Introduction to endoscopes and disinfection


Published on

1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Introduction to endoscopes and disinfection

  1. 1. Endoscopy Services Freeman Hospital Endoscopy Unit STUDENT NURSE Induction Pack Name__________________________ MENTOR_______________________ Start Date_______________________Information produced by Sisters G Nicholson & H Gray 1Date of origin August 2007, Review date August 2008
  2. 2. Introduction to Endoscopy UnitThe Endoscopy Unit at Freeman Hospital is part of the Newcastle upon TyneHospitals NHS Foundation Trust. The Endoscopy Services within the Trustare provided over 4 sites - Royal Victoria Infirmary, Freeman Hospital,Newcastle General Hospital, and Biddlestone Road Health Centre andcurrently carries out 15,000 procedures per year. These are performed byConsultant Gastroenterologists, Consultant Respiratory Physicians,Consultant Surgeons, Consultant Radiologists and Nurse Endoscopists. Theservice is also a tertiary referral centre for Gastro-Oesophageal Cancer andHepatobiliary Disease. This is reflected in particular areas of expertise and thecomplexity of some procedures. Endoscopy Services lies within the SurgicalDirectorate and provides ‘same day’ endoscopic investigation, diagnosis andtreatment for gastrointestinal and respiratory disorders and disease.The Freeman Endoscopy Unit is located in the cardio block (Ward 28) and isin temporary accommodation It has two procedure rooms and seesapproximately 6,000 patients each year, the majority of these are daypatients. The day patients are admitted to the Day Treatment Centre (Ward21) where a pre procedure assessment is carried out. The Unit works closelywith the hepatobiliary team, the colorectal team, the general medical teamand provides an in patient service. The unit is open Monday to Friday from7.30am to 6pm. The on call theatre team provides an out of hour’s service.The term ‘Endoscopy’ literally means ‘to look in and see’, it can describe avariety of procedures, it is a term that is widely used and may cause someconfusion, it is therefore preferable to use specific terminology:Gastroscopy - examination of oesophagus, stomach and duodenumColonoscopy - examination of the large bowelFlexible sigmoidoscopy - examination of the left side of bowelAn endoscopic procedure is described as either diagnostic - when a cause forpatient’s symptoms may be discovered or therapeutic - where treatment canbe administered to ease a patient’s problem/diseaseUseful reading (all available within the endoscopy for reference)Practical Gastrointestinal Endoscopy, 4th Edition, Cotton & WilliamsPractical Endoscopy, Shephard and MasonBritish Society of Gastroenterology GuidelinesInformation produced by Sisters G Nicholson & H Gray 2Date of origin August 2007, Review date August 2008
  3. 3. Philosophy of CareThe Endoscopy Unit is a highly technical area where patients can feelvulnerable resulting in high levels of anxiety. Our aim in each endoscopy unitis to use resources effectively and ensure patient safety by providingcontinuity of care from the time of assessment, through the admission, duringthe procedure to discharge. We shall endeavour to understand the patient asan individual so that their emotional and physical needs are met.Communication will be open and honest with all patients and staff, includingrelatives and carers, as appropriate, without breaches of confidentiality.Patients will be cared for by staff with relevant knowledge and skills.This document is for use by the multi-disciplinary teams, working at Newcastleupon Tyne Hospitals NHS Foundation Trust, for patients attending forendoscopic procedures in the Endoscopy Units and associated areas such asthe X-ray Departments. It outlines the provision of high quality, holistic andeffective care underpinned by evidence-based practice with the patient as theprimary focus.Information produced by Sisters G Nicholson & H Gray 3Date of origin August 2007, Review date August 2008
  4. 4. Week 1 Objectives:Orientation, observation and discuss outline of programme. AchievedIntroduction to the unit • Geography • Multidisciplinary team • Session times • Health and safety • Conscious sedation • Informed consentIntroduction to endoscopes and disinfection • Recognition of endoscopes • COSHH • Traceability • Decontamination of equipment • Storage of endoscopes • Set up endoscope for useThe Endoscopy Resource File will be a useful reference.Specialist text books can be borrowed from Sister’s Office.Week 2 Objectives:Under supervision observe • Care of patient undergoing Gastroscopy • Care of patient undergoing Colonoscopy • Nursing documentation /observations • Cleaning and disinfection of endoscope • Traceability and storage of endoscopes • Drying cabinets • Checking out of hours trolley • Checking arrest trolley • Calibration of blood sugar monitoring equipment • Receiving and discharging of patientsInformation produced by Sisters G Nicholson & H Gray 4Date of origin August 2007, Review date August 2008
  5. 5. Observe the following • Care of patient during ERCP • Care of patient undergoing EUS/FNA • Ward visits • Pre assessment • Biopsy taking, processing of specimens Introduction to drugs used in the department, including reversal agents. Implications of their use.Weeks 3 & 4 Objectives:Develop knowledge of cleaning processes • Leak testing • Manual cleaning of - Gastroscope • Manual cleaning of - Colonoscope • Use of washer disinfectors • Reprocess an endoscope • Traceability and storage of endoscopesIntroduction to accessories & equipment used in gastroscopy &colonoscopy. • Biopsy forceps • Cytology brushes • Cytology slides • Snares • Grabbers • Baskets • Injection needles • Diathermy units • Gold probes • Quick clipsInformation produced by Sisters G Nicholson & H Gray 5Date of origin August 2007, Review date August 2008
  6. 6. Recommended Independent Study • Patient care/safety, pre, peri and post procedure. • Anatomy and physiology of G.I. tract • Therapeutic gastroscopy • Therapeutic colonoscopy • ERCP • EUS/FNA • Commonly used drugs and their administration, including I.V. antibiotics • Referral routes of patients • Bowel preparation • Patient information leaflets • Local guidelinesInformation produced by Sisters G Nicholson & H Gray 6Date of origin August 2007, Review date August 2008
  7. 7. Freeman Endoscopy Unit StaffDirectorate: General SurgerySpeciality Manager: Gill BewickModern Matron:Endoscopy Services Manager: Linda HodgsonNursing Staff: Sister Gill Nicholson (Manager) Sister Heather Gray Staff Nurse Robbie Brady Staff Nurse Jan Gaffney Staff Nurse Judith Bryson Staff Nurse Janet Bowman Staff Nurse Joan Wood Staff Nurse Chris Wallace Staff Nurse Val Mills Staff Nurse Julia Lambourn Staff Nurse William Cresswell Staff Nurse Paul Watson Staff Nurse Gillian Campbell Staff Nurse Sarah Jack HCA Philip Wilson HCAAdmin & Clerical Staff: Michelle Cullen (Office Administrator) Vanessa Chirnside (Office Administrator) Brenda Wilson Alyson MarshConsultant Physicians: Dr Kofi Oppong (Lead Clinician for Endoscopy) Dr Mark Hudson Dr Nick Thompson Dr Steve StewartConsultant Surgeons: Mr Richard Charnley (Hepatobiliary) Mr Alan Horgan (Colorectal) Mr Paul Hainsworth (Colorectal)Porter Michael BarlowWard 21 Day Sister Kath TyrellTreatment Centre Sister Sarah CaiseRVI Endoscopy Unit Sister Eileen Woodall (Unit Manager) Sister Helen Wright Sister Jill Doyle June McAllister (Office Administrator)Nurse Endoscopists: Sister Elaine Stoker, (Freeman) Sister Mandy Robinson (RVI) Sister Lesley Jeffrey (Freeman) Sister Jayne Robinson (RVI)Information produced by Sisters G Nicholson & H Gray 7Date of origin August 2007, Review date August 2008
  9. 9. Summary of Procedures1. GastroscopyThe complete title should be oesophagastroduodenoscopy, but for practicalreasons has been shortened to gastroscopy.The lining of the oesophagus, stomach and duodenum are visualised. Youmay hear the abbreviation OGD also used.To have the examination performed patients are given a choice of either localanaesthetic spray applied to the back of their throat or intravenous sedation.Patients are only able to receive sedation if they have a responsible adult totake them home and stay with them overnight.Patients receiving sedation require close observation. Their level ofconsciousness and respiratory function must be monitored throughout theprocedure and immediately afterwards.Oxygen is given to all patients receiving sedation as per policy.All patients must be nil by mouth, 4 hours for food and 2 hours for fluids priorto the procedure to minimise risk of aspiration.The procedure takes approximately 10-15 minutes 9
