Provision of Endoscopy Related Servicesin District General Hospitals

BSG Working Party Report 2001

The Report of a Working Party of theBritish Society of Gastroenterology Endoscopy Committee

BACKGROUND

Nearly 10 years ago, a BSG Working Party reported onthe Provision of GI Endoscopy and Related Services forthe District General Hospital.1 The Report was preparedto inform Hospital Managers of the need forGastrointestinal Endoscopy and the facilities that wererequired for its delivery. Progress in the management ofpatients with gastrointestinal disease and new technologymeans that these guidelines are now out of date. Changesin equipment, requirements for the sterilisation ofendoscopes,2, 3 advice on re-use of endoscopic accessories4

and clinical governance are only a few of the changes thathave occurred during the last ten years. In addition, theintroduction of Evidence Based Practice and the widespreaduse of Clinical Guidelines and protocols are significantfactors influencing the work of Endoscopy Units.

This Report focuses on a number of key areas, includingthe requirements for endoscopy, where this should beperformed, the facilities required in an endoscopy unit,the provision of emergency endoscopy and the relationshipbetween the secondary and primary care sectors in thedelivery of the service.

PROVISION OF ENDOSCOPY SERVICES

Referrals to most gastrointestinal endoscopy units fall intothree main categories:

a Open Accessb Outpatient Generatedc Urgent Inpatients

The Department of Health has now maderecommendations on the minimum provision ofGastrointestinal Endoscopy in District General Hospitalswhich accept emergency patients and these should act asa bench mark for all DGH Units.5 Appendix These Servicestandards clearly establish the quality framework forEndoscopy Units in District General Hospitals in termsof staffing, record keeping, equipment, and liaison withother departments.

CLINICAL NEED FOR AN EFFECTIVEENDOSCOPY SERVICE

a Diagnostic Upper Gastrointestinal EndoscopyThe requirement for Upper Gastrointestinal

Endoscopy in the general population is now in excessof 10 per 1000 population per annum and may be ashigh as 15 per 1000 population per annum wheregeneral practitioners have unrestricted access to uppergastrointestinal endoscopy (M G Bramble personalcommunication). This compares to a figure of 8.6 per1000 population in 19926 and gives an annualworkload of approximately 3000 examinations in aDistrict General Hospital serving a population of250,000. It is likely that the number of elderly patientsrequiring gastroscopy will gradually rise whilstyounger patients will be treated more frequentlywithout recourse to diagnostic gastroscopy.

b Flexible SigmoidoscopyThe current requirement for flexible sigmoidoscopyin the general population is much more difficult tocalculate as many examinations are basically limitedcolonoscopies. A reasonable estimate would be 2–2.5per 1000, giving a workload of between 500–600examinations per year.

This is likely to increase with the advent of therequirement to provide more rapid diagnosis ofcolorectal cancer. Many hospitals are now trying toestablish endoscopy lists specifically devoted topatients with new onset rectal bleeding, this is likelyto lead to an increased number of flexiblesigmoidoscopies and colonoscopies being performed.The inability of the endoscopist to reach the splenicflexure with a flexible sigmoidoscope7 means that acolonoscope should be used in preference for mostexaminations. This also leaves the endoscopist theoption of performing a full examination, if indicatedat the time.

c ColonoscopyThe majority of District General HospitalGastroenterology Units now perform between 2.5 and5.0 colonoscopies/1000 population/year. This numberhas been steadily increasing

6 and many units are under

great pressure to increase throughput because of theCalman-Hine initiative8 on colorectal cancer. For mosthospitals waiting lists for Colonoscopy areunacceptably long and exceed the capacity of cliniciansto meet this demand. Training nurses to perform largebowel examination may be one logical way aroundthis problem.9

Provision of Endoscopy Related Services in DistrictGeneral HospitalsAUTHORS

Dr 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.

