Unit design

Proper design of the pediatric endoscopy unit is crucial to the experience of the patient as well as the efficiency of the endoscopy team. Pediatric‐focused facilities prioritize the child and family experience with the goal of reducing patient anxiety and providing age‐appropriate analgesia [1,2]. Design and management of the endoscopy unit needs to be specialized for this unique patient population. A calming environment and smooth patient flow are critical. Ideally, encounters between preprocedure and postprocedure patients should be minimized.

In the United States, endoscopy procedures in children are performed in a variety of locations, including operating rooms, procedure rooms, dedicated endoscopy suites, and ambulatory surgery centers [1,2]. In low‐volume centers, use of the operating room may be appropriate. For those units located in general hospitals, a combined adult/pediatric unit can offer cost savings in terms of equipment and facilities, as well as close proximity for pediatric endoscopists to adult therapeutic endoscopists. Recent survey data suggest up to 40% of centers in the United States currently perform endoscopy in a dedicated pediatric endoscopy unit [1]. Sharing space with other specialties such as pulmonology may be an option, but this can decrease the ability to customize the space for gastrointestinal endoscopy.

An endoscopy suite with at least two procedure rooms is desirable depending on the number of endoscopists and volume of procedures. Two rooms allow for concurrent procedures to take place and the ability to perform emergent inpatient procedures. Adult teaching hospitals are generally expected to do 1000 procedures per room per year [3]. In addition, the unit can include a motility room, capsule endoscopy viewing room, and advanced endoscopy room for fluoroscopic procedures. Plans for designing a pediatric endoscopy unit should include anticipated volume, procedural complexity, and growth of the unit over time. Considerations of space are difficult and carry the greatest implications for overall construction costs [4].

All units should have a reception area and waiting room, where children and caregivers are greeted when they first arrive. The waiting areas should be child friendly. Bathrooms should be easily accessible, with special considerations for obese patients or handicapped patients in a wheelchair. Once escorted into the unit, patients require a clear area to be prepared for the procedure. From this area, the patient is transported directly to the procedure area. In general, a procedure room should be at least 400 square feet with more space often needed for advanced therapeutic cases involving fluoroscopy. Two separate doors should provide access to the procedure rooms: one to allow for the entry of the patient and clean supplies and the other for the removal of used equipment and specimens. Procedure rooms should be equipped to provide CO₂, oxygen, suction, and adequate electrical socket outlets for ancillary equipment. Ceiling‐mounted booms may be helpful in keeping lines and equipment off the floor. One side of the room should be dedicated to nursing. Anesthesia and associated medications and supplies should be located at the head of the bed. After the procedure, a dedicated space for immediate and/or final recovery is needed.

A work area for physicians is an important consideration so endoscopists can complete procedure notes, enter patient orders, and coordinate care by phone. Including a room for consultation with patients and families to allow for confidential conversations is also important [1].

A major decision that must be made is where endoscopes will be stored and reprocessed between cases. Ideally, reprocessing is most efficient when it can be located directly adjacent to and shared with the other procedure rooms. Contaminated endoscopes have been linked to many outbreaks of device‐related nosocomial infections. There have also been outbreaks recently related to the elevator mechanism of the duodenoscope [5]. Endoscopy staff should be well trained in disinfection procedures and skills should be annually assessed. Flexible GI endoscopes should first be comprehensively cleaned manually and then subjected to at least high‐level disinfection (HLD). HLD can be performed in an automated endoscope reprocessor or using manual processes. Step‐by‐step guidelines on appropriate scope disinfection can be found in the multi‐society guidelines originally published in 2011 [6] and updated in 2016 [7]. An understanding of how a specific reprocessor might be integrated into a unit under design is critical to avoiding last‐minute space refitting, as well as potential breaches in patient safety once procedures are being performed.

When preparing plans for construction of the endoscopy unit, thorough discussion should take place with the hospital system facility management or a licensed architect familiar with healthcare facilities. The coding of these facilities will vary from state to state and country to country. To prevent future problems, the architect and licensing agencies should be consulted regarding all possible uses of the unit, as regulations vary depending on the use of the unit. Attention to these possibilities may prevent the possibility of retrofitting after the unit is already built.