  10. 10. 2. Colonoscopy.During colonoscopy the internal lumen of the large bowel is visualised. It ispossible to inspect from rectum to caecum. Patients receive intravenousPethidine or Fentanyl as pain relief and Midazolam as sedation. Prior tocolonoscopy patients must stop all iron supplements for 1 week, commence alow residue diet for 48 hours prior to the procedure and take bowelpreparation the day before the procedure to ensure the bowel is completelyempty so that the mucosal wall can be visualised.The procedure takes approximately 20-30 minutes.3. Flexible sigmoidoscopyThe lower part of the colon is visualised during flexible sigmoidoscopy, fromrectum to splenic flexure.Patients usually do not require sedation for this procedure.To clear the lower part of the bowel the patient is given 1-2 phosphateenemas 1-2 hours prior to the procedure. These can be self administered athome or given by the ward nurse in hospital.The test takes 5-10minutes. 10
  11. 11. 4. E.R.C.P.Its literal meaning is ENDOSCOPIC - via an endoscope RETROGRADE - directed backwards CHOLANGIO PANCREATOGRAPHY - to visualise and obtain x-rayimages of the gallbladder, common bile duct, pancreatic duct and biliary tree.This is a highly skilled and technical procedure, probably the most demandingof all endoscopic procedures. It is performed under x-ray vision in theendoscopy department. The aim is to visualise the biliary and pancreaticsystem using x-ray contrast, in order to remove stones, obtain brushings forhistological examination or drain the biliary system by inserting a stent.This procedure can last any where from 20-60 minutes.Prior to the procedure patients must have no food for 4- 6 hours and no fluidsfor 2 hours.All patients must have recent blood screening to check: • Clotting studies • Liver function • ElectrolytesMost patients will require IV antibiotics 1 hour before the procedure. 11
  12. 12. 5. Endoscopic Ultrasound (EUS)An Endoscopic Ultrasound is an internal scan of the upper GI tract givingaccurate images of the Hepatobiliary system.Samples can be taken of any lesions found; this is called a fine needleaspiration (FNA). Before an FNA is performed; the patients clotting has to bechecked and found to be within normal limits.Patients must have nothing to eat for 4-6 hours and water only up to 2 hoursbefore the procedure. 12
  13. 13. COMMONLY USED DRUGS IN ENDOSCOPYBENZPDOAZEPINES - These possess useful properties, including,reducing anxiety, causing amnesia and sedation. They have noanalgesic effect, so opioids can be given in conjunction with them forpain relief. The main side effect is respiratory depression and thereversal drug is Flumazenil. Other side effects include, in profoundsedation, sexual fantasies.Midazolam (Hypnoval)Midazolam is the drug of choice in the majority of our procedures;Gastroscopy, Colonoscopy, PEG, ERCP etc. with a sedative effect forup to 24 hours. Midazolam has a faster recovery time than otherBenzodiazepines.Given IV. Draw up 1 ampoule in 5 ml labelled syringe. Concentrationis 10mg/5ml – 2mg/1ml.Diazepam (Diazemuls)Diazepam is the preference of some doctors for ERCP. It is longeracting and can have a second period of drowsiness after severalhours. It comes ready prepared as a white emulsion.Given IV. Draw up 2x10mg ampoules into a 5ml labelled syringe.Concentration is 5mgs in 1ml.OPIOIDS - Opoids are used to relieve moderate to severe pain. Themain side effects include nausea, vomiting, constipation, drowsiness,hypotension and respiratory depression. The reversal drug isNaloxone (Narcan).PethidinePethidine is given during Colonoscopy and ERCP. Produces promptshort lasting analgesia.Given IV. Draw up 1 ampoule in a 2ml labelled syringe.Concentration is 50mg/1ml.FentanylFentanyl is the preference of some doctors for Colonoscopy. It is veryquick acting.Given IV. Draw up 1 ampoule in 2ml labelled syringe. Concentrationis 100mcg in 2mls, 50mcg in 1ml. 13
  14. 14. REVERSAL DRUGS - Used as antagonists. Both Naloxone andFlumazenil have shorter half life that the drugs they reverse, and thepatient is at risk of becoming re-sedated.Flumazenil (Anexate)Flumazenil is used to reverse Benzodiazepines. It is short acting andmay need to be repeated.Given IV. Draw up 1 ampoule in 5ml labelled syringe. Concentrationis 500mcgs in 5mls, 100mcgs in 1ml.Naloxone (Narcan)Naloxone is used to reverse Opioid drugs. It is short acting and mayneed to be repeated.Given IV. Draw up 1 ampoule in 2ml labelled syringe. Concentrationis 400mcg in 1ml.ANTISPASMODICSUsed to relax the gut during therapeutic procedures and Colonoscopyby reducing peristalsis and spasm.Hyoscine Butylbromide (Buscopan)The side effects include bradycardia and tachycardia: therefore itshould not be used for patients who have recently had an MI, orcardiac rhythm disturbances.Given IV. Draw up I or 2 ampoules, depending on the dose required,in a 2ml labelled syringe. Concentration is 20mg in 1mlGlucagonGlucagon inhibits gut motility and tends to be used when Buscopan iscontraindicated. Caution must be given to diabetic patients, as it is ahyperglycaemic agent. Glucagon comes in a ready prepared “hypokit”.Given IV. The pack contains a syringe containing water and a vial ofpowder to be reconstituted, inject the water into the vial and then drawit up into a normal syringe so that the needle can be removed in orderto be given IV. Concentration is 1 unit (1mg) in 1ml.LOCAL ANAESTHETICSLidocaine Throat Spray (Xylocaine)Lidocaine is used for Gastroscopy patients who do not want to besedated. It works by numbing the mouth and throat. The loss ofsensation may make swallowing difficult and reassurance is given tothe patient that swallowing and breathing remain the same. This effectcan last for up to one hour and the patient is kept nil by mouth for onehour to reduce the risk of aspiration. 14
  15. 15. LEARNING OPPORTUNITIES KEY ELEMENT RESOURCE/DEPARTMENTCLINICAL SKILLS PERSONEL/DEPARTMENT Learning Opportunities Resource/Relevant/ Personel/Department Patient Hygiene Skin carePressure care prevention Registered Nurse/HCA(waterlow scoring) Registered/HCA/Doctorrecording of physiological Ward staffobservationsBP Registered nurse/diabetic specialistTPR nurseBlood Glucose Registered/HCAMaintaining accurate charts RegisteredGiving medications nurse/pharmacist/doctorsRectalIntravenousIV infusionsCannulation/care of venflons Registered nurse/infection controlMedical devices nurseAdministration of blood and blood Registered nurse/medicalproduct electronics/equip libraryAseptic techniques (Peg)Risk assessmentBMI nutritional assessmentMoving and HandlingInfection controlPatient SafetyChecking equipmentConsentInformationNon-invasive radiology 15
  16. 16. LEARNING OPPORTUNITIES RESOURCE/RELEVANT PERSONEL/DEPARTMENT Colo-RectalAnatomy-physiology Registered nurses/nurseDisorders specialist/doctors/books/computerInvestigationsInfections Microbiology/infection controlTreatmentDrugs Pharmacy/registeredRole of nurse specialist nurse/doctor/nurseSupport mechanisms specialist/registered nurse Hepato-BiliaryAnatomy-physiologyDisorders Registered nurse/nurseSymptoms specialist/doctors books/computerInvestigationsTreatment optionsDrugsRole of nurse specialist Pharmacy/registered nurse/doctorSupport mechanisms Hepato-biliary nurse specialist NutritionNasog – gastric tubes insertionNaso jejunal tubes insertion Registered nurse/nurseNutrition nurse specialist specialist/dietician/nurse specialist/Support mechanisms dietician 16
  17. 17. KEY ELEMENTHEALTH DEVELOPMENT OPPORTUNITIESLEARNING OPPORTUNITIES RESOURCE/RELEVANT PERSONEL/DEPARTMENT Healthy life style in relation toSmoking cessationAlcoholic liver diseaseBowel disordersCancerObesityDiabetes Patient information leaflets andEating for a healthy heart HealthDrug and alcohol abuse Promotion unitPromotion of exerciseHealthy heart 17
  18. 18. KEY ELEMENTMANAGEMENT OF CARELEARNING OPPORTUNITES RESOURCE/RELEVANT/ PERSONEL/DEPARTMENTNursing process Assessment Registered nurse/pre-assessment nurseWho assesses Source of informationHow is assessment carried out/open Patient,relatives,doctor,pharmacist,or closed questions notesWhat is assessed District nurses,specialist nurseWhere does it take placePlanningCare plansRisk assessment toolsCare pathwaysMulti disciplinary plan/working Registered nurseReferrals to other agencies MDTSpecialist nurses Registered nurse Implementation/Evaluation Registered nurseMDTDocumentationStandards Registered nurseProtocols Registered nursePolicies Registered nurseCommunication/relative/patient Registered nurse/royal marsdenTime management Handbook/intranetPlanning priorities Registered nurse/doctor/nurseDealing with difficult situations specialistPatient property Registered nurseReligious needs Registered nurse Registered nurse/doctor/nursing manager General office/registered nurse Registered nurse/hospital/chaplain priest 18