Working party report

BSG Working Party2

It is highly likely that the requirements forendoscopic large bowel examination (flexiblesigmoidoscopy and colonoscopy) will continue toincrease and that at present there is a significant unmetdemand. Some units are already performing 8 – 10large bowel examinations per 1000 population wherefacilities allow (Dr P. A. Cann personalcommunication) and the average DGH should beplanning for a similar workload (2000–2500examinations/year) in terms of equipment andmanpower.

d ERCPThe pattern of provision of ERCP is changing.10 Arecent survey showed that a large majority of AcuteHospitals in the U.K. provided ERCP, with theprovision moving away from Surgeons andRadiologists toward medical gastroenterologists.Approximately 0.75 examinations are carried out per1000 population per year, with an average DistrictGeneral Hospital performing about 200 procedures.This is also an increase on figures relating to practicein 1992 when 0.54 examinations were performed per1000 population.6 Three quarters of these patients willrequire therapeutic intervention.

e Endoscopic UltrasoundAt present, endoscopic ultrasound and enteroscopyare only performed in specialist centres, but theseprocedures are time consuming and may impact onthe provision of routine lists.

Open Access Endoscopy

The rise in demand for all forms of endoscopy has led toan increase in the proportion of patients, particularly thoserequiring gastroscopy and flexible sigmoidoscopy, beinginvestigated in ‘open access’ services.11 The majority ofreferrals to open access services are being made usingagreed guidelines and protocols.11 There has been a steadyincrease in the overall numbers of open access proceduresresulting in many Endoscopy Units reconfiguring theirlists to accommodate more endoscopies being preformedby hospital practitioners or Nurse Endoscopists (videinfra).

One of the original intentions of the Open AccessService was to reduce the waiting time for endoscopy andmost units have protocols with their local GPs, whichallow certain categories of patients to be investigatedwithout referral to a hospital specialist. The benefits ofopen access gastroscopy in terms of patient managementare clear12 but so far there is little evidence to show anybenefit in detecting malignancy at an early stage .13

Attempts are now being made to use H.pylori screeningin younger patients without alarm symptoms to reducethe number of referrals. This ‘test and treat’ policy has sofar, had little impact on the workload of Endoscopy Unitsbut the potential to reduce referrals could be as high as73%14 and should prove to be economically justified inyounger patients. Over the age of 50 gastroscopy is costeffective15 providing the cost of gastroscopy is low(approx. £100).

The role of primary care endoscopy remains unclearalthough there are currently in excess of 25 primary careendoscopy units (R Stevens personal communication).There is very little point in establishing an off-siteEndoscopy Unit, which only carries out a small numberof sessions per week. Calculations on the cost benefit ofthese Units in terms of reducing waiting times forendoscopy, or more rapid diagnosis of serious pathology,need to be undertaken. Co-operation with the secondarycare sector is vital if primary care endoscopy units are tocontinue, as this will ensue that standards are the same inboth sectors. This should include regular audits of safetyand outcome utilising the same referral protocols. In somehospitals it might be appropriate to have GP run sessionsin the hospital unit rather than a peripheral unit which isunder-utilised.

District General Hospitals will continue to provide allemergency endoscopy.

PLANNING OF OPEN ACCESS SERVICES

Open Access Services should fulfil the following qualitycriteria.

1 Referrals should be made using locally agreedguidelines and protocols, which fulfil long term ServiceAgreements.

2 Referrals should be made using standard ReferralForms which are suitable for audit and containinformation which is required for a Minimum DataSet for Gastrointestinal Endoscopy (16)

3 Clerical and IT support for the Endoscopy Unit shouldbe sufficient for family practitioners and patients tobe informed of their appointment date and time within7 working days of receipt of the referral. Notificationto patients should include information about theprocedure, possible complications and alsoarrangements for discharge from the Endoscopy Unit.

4 Clinical responsibility for the patient must be clearlydefined.

5 The British Society of Gastroenterology QualityStandards for Informed Consent, should be used (17)

6 There should be sufficient trained staff available tospeak to patients on arrival in the ward, and on leaving,so that they can be informed of the results of theirendoscopy. Written results should be the gold standardfor sedated patients and arrangements for follow upshould be made before the patient leaves the Unit.

