5 Design of the Endoscopy Suite
Endoscopic techniques continue to develop rapidly, and a myriad of other diagnostic imaging modalities have become more and more important and clinically relevant. When planning and designing a new endoscopic suite, these changing demands of technical equipment and information technologies have to be considered. Former guidelines can only be partially adapted to these recent changes. New demands to imaging, flexibility, and connectivity have to be defined. In general, the space and facilities required in endoscopic units depend on the spectrum and quantity of the procedure performed and the staff available. Additionally, it is important to predefine which endoscopic techniques should be performed or subsequently introduced. When required, the facilities should be sufficiently versatile and flexible to allow handling of emergency cases without disrupting routine procedures.
There are some general questions and considerations which should be answered in a checklist before planning and building an endoscopic suite.
5.2 General Questions and Considerations
For what purposes are the endoscopy suite used?
Only elective/planned procedures?
Only outpatient or ambulatory patients or also inpatients?
Estimated number of procedures and procedure types per day/week?
Number and frequency of complex procedures (e.g., endoscopic submucosal dissection [ESD], peroral endoscopic myotomy [POEM], double-balloon endoscopy, cholangioscopy)?
What types of therapeutic and invasive procedures are performed?
Are special patient groups treated (e.g., pediatric patients, bariatric patients)?
What types of complex procedures are performed?
Frequency of X-ray and radiological demands?
Need for navigated work or procedures?
Need for combined imaging (e.g. endoscopic ultrasound [EUS] plus radiology)?
Are there plans for NOTES (natural orifice transluminal endoscopic surgery) procedures (POEM, peroral endoscopic tumor resection [POET], ESD)?
Are other procedures and tests (manometry, capsule endoscopy, function tests) performed within the unit?
What are the streams of material/patients/doctors/nurses?
What is the most effective way for patients to navigate from the time of admission until the end of recovery?
Which pathway is most effective for endoscopic staff and nurses?
How can the time and efficiency of physicians be optimized?
How can the endoscopic equipment be used most effectively?
How and when is the endoscopic report generated and given/explained to the patient?
Which reprocessing concept is planned?
Processing of endoscopes within the unit or in central facility?
Reprocessing of material or exclusive single use?
What concept of reprocessing the endoscopes is carried out (separation of unclean and clean area), and what type of reprocessing machines will be used?
What room concept (ceiling supplies or trollies) is planned?
How is sedation performed in the endoscopic suite?
Percentage of procedures with sedation.
What type of sedation is used and what is the process for patient monitoring during and after the procedure?
Need for and frequency of general anesthesia.
How is general anesthesia performed?
Does the endoscopy suite provide care to children of all ages?
5.3 Guidelines for Planning an Endoscopy Suite
The space concept of an endoscopic suite is influenced by many factors. If the endoscopy suite is planned de novo or in a new building, an ideal room concept can be realized. However, if the unit is built into an existing building, there is always a compromise between demands and technical feasibility. The number of endoscopy rooms within the endoscopy suite depends on several factors such as the estimated number of endoscopic procedures and the breakdown by type, complexity, and need for fluoroscopy or radiography. Precise updated numbers and a development plan for the upcoming years should be made available for planning, as these statistics are often outdated. 1
Furthermore, transport and waiting times as well as the management of patients outside of the procedure rooms are relevant. A clearly defined and structured monitoring of sedated patients is mandatory, and sufficient space, monitors, and staff personal for this need to be considered. Some units have individual pre-procedural rooms for each patient, to assess, undress, recover, dress, and review patients before discharge. In some countries, the requirements for the postprocedural recovery are clearly regulated and need to be considered before planning. 2 When there is limited recovery space and when more than one patient shares a room, there should be one or two interview rooms available for postprocedure consultation (▶Fig. 5.1, ▶Fig. 5.2).
5.4 Pathways for Patients, Staff, and Material
When planning a new unit, it is advisable to first plan the pathways of individual patient populations (inpatients, outpatients), endoscopes, doctors, and nursing staff. Questions to be addressed include: where does the patient (outpatient or bedbound) enter the endoscopy unit, where do the preparation, undressing, and preprocedural assessment take place, and how and where does the patient leave the unit. If possible, preparation and recovery of the patients should be carried out independently of the procedure rooms, as this increases flexibility and productivity of the unit. On the other hand, separated recovery areas require additional staff and space. Furthermore, it is advisable to separate patients waiting for procedures from those recovering. Additionally, the number and timing of outpatient procedures performed without sedation have to be estimated, as these patients require less infrastructure and nearby changing rooms eventually with direct access to the procedure room.