  19. 19. KEY ELEMENTORGANISATIONAL AND MANGERIAL ISSUESLEARNING OPPORTUNITIES RESOURCE/RELEVANT/ PERSONAL/DEPARTMENTManaging a team Organisational skills Registered nurse/nurse managersDelegation skills Registered nursePrioritising skills Registered nurse/doctorsTime management Registered nurse/all ward staffLeadership SisterOff duty Sister/E grade staff nurseManaging patient work load Registered nurseQuality Registered nurse/audit tools/specStandards of care nurseImplementing change Registered nurseDocumentation Registered nurse Giving information to Clerical/registered nurse StaffDoctors Sister/nurse managerPatients Sister/registered nurseRelatives Registered nurse/doctorMulti-disciplinary team members Registered nurse/doctorOther departments Registered nurses Resources Registered nurses/doctors Stock controlDrugs Registered nurse/pharmacists/storesMaterials management Registered nurse/pharmacistsNon stock Registered nurse/stores/materialStationary managEstablishment/skill mix Sister/charge nurse/stores deptBudget control Sister/charge nurse/clerical Managing risk Sister Policies and procedures SisterEquipment safety checksQuality control Sister/registered nurse/computerWeekly environment checks Health &Infection control Safetyofficer/elect/housekeeperMoving and handling Health & Safety officer Emergency situations Unit nurseCardiac arrest Control of infection sisterFast bleep system Moving and handling co-ordinator 19
  20. 20. Violent incidentsFire Cardiac arrest team/registered nurse Staff developments Registered nurses/switchboard Clinical supervision Registered nurse/security officerReflective practice Fire officer/registered nurse Registered nurses Registered nurses 20
  21. 21. MULTIPLE GASTROINTESTINAL BIOPSIESThe millipore filter is a disc of up to 12 squares wide and which areapproximately 3mm2. A strip of the filter paper two squares wide will beprovided.At endoscopy, place the biopsies in sequence starting at the pointed end andas close as possible to the bottom edge of the filter paper strip (as below).Once the endoscopy has finished and all the biopsies have been taken (nomore than 6 should be put on a strip), place the millipore strip into a universalcontainer with sufficient formalin, for processing in the laboratory. If you havetaken more than one strip of biopsies, then put each strip in a differentuniversal container.This procedure should not be used for macroscopic polyps which should besent in separate pots as previously.Potential savings are1. Less handling of the tissue2. Fewer specimen pots are required for each investigation3. For upper gastrointestinal biopsies a greater range of special stains can be applied as a routine.Ref: J Clin Pathol 1992; 45: 751-755 ACP Broad sheet 132 21
  22. 22. SCOPE TYPE SCOPE SERIAL CHANN DISTAL SERVICE NO: NO: EL SIZE END CONTRACT & SIZE EXPIRY DATEGASTROSCOPESGIFIT240 A 0910 2030109 3.7mm 10.9mm Keymed 28/02/08GIFIT240 B 3410 2430266 3.7mm 10.9mm Keymed 31/03/08GIFIT240C 2710 2630363 3.7mm 10.9mm Keymed 26/02/10GIFXQ230 A 0808 2715463 2.8mm 9.2mm T.B.S. 28/02/08GIFXQ230 B 0308 2715462 2.8mm 9.2mm Keymed 28/02/08GIFP230 0608 2700475 2.2mm 8.7mm T.B.S. 28/02/08GIF2T240 4113 2430754 L 2.8mm 11.8mm Keymed 31/03/08 R 3.7mmXQ260A 3508 2521986 2.8mm 9.0mm Keymed 31/03/08XQ260B 3608 2521994 2.8mm 9.0mm Keymed 31/03/08GIFQ230 A 0708 2701460 2.8mm 10.5mm T.B.S. 28/02/08EUS SCOPESEG383 OUT 3214 E110021 3.8mm 12.8mm Pentax no contractEG363 OUR 3110 E110164 2.4mm 12.1mm Pentax no contractEG363 OU 3314 E110215 2.4mm 12.1mm Pentax no contractCOLONOSCOPESCF240DLA 2908 2300127 3.2mm 12.2mm Keymed 24/04/08CF240DLB 3008 2300129 3.2mm 12.2mm Keymed 02/06/08CF240AL 2208 2010126 3.2mm 12.2mm Keymed 28/02/08CF240L 1708 2900394 3.2mm 12.2mm Keymed 28/02/08CF230L 2110 2700892 3.2mm 13.6mm No contractIT200LA 1810 2500236 4.2mm 15.4mm T.B.S 28/02/08IT200LB 1910 2700275 4.2mm 15.4mm T.B.S. 28/02/08GIFQ260DLA 3708 2510218 3.2mm 12.2mm Keymed 31/03/08GIFQ260DLB 3808 2510225 3.2mm 12.2mm Keymed 31/03/08GIFQ260DLC 3908 2510232 3.2mm 12.2mm Keymed 31/03/08GIFQ260DLD 4008 2510242 3.2mm 12.2mm Keymed 31/03/08CFH260AL 2808 2700551 3.7mm 13.2mm Keymed 26/02/10DUODENOSCOPESTJF200 2309 2700798 4.2mm 13.0mm T.B.S. 28/02/08TJF240 2509 2030238 4.2mm 13.5mm Keymed 28/02/08JF230 2409 2700995 3.2mm 12.0mm Keymed 28/02/08TJF260V 2609 2700282 4.2mm 13.5mm Keymed 18/02/10BRONCHOSCOPESLF-02 1602 2714612 1.5mm 4.1mm Keymed / TheatreLF-GP 4202 1212730 1.5mm 4.1mm Keymed /TheatreLF-TP 4302 1001547 2.6mm 5.2mm Keymed /G.I.T.U. Company Service Contract - Contact numbers: KEYMED 01702 616333 TBS (MDS) 01702 608728 Hitachi (pentax) 01933402111 22
  23. 23. Equipment requiring endoscopes with certain dimensions• SIX SHOOTER BANDER (9.5-13mm distal end) 2.8mm channel size.• N.J. TUBES 8fr (3.2mm) 10fr (3.7mm)• COLONIC STENTS 3.7mm minimum channel size.• GOLD PROBE 7fr (2.3mm) 10fr (3.2mm)• PAEDIATRIC SCOPE (P230) forceps FB-241K blue handle• OVER TUBES short (8.6-10mm) long (10.0 – 11.7mm) 23
  24. 24. Cleaning and disinfection of equipment used for gastrointestinal flexible endoscopyImmediately post procedures perform the following: • Wipe down scope immediately post procedure with a gauze swab warm water and detergent • Suck through suction channel until suction runs clear or for at least 10 seconds • Blow and bubble with air water valve for at least 10 seconds • Remove air water valve and replace with flushing valve depress this for ten to 15 seconds with tip under water • Dispose of biopsy bung if biopsies have been taken • Place scope in a plastic disposable transportation tray or bag and place in stack marked contaminated scopes outside cleaning roomEndoscopy cleaning room: • Fill sink with warm water to marked level on sink and press button on wall for measured amount of enzymatic cleaner. • Ensure leak test cap is in place switch on leak tester, attach to leak test cap. • Using large then small angulations wheels check that angulations are working check for air leaks at distal tip. • Immerse all of the scope in the sink and check for leaks. If a leak is seen wipe external surface of scope with alcohol wipes and leave on clean waterproof towel, inform endoscopy staff to arrange repair. • Switch off leak detector and leave attached for 30 seconds to deflate. • Using the flushing devise flush all channels with diluted enzymatic fluid at least 3 times. • Use 5ml syringe + connector to flush back channels where fitted with dilute enzymatic cleaner. • Cleaning brushes can be found on the first shelf to the left of the sink. • Brush distal end with large end of cleaning brush paying particular attention to air water outlet and bridge elevator if fitted. • Brush around biopsy channel, suction and air water ports brush down these channels with large end of brush for approximately 1 inch with the scope under water.Internal cleaning process: • With the scope fully immersed brush through at least three times from each port with small end of cleaning brush, cleaning brush each time it emerges. 1. Brush from biopsy port until brush emerges from distal end. 2. Brush through suction port and down until brush emerges from distal end. 3. Brush from suction port though umbilical cord until brush emerges from suction connector. 24
  25. 25. • On endoscopes with a raiser bridge attach a bridge channel adapter and flush with dilute enzymatic solution found on back of sink and a 2 ml syringe• Using an all channel irrigation device; Blue for 230 series Green for 240 and 260 series• Flush 60mls of dilute enzymatic cleaner down each port on device.• The scope is now ready to connect to the Labcaire Washer Disinfector for disinfecting• All valves should be scrupulously cleaned• Rinse water bottle and dry 25