7 The Unit should have a computerised Endoscopy/Patient Record System in which data is recordedlocally, stored centrally and is backed up on a regularbasis, so that analysis for Clinical Governancepurposes, is easily available. The Endoscopy reportshould be available to be returned to the referringdoctor on the day of the procedure and ideally, thisshould be electronically transmitted.

8 Regular audit of the Open Access Service should takeplace.

9 Open Access Endoscopy should be performed byexperienced, non-training grade staff, or by traininggrades under direct supervision.

10 The Unit should have clear Protocols for dealing withpatients found to have serious pathology at open

Provision of Endoscopy Related Services in District General Hospitals 3

access endoscopy. In particular, the softwareprogramme used to provide the endoscopy reportshould also have the flexibility to incorporate biopsyresults and indeed provide reminders to chase biopsyresults when specimens are taken for pathology.

The responsibility for arranging referrals forsurgery or other investigations should be clearlydefined and the effectiveness of the process should beaudited on a regular basis.

11 Referring doctors should receive regular bulletins onthe activities of the Open Access Service includingwaiting times, summaries of findings, complicationrates and plans for development.

SummaryIdeally, all gastrointestinal endoscopy should take place ina single dedicated unit but it is possible that satellite unitswill increase in numbers. Gastroenterology Departmentswill need to work with their locality GPs to determine thebest way of providing endoscopy services bearing in mindall the factors which influence patient acceptability. In someareas the distances patients need to travel may makecommunity endoscopy units a preferable option.

It is extremely important that the quality of thediagnostic endoscopy service in Community-based Units,is exactly the same as that for the main hospital site andin particular, facilities for monitoring, provision of cardio-pulmonary resuscitation and recovery areas must bemaintained to the highest possible level and equivalent tothose in the main hospital. If these facilities cannot beprovided, then endoscopy in community-based unitsshould only be performed on unsedated patients. TheRoyal College of Anaesthetists are currently producingguidelines on sedation in a non hospital setting.

WORKLOAD OF ENDOSCOPY UNITS

The Royal College of Physicians18 has recently madespecific recommendations on the workload of the averageGastroenterology Department dealing with a populationof 250,000. An increase in the requirements for diagnosticand therapeutic endoscopy has resulted inrecommendations that 8 notional half days per week, arerequired for gastroscopy based on the assumption thatthere will be 2500–3000 diagnostic and therapeutic upperGI endoscopies performed per annum. The assumptionthat the average Unit should perform 600–800Colonoscopies per year and a similar number of flexiblesigmoidoscopies (which would occupy another 8 notionalhalf days) is an underestimate. The average DGH shouldbe planning sufficient endoscopy time to allow for 12–14notional half days, ERCP lists would occupy 2 notionalhalf days. It should be noted, however, that mostConsultants are unavailable to perform endoscopy forup to 10 weeks per year because of the requirements ofannual leave, study leave and managementresponsibilities. Therefore the numbers of endoscopies thatcould be performed may need to be revised down to allowfor this, particularly in units where there are single-handedgastroenterologists, allowing cover during holidays andstudy leave, in addition to sharing the burden of anincreasing endoscopy workload.

These recommendations do not include the time that isrequired for proper assessment of in-patient referrals forendoscopy, nor do they include the increasing demand forpercutaneous endoscopic gastrostomy (PEG). Whilst nurseendoscopy will overcome some of these problems, ultimateresponsibility will remain with consultants and it is nolonger acceptable to have single handed gastroenterologistsin a DGH covering more than 100,000 people. The averageDGH now requires 3 gastroenterologists and twoendoscopy rooms able to run parallel sessions. A large DGHwill require three endoscopy rooms with a correspondinglylarge recovery area.