Unit management

The Society of Gastroenterology Nurses and Associates (SGNA) has published guidelines suggesting the minimum number of qualified personnel who should be allocated to various positions during endoscopic procedures [8]. Running a cost‐effective and safe endoscopic practice is a balance between appropriate staffing and the expense of maintaining that staff. Determining the number of staff needed to run the endoscopy unit is dependent on several factors. These include availability of equipment, time, types of procedures, complexity of patients, and presence of trainees. Maintenance of certification and licensing of endoscopy nurses are state specific in the United States (http://ce.nurse.com/RState Reqmnt.aspx). It would be prudent for the endoscopy unit to have annual assessments and training set up for all employees. A recent survey of pediatric centers suggests that more than 70% use an endoscopy RN and an endoscopy technician in the room during the performance of each procedure, and 100% use dedicated anesthesia staff [1].

Plans for after‐hours coverage should be determined for weekend and after‐hours emergencies. Based on a recent survey [1], 66% of US centers currently have a system in which a GI technician, a GI RN, or both are available on call. On‐call staff should be cross‐trained so that they can function well in all areas of the procedure. In some centers, general operating room staff assist with emergent after‐hours cases. These staff may not be trained in endoscopic procedures. Assigning a unit director is important in ensuring a focus on process improvement activities, and ensuring that equipment and services remain competitive.

It is important to recognize that an endoscopy unit should not target 100% efficiency, as this will lead to scheduling conflicts and decreased patient satisfaction. Instead, standard efficiency rates should be considered to be 70–85% [9]. The unit may have a dual purpose of serving both inpatient and outpatient populations, as opposed to an outpatient endoscopy center. It should therefore provide easy access to both types of populations. Optimizing turnover time should be a target for quality improvement initiatives as it impacts unit productivity. Patient no‐show may be an important barrier to improved efficiency. Preprocedure interventions have been shown to be effective in decreasing the no‐show rate [10]. On‐time starts and decreased turnover time can help maximize room efficiency [11]. Patient satisfaction surveys should be used as an indicator of quality of service. A recent study on patient experience in pediatric endoscopy identified important aspects from the patient and family perspective [12].

Documentation is an important aspect of endoscopy unit management. There are three broad areas of documentation: nursing documentation before and after procedure, the procedure itself, and sedation record. The Joint Commission on Accreditation of Healthcare Organizations provides guidance on components of documentation.

Equipment

Pediatric patients often have limitations in therapy due to size and approved measures. Endoscopic equipment can be purchased used or new or leased for a predetermined amount of time.

Purchasing or leasing endoscopy equipment represents a significant capital budget item for any setting in which pediatric endoscopy will be performed. Fewer endoscopes may be necessary to run concurrent rooms in smaller centers, compared with larger centers that feature more endoscopists and more endoscopy rooms. There are no data to guide how many scopes should be on hand at any endoscopy unit. To maximize efficiency, one light source and processor should be available per endoscopy room and one scope reprocessor allocated for each 1000 procedures per year. For adult units, one colonoscope and gastroscope per 350 procedures per year has been suggested as ideal [4], but this general recommendation may not apply to pediatric endoscopy in which there may be a need for endoscopes of various diameters and sizes to accommodate infants and children. The frequency of endoscope upgrades is also a major factor in determining how many endoscopes should be purchased. In a recent survey, most centers reported replacing the endoscopes every 6–7 years [1].

An ideal endoscopy unit offers diagnostic endoscopy, including capsule endoscopy, small bowel enteroscopy, pH impedance testing, and motility testing. Therapeutic endoscopy should be available at pediatric centers or offered by an adult gastroenterologist in the area. If trained endoscopy staff are not always available to participate in emergent cases, having specific toolkits such as a bleeding or foreign body removal kit can ensure that correct endoscopic accessories are available.

Conclusion

Well‐designed pediatric gastrointestinal endoscopy units are critical to the effective diagnosis and management of gastrointestinal disorders in children. A thoughtful approach to the design, management, and necessary equipment for the unit is essential.