  26. 26. Cleaning Pentax E.U.S. ScopesImmediately after removal from patient. 1. Remove balloon and securing ‘o’ ring. 2. Wipe down scope with a gauze swab in warm water with detergent. 3. Depress valves to suck and blow channels clear. 4. .Remove balloon valve and put on white cap, remove air water and suction valves and put in channel separator. 5. Place distal end in sink and suck through for 5 seconds. 6. Remove scope from processor and put on metal cap, remove relay end from Hitachi machine and secure in metal box. 7. Ensure metal water resistant cap is on scope (do not put box in sink). 8. Place in carrying tray, cover and send to cleaning In Cleaning Room1. Leak test box (do not release pressure as this makes air tight seal.)2. Leak test as usual on tree and release pressure.3. Remove all valves. Clean them with small brush and place in ultrasonic cleaner for 30mins. Then disinfect.4. Place white cap on balloon port and screw channel separator in place andput clean biopsy cap over biopsy port.5. Flush back channel with dilute enzymatic solution, 10mls in 10ml syringe x 3.6. Flush bridge wash channel with dilute enzymatic solution, 2mls in 2ml syringe x 3, moving bridge, to dislodge any tissue.7. Plug flushing adaptor into water bottle port, block suction port on tree with finger and flush 60mls of dilute enzymatic solution through adapter. Then flush 60mls of solution through suction port with biopsy cap in place and with flushing adapter still in water bottle port.8. Clean ports and bridge with a small brush. Clean raiser bridge carefully with an orange stick covered with cotton wool.9. Remove white balloon cap and red and blue washing valves.10. Brush at least 3 times or until clean, from suction port on tree to suction valve. 26
  27. 27. 11. Brush at least 3 times or until clean, from suction valve to balloon port with white cap off.12. Brush at least 3 times or until clean, from biopsy port to tip.13. Replace white balloon cap, washing valves and place the clean biopsy cap over biopsy port.14. Repeat steps 6. 7. & 8.15. Endoscope is now ready for chemical disinfection. 27
  28. 28. Returning an endoscope for repairFailed leak test after use: • Remove gross debris, with solution of water and enzymatic cleaner. Then dry exterior of scope and wipe down with alcohol.Mechanical or electronic fault: • Reprocess as normal. 1. Remove I.D. disc from scope, place it in a small white autoclave bag and label it with scope no: stick it to bottom of white board in cleaning room. Complete movement details on board. Also remove all caps and valves. 2. Fill in appropriate decontamination certificate and pack this along with the scope in the correct case. (check serial numbers) 3. Refer to back page of scope movement record book, for maintenance contract details. 4. Note, model, serial no. and maintenance contractor. • Keymed - 01506416655 courier tel. #61384 • M.D.S./T.B.S. - 01702608728 courier tel. #861383 • HITACHI (pentax) - 01933402111 Inform them you are returning a scope for repair, they will require: contact name, decontamination status, details of fault, scope model and serial no. Request a loan scope of equal specification. 5. Fill in ALL details in scope movement book. Arrange for appropriate courier to pick up scope from stores between 08.30 and 15.30. They will require hospital post code : NE7 7DN. Phone stores they will pick up the scope from the department for collection by the courier, for return to Keymed/T.B.S.(MDS) 6. Pentax scopes are returned via medical electronics. Receiving a loan scope: • Document, date, type, serial no. and contractor’s name, in scope movement log • Attach pt. I.D. label onto scope & case with above details • Fill in scope movement details on white board in cleaning room Receiving repaired scope: • Complete paperwork in log book. • Attach I.D. disc. • Pack up loan scope with decontamination certificate and arrange return of loan equipment. 28
  29. 29. Self Disinfect Process for Labcaire Washer DisinfectorThe self disinfect process is controlled by a step by step procedure that isdisplayed on the screen of the control panel. The process is controlled by theleft hand control panel only. Before commencing the self disinfect cycle, thecontrol panel must display the auto ready screen.The procedure: 1. Remove scope connector and connect the self disinfect outlets. Make sure that they are firmly in place. 2. Empty the detergent container, rinse and place in the front of the tray with the opening towards the drainage outlet. 3. Close the machine and press proceed. 4. Wait as the water filtration trolley drains some water away to the drain, which brings the water in the tank down to the correct level. 5. The screen will prompt you to add the Autosan solution to the filtration tank. 6. Another menu will come up asking for when the self disinfect is required either now or 1st, 2nd or 3rd day. 7. When the process is completed the printer will print out details of whether the process has passed or failed. I f failed for no obvious mistake made in the processing, contact maintenance for appropriate action. 8. If the process is satisfactory, open the machine and place a small quantity of detergent into the container and then fill it up with sterile water, rinse the filters under the running tap. 9. Top up the alcohol bottle. 10. Clean the machine with wet blue roll and detergent both internally and externally. Wipe the detergent off with clean wet blue roll. Wipe the tray and the non plastic part of the interior with alcohol wipes. 11. Replace the scope connections, ready for use. 12. Complete the paper work in the appropriate file and then sign the necessary documentations. 29
  30. 30. Newcastle upon Tyne Hospitals NHS Foundation Trust Endoscopy Services Guidelines for Performing Endoscopic Procedures as Day Cases in Patients with DiabetesThese guidelines are based on expert opinion and pragmatism rather thanrobust evidence.The following guidelines are for preparing diabetic patients who are wellcontrolled, fit (without major co morbidity) and are able to check capillaryglucose levels. All Diabetics must have a pre procedure assessment.Insulin Dependent Diabetics requiring therapeutic procedures should be daycase in patients & have a GKI if necessary.Diabetic patients who are controlled by diet alone should follow normal nondiabetic preparations and can be on am or pm lists.1. Gastroscopy:Gastroscopy (especially diagnostic) is a relatively short procedure and caneasily be performed as a day case procedure provided every effort is made toperform such procedures first on the morning list.Gastroscopy in Insulin Dependent Diabetic patients:  Patients should not eat anything from midnight, but may drink water (or Lucozade if required) up to 2 hours before appointment time.  Patients should omit morning dose of insulin, unless this is insulin glargine (Lantus) which should be given as usual.  Patients should check capillary blood glucose first thing in the morning and drink Lucozade (one glass; ~200 ml) if glucose 4 mmol/l or less.  Patients should bring insulin with them to the Endoscopy Unit.  On arrival at the Endoscopy Unit, the patients blood glucose must be checked by endoscopy nurse before the procedure – ensure ≥5 mmol/l.  Post procedure: If before 11 am, as soon as the patient can safely eat give usual morning dose of insulin and carbohydrate equivalent to usual breakfast If pre-lunch, on basal/bolus regimen, as soon as the patient can safely eat, give usual quick-acting lunchtime insulin and lunch carbohydrate If pre lunch on twice daily insulin, as soon as the patient can safely eat give half doses of the pre-breakfast usual insulin(s) and lunch carbohydrate  Check blood glucose hourly until next meal. 30
  31. 31. Gastroscopy in Diabetic Patients on oral hypoglycaemic agents  Patients should not eat anything from midnight, patients may drink water (or Lucozade if required) up to 2 hours before appointment time.  Patients should omit morning dose of oral hypoglycaemic agent.  Patients should restart usual tablets and diet with the first meal post endoscopy.  Patients on Chlorpropamide and Glibenclamide should possibly be converted to short acting sulphonylureas (e.g. Gliclazide) at least 48hrs prior to endoscopy to prevent hypoglycaemia. Patients should contact their own diabetic team for advice.2. Flexible Sigmoidoscopy:  Patients should not alter medication or eating routine3. Colonoscopy:Colonoscopy is more of an issue as this requires a more prolonged period ofpreparation prior to the procedure. Outpatients should always have theirprocedure first on the morning list.Colonoscopy in Diabetic patients who are Insulin Dependent or on oralhypoglycaemic agents  Patients should do regular checks of blood glucose (at least before each meal and at bed time) in the 48hr period prior to the procedure.Day prior to colonoscopy:Patients should –  Start their preparation as instructed at 8am on the morning before the procedure  Drink plenty of fluids during the preparation period as instructed (at least 6 pints during the day)  Patients should follow bowel preparation leaflet but in place of diet take one Enlive Plus drink each for breakfast, lunch, evening meal and supper (total of 4). The entire contents of the cartons must be drunk. If blood glucose low at any point take a drink of Lucozade (1 glass; ~200 ml). Continue usual insulin/oral agents during this time. Consult your own diabetes care team if you are unsure what to do.Day of colonoscopy:  Omit their morning dose of insulin and/or oral hypoglycaemic tablets on the morning of the procedure unless this is insulin glargine (Lantus) which should be given as usual.  Patients may drink water (or Lucozade if required) up to 2 hours before appointment time. 31