NURSE ENDOSCOPISTS

In a previous report, The British Society ofGastroenterology concluded that nurses who weresuitably trained and supervised would be able to carryout certain endoscopic procedures. Recommendations onstandards as well as general considerations, such asmedico-legal issues, risks and practical problems wereoutlined in the document, ‘The Nurse Endoscopist’.10

The demand for endoscopy is now outstripping thecapacity for medical endoscopists to provide the servicerequired within a reasonable time scale. This has led to avariety of solutions, including the widespread introductionof Open Access Services, Primary Care Based Endoscopyand the introduction of Nurse Endoscopists.

In principle, the United Kingdom Central Council(UKCC) has no objection to nurses developing theirprofessional practice, including training in gastrointestinalendoscopy. However, it specifically recommends that thenurses concerned are proven to be competent for thepurpose and are mindful of their professionalaccountability for their actions.

The General Medical Council recognises and welcomesnurses undertaking new roles that may previously havetraditionally undertaken by a doctor. However, the GMCalso cautions that a doctor who delegates treatment orprocedures to be performed by another person, must beassured that the person’s training is adequate for thepurpose and that the doctor retains ultimate responsibilityfor the patient’s management.10

RECRUITMENT

Recruitment to a Nurse Endoscopy Post should beconsidered in a wider context than just the EndoscopyServices’ requirement. The development of all SpecialistNurses should be part of local workforce planningarrangements and tailored to meet local and regionalneeds. Good workforce planning will ensure that theNurse Endoscopist has a proper career structure and thattheir Continuing Professional Development isappropriately structured.

Five years ago, there were few nurses in the UnitedKingdom with sufficient experience to perform endoscopyunsupervised, and many Units have now taken on trainingtheir own staff to perform routine Gastroscopy and/orFlexible Sigmoidoscopy. A common dilemma is whetherit is more suitable to train nurses from within theEndoscopy Unit, or recruit a trained nurse from outside.

BSG Working Party4

There are now nationally recognised Nurse EndoscopyTraining Units and currently approximately 75 nurses peryear receive Accreditation.

DEVELOPMENT OF THE ROLE OF THE NURSEENDOSCOPIST

The Joint Advisory Group (JAG) has identified minimumstandards for Units training in Endoscopy (19). JAGexpects Nurses undertaking endoscopy to train to thesame criteria and standards as medical endoscopists. Thedevelopment of the Nurse Endoscopist into a competentpractitioner requires a linked approach to professionaland academic developments in clinical endoscopy training.The Nurse Endoscopist should undergo definedapprenticeship under close supervision. National coursesaccredited with the ENB and BSG are available and NurseEndoscopists should attend these during their initialtraining period and then subsequently fulfil national CPDrequirements for Endoscopists.

The nurse Endoscopist should work closely withmedical and surgical consultant Gastroenterologistsensuring that both medical and nursing supervision areidentified with clear line management. The posts’ roleand responsibilities should be clearly defined to preventconfusion, but should be flexible enough to allowexpansion and development. Nurse Endoscopists shouldwork within Guidelines and use evidence based Protocolsas part of a multi-disciplinary team. The undertaking ofresearch, practice development and audit should be seenas fundamental to the post.

Careful consideration should be given to sessionalcommitments to endoscopy, and to remain competent,at least two or more sessions weekly should be allocated.Conversely, it is professionally inappropriate for a nurseto be used as an endoscopist full time. It is equallyinappropriate to expect a nurse to manage a caseloadlist in the endoscopy unit part time, and then return toduties as an endoscopy nurse for the remainder of theweek. The endoscopy nurse should be regarded as a GINurse Specialist, who provides appropriate care andservices for patients with GI disorders and extends therole by taking on some of the routine follow upresponsibilities such as a clinic for patients with PEGfeeding tubes. In some units, nurses who performendoscopy may be the most appropriate assistants forcomplex therapeutic procedures where non-traininggrade staff work single-handedly.

