Provision of Endoscopy Related Services     in District General Hospitals      BSG Working Party Report 2001             T...
Working party reportProvision of Endoscopy Related Services in DistrictGeneral HospitalsAUTHORSDr IG Barrison, Prof MG Bra...
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Provision of Endoscopy Related Services in District General Hospitals                                                     ...
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Provision of Endoscopy Related Services in District General Hospitals                                                     ...
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Provision of Endoscopy Related Services in District General Hospitals                                                     ...
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Provision of Endoscopy Related Services in District General Hospitals                                                     ...
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Provision of Endoscopy Related Services in District General ...
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  1. 1. Provision of Endoscopy Related Services in District General Hospitals BSG Working Party Report 2001 The Report of a Working Party of theBritish Society of Gastroenterology Endoscopy Committee
  2. 2. Working party reportProvision of Endoscopy Related Services in DistrictGeneral HospitalsAUTHORSDr IG Barrison, Prof MG Bramble, Dr M Wilkinson, R. Hodson, Dr PD Fairclough, Dr CP Willoughby and Dr MDHellier on behalf of the Endoscopy Committee of the British Society of Gastroenterology.BACKGROUND Endoscopy in the general population is now in excess of 10 per 1000 population per annum and may be asNearly 10 years ago, a BSG Working Party reported on high as 15 per 1000 population per annum wherethe Provision of GI Endoscopy and Related Services for general practitioners have unrestricted access to upperthe District General Hospital.1 The Report was prepared gastrointestinal endoscopy (M G Bramble personalto inform Hospital Managers of the need for communication). This compares to a figure of 8.6 perGastrointestinal Endoscopy and the facilities that were 1000 population in 1992 6 and gives an annualrequired for its delivery. Progress in the management of workload of approximately 3000 examinations in apatients with gastrointestinal disease and new technology District General Hospital serving a population ofmeans that these guidelines are now out of date. Changes 250,000. It is likely that the number of elderly patientsin equipment, requirements for the sterilisation of requiring gastroscopy will gradually rise whilstendoscopes,2, 3 advice on re-use of endoscopic accessories4 younger patients will be treated more frequentlyand clinical governance are only a few of the changes that without recourse to diagnostic gastroscopy.have occurred during the last ten years. In addition, theintroduction of Evidence Based Practice and the widespread b Flexible Sigmoidoscopyuse of Clinical Guidelines and protocols are significant The current requirement for flexible sigmoidoscopyfactors influencing the work of Endoscopy Units. in the general population is much more difficult to This Report focuses on a number of key areas, including calculate as many examinations are basically limitedthe requirements for endoscopy, where this should be colonoscopies. A reasonable estimate would be 2–2.5performed, the facilities required in an endoscopy unit, per 1000, giving a workload of between 500–600the provision of emergency endoscopy and the relationship examinations per year.between the secondary and primary care sectors in the This is likely to increase with the advent of thedelivery of the service. requirement to provide more rapid diagnosis of colorectal cancer. Many hospitals are now trying toPROVISION OF ENDOSCOPY SERVICES establish endoscopy lists specifically devoted toReferrals to most gastrointestinal endoscopy units fall into patients with new onset rectal bleeding, this is likelythree main categories: to lead to an increased number of flexible sigmoidoscopies and colonoscopies being performed.a Open Access The inability of the endoscopist to reach the splenicb Outpatient Generated flexure with a flexible sigmoidoscope7 means that ac Urgent Inpatients colonoscope should be used in preference for most examinations. This also leaves the endoscopist theThe Department of Health has now made option of performing a full examination, if indicatedrecommendations on the minimum provision of at the time.Gastrointestinal Endoscopy in District General Hospitalswhich accept emergency patients and these should act as c Colonoscopya bench mark for all DGH Units.5 Appendix These Service The majority of District General Hospitalstandards clearly establish the quality framework for Gastroenterology Units now perform between 2.5 andEndoscopy Units in District General Hospitals in terms 5.0 colonoscopies/1000 population/year. This numberof staffing, record keeping, equipment, and liaison with has been steadily increasing and many units are under 6other departments. great pressure to increase throughput because of the 8 Calman-Hine initiative on colorectal cancer. For most hospitals waiting lists for Colonoscopy areCLINICAL NEED FOR AN EFFECTIVE unacceptably long and exceed the capacity of cliniciansENDOSCOPY SERVICE to meet this demand. Training nurses to perform largea Diagnostic Upper Gastrointestinal Endoscopy bowel examination may be one logical way around The requirement for Upper Gastrointestinal this problem.9
  3. 3. 2 BSG Working Party It is highly likely that the requirements for The role of primary care endoscopy remains unclear endoscopic large bowel examination (flexible although there are currently in excess of 25 primary care sigmoidoscopy and colonoscopy) will continue to endoscopy units (R Stevens personal communication). increase and that at present there is a significant unmet There is very little point in establishing an off-site demand. Some units are already performing 8 – 10 Endoscopy Unit, which only carries out a small number large bowel examinations per 1000 population where of sessions per week. Calculations on the cost benefit of facilities allow (Dr P. A. Cann personal these Units in terms of reducing waiting times for communication) and the average DGH should be endoscopy, or more rapid diagnosis of serious pathology, planning for a similar workload (2000–2500 need to be undertaken. Co-operation with the secondary examinations/year) in terms of equipment and care sector is vital if primary care endoscopy units are to manpower. continue, as this will ensue that standards are the same in both sectors. This should include regular audits of safetyd ERCP and outcome utilising the same referral protocols. In some The pattern of provision of ERCP is changing.10 A hospitals it might be appropriate to have GP run sessions recent survey showed that a large majority of Acute in the hospital unit rather than a peripheral unit which is Hospitals in the U.K. provided ERCP, with the under-utilised. provision moving away from Surgeons and District General Hospitals will continue to provide all Radiologists toward medical gastroenterologists. emergency endoscopy. Approximately 0.75 examinations are carried out per 1000 population per year, with an average District PLANNING OF OPEN ACCESS SERVICES General Hospital performing about 200 procedures. Open Access Services should fulfil the following quality This is also an increase on figures relating to practice criteria. in 1992 when 0.54 examinations were performed per 1000 population.6 Three quarters of these patients will 1 Referrals should be made using locally agreed require therapeutic intervention. guidelines and protocols, which fulfil long term Service Agreements.e Endoscopic Ultrasound 2 Referrals should be made using standard Referral At present, endoscopic ultrasound and enteroscopy Forms which are suitable for audit and contain are only performed in specialist centres, but these information which is required for a Minimum Data procedures are time consuming and may impact on Set for Gastrointestinal Endoscopy (16) the provision of routine lists. 