  32. 32.  Check their blood glucose before leaving home for the hospital where the procedure will be performed.  On arrival at the Endoscopy Unit, your blood glucose will be checked by endoscopy nurse before the procedure – ensure ≥5 mmol/l  After the procedure, patients should have their blood glucose checked and insulin or oral hypoglycaemic agent administered as per instructions for gastroscopy when patient has recovered from sedation and ready to eat. Patients with multiple co morbidity and those who are frail or for any reason unable to regularly check their blood glucose levels should be admitted for in- patient preparation and probably have a glucose-potassium-insulin infusion for their procedure.The same should apply to patients who have planned complex therapeutic colonoscopy procedures. 32
  33. 33. Newcastle upon Tyne Hospitals NHS Foundation Trust Endoscopy Services Guidelines for Diabetic Patients attending for Gastroscopy as a Day Case  All diabetic patients on Insulin or Oral Hypoglycaemic Tablets should have a pre procedure assessment and be first on the morning list Does the patient take Insulin or Oral Hypoglycaemic Tablets No Yes Patient follows What type of treatment does normal the patient have? Non diabetic preparation & can be on am or Insulin pm list Oral Hypoglycaemic Tablets Nothing to eat from 12 midnight, may drink water (or lucozade if required) Nothing to eat from 12 midnight, up to 2hours prior to test may drink water (or lucozade ifrequired) up to 2hours prior to test Omit morning dose of insulin unless Insulin Glargine (Lantus) which should be given as usual Monitor Blood Glucose - if 4mmol/l or Omit morning dose less, drink 1x 200ml glass of Lucozade Bring Insulin to hospital Monitor Blood Glucose - if4mmol/l or less drink 1x 200ml glass of Lucozade Patient to have blood glucose checked on arrival to ensure 5 mmol/l or more (See Day case Protocol) Bring medication to hospital Post procedure, if Post procedure, if pre Post procedure, if preRestart tablets and diet with first before 11am – usual lunch on bolus regime lunch on twice daily - meal post procedure insulin dose & - give quick acting give half usual dose of carbohydrate lunchtime insulin & pre breakfast insulin(s) equivalent to usual usual lunch & usual lunch breakfast carbohydrate carbohydrate Check blood glucose hourly until next meal 33
  34. 34. Newcastle upon Tyne Hospitals NHS Foundation Trust Endoscopy Services Guidelines for Diabetic Patients attending for Colonoscopy as a Day Case  All Insulin Dependent Diabetic patients must have a pre procedure assessment  All diabetic patients should do regular checks of blood glucose levels (at least before each meal and at bedtime) in the 48hours prior to the procedure Does the patient take Insulin or Oral Hypoglycaemic Tablets must be on am list No Yes Day prior to colonoscopy Day of Colonoscopy Nothing to eat from 12 midnight, may Patient follows Take usual dose of Insulin or drink water (or lucozade if required) normal Oral Hypoglycaemic Tablets up to 2hours prior to test Non diabetic preparation & Insulin Dependent Diabetics Omit morning dose of Insulin or Oral can be on am or Follow bowel preparation Hypoglycaemic Tablets unless Insulin pm list instructions but in place of Glargine (Lantus) which should bediet/food take a total of 4 Enlive given as usual Plus drinks throughout the day e.g. breakfast, lunch, evening meal and supper. Monitor Blood Glucose - if 4mmol/l or The entire contents of the less, drink 1x 200ml glass of Lucozade cartons must be drunk. Diabetics on Oral Bring Insulin or Oral Hypoglycaemic Hypoglycaemic Tablets Tablets to hospital Follow bowel preparationinstructions. Take no further oral hypoglycaemic tablets after Patient to have blood glucose checked lunchtime food on arrival to ensure 5 mmol/l or more (see Day case Protocol) Monitor Blood Glucose - if4mmol/l or less drink 1x 200ml Post procedure, if Post procedure, if Post procedure, if pre glass of Lucozade before 11am – usual pre lunch on bolus lunch on twice daily - insulin dose and regime - give quick give half dose of pre carbohydrate acting lunchtime breakfast usual insulin(s)Consult your own diabetes care equivalent to usual insulin and lunch & lunch carbohydrate team if unsure breakfast carbohydrate Post procedure - patients taking oral hypoglycaemic tablets should recommence tablets with food All patients should check blood glucose hourly until next 34 meal
  35. 35. Newcastle upon Tyne Hospitals NHS Foundation Trust Endoscopy Services Guidelines for Patients with Diabetes attending as Day Cases for Endoscopic Procedures whilst in the Endoscopy UnitPre procedure: • All diabetic patients to have pre procedure Blood Glucose Level checked to ensure 5mmol/l or above • All insulin dependent diabetics have IV access in situ for any endoscopic procedure with or without sedation Blood Glucose Range:< 3.3 mmol/l Inform Endoscopist - follow NUTH Guidelines for the Treatment of Hypoglycaemia in Hospital (found on Intranet)4-7 mmol/l optimal level for fasting blood glucose> 11 mmol/l Inform EndoscopistPost procedure:• Follow NUTH Guidelines for performing Endoscopic procedures as Day Cases in Diabetic Patients• All diabetic patients to have Blood Glucose Level checked prior to discharge• If Blood glucose > 11mmol/l patient advised to have follow up with GP or Diabetic Centre, NGH.Guidelines on the Trust Intranet: • NUTH Guidelines for Management of Patients with Diabetes during surgery • Guidelines for Diabetes management using Glucose Insulin Potassium (GKI) Infusion. • Guidelines for the Treatment of Hypoglycaemia in Hospital • Guidelines for the Management of Hyperglycaemia Emergencies 35
  36. 36. Guidelines on the Management of Anticoagulation for Endoscopic Procedures1. The decision to reverse anticoagulation and the extent of anticoagulation reversal should beindividualised, weighing the risk of thromboembolism against the risk of continual bleeding.2. A supratherapeutic INR may be corrected with the infusion of fresh frozen plasma. Correctionof the INR to 1.5 or less permits effective endoscopic diagnosis and therapy.3. In cases of acute bleeding and the need for emergency Endoscopy, Beriplex is probably thetreatment of choice for reversal of INR but liaison with the on–call Haematologist and referenceto the INR reversal document is advised4. Reinstitution of anticoagulation should be individualised.5. Recommendations for the management of anticoagulation, aspirin and Clopidogrel use inpatients undergoing endoscopic procedures based on relative risks of the procedure andunderlying condition.6. Patients should have INR check on day of or day prior to Endoscopy High risk condition Low risk condition Discontinue Warfarin 5 days before procedure Discontinue Warfarin 5High Risk Consider IV Heparin while INR is below days before procedureProcedures therapeutic level, stop 4hrs before time of Re-institute Warfarin procedure after procedure No change in anticoagulation. Discontinue Warfarin 5Low Risk Elective procedures should be days before procedureProcedure delayed while INR is in Re-institute Warfarin supratherapeutic range after procedure High Risk Procedures Low Risk Procedures  Polypectomy  Diagnostic  Biliary sphincterotomy - OGD +/- biopsy  Pneumatic or bougie dilatation - Flex sigmoidoscopy +/- biopsy  Endosonographic guided fine needle - Colonoscopy +/- biopsy aspiration  ERCP without sphincterotomy  PEG placement  Biliary/pancreatic stent without  Laser ablation and coagulation sphincterotomy  Treatment of varices  Endosonography without fine needle aspiration  Enteroscopy High Risk Conditions Low Risk Conditions  Atrial fibrillation associated with  Deep vein thrombosis over 12 weeks ago valvular heart disease  Uncomplicated or paroxysmal non-valvular  Mechanical valve in the mitral arterial fibrillation position  Bio prosthetic valve  Mechanical valve and prior  Mechanical valve in the aortic position, but thromboembolic event if patient’s normal INR target range is  Thromboembolic event less than 4 greater than 3.0 seek advise from weeks previously cardiologist  Anti-phospholipid syndrome  INR target range greater than 3.0 Aspirin and Clopidogrel Use (High Risk Procedures)In the absence of a pre existing bleeding disorder, endoscopic procedures may be performed.  Emergency procedures – proceed immediately, give platelets if bleeding occurs  Urgent procedures - stop 48 hours pre procedure  Elective procedures - stop 10 days pre procedureGuidelines adapted from American Society for Gastrointestinal Endoscopy (2002). Guideline on the management ofanticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointestinal Endoscopy, Vol 55 (7), 775-779 36
