Implementation of Colonoscopy for Mass Screening for Colon Cancer and Colonic Polyps: Efficiency with High Quality of Care




As awareness of colon cancer by the public continues to increase, screening colonoscopy procedures will proportionately increase. There is much written on the design of new ambulatory gastroenterology clinics, but little practical information about high-volume, mass colonoscopic screening of patients in the hospital outpatient setting. Many institutions struggle with inefficient endoscopy units that cannot always meet the dual needs of high quality and efficient performance of screening endoscopy. The patient undergoing screening colonoscopy seeks an efficient unit with state-of-the-art equipment, highly skilled physicians, highly competent staff, accurate case documentation, comfortable surroundings, and consumer-friendly follow-through of care. Optimizing these factors in existing spaces may require revision of an endoscopy unit’s operations and, possibly, renovation of the endoscopy suite.


As awareness of colon cancer by the public continues to increase, screening colonoscopy procedures will proportionately increase. There is much written on the design of new ambulatory gastroenterology clinics, but little practical information about high-volume, mass colonoscopic screening of patients in the hospital outpatient setting. Many institutions struggle with inefficient endoscopy units that cannot always meet the dual needs of high quality and efficient performance of screening endoscopy. The patient undergoing screening colonoscopy seeks an efficient unit with state-of-the-art equipment, highly skilled physicians, highly competent staff, accurate case documentation, comfortable surroundings, and consumer-friendly follow-through of care. Optimizing these factors in existing spaces may require revision of an endoscopy unit’s operations and, possibly, renovation of the endoscopy suite.


This article is based on our practical experience in a 10–procedure room endoscopy unit, located in a nearly 1100 bed teaching hospital that performs about 23,000 endoscopies annually. Although in this endoscopy unit multiple specialties use the endoscopy suite and various different endoscopic procedures are performed, this article focuses on screening colonoscopy. Standard practices within an endoscopy unit should enhance the efficiency of mass screening colonoscopy, whereas deviations from these standards can decrease the quality or efficiency of the service.


Colon Cancer Screening


An estimated 112,000 cases of colon cancer and 41,000 cases of rectal cancer were expected to occur in 2007. Screening is used to detect colorectal cancer at an early stage when it is more likely to be curable. Screening can also result in the detection and removal of colorectal polyps before they become cancerous and can thereby prevent colon cancer. Both of these effects can decrease the overall mortality from colon cancer .


Men and women at average risk for developing colorectal cancer should begin screening at age 50. Personal risk for colon cancer varies along with the best screening method for individuals. The American Cancer Society recommends one of the five following screening methods for adults at average risk beginning at age 50:




  • Annual fecal occult blood test (FOBT)



  • Flexible sigmoidoscopy every 5 years



  • Annual FOBT and flexible sigmoidoscopy every 5 years



  • Double contrast barium enema every 5 years



  • Colonoscopy every 10 years .



Colonoscopy has become the most important method of screening because of a high diagnostic sensitivity and specificity, the ability to procure tissue from identified lesions for histologic analysis, and the ability to completely remove polyps during the procedure.




Practical Considerations in High-Volume Units


Scheduling


Scheduling, or boarding, involves several considerations. For maximal efficiency, open dates and times should be immediately available when scheduling. The boarding office should have software that links patient data (medical record number, date of birth, and so forth) with physician and room availability. Blockboarding schedules built into software grids streamline the process, allowing individual physicians or their office staff to schedule procedures many weeks ahead at designated times. These blocks should be periodically monitored for use, usually targeted at 75% to 80% use, and the blocked times adjusted to accommodate the physician’s volume. Open blocks of time should be available to accommodate urgent procedures or cases performed by physicians not using blocked time. Having 100% blocked times, with a release date to automatically open up the blocked time 3 to 7 days before the procedure date, provides for efficient usage but is problematic for endoscopic physicians who do not block board. A mixture of 80% blocked time and 20% unblocked time is a reasonable compromise. The ability of a physician or office personnel to directly access the hospital’s scheduling system to schedule a procedure in the predetermined blocked time requires safeguards to protect patient confidentially. Faxing and phoning directly to the boarding office are alternatives.


The scheduling of procedures has many variations. Procedure length varies according to case complexity and individual physician performance patterns. To minimize delays, the average time of a procedure should be considered when scheduling boarding times for procedures, which is simply determined by averaging the time for the last 50 procedures for the particular physician. Average screening colonoscopy times vary from 30 to 45 minutes. Extra time must be added if the colonoscopy is combined with an upper endoscopy or if the patient has multiple comorbidities. In a teaching hospital, fellows and residents often accompany the attending physician during the procedure, which can increase the average procedure time.


