As pediatric gastrointestinal endoscopy continues to develop and evolve, pediatric gastroenterologists are more frequently called on to develop and direct a pediatric endoscopy unit. Lack of published literature and focused training in fellowship can render decision making about design, capacity, operation, equipment purchasing, and staffing challenging. To help guide management decisions, we distributed a short survey to 18 pediatric gastroenterology centers throughout the United States and Canada. This article provides practical guidance by summarizing available expert opinions on the topic of setting up a pediatric endoscopy unit.
Key points
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Gastrointestinal endoscopy in children can be performed in a variety of settings, but each should ensure a child-friendly design and pediatric-trained staff.
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Determining the capacity for a pediatric endoscopy suite depends on unit efficiencies such as procedure and turnover times.
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Having some flexibility in the unit’s schedule can help accommodate more urgent cases and lead to better patient satisfaction.
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Endoscopies are performed in children of all ages and sizes and the pediatric endoscopy suite should stock appropriate equipment sizes to accommodate all patients.
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Data from 18 centers around the country are summarized to help guide design, operational, and equipment management decisions.
Introduction
As pediatric gastrointestinal endoscopy continues to develop and evolve, pediatric gastroenterologists are more frequently called on to develop and direct a dedicated pediatric endoscopy unit. Lack of published literature and focused training in fellowship has rendered decision making around procedural unit design, operation, equipment purchasing, and staffing challenging.
To help guide management decisions, we distributed a short survey to 18 pediatric gastroenterology (GI) centers throughout the United States and Canada. The survey was sent to members of the North American Society of Pediatric Gastroenterology Hepatology and Nutrition Endoscopy and Clinical Practice Committee. Eighteen members from unique programs responded. Sixty-six percent of the respondents described themselves as performing procedures in centers that also trained pediatric GI fellows. In turn, responses to the survey were representative of both academic and community-based units, contributing to our intention to provide practical information that may be of help to those responsible for setting up and managing pediatric endoscopy units.
Introduction
As pediatric gastrointestinal endoscopy continues to develop and evolve, pediatric gastroenterologists are more frequently called on to develop and direct a dedicated pediatric endoscopy unit. Lack of published literature and focused training in fellowship has rendered decision making around procedural unit design, operation, equipment purchasing, and staffing challenging.
To help guide management decisions, we distributed a short survey to 18 pediatric gastroenterology (GI) centers throughout the United States and Canada. The survey was sent to members of the North American Society of Pediatric Gastroenterology Hepatology and Nutrition Endoscopy and Clinical Practice Committee. Eighteen members from unique programs responded. Sixty-six percent of the respondents described themselves as performing procedures in centers that also trained pediatric GI fellows. In turn, responses to the survey were representative of both academic and community-based units, contributing to our intention to provide practical information that may be of help to those responsible for setting up and managing pediatric endoscopy units.
Unit design
Pediatric endoscopy procedures are currently performed in a variety of settings, including general operating rooms (ORs), procedure/sedation rooms, dedicated endoscopy suites, and stand-alone surgical centers ( Fig. 1 ). Some design elements should be incorporated regardless of location. In particular, all settings where pediatric endoscopy is performed should aim to provide a calming atmosphere. Less preprocedure anxiety in children has been shown to decrease postoperative pain and increase satisfaction scores. Achieving a calming atmosphere can be accomplished by creating a play area for both younger and older children, with a variety of age-appropriate entertainment, including gaming systems, books, children’s furniture, toys, and TV screens with child-appropriate programming.
The layout of all types of units should ideally feature a physical and obvious separation between the check-in/waiting area and the clinical and procedural areas in terms of design and feel. Patients and medical staff movement should be directed so as to limit encounters of preprocedure with postprocedure patients. Design of patient flow is crucial to envision before building the unit. Expected duration of time that patients will spend in the most relaxing and family-centered environments should be maximized. Facilities should offer easily accessible and private bathrooms at all stages of the procedure, as well as a refreshments station for parents, who are likely to spend most of their time in the waiting area. One more recent option has featured patient monitoring screens, which allow family members to stay updated on the patient’s progress while in surgery.
There are clear benefits and drawbacks for various models of endoscopy settings. For example, a combined adult/pediatric unit can offer cost savings in terms of equipment and facilities, as well as close proximity for pediatric endoscopists to therapeutic endoscopists performing procedures in adults. However, this model may lack in the pediatric-specific design and pediatric-trained nursing staff.