3 Clerical and IT support for the Endoscopy Unit should be sufficient for family practitioners and patients toOpen Access Endoscopy be informed of their appointment date and time withinThe rise in demand for all forms of endoscopy has led to 7 working days of receipt of the referral. Notificationan increase in the proportion of patients, particularly those to patients should include information about therequiring gastroscopy and flexible sigmoidoscopy, being procedure, possible complications and alsoinvestigated in ‘open access’ services.11 The majority of arrangements for discharge from the Endoscopy Unit. 4 Clinical responsibility for the patient must be clearlyreferrals to open access services are being made using defined.agreed guidelines and protocols.11 There has been a steady 5 The British Society of Gastroenterology Qualityincrease in the overall numbers of open access procedures Standards for Informed Consent, should be used (17)resulting in many Endoscopy Units reconfiguring their 6 There should be sufficient trained staff available tolists to accommodate more endoscopies being preformed speak to patients on arrival in the ward, and on leaving,by hospital practitioners or Nurse Endoscopists (vide so that they can be informed of the results of theirinfra). endoscopy. Written results should be the gold standard One of the original intentions of the Open Access for sedated patients and arrangements for follow upService was to reduce the waiting time for endoscopy and should be made before the patient leaves the Unit.most units have protocols with their local GPs, which 7 The Unit should have a computerised Endoscopy/allow certain categories of patients to be investigated Patient Record System in which data is recordedwithout referral to a hospital specialist. The benefits of locally, stored centrally and is backed up on a regularopen access gastroscopy in terms of patient management basis, so that analysis for Clinical Governanceare clear12 but so far there is little evidence to show any purposes, is easily available. The Endoscopy reportbenefit in detecting malignancy at an early stage . 13 should be available to be returned to the referringAttempts are now being made to use H.pylori screening doctor on the day of the procedure and ideally, thisin younger patients without alarm symptoms to reduce should be electronically transmitted.the number of referrals. This ‘test and treat’ policy has so 8 Regular audit of the Open Access Service should takefar, had little impact on the workload of Endoscopy Units place.but the potential to reduce referrals could be as high as 9 Open Access Endoscopy should be performed by73%14 and should prove to be economically justified in experienced, non-training grade staff, or by trainingyounger patients. Over the age of 50 gastroscopy is cost grades under direct supervision.effective 15 providing the cost of gastroscopy is low 10 The Unit should have clear Protocols for dealing with(approx. £100). patients found to have serious pathology at open
  4. 4. Provision of Endoscopy Related Services in District General Hospitals 3 access endoscopy. In particular, the software These recommendations do not include the time that is programme used to provide the endoscopy report required for proper assessment of in-patient referrals for should also have the flexibility to incorporate biopsy endoscopy, nor do they include the increasing demand for results and indeed provide reminders to chase biopsy percutaneous endoscopic gastrostomy (PEG). Whilst nurse results when specimens are taken for pathology. endoscopy will overcome some of these problems, ultimate The responsibility for arranging referrals for responsibility will remain with consultants and it is no surgery or other investigations should be clearly longer acceptable to have single handed gastroenterologists defined and the effectiveness of the process should be in a DGH covering more than 100,000 people. The average audited on a regular basis. DGH now requires 3 gastroenterologists and two11 Referring doctors should receive regular bulletins on endoscopy rooms able to run parallel sessions. A large DGH the activities of the Open Access Service including will require three endoscopy rooms with a correspondingly waiting times, summaries of findings, complication large recovery area. rates and plans for development. NURSE ENDOSCOPISTSSummary In a previous report, The British Society ofIdeally, all gastrointestinal endoscopy should take place in Gastroenterology concluded that nurses who werea single dedicated unit but it is possible that satellite units suitably trained and supervised would be able to carrywill increase in numbers. Gastroenterology Departments out certain endoscopic procedures. Recommendations onwill need to work with their locality GPs to determine the standards as well as general considerations, such asbest way of providing endoscopy services bearing in mind medico-legal issues, risks and practical problems wereall the factors which influence patient acceptability. In some outlined in the document, ‘The Nurse Endoscopist’.10areas the distances patients need to travel may make The demand for endoscopy is now outstripping thecommunity endoscopy units a preferable option. capacity for medical endoscopists to provide the service It is extremely important that the quality of the required within a reasonable time scale. This has led to adiagnostic endoscopy service in Community-based Units, variety of solutions, including the widespread introductionis exactly the same as that for the main hospital site and of Open Access Services, Primary Care Based Endoscopyin particular, facilities for monitoring, provision of cardio- and the introduction of Nurse Endoscopists.pulmonary resuscitation and recovery areas must be In principle, the United Kingdom Central Councilmaintained to the highest possible level and equivalent to (UKCC) has no objection to nurses developing theirthose in the main hospital. If these facilities cannot be professional practice, including training in gastrointestinalprovided, then endoscopy in community-based units endoscopy. However, it specifically recommends that theshould only be performed on unsedated patients. The nurses concerned are proven to be competent for theRoyal College of Anaesthetists are