Sinnuss1

F, ct al. lnacuvanon oflymphadcnopmh1 a,sociared viru, hy chemical d isinfocrnnr,. Lancet l 984;i :899-90 I.

24. Resnick L, Veren K, Salahudd in SZ, ct al. Stability and inactivation of l lLTV-11 1/LAV under clinical and laboratory environment,. JAMA 1986;255: 1887-9 l.

25. Kobayash i H, Tsuzuki M, Ko,himizu K, et al. S usceptibility of hepatitis B virus

to disinfocrnnrs of hc.tt. J C l Ill M 1cmh10I 1984;20: 214-6.

26. Bond WW, Favero MS, Petersen NJ, ct al. lnactivat inn of hcpatit 1;, B virn, hy imcrmed1.irc ro high level d1smfoctant chemical,. J Clin Microhiol 1983;18:535-8.

27. Raufman JP, Srmus EW. Ga,trointc,tinal endoscopy 111 patient, wnh ,1cquired immune deficiency syndrome: An evaluatitm of current practices. Gastrointcst Endosc 1987;31:76-9.

CAN J GA-.TROENTl:Rl)l VL)L 4 No 6 SEl'TEMBl:R/C.). 'TOlll:R 1990

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