EMERGENCY ENDOSCOPY

The majority of requests for emergency or out-of-hoursendoscopy involve the management of patients with acutegastrointestinal bleeding. Pressure to reduce the hours ofwork of training grade doctors and restrictions imposedby the European Working Time Directive, have led to thegradual disappearance of on-call rotas in District GeneralHospitals for patients with acute bleeds and theintroduction of more structured arrangements. In thosehospitals where an on-call rota for training grade doctorsstill applies, it is essential that ConsultantGastroenterologists are available to come to the Endoscopy

Unit, when necessary, to supervise the management ofpatients with acute gastrointestinal haemorrhage.

The NHS standards of service recommendations makeit quite clear that District General Hospitals must haveclear Guidelines and Protocols for the provision ofemergency endoscopy, which should be available within24 hours of admission/or request.

The British Society of Gastroenterology and RoyalCollege of Surgeons’ audit into the Management of AcuteGastrointestinal Bleeding20 revealed that the mortalityfrom gastrointestinal bleeding in District GeneralHospitals, tended to be confined to the elderly with multisystem disease. This constant mortality rate of about 14%contrasts sharply with the fall in mortality that has beenachieved over the last 20 years in younger patients withbleeding peptic ulcers, at least in part due to the successof interventional therapeutic endoscopy

In addition, there is strong evidence to show that theconcentration of patients with acute gastrointestinalhaemorrhage in Specialist Units, leads to a significantreduction in mortality which is achieved by an aggressiveendoscopic approach and combined management betweenphysicians and surgeons.21,22 The low mortality associatedwith gastrointestinal haemorrhage for patients under theage of 60 (1%), has led to several prospective studies onthe requirement for hospital admission for all patients.There are now data to show that patients withuncomplicated upper gastrointestinal bleeding do notrequire admission, provided the patients undergo earlyGastroscopy with the provision of a definitive diagnosis,and that bleeding has ceased.23

What then is the best model for dealing with emergencyendoscopy? Certain basic provisions are essential.

1 There should be an adequate number of properlyfunctioning end viewing endoscopes with biopsychannels sufficiently wide to allow therapeuticintervention – often these will be large diameter twinchannel instruments.

2 An experienced endoscopist – emergency endoscopyshould not be performed by training grade doctorsunless under direct supervision, or until they haveachieved the required experience.

3 Emergency endoscopy should be performed in themain Endoscopy Unit with experienced nursing staffavailable – not as a rushed procedure, either in a sideroom on a medical ward, or in a main operatingtheatre, unless the endoscopy is being performedimmediately prior to surgery.

4 Endoscopes are most likely to become blocked whenused for patients with gastrointestinal haemorrhage– careful attention to mechanical cleaning of theinstrument after use is essential. This is one of themain reasons for performing emergency endoscopywithin Endoscopy Units during working hours so thatexperienced endoscopy nurses are available to handlethe instruments after use.

5 Emergency endoscopy should be performed withfacilities for therapeutic intervention available, i.e.injection needles, 1:10,000 adrenaline, sclerosants,banding apparatus and thermal methods of controllinghaemorrhage.

Provision of Endoscopy Related Services in District General Hospitals 5

The essential requirements for an emergency endoscopyservice as stated above, suggest that only one or twomodels will be reliable and predictable. Most DistrictGeneral Hospital Endoscopy budgets do not providesufficient funding for a seven day a week, 24 hour on-call service by endoscopy nurses, and as a consequence,endoscopies, out-of-hours and at week ends areperformed as little as possible. Rota restrictions tend tolead to medical and surgical ConsultantGastroenterologists being called in to deal with thesepatients, often being required to use sub-standardequipment in operating theatre annexes. ClinicalGovernance Initiatives indicate the need to maintainquality at all times including a minimum level of serviceprovision. This is supported by the Quality AssuranceProtocols Initiative and ‘ad hoc’ arrangements to coveremergency admissions with gastrointestinal bleeding areno longer acceptable.