After a procedure is scheduled, patients should receive instructions that include the procedure date and time, designated area of arrival, and colonoscopy preparation directions. The patient may also be given a simple educational pamphlet about screening colonoscopy, to better inform the patient and to enhance the procedural experience. Directing the patient to arrive 45 to 60 minutes before the procedure provides ample time for them to arrive, register, and be assessed by the nursing staff. This amount of time provides a safety margin for late arrivals. If a patient is tardy, the next patient can be selected ahead of time. If the patient arrives prepped on the wrong day, every attempt should be made to accommodate him. Adding them after the end of a block of time may be feasible, but this may require starting some initial steps, such as intravenous infusion, during the waiting period.


No-show patients impact the flow and efficiency of the daily schedule. If this occurs frequently, the communication processes with the patient should be reviewed. The following steps are recommended to ensure communication of the correct date and time:



  • 1.

    Hospital scheduler and physician’s office scheduler verify correct information at the time of boarding and reconfirm the schedule 1 week before the scheduled procedure.


  • 2.

    Patient is mailed a confirmation letter from the hospital 1 week before the procedure, providing an opportunity to instruct the patient to complete an updated medication list for medication reconciliation.


  • 3.

    Patient is called 24 to 48 hours before the scheduled procedure as a reminder. If the patient does not answer but an answering machine is on, a message should be left with an accessible number to be called back to confirm or cancel the procedure.



These measures should greatly reduce the no-show rate. Timeliness of the procedures also requires physician punctuality. The first procedure of the day should start on time. A delay in this procedure impacts on the remainder of the daily schedule and does a disservice to the following patients and physicians. Restricting a chronically tardy endoscopist to cases later in the day may solve the problem.


Computerization


Computerization of the endoscopy unit improves the efficiency of communication. Linking the patient data, at the time of boarding, with registration services expedites the patient processing at the time of the endoscopy. If appropriately interfaced, the data will link and prefill the demographics to the hospital’s on-line reporting pieces, such as documented care, endoscopy reports, pathology reports, and discharge instructions. Oral dictation, with reports being subsequently transcribed and downloaded to the patient’s on-line chart, should be available for when the computer system is down, or for endoscopists who are unable to use computers.


Credentialing


Credentialing for procedures is based on established hospital criteria. New physicians apply for privileges determined by their past experience and training. A review by the appropriate service chief, an expert in the specialty, ensures maintenance of quality. If the established criteria are not met, however, a mentoring process is followed to guide the endoscopist to the expected level of performance.


Consent


Informed consent requires the patient to understand the risk for complications. Information given to the patient, in the form of a handout that provides procedure-specific facts, can supplement the physician’s discussion with the patient . This handout can promote efficiency in the preprocedure area by reducing the need for addressing questions by the patient. Obtaining consent for inpatients at the bedside allows the patient or staff sufficient time to inform family members who may desire to be present at the procedure and can decrease delays from questions and answers at the time of service. Mentally incompetent patients require a legal guardian’s consent for an elective procedure. In an emergency, the endoscopist can notify and obtain concurrence for the procedure from the appropriate service chief, when the legal guardian is unavailable.


Open Access


In open access, patients referred for screening colonoscopy do not meet their endoscopist until the time of service. This method eliminates one visit for the patient and the endoscopist, but may impact the flow if required information is not in place before the procedure. A preassessment patient profile provides the necessary information to formulate a plan of care for the patient, a requirement of the Joint Commission on Accreditation of Healthcare Organizations . To avoid another office visit for the patient, referring physicians should complete this profile when the referral is made and forward it to the appropriate office for submission to the endoscopy suite. The attending physician does not need to meet the patient before the procedure if all this was correctly performed.


Patients Requiring Special Care


The preassessment profile alerts endoscopy staff of the special needs of particular patients. Staff, such as nurse clinicians, should screen the patient profiles at least 24 hours before the procedure and initiate an action plan to address these alerts. Potential actions include arranging for turning cardiac defibrillators off and on, administration of prophylactic antibiotics, or ordering special equipment for handicapped patients or large patients. Interpreters, located by a hospital database or supplied by an outside agency, can be prearranged to accommodate non-English speaking or hearing impaired patients when necessary.


Patients on anticoagulants require special instructions for discontinuance of their medications before the procedure. Compliance is crucial in the event of polypectomy during endoscopy. The instructions are best provided in advance of the procedure at the office visit to the internist or the endoscopist. Patients who have communicable diseases, such as tuberculosis, require special handling. Ideally, the procedure should be performed at the bedside for inpatients to reduce the exposure of other patients. For outpatients, planning for a mask to be presented to them at their arrival and limiting their contact with others throughout the visit is important.