  37. 37. By Dr M Gunn Consultant Gastroenterologist, Dr P Kesteven Consultant Haematologist, L Hodgson Endoscopy ServicesManager. Date of origin July 2007 Review Date July 2008 Endoscopy Services Policy for withdrawal of consent during an endoscopic procedureThe purpose of this guideline is to assist clinicians and endoscopy staff when confronted withthe situation where a patient wishes to withdraw consent whilst undergoing an endoscopicprocedure. It also offers some practical guidance within the clinical setting.Introduction:The process of consent starts when options for treatment are first discussed with a patient inthe GP surgery, outpatients department, or ward. It continues up to and during the procedure.If the process is to be meaningful, refusal must be one of the patient’s options. Additionally,the patient is entitled to change their mind at any time.A component of the consent procedure is a discussion with the patient on alternativetreatments or tests available for their condition. As part of this discussion, the patient shouldbe made aware of the consequences should the procedure not be performed or completed.Where the patient has signed a consent form and subsequently changes their mind, theperson taking consent or the endoscopist performing the procedure (and where possible thepatient) should note this on the consent form. However, this information must be documentedin the medical notes.Guidance:Directly before their procedure, the patient should have the opportunity to discuss thisguideline either with the nurse looking after them or the endoscopist.The patient should be informed that: • The procedure will only be carried out with their consent. • They can withdraw their consent at any time throughout the procedure. • In the event of a life-threatening situation, the endoscopist will decide whether to continue the procedure based on the patients best interests.The Sedated Patient (All Procedures):Sedation used for all endoscopic procedures is ‘conscious sedation’. This has been definedas“a technique in which the use of drug or drugs produces a state of depression of thecentral nervous system enabling treatment to be carried out, but during which verbalcontact with the patient is maintained throughout the period of sedation. The drug andtechniques used to provide conscious sedation should carry a margin of safety wideenough to render loss of consciousness unlikely”.If purposeful or verbal responsiveness is lost the patient requires a level of care identical tothat needed for general anaesthesia. Safety and sedation during endoscopic procedures BSG Guidelines 2003When a patient has been sedated it is a reasonable assumption that the patient has impairedability to give valid consent. The anticipated effect of sedation is that the patient will be able to 37
  38. 38. communicate, but is in a relaxed state. However, sedation is unpredictable and patients areunreliably affected.Assessing capacity during a procedure can be difficult. Therefore, the decision to stop theprocedure is a matter of clinical judgement. There needs to be a balance between the level ofdistress being experienced by the patient and the need to complete the endoscopy at thattime.If the patient wishes the procedure to be stopped whilst under the influence of conscioussedation:“The endoscopist should try to establish whether the patient has capacity to withdrawa previously given consent. If capacity is lacking, it may be justified to continue in thepatient’s best interest” “Reference Guide to Consent to Examination or Treatment” DOH: Chapter 1;18.1In addition to the endoscopist, nurses attending the patient during the procedure have a dutyto minimise the risk to patients.Doses of sedation or analgesia can be repeated according to clinical need. However, incertain types of patients e.g. liver disease, increased doses of sedation can cause increasedconfusion/disinhibition rather than increased co-operation or tolerance to the procedure.Additionally, increased doses of sedation can induce respiratory depression, a potentially life-threatening condition.General:Once concern has been raised by either the patient or the nurse during the procedure, theendoscopist should stop the procedure and assess the situation. In some instances it will bein the patients best interest to continue the procedure and complete a specific aspect of theprocedure e.g. duct clearance or stent insertion. It may also be possible reduce patientdiscomfort eg by reducing looping of the colonoscope or to increase sedation, with thecaveats as above. This should be fully explained to the patient. If the patient clearly wishesthe procedure to stop despite these manoeuvres and understands the consequences of thatdecision then that decision should be respected.Audit:Is there is disagreement between the nurses attending the patient and the endoscopist, theevent will be reviewed afterwards. An Adverse Clinical Incident (ACI) form will be completedas per Trust policy, and will be discussed at the quarterly clinical governance meeting.References:Good Practice in consent Implementation Guide: Consent to Examination or Treatment.Department of Health November 2001. DOH 25751 1p10KReference Guide to Consent to Examination or TreatmentDOH October 2002: 24811 3p 15kSeeking patients consent, the ethical considerations.GMC guidelines November 1998Safety and sedation during endoscopic proceduresBSG Guidelines September 2003Code of Professional Conduct (2002)Nursing and Midwifery CouncilInformation produced by Dr Nick ThompsonAdapted from Gloucester Endoscopy Unit24-3-06 38
  39. 39. 39
  40. 40. Newcastle upon Tyne Hospitals NHS Foundation Trust Moving & Handling Protocol - Endoscopy Unit Please assess and record score for all patients attending for Endoscopy 1 2 Mobile patients having throat spray Partially dependant or dependant patients having throat spray Assessment AssessmentPatient able to climb on and off trolley Patient may require assistance onto theand position themselves unaided. trolley and to position themselves. Method Method• place trolley in procedure room at • place trolley in procedure room at lowest height required height• provide a step if fixed height trolley • using an approved handling technique in use and a minimum of 2 people, assist• ask patient to climb onto trolley patient onto trolley (PAT slide or• ask patient to position themselves in hoist should be used if necessary) the required position • assist patient if necessary using a slide• position trolley at correct working sheet and a minimum of 2 people, height if adjustable sliding not lifting • position trolley at correct working height, if adjustable Recovery Recovery• ask patient to sit up on trolley, • using an approved handling technique allowing time to recover and a minimum of 2 people sit patient• lower trolley height, if adjustable up on trolley and raise back rest,• ask patient to climb down from allow time to recover, lower trolley trolley, using step if necessary height• give any required information and • using an approved handling technique discharge and a minimum of 2 people, assist patient from trolley into chair / wheelchair or onto their feet (a hoist should be used if necessary) • if transfer to another trolley required, use PAT slide and a minimum of 4 people • give required information and discharge 40