In the first instance, therefore, it is recommended thatall hospitals carrying out emergency endoscopy attemptto establish an out-of-hours rota for their endoscopynurses, so that emergency endoscopy can be performedin the best possible circumstances. A business case wouldneed to be constructed to justify the additionalexpenditure.

Secondly, the European Working Time Directivedetermines that there should be a re-assessment of theworking practices of Consultant Medical and SurgicalGastroenterologists. Attending the hospital out-of-hoursand at weekends, to perform emergency endoscopy, mustbe recognised as part of their regular duties and be takeninto account in constructing their job plans.

This will inevitably lead to the requirement for theappointment of additional Consultant Medical andSurgical Gastroenterologists in Units regularly performingemergency endoscopy out-of-hours.

Thirdly, endoscopists should no longer carry outemergency procedures or any other investigations, unlessthere is proper nursing and equipment support.

The concentration of patients in acute Gastrointestinalbleeding beds with dedicated endoscopic equipment andconcentration of medical resources has led to a markedimprovement in the mortality and morbidity of acutegastrointestinal haemorrhage in larger hospitals. Thereare still difficulties in providing ring-fenced beds, out-of-hours endoscopy nurse cover, and a socially acceptablerota of experienced endoscopists, particularly in smallerDistrict General Hospitals, where the number of patientsrequiring out-of-hours endoscopy, may be as few as oneor two per week.

One way of minimising the necessity for out-of-hoursendoscopy is to provide a short session at the start of theday, in the main endoscopy unit. Patients admitted duringthe previous 24 hours could be endoscoped between 8and 9.00 in the morning and the management of thesepatients would then not interfere with the running ofsubsequent lists during the day. However, this systemrequires a robust referral procedure in whereby referralsare received by the Endoscopy Unit early in the morning,rather than at lunchtime or later in the day. Individualunits need to organise themselves to facilitate thisarrangement.

This approach would lead to larger lists on a Mondaymorning to deal with week-end admissions and theMonday morning lists may need to be extended up to9.30 a.m., but one hour should be sufficient in theremainder of the week. Admitting teams would knowthat patients could be endoscoped the morning afteradmission, and should manage their patients accordingly.The endoscopy unit’s day to day work would be moreeasily managed if emergencies were dealt with earlier inthe day.

This concentration of emergency work at the start ofthe day would also allow a rota to be established forexperienced endoscopists and would provide a focusedtraining opportunity for medical and surgical traineeGastroenterologists. Audit of the Management of GIBleeding would also be facilitated

Where does this model break down? Clearly, difficultieswill arise for patients admitted in the early part of theweek-end although some hospitals do have a routineSaturday morning endoscopy list to deal with patientswith gastrointestinal haemorrhage admitted on a Fridayevening. We would suggest that GI Endoscopy Unitsprospectively audit the true requirement for emergencyendoscopy on Saturdays and Sundays, before makingformal provision for weekend endoscopy lists.

This report deals with the organisation of GI EndoscopyServices in District General Hospitals – Teaching Hospitalsand Specialist Units dealing with tertiary referrals withgastrointestinal bleeding – particularly Liver Units, willrequire different arrangements to deal with the largenumber of patients with variceal bleeding that theyreceive.

EQUIPPING DGH GASTROINTESTINALENDOSCOPY UNITS

a The numbers and types of endoscopes required byDGH Units, will be linked to the mix of workperformed and the restrictions placed on throughputby the minimum immersion times required for cleaningand disinfection, which govern the number of casesthat can be accommodated on a list.

As previously stated, the average District GeneralHospital serving a population of 250,000, wouldnormally spend up to 14 notional half days per weekcarrying out elective procedures in addition to 1–2ERCP lists (taking place either in the x-ray departmentor in a separate endoscopy room). In addition, therewill be requirements for emergency procedures.

The minimum endoscope requirements to servicethese lists are as follows:

6 Gastroscopes4 Colonoscopes2 Flexible Sigmoidoscopes3 side-viewing duodenoscopes.

In addition, a paediatric colonoscope will be requiredin Units dealing with large numbers of children, andthis instrument is often helpful negotiating the sigmoidcolon for patients with advanced diverticular diseaseand/or distal colonic strictures.