currently producing purpose and are mindful of their professionalguidelines on sedation in a non hospital setting. accountability for their actions. The General Medical Council recognises and welcomesWORKLOAD OF ENDOSCOPY UNITS nurses undertaking new roles that may previously haveThe Royal College of Physicians18 has recently made traditionally undertaken by a doctor. However, the GMCspecific recommendations on the workload of the average also cautions that a doctor who delegates treatment orGastroenterology Department dealing with a population procedures to be performed by another person, must beof 250,000. An increase in the requirements for diagnostic assured that the person’s training is adequate for theand therapeutic endoscopy has resulted in purpose and that the doctor retains ultimate responsibilityrecommendations that 8 notional half days per week, are for the patient’s management.10required for gastroscopy based on the assumption thatthere will be 2500–3000 diagnostic and therapeutic upper RECRUITMENTGI endoscopies performed per annum. The assumption Recruitment to a Nurse Endoscopy Post should bethat the average Unit should perform 600–800 considered in a wider context than just the EndoscopyColonoscopies per year and a similar number of flexible Services’ requirement. The development of all Specialistsigmoidoscopies (which would occupy another 8 notional Nurses should be part of local workforce planninghalf days) is an underestimate. The average DGH should arrangements and tailored to meet local and regionalbe planning sufficient endoscopy time to allow for 12–14 needs. Good workforce planning will ensure that thenotional half days, ERCP lists would occupy 2 notional Nurse Endoscopist has a proper career structure and thathalf days. It should be noted, however, that mostConsultants are unavailable to perform endoscopy for their Continuing Professional Development isup to 10 weeks per year because of the requirements of appropriately structured.annual leave, study leave and management Five years ago, there were few nurses in the Unitedresponsibilities. Therefore the numbers of endoscopies that Kingdom with sufficient experience to perform endoscopycould be performed may need to be revised down to allow unsupervised, and many Units have now taken on trainingfor this, particularly in units where there are single-handed their own staff to perform routine Gastroscopy and/orgastroenterologists, allowing cover during holidays and Flexible Sigmoidoscopy. A common dilemma is whetherstudy leave, in addition to sharing the burden of an it is more suitable to train nurses from within theincreasing endoscopy workload. Endoscopy Unit, or recruit a trained nurse from outside.
  5. 5. 4 BSG Working PartyThere are now nationally recognised Nurse Endoscopy Unit, when necessary, to supervise the management ofTraining Units and currently approximately 75 nurses per patients with acute gastrointestinal haemorrhage.year receive Accreditation. The NHS standards of service recommendations make it quite clear that District General Hospitals must haveDEVELOPMENT OF THE ROLE OF THE NURSE clear Guidelines and Protocols for the provision ofENDOSCOPIST emergency endoscopy, which should be available within 24 hours of admission/or request.The Joint Advisory Group (JAG) has identified minimum The British Society of Gastroenterology and Royalstandards for Units training in Endoscopy (19). JAG College of Surgeons’ audit into the Management of Acuteexpects Nurses undertaking endoscopy to train to the Gastrointestinal Bleeding20 revealed that the mortalitysame criteria and standards as medical endoscopists. The from gastrointestinal bleeding in District Generaldevelopment of the Nurse Endoscopist into a competent Hospitals, tended to be confined to the elderly with multipractitioner requires a linked approach to professional system disease. This constant mortality rate of about 14%and academic developments in clinical endoscopy training. contrasts sharply with the fall in mortality that has beenThe Nurse Endoscopist should undergo defined achieved over the last 20 years in younger patients withapprenticeship under close supervision. National courses bleeding peptic ulcers, at least in part due to the successaccredited with the ENB and BSG are available and Nurse of interventional therapeutic endoscopyEndoscopists should attend these during their initial In addition, there is strong evidence to show that thetraining period and then subsequently fulfil national CPD concentration of patients with acute gastrointestinalrequirements for Endoscopists. haemorrhage in Specialist Units, leads to a significant The nurse Endoscopist should work closely with reduction in mortality which is achieved by an aggressivemedical and surgical consultant Gastroenterologists endoscopic approach and combined management betweenensuring that both medical and nursing supervision are physicians and surgeons.21,22 The low mortality associatedidentified with clear line management. The posts’ role with gastrointestinal haemorrhage for patients under theand responsibilities should be clearly defined to prevent age of 60 (1%), has led to several prospective studies onconfusion, but should be flexible enough to allow the requirement for hospital admission for all patients.expansion and development. Nurse Endoscopists should There are now data to show that patients withwork within Guidelines and use evidence based Protocols uncomplicated upper gastrointestinal bleeding do notas part of a multi-disciplinary team. The undertaking of require admission, provided the patients undergo earlyresearch, practice development and audit should be seen Gastroscopy with the provision of a definitive diagnosis,as fundamental to the post. and that bleeding has ceased.23 Careful consideration should be given to sessional What then is the best model for dealing with emergencycommitments to endoscopy, and to remain competent, endoscopy? Certain basic provisions are least two or more sessions weekly should be allocated.Conversely, it is professionally inappropriate for a nurse 1 There should be an adequate number of properlyto be used as an endoscopist full time. It is equally functioning end viewing endoscopes with biopsyinappropriate to expect a nurse to manage a caseload channels sufficiently wide to allow therapeuticlist in the endoscopy unit part time, and then return to intervention – often these will be large diameter twinduties as an endoscopy nurse for the remainder of the channel instruments.week. The endoscopy nurse should be regarded as a GI 2 An experienced endoscopist – emergency endoscopyNurse Specialist, who provides appropriate care and should not be performed by training grade doctorsservices for patients with GI disorders and extends the unless under direct supervision, or until they haverole by taking on some of the routine follow up achieved the required experience.responsibilities such as a clinic for patients with PEG 3 Emergency endoscopy should be performed in thefeeding tubes. In some units, nurses who perform main Endoscopy Unit with experienced nursing staffendoscopy may be the most appropriate assistants for available – not as a rushed procedure, either in a sidecomplex therapeutic procedures where non-training