Results of our survey suggest that 40% of centers currently perform procedures in a dedicated pediatric endoscopy suite. The rooms can be customized for endoscopic procedures and equipment reprocessing. In addition, the unit can include a pediatric-specific motility suite, capsule endoscopy viewing room, and an advanced endoscopy room for fluoroscopic procedures.
To save space and costs, some centers have opted to have their pediatric endoscopy unit function within the broader practice of a multispecialty day surgery department within a hospital. Staffing of day surgery centers, although vital for GI procedures, involves a profit loss because staff cannot be billed directly. This model can allow departments to share the cost associated with using waiting room and recovery staff. At present, outpatient centers and open center endoscopy models are popular in adult GI practice, but are not commonly used in pediatrics. This model likely offers high efficiency throughput because of limited delays often associated with inpatients, trainees, and emergent cases. To make this model profitable for a pediatric group, it needs to be a high volume or be shared with other subspecialties. In contrast, sharing space with other subspecialties may also decrease the potential to customize rooms for endoscopy and may present limitations for procedure scheduling and expansion options.
General endoscopy unit areas
All endoscopy units are required to meet the same periprocedural needs of patients and staff, and should have areas that are dedicated to specific parts of the procedure. In particular, all units should have a clear reception and waiting room, where patients are greeted when they first arrive for a procedure. Once escorted into the unit, patients require a clear area to be prepared for the procedure. This space needs to be appropriate for private examination. It is common to have a television with child programming in the room as well as a computer for accessing the electronic medical records. From this area the patient is transferred directly to a procedure room. After the procedure, a dedicated area for immediate and/or final recovery is needed, whereas a separate, private space for consultation with parents is desirable. Some facilities may choose to play easy-listening music in this area. To facilitate efficient procedures, an area for cleaning and reprocessing of endoscopes is necessary, as well as dedicated space for endoscope storage. In addition, if staff members are to be comfortable, dedicated changing rooms and specific spaces for conferences as well as breaks should be made available. Allocating offices for unit leaders, including the medical endoscopy director and/or the nurse manager, allows them to work throughout the day and be easily accessible to unit staff.
Unit size and capacity
An endoscopy suite with a minimum of 2 endoscopy rooms is preferable if at least 2 endoscopists will be performing procedures. Two rooms allow for concurrent examinations and the ability to perform emergent procedures. Three endoscopy rooms are recommended if the goal is to perform 3000 or more procedures per year. Adult teaching hospitals are generally expected to do 1000 endoscopic procedures per room per year. A nonteaching institution generally aims to be 30% to 40% more productive, and may set as a goal 1300 to 1500 procedures per room per year. Plans for designing a pediatric endoscopy unit should originate with anticipated volume, procedural complexity and growth of the unit over time. Mulder et al. have proposed equations to estimate the daily projected volume (DV), room capacity (RC) and number of endoscopy rooms needed (ER)
Based on our survey, including turnover time, an esophagogastroduodenoscopy (EGD) is on average allocated 43 minutes, colonoscopy 58 minutes, and the two procedures combined 76 minutes ( Fig. 2 ). It is important to recognize that an endoscopy unit should not target 100% efficiency, because this leads to less patient satisfaction and more scheduling conflicts. Instead, standard efficiency rates should be considered to be 70% to 85%. The suggested procedure times can be multiplied by the efficiency factor (0.7–0.85) to estimate yearly procedure volumes. It may be important to discuss this point with administrators when considering more OR time or space planning.
In pediatric endoscopy, turnover time, or the room time between procedures, clearly varies from center to center. In our survey, most respondents reported turning over a room in 16 to 20 minutes, with 1 center reporting an average turnover time of more than 30 minutes ( Fig. 3 ). Optimizing turnover time should be a target for quality improvement initiatives because it has direct impact on unit productivity.
Reprocessing
A major decision that must be made regarding any space used for pediatric endoscopy is where and how endoscopes will be reprocessed between cases. High Level Disinfection (HLD) is considered the standard of care for flexible endoscopes and is defined as a 106 reduction in bacteria. In general, the risk of infection from cross-contamination between patients is estimated to be very low at 1 in 1.8 million. However, cross-contamination between patients undergoing endoscopic procedures may be underreported. Endoscopy staff should be well trained in disinfection procedures and skills should be assessed on an annual basis. Step-by-step guidelines on appropriate scope disinfection can be found in the multi-society guidelines published in 2011. To improve adherence to protocols, all technicians and nurses should receive training. Scope processing can be manual or automated. There are benefits and drawbacks to both, which are further discussed in Table 1 .
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