  41. 41. 3 4 Mobile patients having sedation Partially dependant or dependant patients having sedation Assessment AssessmentPatient able to climb on and off trolley Patient may require some assistanceand position themselves unaided. climbing onto trolley and to position themselves. Method Method• place trolley in procedure room at • place trolley in procedure room at lowest height lowest height• provide a step if fixed height trolley • using an approved handling technique being used & a minimum of 2 people, assist• ask patient to climb onto trolley patient onto trolley (a hoist or PAT• ask patient to position themselves in slide should be used if necessary) the required position • encourage patient to position• position trolley at correct working themselves in the required position height, if adjustable • assist if necessary using an approved handling technique, slide sheet and a minimum of 2 people, sliding not lifting • position trolley at correct working height, if adjustable Recovery Recovery• push trolley from procedure room to • push trolley from procedure room to recovery area using 2 people recovery area using 2 people• when recovered, ask patient to sit up, • when recovered, using an approved raise back rest handling technique sit patient up,• lower trolley to lowest height, if raise back rest adjustable • lower trolley to lowest height, if• ask patient to climb down from adjustable trolley, using step if necessary, walk • using an approved handling technique to chair, assist if necessary and a minimum of 2 people assist• discharge patient when discharge patient to chair / wheelchair (a hoist criteria met should be used if necessary) • discharge patient when discharge criteria met 41
  42. 42. 5 6 Dependant patients unable to fully Dependant patients unable to weightweight bear, unsteady on feet but able bear having sedationto stand with support having sedation Assessment AssessmentPatient requires assistance on and off Patient requires assistance to move,trolley. unable to move themselves. Method Method• place adjustable height trolley in the • place adjustable height trolley in the procedure room at its lowest height procedure room at the required height• bring patient into procedure room in • bring patient into procedure room wheelchair if necessary • using an approved handling technique• using an approved handling technique and a minimum of 2 people, assist and a minimum of 2 people, assist patient onto trolley and lie in correct patient onto trolley and lie in correct position (hoist or slide sheet should be position (hoist or slide sheet should used if necessary) be used if necessary) • if patient requires transfer, trolley to• if patient requires transfer, trolley to trolley, use PAT slide and a minimum trolley, use PAT slide and a minimum of 4 people of 4 people • position trolley at correct working• position trolley at correct working height height Recovery Recovery• push trolley from procedure room to • push trolley from procedure room to recovery area using 2 people recovery area using 2 people• if necessary, using an approved • if necessary, using an approved handling technique and a minimum of handling technique and a minimum of 2 people, help patient to change 2 people, help patient to change position using slide sheet, sliding not position using slide sheet, sliding not lifting lifting• when recovered, using an approved • when recovered, using an approved handling technique and a minimum of handling technique and a minimum of 2 people, sit patient up & raise back 2 people, sit patient up & raise back rest, lower trolley to lowest height rest, lower trolley to lowest height• using an approved handling technique • using an approved handling technique and a minimum of 2 people assist and a minimum of 2 people assist patient to chair / wheelchair (a hoist patient to wheelchair (a hoist should should be used if necessary) be used if necessary)• discharge patient when discharge • if ambulance, transfer patient to criteria met ambulance stretcher using an approved handling technique with PAT slide and a minimum of 4 people • discharge patient when discharge criteria met 42
  43. 43. The Newcastle Upon Tyne Hospitals NHS Foundation Trust Surgical Directorate - Endoscopy Services Safety of Sedated Patients During Recovery Following Endoscopic ProceduresThe Trust has a responsibility to ensure the safety of sedated patients during therecovery period following endoscopic procedures. Based on the following nationalguidelines1,2 and the Trust Intravenous Sedation Drug Policy3, the following criteriafor the practice of recovering sedated patients are recommended. These should beimplemented in all sites of the Trust where intravenous sedation is practiced. • Clinical monitoring of the patient should be undertaken continuously throughout the period of sedation and recovery • Pulse oximetry must be used on all sedated patients from the induction of sedation until the patient is assessed to be sufficiently recovered • Patients may require supplementary oxygen (2 litres O2 per minute) to be continued during the recovery period as instructed by Endoscopy Staff • There must be an appropriately trained qualified nurse whose responsibility is to provide dedicated monitoring and care for the sedated patients • Resuscitation equipment must be available in the treatment and recovery areas • A source of oxygen, high volume suction and a trolley which has the facility to tilt the patient head down must also be available • Day cases should be assessed as to their suitability for discharge home • The minimum criteria for discharge should include stable vital signs, the ability to walk without support, toleration of fluids, the ability to void urine, minimal nausea and adequate analgesia if required • Day cases must be accompanied home and supervised by a responsible adult for 24hours • Patients must be advised in writing not to drive, operate machinery, drink alcohol or sign any legal documents for 24hours • A written record of the sedation episode should be included in the patient notes. As a minimum this should include the drugs and dosage used, the site of venous access and a record of all clinical monitoringReferences 1. Guidelines for Sedation by Non Anaesthetists. Royal College of Surgeons of England (1993) 2. Safety and Sedation during Endoscopic Procedures. British Society of Gastroenterology (2003) - update from Recommendations for Standards of Sedation and Patient Monitoring during Gastrointestinal Endoscopy. British Society of Gastroenterology (1990) 3. NUTH Guidelines for the Practice of Intravenous Sedation (2000) 43
  44. 44. NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Infection Control Committee HAND HYGIENE POLICYSummary1. Hands must be decontaminated immediately before each and every episode of direct patient contact/care and after any activity or contact that potentially results in hands becoming contaminated.2. Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material must be washed with liquid soap and water.3. Apply an alcohol based hand gel or wash hands with liquid soap and water to decontaminate hands between caring for different patients, or between different caring activities for the same patient.4. All wrist and ideally hand jewellery (particularly stoned rings) should be removed before hand decontamination. Cuts and abrasions must be covered with waterproof dressings.5. Effective handwashing technique involves three stages: preparation, washing and rinsing, and drying. Preparation requires wetting hands under tepid running water before applying liquid soap or an antimicrobial preparation. The handwash solution must come into contact with all surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 10-15 seconds paying particular attention to the tips of the fingers, the thumbs and areas between the fingers. Hands should be rinsed thoroughly prior to drying with good quality paper towels.6. When decontaminating hands using an alcohol based hand gel, hands should be free of dirt and organic material. The handrub solution must come into contact with all surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 15 – 30 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, and until the solution has evaporated and the hands are left dry.7. Apply a clinically compatible emollient hand cream regularly to protect skin from the drying effects of regular hand decontamination. If a particular soap, antimicrobial handwash or alcohol causes skin irritation, complete an incident form and seek occupational health advice. 44