room on a medical ward, or in a main operatinggrade staff work single-handedly. theatre, unless the endoscopy is being performed immediately prior to surgery.EMERGENCY ENDOSCOPY 4 Endoscopes are most likely to become blocked when used for patients with gastrointestinal haemorrhageThe majority of requests for emergency or out-of-hours – careful attention to mechanical cleaning of theendoscopy involve the management of patients with acute instrument after use is essential. This is one of thegastrointestinal bleeding. Pressure to reduce the hours of main reasons for performing emergency endoscopywork of training grade doctors and restrictions imposed within Endoscopy Units during working hours so thatby the European Working Time Directive, have led to the experienced endoscopy nurses are available to handlegradual disappearance of on-call rotas in District General the instruments after use.Hospitals for patients with acute bleeds and the 5 Emergency endoscopy should be performed withintroduction of more structured arrangements. In those facilities for therapeutic intervention available, i.e.hospitals where an on-call rota for training grade doctors injection needles, 1:10,000 adrenaline, sclerosants,still applies, it is essential that Consultant banding apparatus and thermal methods of controllingGastroenterologists are available to come to the Endoscopy haemorrhage.
  6. 6. Provision of Endoscopy Related Services in District General Hospitals 5The essential requirements for an emergency endoscopy This approach would lead to larger lists on a Mondayservice as stated above, suggest that only one or two morning to deal with week-end admissions and themodels will be reliable and predictable. Most District Monday morning lists may need to be extended up toGeneral Hospital Endoscopy budgets do not provide 9.30 a.m., but one hour should be sufficient in thesufficient funding for a seven day a week, 24 hour on- remainder of the week. Admitting teams would knowcall service by endoscopy nurses, and as a consequence, that patients could be endoscoped the morning afterendoscopies, out-of-hours and at week ends are admission, and should manage their patients accordingly.performed as little as possible. Rota restrictions tend to The endoscopy unit’s day to day work would be morelead to medical and surgical Consultant easily managed if emergencies were dealt with earlier inGastroenterologists being called in to deal with these the day.patients, often being required to use sub-standard This concentration of emergency work at the start ofequipment in operating theatre annexes. Clinical the day would also allow a rota to be established forGovernance Initiatives indicate the need to maintain experienced endoscopists and would provide a focusedquality at all times including a minimum level of service training opportunity for medical and surgical traineeprovision. This is supported by the Quality Assurance Gastroenterologists. Audit of the Management of GIProtocols Initiative and ‘ad hoc’ arrangements to cover Bleeding would also be facilitatedemergency admissions with gastrointestinal bleeding are Where does this model break down? Clearly, difficultiesno longer acceptable. will arise for patients admitted in the early part of the In the first instance, therefore, it is recommended that week-end although some hospitals do have a routineall hospitals carrying out emergency endoscopy attempt Saturday morning endoscopy list to deal with patientsto establish an out-of-hours rota for their endoscopy with gastrointestinal haemorrhage admitted on a Fridaynurses, so that emergency endoscopy can be performed evening. We would suggest that GI Endoscopy Unitsin the best possible circumstances. A business case would prospectively audit the true requirement for emergencyneed to be constructed to justify the additional endoscopy on Saturdays and Sundays, before makingexpenditure. formal provision for weekend endoscopy lists. Secondly, the European Working Time Directive This report deals with the organisation of GI Endoscopydetermines that there should be a re-assessment of the Services in District General Hospitals – Teaching Hospitalsworking practices of Consultant Medical and Surgical and Specialist Units dealing with tertiary referrals withGastroenterologists. Attending the hospital out-of-hours gastrointestinal bleeding – particularly Liver Units, willand at weekends, to perform emergency endoscopy, must require different arrangements to deal with the largebe recognised as part of their regular duties and be taken number of patients with variceal bleeding that theyinto account in constructing their job plans. receive. This will inevitably lead to the requirement for theappointment of additional Consultant Medical and EQUIPPING DGH GASTROINTESTINALSurgical Gastroenterologists in Units regularly performing ENDOSCOPY UNITSemergency endoscopy out-of-hours. Thirdly, endoscopists should no longer carry out a The numbers and types of endoscopes required byemergency procedures or any other investigations, unless DGH Units, will be linked to the mix of workthere is proper nursing and equipment support. performed and the restrictions placed on throughput The concentration of patients in acute Gastrointestinal by the minimum immersion times required for cleaningbleeding beds with dedicated endoscopic equipment and and disinfection, which govern the number of casesconcentration of medical resources has led to a marked that can be accommodated on a list.improvement in the mortality and morbidity of acute As previously stated, the average District Generalgastrointestinal haemorrhage in larger hospitals. There Hospital serving a population of 250,000, wouldare still difficulties in providing ring-fenced beds, out-of- normally spend up to 14 notional half days per weekhours endoscopy nurse cover, and a socially acceptable carrying out elective procedures in addition to 1–2rota of experienced endoscopists, particularly in smaller ERCP lists (taking place either in the x-ray departmentDistrict General Hospitals, where the number of patients or in a separate endoscopy room). In addition, thererequiring out-of-hours endoscopy, may be as few as one will be requirements for emergency procedures.or two per week. The minimum endoscope requirements to service One way of minimising the necessity for out-of-hours these lists are as follows:endoscopy is to provide a short session at the start of theday, in the main endoscopy unit. Patients admitted during 6 Gastroscopesthe previous 24 hours could be endoscoped between 8 4 Colonoscopesand 9.00 in the morning and the management of these 2 Flexible Sigmoidoscopespatients would then not interfere with the running of 3 side-viewing duodenoscopes.subsequent lists during the day. However, this systemrequires a robust referral procedure in whereby referrals In addition, a paediatric colonoscope will be requiredare received by the Endoscopy Unit early in the morning, in Units dealing with large numbers of children, andrather than at lunchtime or later in the day. Individual this instrument is often helpful negotiating the sigmoidunits need to organise themselves to facilitate this colon for patients with advanced diverticular diseasearrangement. and/or distal colonic strictures.