Unstable or extremely ill patients, with an American Society of Anesthesiologists class rating of IV, are at an increased risk for adverse sedation reactions and should be closely monitored by an anesthesiologist. This arrangement allows the endoscopist and staff to focus on the procedure. Untoward medication reactions must be quickly addressed. Procedure rooms need intercoms or telephones to call for cardiopulmonary resuscitation (CPR) if necessary. A readily available in-house team offers support for these emergencies. An unstable patient is best served with mobile endoscopy at the bedside in the emergency room or the intensive care unit. These areas are staffed and equipped to address the needs of unstable patients. A colonoscopy in a pregnant woman who has strong procedure indications requires additional safety measures regarding awareness of medication effects, including bowel preparation, on the fetus. Obstetric consultation is required .


Patients who undergo an unsuccessful colonoscopy have several options, including a barium enema or a virtual colonoscopy. Both of these diagnostic tools need to be coordinated with the radiology department. They may possibly be performed immediately following the failed colonoscopy for the patient’s convenience.


Equipment


Colonoscopes are manufactured to meet the varied preferences among endoscopists. Recent models offer features such as variable stiffness, forward water-jet channels with a flushing pump, and different diameters and lengths. Recent models offer greater flexibility and visual fields of 180 degrees for better visualization of colonic mucosa. The newest generation colonoscopes also offer enhanced optics, such as narrow band or high-definition imaging. For fast turnaround, three colonoscopes should be in service per an endoscopist who performs screening colonoscopies within 30 minutes. If the blocked schedule alternates between upper and lower endoscopic procedures, two colonoscopes may be sufficient.


Technical support and backup are important to maintain endoscopes. Rapid turnaround time for repairs depends on efficient processes for sending a malfunctioning endoscope from the facility to the repair shop, promptly repairing the endoscope, and promptly returning it to the facility. Providing accurate information to the repair facility concerning the malfunction expedites the repair. Dealing with the original endoscope manufacturer guarantees correct parts are used in the service repair, which often extends the life of the endoscope. The life expectancy of an endoscope used in a teaching hospital staffed with residents and training fellows is decidedly less than otherwise expected. In a large endoscopy suite that performs about 23,000 procedures per year, the average life expectancy of an endoscope is about 1 year. To extend endoscope life, an endoscope can have major overhauls up to the $7000 range. These costly repairs have to be weighed against the enhancements that occur approximately every 3 years as new generations of colonoscopes are manufactured. Providing state-of-the-art endoscopes versus repairing outdated endoscopes that do not provide the highest quality of screening is the dilemma. On average, one major overhaul repair should be budgeted annually for frequently used endoscopes.


Mobile carts, for on-call and bedside colonoscopy procedures, and typical procedure room carts should be equipped with the following:




  • Colonoscope with processor, light source, monitor, heater probe unit, cautery, and grounding pads



  • Sterile water, lubricant, and appropriate gowns, gloves, and masks



  • Snares of various size and shape, such as rotatable, small, hexagonal, and oval with spiral wire barbs, suitable for sessile polyps; and forceps, regular or large capacity



  • Cytology brushes, sclerotherapy needles, sclerosant solutions, retrieval baskets, nets, and specimen traps



  • Polyp injection solutions (usually saline) used before polypectomy



  • Sterile ink for injection to tattoo a polyp or lesion before surgery



  • Ligating devices, such as detachable loops and clips of different lengths



  • Epinephrine to deal with postpolypectomy bleeding and an argon plasma coagulator on stand-by for surface cautery



  • Specimen jars and preservative



The endoscopy unit should have a CPR cart equipped with an automatic defibrillator, oxygen, suction, and resuscitation supplies.


An enhancement to the endoscopy unit is rigid endoscopic ultrasound probes for measuring intramural depth of rectal polyps or cancer in preparation for surgery. Cautery must be used cautiously. An increasing number of patients are presenting with automatic defibrillators that must be turned off temporarily during colonoscopy if polypectomy is possible. Identifying this type of patient ahead of time and notifying appropriate cardiologic staff in advance reduces delays. An increasing number of patients have a metal prosthesis, which requires careful placement of the cautery ground pad preferably on the flank side closest to the polyp site and away from the prosthesis.

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Feb 26, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Implementation of Colonoscopy for Mass Screening for Colon Cancer and Colonic Polyps: Efficiency with High Quality of Care
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