  45. 45. 1 INTRODUCTION Health care workers should appreciate that hand washing is a complex practice which is important in providing quality care with minimal risk of infection. Good hand washing technique and practice assists greatly in reducing the spread of infection. Microorganisms are invisible to the naked eye and health care workers must be aware that their hands are sometimes responsible for cross infection. Normal flora or commensals on the hands are referred to as resident microorganisms. Resident microorganisms are usually present on the skin and protect against invasion by more harmful microorganisms. Transient microorganisms exist on the skin surface and can be viral or bacterial. They are termed “transient”, as they are transferable through direct contact with equipment, the environment or individuals. The ease with which these microorganisms can transfer makes hands extremely efficient vectors of infection. Transient microorganisms, unlike resident flora, are easily removed by hand washing. Therefore the risk of cross infection can be greatly reduced by adopting a good hand hygiene technique. A healthy person usually has defences against transient organisms; however, an ill person has an increased risk of cross infection. Effective hand washing with a liquid soap removes transient organisms and renders hands socially clean. This level of decontamination is sufficient for general social contact. The use of an antimicrobial liquid soap will remove transient microorganisms and reduce resident flora. The effective use of alcohol based hand gels on contaminated hands will also result in substantial reductions of transient microorganisms, although alcohol is not effective at removing dirt and organic material. However, alcohol based hand gels offer a practical and acceptable alternative to handwashing when the hands are not soiled and are recommended for routine use.2 FACILITIES All clinical areas should have • appropriate number and type of hand washing facilities appropriate to the area • clear unobstructed access to all hand washing sinks • hand washing sinks for that purpose only and clear of inappropriate items • hand washing sinks fitted appropriately with elbow or wrist operated mixer taps • liquid soap available at every sink • hand drying facilities must be readily available at every sink • hand washing posters should be placed by each sink The Infection Control Team must be consulted before any new construction or refurbishment work is planned to advise on sink type, number and placement of hand washing facilities. Facilities in patients homes for hand washing may be not ideal. If necessary healthcare workers should be provided with appropriate liquid soap solution and paper hand towels. If hands are physically clean an alcohol hand gel may be applied if hand disinfection is required. 45
  46. 46. 3 HANDWASHING TECHNIQUE 3.1 Preparation Artificial nails and the wearing of nail polish may increase the microbial load on hands and should not be worn. Similarly higher bacterial counts have been reported when stoned rings are worn. Stoned rings and wristwatches must be removed prior to hand washing. Wedding bands must moved around during hand washing. 3.2 When, Why and How SOCIAL HAND WASH WHEN Before all routine tasks within general wards/departments and after every patient contact (hand disinfection may be required) WHY To render hands socially clean and remove transient microbes HOW A thorough wash with an acceptable liquid soap for 15-30 seconds HAND DISINFECTION WHEN During outbreaks of infection, in high risk areas and before aseptic procedures. Particularly after leaving source isolation areas. After contact with any secretions and excretions – even if gloves have been worn. WHY To remove transient organisms and reduce resident flora HOW A thorough wash for 15-30 seconds with an antimicrobial liquid soap or detergent e.g. chlorhexidine, povidone-iodine. In order to disinfect hands, apply an alcohol based hand gel. SURGICAL HANDWASH WHEN Prior to surgery or invasive procedure WHY To reduce resident flora and to remove or destroy transient organisms HOW Apply antimicrobial soap or detergent e.g. chlorhexidine or povidone-iodine (manufacturers’ recommendations and instructions for use must be followed) to hands and forearms using a defined technique for a minimum of 2 minutes. Dry hands on a sterile towel. In operating theatres, between short cases only, hands may be disinfected by applying two or more applications of 80% alcohol based hand gel. Sterile nailbrushes should be used for nails only. Prolonged or abrasive scrubbing may damage the skin. 46
  47. 47. 3.3 HOW TO WASH HANDS CORRECTLY AND REDUCE INFECTIONWet Hands, apply hand washing agent and use the following procedure: - 1. Rub palm to palm 2. Rub back of both hands 3.Rub palm to palm with fingers interlaced 4. Rub backs of fingers (interlocked) 5. Rub all parts of both thumbs 6. Rub both palms with finger tips 7. Rinse hands under running water and dry thoroughly.(Adapted from Ayliffe GAJ, et al (1978) and Gould D (1994) 47
  48. 48. 3.4 HOW TO APPLY ALCOHOL BASED HAND GELCORRECTLY4. HANDWASHING AGENTS There are three types of agent that can be used to remove microorganisms from hands: soap, alcohol based hand gel and antimicrobial agents. Soap - will mechanically remove transient microorganisms but has little effect on resident microorganisms. However, hand washing with soap is usually all that is necessary to prevent cross infection and protects staff and patients from acquiring infection. The infection control team recommend the use of liquid soap in containers which supply a measured dose, and which cannot be topped up. This minimises the risk of microbial contamination. 48
  49. 49. Antimicrobial Agents- are designed to remove transient and reduce residentskin microorganisms. Chlorhexidine based preparations have been found tobe more effective than iodine-based solutions as they have a residual effectwhich influences the survival times of many organisms on hand surfaces.Antimicrobial agents should be used in situations when there is a need toreduce resident microbial flora, e.g. in operating theatres or similardepartments or when dealing with patients in isolation and before performingan invasive procedure.Alcohol-Based Hand Gels - can be applied quickly without access to water.However they are not effective in removing soiling and should only be used if handsare visibly clean.Recent legislation advocates the use of alcohol based hand gels betweeneach patient contact as a measure to reduce the incidence of healthcareacquired infections.5. Hand Drying Agents Drying hands with paper products is preferable to using hot air or linen towels. The use of hot air dryers should not be used in clinical areas as these spread airborne bacteria by re-circulating the surrounding environmental air. Drying with a high absorbency paper towel will remove some of the transient organisms that remain after hand washing. Paper towel dispensers should be wall mounted.6. Hand Cream And Handcare Frequent use of antimicrobial and liquid soaps can cause skin damage to some health care workers, with consequential increases in levels of bacteria on the skin. The use of an appropriate hand cream i.e. compatible with the hand washing agent will help overcome some of these adverse effects. Compatible hand creams should be provided in measured-dose pump dispensers. Advice re compatibility may be obtained from pharmacy. Health care workers must complete an Incident Form and consult the Occupational Health Department if they experience any skin problems, which could be attributed to the hand washing agent being used.7. PATIENT HAND HYGIENE Hand hygiene for patients must be encouraged as it is equally as important in the prevention and control of infection. Staff must ensure that patients are afforded an opportunity to hand wash prior to meals, 49
  50. 50. after having used a bedpan/urinal or commode/toilet or when hands are otherwise soiled.References1. The epic Project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase 1: Guidelines for preventing hospital-acquired infections. J. Hosp. Infect (2001) 47 (Supplement): S1 – S82 Also available on Department of Health website at Infection Control: Prevention of Healthcare-associated infection in Primary and Community Care. Pellow CM et al. Journal of Hospital Infection 55 (Supplement 2): 1 - 1273. National Patient Safety Alert (2004) Alcohol Based Hand Gels4. The epic project. Updating the evidence-base for national evidence- based guidelines for preventing healthcare associated infections in NHS hospitals in England: a report with recommendations. Pellow CM et al. British Journal of Infection Control, (December 2004), vol 5 No 6, 10 - 165. Winning Ways: Working together to reduce healthcare associated infections in England, A Report from the Chief Medical Officer (2003) NHS Estates (2002) Infection Control in the Built Environment – design and briefing (2002). Also available on www.nhsestates@gov.uk7. Larsen EL. Draft APIC Guidelines for Hand Hygiene and Hand Asepsis in Health Care Settings. Am. J. Infect. Control 1994; 22: 25A-47A. Further Reading1. Guidelines for Hand Hygiene, Infection Control Nurses Association (2000) MMWR: Morbidity and Mortality Weekly Report. Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. October 25 2002/vol51/No RR – 16. Morgan Issue Date: July 2006Review Date: July 2008 50
  51. 51. 51