  7. 7. 6 BSG Working Party Sufficient washing machines to process at least 4 Cleaning Equipment instruments at a time are necessary to maintain COSSH regulations on the cleaning and disinfection throughput and avoid delays between patients. of endoscopes specify the requirement for careful We recommend video endoscopes because of the mechanical cleaning of the endoscope before inserting enhanced image quality available with these into automatic washers where the minimum instruments as well as the ability to teach and inform immersion time should be 10 minutes. Standards for other members of the GI team. washing machines were discussed in the BSG report ‘Cleaning and Disinfection of Endoscopes’.2b Endoscope Accessories This minimal immersion time means that an The increasing amount of therapeutic work carried endoscope will essentially be out of action for 30 out via endoscopes, re-enforces the requirement for minutes whilst being cleaned, washed, disinfected and Units to have a wide range of accessories available, washed again. Therefore to avoid delays, at least four which should include: gastroscopes will be required for a 10–12 patient gastroscopy list in a single room and three Oesophageal Disease colonoscopes for an ordinary colonoscopy list.24 (i) Bougie Dilators, through the endoscope balloon dilators and Achalasia Balloons. Cleaning and Disinfection of Accessories (ii) A wide range of oesophageal metal stents, covered A recent European Community Directive requirement and uncovered. for single use disposable accessories has created some (iii) Banding and injection sclerotherapy equipment problems for Endoscopy Units and certainly increased for dealing with oesophageal varices. costs. It is recommended that Endoscopy Departments (iv) Foreign body retrieval forceps. budget for single use biopsy forceps, injection needles, (v) Large spiked forceps. snares and sphincterotomes following the manufacturer’s recommended practice in the use of Diagnosis and Treatment of Stomach Lesions all these accessories. (i) Polypectomy snares. Where accessories can be re-used, a close working (ii) Needles for injection of adrenaline and saline for relationship should be established with the hospital’s submucosal stripping procedures and for the CSSD Department, to ensure that accessories are dealt control of bleeding. with properly and that there are agreed Quality (iii) Biopsy forceps (multiple of varying types). Standards for packaging and processing, particularly (iv) Balloon Dilators for pyloric strictures. of accessories that are autoclaved. (v) Pyloric canal stents. Equipment Purchase & Service Contracts ERCP-Related Equipment Significant discounts can be achieved in the purchase (i) Wide range of injection cannulae, including fine of endoscopes, e.g. in District General Hospitals and metal tipped cannulae. merging into larger Trusts, or by individual Units (ii) A range of sphincterotomes, including pre-cut clubbing together. Careful attention should be paid needles, pre-cut knives, and Sharks-fin to the requirements of the European Union, in terms Sphincterotomes for patients with Bilroth II of invitations to tender for the provision of endoscopy Gastrectomies. equipment, option appraisal of bids to tender and (iii) Biliary dilatation balloons for dealing with leasing contracts that may be established. strictures and for Sphincteroplasty. (iv) Biliary metal stents. (v) Mechanical Lithotripters. DESIGN OF THE ENDOSCOPY UNIT (vi) Plastic stents in a range of lengths and sizes. The last British Society of Gastroenterology Guidelines on the design of Endoscopy Units, were published in Colonoscopy Associated Procedures 1990.25 In addition, specific Guidelines on the cleaning (i) Biopsy Forceps. and disinfection of Endoscopes have been provided and (ii) A wide range of snares including hexagonal and these include recommendations on how Units should be rotating snares. designed to handle the toxic agents used in disinfection. (iii) Injection needles for lifting sessile polyps, injecting District General Hospital Endoscopy Units have to deal India Ink and for controlling colonoscopic focal with the passage of an average of 100–150 patients/week bleeding. through the Unit, including emergency endoscopy, (iv) Through the endoscope balloons for dilating complex therapeutic procedures and in many cases, ERCP. colonic strictures. In these circumstances, full time clerical staff working in (v) Clipping devices for dealing with bleeding polyp a reception area, closely linked to a recovery area stalks. containing a mixture of 8 to 10 trolley beds and an equal number of reclining chairs, seems to be the optimum Desirable Equipment arrangement. The recovery area should be fully equipped Argon laser to allow all sedated patients to be monitored using pulse Endoscopic ultrasound oximetry. Facilities for measuring and monitoring blood Argon Plasma Coagulator pressure should be readily available. Piped oxygen should High pressure washers also be accessible for each trolley/bed.