For the endoscopists, it is important to define the endoscopic workflow beforehand. Who performs sedation (specialized staff, Nurse Administered Propofol Sedation [NAPS] nurses, anesthetist, second physician)? When and how is the procedure report created? Will there be a report given to the patient prior to leaving the unit, or will it be finalized after the patient leaves? According to the answers, the pathways (computer-based report generation location, printout, and signature) have to be developed. Similar pathways should be defined for equipment and material including endoscopes and working/break areas for the endoscopy staff. A close proximity between procedure rooms and cleaning and disinfection area is desirable. In this context, it is important to define how the contaminated endoscopes are transported back to the unclean area of the cleaning facilities and how the cleaned endoscopes are transported back into the procedure room. In many modern endoscopy units, a special closed trolley system is used for this purpose.
5.5 Location of the Unit
The strategic location of the unit is crucial and should be based on the number of inpatient and/or outpatient procedures. If the majority of endoscopic examinations are outpatient procedures, a location next to the outpatient department or day care unit is desirable (▶Fig. 5.1, ▶Fig. 5.2), unless daycare facilities are fully provided for within the unit itself. 1 , 3 At many units, the majority of patients are ambulatory, with a significant minority arriving in wheelchairs or trolleys, or even on hospital beds. A suitable reception area is needed, as well as an area for patients to await endoscopy on trolleys, on which they will be transported directly into the endoscopy room. Changing facilities in or near this waiting area must be provided. The waiting area can also serve as the recovery area to which patients are returned after endoscopy, though it is advisable to have separate waiting and recovery areas. Waiting and recovery areas must also be provided with toilet facilities. After full recovery, ambulatory patients should await discharge in the reception area, which can also be occupied by relatives and friends. Waiting-room space can be calculated on the basis of eight chairs for each endoscopy procedure room. This is based on two or three seats for the waiting patient and family members, and two each for family members of the two patients in recovery and the patient undergoing the procedure.
If outpatients and inpatients are treated, then simultaneous but separate patient flow pathways should be created (▶Fig. 5.1). There should be an interview room where the details of the procedure prior to endoscopy and the results of endoscopy and further arrangements can be discussed in privacy with the patients and/or their relatives, as appropriate.
5.6 Number of Rooms
In general, upper and lower gastrointestinal (GI) tract endoscopies are separated, and thus there is a minimum of two endoscopy rooms even for a small unit. For larger units, approximately one endoscopy room per 1,000 examinations (diagnostic and low-scale therapeutic) annually is a rough estimate for capacity planning. The British Society of Gastroenterology recommends a minimum of 2 + 1 endoscopy rooms for 3,000 endoscopies per year. 3 , 4
In larger units, the concept should also include a radiography unit and a multipurpose room for various procedures such as laser therapy, EUS, and emergency cases. 5 Providing care for emergency cases has to be standardized and separated into those suitable for the endoscopy unit and those who should be treated in the intensive care unit or operating room. If a high volume of emergency and unscheduled cases are seen, then it is important to have at least one additional room for flexibility without interrupting the routine scheduled endoscopic program. 3
When additional techniques such as video capsule endoscopy and functional GI tests (manometry, breath test, absorptive tests) are planned and performed by the same staff, additional rooms for these tests and for reviewing capsule endoscopy should be planned for. In larger units or specialized centers performing 6,000 procedures (the 4 + 2 room model), a dedicated room for EUS, laser therapy, and photodynamic therapy should also be present. 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16
Therapeutic endoscopic procedures are increasingly time-consuming and result in lower productivity per room. Such interventional techniques as ESD, POEM, and double-balloon enteroscopy, which have longer procedure times, should be taken into account for workflow. There are recent reviews and published overviews on the time demands of the various endoscopic procedures, which have been validated. 8 , 9 , 17
The amount of teaching that takes place in the endoscopy unit also has considerable impact on procedure performance time and can amount to as much as an additional 30% of time per procedure.
Furthermore, the concept of report generation has to be considered (see below). If the report is generated immediately after the procedure with a computer-based documentation system, the time can be utilized for patient and room turnover. Thus, a single endoscopist could continuously work in one room. However, often the concept of switching rooms between procedures is applied. This increases the productivity of the individual endoscopist, but report writing and documentation might be less accurate. Capacity planning is important, and all calculations for procedure room capacity have to incorporate a realistic period (e.g., 10–15minutes) for cleaning and setting up the room for the next procedure. 6 – 16 However, capacity and productivity planning is often greatly affected by local characteristics (waiting time, in-house transportation, recovery facilities). Room productivity is a valuable quality measure for organization of the unit. However, productivity of a procedure room is also influenced by the availability of instruments (endoscopes) and the cleaning preparation cycles.