  8. 8. Provision of Endoscopy Related Services in District General Hospitals 7 The Unit should be self contained and there should be and facilities for bronchoscopy and possibly cystoscopy,ease of movement of patients from the trolley/reclining chair should have its’ own budget and be managed by aarea to the Endoscopy Unit, using modern trolleys which designated Senior clinician working closely with the seniorcan be tilted and can be ‘head-up’ or ‘head-down’ and allow non medical manager in the department with properpatients to be easily turned during Colonoscopy and ERCP. support from the local Trust Finance Department. Larger hospitals will need to have at least two (possibly Precise recommendations on the levels of staffing willthree with bronchoscopy) endoscopy rooms working side depend on the model of service provided, the followingby side. Ideally, one of these should provide for high are provided as examples. All nurses should have receivedquality pulsed digital fluoroscopy for ERCP, with basic life support training.appropriate resuscitative facilities, and x-ray support. Theendoscopy room should also have piped oxygen and MODEL Asuction. One room may need to accommodate endoscopicultrasound as this investigation becomes more available. G Patients attending the Endoscopy Unit will be admitted Pulse oximetry, piped oxygen and suction, electronic by an Endoscopy Nurse who will follow the patientblood pressure cuffs, and facilities for ECG monitoring through the Department. Assuming that the averageshould be made available in the recovery area as well as Gastroscopy list will contain 10–15 patients, twoin the endoscopy rooms. nurses will be required in the reception/trolley area. All units should have full resuscitation facilities G In the Endoscopy Room, a minimum of 1 qualifiedavailable including a cardiac defibrillator and emergency nurse and 1 trained assistant will be required, with adrugs tray which includes any drugs which might be further nurse/endoscopy technician being responsibleneeded for a cardiac arrest within the department. for cleaning and disinfection. The minimum size for an ordinary endoscopy room, is G The recovery area should have at least 1 qualifiedapproximately 7.5 metres x 3.5 metres. This allows a nurse and trained assistant to manage patients whostandard trolley to be turned within the Unit, the siting are returning from the endoscopy roomof a light source/video processor on one wall and fixingof a video monitor opposite. In a room of this size G Clearly, these numbers of staff will need to be increasedcupboards for hanging endoscopes can be provided for Units that have two rooms in action runningtogether with a reasonable amount of work surface. A parallel lists. Under these circumstances the recoveryseparate cleaning room is required with washing machines nurse levels will be the same but 1 extra qualifiredand extraction facilities to satisfy COSSH requirements. nurse and 1 extra trained assistant will be requiredThe endoscopy room should be cabled for local area for the second room.networks, wide area networks and ISDN. G Allowing for holiday/annual leave and sick leave, the Care should be taken to ensure sound from the average department running a single endoscopy room,endoscopy room cannot be transmitted to the patient will require a minimum of 6 wte staff, one of whomwaiting/recovery areas. Windows are not required and will be the senior nurse responsible for managing themay positively be a disadvantage when procedures department. These numbers will need to be increasedrequiring transillumination are necessary (eg PEG and to 9 wte staff in Units where two rooms are runningColonoscopy) parallel lists on a regular basis. G For ERCP the number of nurses and trained assistantsLighting required per room is 3.Although windows are not required in the endoscopyroom, these are advantageous elsewhere and recovering G In Departments in which nurses undertake endoscopy,patients should have access to natural light. In the additional nursing hours will be required to replaceendoscopy room itself there should be facilities to have the routine work that would have been undertakenvarying light levels ranging from bright to very subdued. by the nurse endoscopist.Dimmer lights are ideal for background lighting when G In this self-contained model, the Unit will usually havethe main lights have been switched off. a devolved budget for the purchase of endoscope accessories and to cover the revenue costs of staff.Security G As stated previously, it is likely that economies of scaleEndoscopy units house a great deal of expensive would be achieved by merging the purchasingequipment and should therefore be regarded as areas requirements of separate DGH Departments, but therequiring a high level of security. This can be provided Endoscopy Unit should have a clear policy for theduring the working hours by having a reception area repair and replacement of endoscopes, with rollingmanned by a full time clerk. At other times the unit must capital requirements being clearly identified, andbe secured with high quality door locks or code locks included in business plans.which will prevent easy access to an intruder. G It is extremely important that the skill mix ensures that all the staff are able to assist with complexSTAFFING OF ENDOSCOPY UNITS procedures.A core of highly trained, permanent staff is essential with G The day to day running of the Unit should be in theclear lines of accountability to experienced management. hands of a Senior Nurse Manager who would usuallyThe endoscopy service, which might also provide staff be a highly experienced endoscopy nurse.
  9. 9. 8 BSG Working PartyG It will be the responsibility of the Consultant OTHER GASTROENTEROLOGICAL SERVICES TO Gastroenterologists in the Department and the Senior BE PROVIDED IN THE DISTRICT GENERAL Nurse to ensure that endoscopy is conducted safely HOSPITAL by properly trained staff and that the quality criteria The provision of these services will depend on the specific stated previously, are fulfilled. Regular audit must take needs of the local population and of the Physicians and place, and it is strongly recommended that the Surgeons with a GI interest. What needs to be provided Department’s Management Committee meet at least will also depend on the availability of other procedures on a monthly basis to ensure that quality control and at Regional and Sub-Regional level. budgetary planning are properly performed. All Gastroenterologists require access to Oesophageal PH and Manometric testing. In many regions these areMODEL B concentrated in one or two centres which perform aAn alternative arrangement for endoscopy is that this sufficient number of procedures to provide reliable andtakes place in a hospital’s Day Unit where the admission reproducible results. Many District General Hospitals doof patients is dealt with by permanent Day Unit staff, but not have this facility, but have good relationships with athe Gastrointestinal Endoscopy takes place in a separate regional centre, which can provide a rapid reliable and this is where the Endoscopy Unit staff will be The provision of Oesophageal PH and Manometricbased. The requirements for permanent endoscopy staff testing within a DGH will almost invariably requirein this Model, are slightly less than Model A, but would additional funding for a Specialist Nurse and/orstill require at least 4 wte, and is probably less satisfactory Technician. These personnel will also often performthan Model A. Hydrogen breath testing on these Units. Many District General Hospital Departments now provide carbon-13 urea breath testing for H.pylori,FACILITIES FOR TRAINING although the funding of this service often depends onSpecialist Registrars in Gastroenterology and in General research support. It is recommended that negotiations takeSurgery now require formal training in gastrointestinal place with Primary Care Groups to build the cost ofEndoscopy. 19 The Joint Advisory Group (JAG) has H.Pylori testing into Service Agreementsproduced specific recommendations on the quality criteriathat Endoscopy Units will have to fulfil to be recognised Core Services provided by Service Departmentsas training departments. Probably the most important 1 A full range of barium studies should be providedaspect of training is the direct supervision of trainees by along with diagnostic and therapeutic ultrasound,experienced endoscopists, but “hands-off” experience can spiral CT scanning and easy access to gained, both in diagnostic and therapeutic procedures.Training departments, as a minimum, will require video 2 Isotope studies – these will include gastric emptying,endoscopy systems, and secondary monitors in adjacent SEHCAT absorption, white cell and HMPAOseminar rooms or offices, usually with voice linkage. scanning. Trainees are required to keep an annual record of theirendoscopic experience and all training units must provide 3 Pathologyadequate computerised endoscopy record systems. Close links with Histopathologists andIncreasingly these will be systems linked to the hospital’s Mircrobiologists are essential, with provision formain patient Master Records System rather than assessments of specimens obtained by biopsy andstandalone PCs. cytological examination. Gastroenterological surgeons Ideally, it is recommended that the offices of the will also require access to frozen section techniques.Gastroenterology Department will be based close to theEndoscopy Unit and here there should be a mini librarycontaining up to date Gastroenterology Journals and 4 Microbiologytextbooks, and again a PC Workstation linked to Medline, This department should provide facilities for thethe Cochrane Database and the Internet. investigation of infectious diarrhoea, culture of intestinal and liver biopsies and serological investigation of gastrointestinal and hepatic disease.Liaison with other departmentsWe recommend that at least fortnightly meetings should 5 Biochemistry/Haematologytake place to review the Department’s x-rays and biopsy These departments will be closely involved in thespecimens and ideally there should be a departmental investigation of gastrointestinal diseases, includingmeeting jointly held with the gastrointestinal surgeons, hormone secreting tumours, haemochromatosis, andpathologists and radiologists, at least once per month. the monitoring of the response to treatment of patientsThere should be clear responsibility for the organisation with malignancy.of departmental meetings, which should form the basisof departmental audit, evidence-based practice and clinical VISION OF GASTROINTESTINAL AND RELATEDgovernance. Indeed in larger departments, a clinician with SERVICES IN THE NEW NHSspecific responsibility for clinical governance should beidentified. Collaborative peer review with Colleagues in All Clinicians are now required to take part inadjacent units should be encouraged. management and Gastroenterologists are no exception.
  10. 10. Provision of Endoscopy Related Services in District General Hospitals 9Clinicians within the department should be identified who These services have proved to be very successful inwill be responsible for the organisation of business reducing waiting times for Gastroenterology Outpatientplanning and contract negotiations. It should be Clinics, but have placed a considerable burden onrecognised that these skills are an essential part of the Endoscopy Units having to deal with increasing demand,department’s activities. with most units reporting normal Gastroscopies in 25%– 40% of patients undergoing endoscopy.28THE NEW NHS 26 The introduction of Guidelines and Protocols governing referrals for endoscopy, should lead to a reduction in theGastroenterology Units will be required to have clear proportion of negative findings. It is stronglyguidelines and protocols agreed with their Primary Care recommended that Endoscopy Units work very closelycolleagues for the management of most common with their local Health Authority and Primary Caregastrointestinal conditions and these are likely to include Groups to establish clear criteria for referral using thethe implementation of care pathways. Gastroenterologists best available contemporary evidence.will also have to work closely with their colleagues, bothat Health Authority and hospital level and on drug and 5therapeutic committees to ensure that funding is identified APPENDIXto allow the introduction for newer treatments for which Bronchoscopy and Endoscopythere is good evidence to support an effective role. In this Emergency general medical care requires the support ofrespect, the cycle of business planning becomes even more upper gastrointestinal endoscopy, sigmoidoscopy,important and it is likely that Gastroenterology Units as colonoscopy and bronchoscopy. Each acute generalwith all other departments, will have to prioritise the hospital must have a fully equipped endoscopy unit,investigations and treatment that they can provide within staffed by experienced nurses or operating departmenttheir budgets. It is to be hoped that these can be agreed assistants, with apparatus for continuous cardio-on a national basis. respiratory monitoring. There should be mobile In future, it is probable that the organisation of services equipment for use elsewhere in the hospital. The use ofwill relate to populations of at least 500,000. In these anaesthetic services must be provided for and built intocircumstances, endoscopy sub-specialization is likely to contracts for this service.occur with not all consultants performing ERCP or Endoscopy should always be available within twelveColonoscopy. Closer co-operation between neighbouring hours of request. There should be a rota of available andacute hospitals will be necessary with the sharing of experienced physician or surgeon endoscopists andexpertise and equipment, and mutually supportive peer experienced endoscopy assistants which identifies theirreview and audit. 24 hour availability. Whenever possible, informed consent must precede endoscopy/bronchoscopy.DEMAND FOR ENDOSCOPY SERVICES There should be an endoscopy unit portering serviceAs the numbers of trained endoscopists and endoscopy for the protection of sedated and often ill patients andunits have increased in the last decade, the demand for their rapid transfer back to a safe environment.Gastroscopy in particular has increased inexorably, with A record of endoscopy findings must be made on thethis procedure now being the most commonly day case patient’s notes, as should a record of complications ofprocedure constituting 12% of all NHS day case the endoscopy. A system must be in place for making theadmissions.27 Approximately 530,000 endoscopies are results of endoscopy immediately available to the referringperformed each year at a cost to the NHS of £50 million. medical team.The demand for endoscopy and the pressure placed onoutpatient clinics by referrals with dyspepsia, have led tothe widespread introduction of Open Access Gastroscopy,with many Units also offering Open Access Flexible CORRESPONDENCESigmoidoscopy.11 to Dr IG Barrison at
  11. 11. 10 BSG Working PartyREFERENCES patients with ulcer like dyspepsia, referred to one hospital1 Working Party of the Clinical Services Committee clinic. Gut 1999;45:186–90.of the British Society of Gastroenterology. Provision of 15 Delaney BC, Wilson S, Roalfe A, Roberts L, Redmangastrointestinal endoscopy and related services for a V, Wearn A, Briggs A, Hobbs FDR. Cost effectiveness ofDistrict General Hospital. Gut 1991;32:95–105. initial endoscopy for dyspepsia in patients over the age2 Working Party report. Cleaning and disinfection of of 50 years: a randomised controlled trial in primary for gastrointestinal endoscopy. Report of a Lancet 2000;356:1965–69.Working Party of the British Society of Gastroenterology 16 Personal communication. Dr IG Barrison.Endoscopy Committee. Gut 1998; 42: 585–593. 17 Working Party of the British Society of3 Working Party Report. Aldehyde disinfectants and Gastroenterology – Guidelines for Informed Consent forhealth in endoscopy units. British Society of Endoscopic Procedures. British Society ofGastroenterology 1993. Gastroenterology 1999.4 Wilkinson M, Simmons N, Bramble M, Leicester R, 18 Consultant Physicians – Working for Patients. RoyalD’Silva J, Boys R, Gray R. Report of the Working Party College of Physicians, June 1999.of the Endoscopy Committee of the British Society of 19 Joint Advisory Group – Recommendations forGastroenterology on the reuse of endoscopic accessories. training in gastrointestinal endoscopy. Royal College ofGut 1998;42:304–306. Physicians, London April 1999.5 NHS Service Standards for Emergency Medical 20 Rockall TA Logan RFA Devlin HB et al IncidenceAdmissions. London Stationery Office 1997. of an mortality from acute gastrointestinal haemorrhage6 Scott BB. Gastroenterology in the Trent Region in in the United Kingdom. BMJ 1995; 311: 222–6.1992 and a review of changes since 1975. Gut 21 Consensus Development Panel. Consensus statement1995;36:468–472. on therapeutic endoscopy and bleeding ulcers.7 Painter J, Saunders B, Bell GD, Williams CB, Pitt R, Gastrointestinal Endoscopy 1990; 36: S62–5.Bladen J. Depth of insertion at flexible sigmoidoscopy: 22 Cook DJ, Guyatt GH, Salera BJ et al. Endoscopicimplications for colorectal cancer screening and therapy for acute non variceal upper gastrointestinalinstrument design. Endoscopy 1999;31:227–31. haemorrhage: a meta-analyses. Gastroenterology 1992;8 Expert Advisory Group on cancer to the Chief 102: 139–48.Medical Officers of England and Wales. A policy 23 Rockall TA Logan RFA, Devlin HB, Northfield TC.framework for commissioning cancer services. London. Selection of patients for early discharge on outpatient careDepartment of Health 1995. following acute upper gastrointestinal haemorrhage.9 Report of the British Society of Gastroenterology Lancet 1996; 347: 1138 – 40.Working Party – The Nurse Endoscopist British Society 24 MacFarlane B. Lenester R. Romaya C. Epstein O.of Gastroenterology 1994. Colonoscopy Services in the United Kingdom. Endoscopy10 Allison MC Colin-Jones DJ: Provision of ERCP 1999.Services and training in the UK. 25 Design of the Endoscopy Unit – BSG 1994.Report to the British Society of Gastroenterology Clinical 26 Secretary of State for Health, The New NHS:Services Committee March 1999. modern, dependable. London Stationery Office 1997 (Ldn11 Silcock J, Bramble MG. Open access Gastroscopy: 3807).second survey of current practice in the United Kingdom. 27 Williams B, Whatmore P, McGill J, Rushton L.Gut 1997;40:192–7. Private funding of elective hospital treatment in England12 Bramble MG, Cooke WM, Corbett WA, Cann PA, and Wales, 1997–8: national survey.Clarke D, Contractor B, Hungin AS. Gut 1993;34:422– 28 Hungin AP, Thomas PR, Bramble MG et al. What27. happens to patients following open access gastroscopy?13 Z Suvakovic, MG Bramble, R Jones, C Wilson, N A study from general practice. Br J Gen. PractIdle, and J Ryott Improving the detection rate of early 1994:44:519–21.gastric cancer requires more than open access gastroscopy:a five year study.Gut 1997 41: 308–313.14 Heaney A, Collins JSA, Watson RGP, McFarlandRJ, Bamford KB, Tham TCK. A prospective randomised ACKNOWLEDGEMENTStrial of “test and treat” policy versus endoscopy based The authors wish to thank Mrs D Findley for typing themanagement in young Helicobacter pylori positive manuscript of this document.
  12. 12. Provision of Endoscopy Related Services in District General Hospitals 11