BSG Working Party6

Sufficient washing machines to process at least 4instruments at a time are necessary to maintainthroughput and avoid delays between patients.

We recommend video endoscopes because of theenhanced image quality available with theseinstruments as well as the ability to teach and informother members of the GI team.

b Endoscope AccessoriesThe increasing amount of therapeutic work carriedout via endoscopes, re-enforces the requirement forUnits to have a wide range of accessories available,which should include:

Oesophageal Disease(i) Bougie Dilators, through the endoscope balloon

dilators and Achalasia Balloons.(ii) A wide range of oesophageal metal stents, covered

and uncovered.(iii) Banding and injection sclerotherapy equipment

for dealing with oesophageal varices.(iv) Foreign body retrieval forceps.(v) Large spiked forceps.

Diagnosis and Treatment of Stomach Lesions(i) Polypectomy snares.(ii) Needles for injection of adrenaline and saline for

submucosal stripping procedures and for thecontrol of bleeding.

(iii) Biopsy forceps (multiple of varying types).(iv) Balloon Dilators for pyloric strictures.(v) Pyloric canal stents.

ERCP-Related Equipment(i) Wide range of injection cannulae, including fine

and metal tipped cannulae.(ii) A range of sphincterotomes, including pre-cut

needles, pre-cut knives, and Sharks-finSphincterotomes for patients with Bilroth IIGastrectomies.

(iii) Biliary dilatation balloons for dealing withstrictures and for Sphincteroplasty.

(iv) Biliary metal stents.(v) Mechanical Lithotripters.(vi) Plastic stents in a range of lengths and sizes.

Colonoscopy Associated Procedures(i) Biopsy Forceps.(ii) A wide range of snares including hexagonal and

rotating snares.(iii) Injection needles for lifting sessile polyps, injecting

India Ink and for controlling colonoscopic focalbleeding.

(iv) Through the endoscope balloons for dilatingcolonic strictures.

(v) Clipping devices for dealing with bleeding polypstalks.

Desirable EquipmentArgon laserEndoscopic ultrasoundArgon Plasma CoagulatorHigh pressure washers

Cleaning EquipmentCOSSH regulations on the cleaning and disinfectionof endoscopes specify the requirement for carefulmechanical cleaning of the endoscope before insertinginto automatic washers where the minimumimmersion time should be 10 minutes. Standards forwashing machines were discussed in the BSG report‘Cleaning and Disinfection of Endoscopes’.2

This minimal immersion time means that anendoscope will essentially be out of action for 30minutes whilst being cleaned, washed, disinfected andwashed again. Therefore to avoid delays, at least fourgastroscopes will be required for a 10–12 patientgastroscopy list in a single room and threecolonoscopes for an ordinary colonoscopy list.24

Cleaning and Disinfection of AccessoriesA recent European Community Directive requirementfor single use disposable accessories has created someproblems for Endoscopy Units and certainly increasedcosts. It is recommended that Endoscopy Departmentsbudget for single use biopsy forceps, injection needles,snares and sphincterotomes following themanufacturer’s recommended practice in the use ofall these accessories.

Where accessories can be re-used, a close workingrelationship should be established with the hospital’sCSSD Department, to ensure that accessories are dealtwith properly and that there are agreed QualityStandards for packaging and processing, particularlyof accessories that are autoclaved.

Equipment Purchase & Service ContractsSignificant discounts can be achieved in the purchaseof endoscopes, e.g. in District General Hospitalsmerging into larger Trusts, or by individual Unitsclubbing together. Careful attention should be paidto the requirements of the European Union, in termsof invitations to tender for the provision of endoscopyequipment, option appraisal of bids to tender andleasing contracts that may be established.

DESIGN OF THE ENDOSCOPY UNIT

The last British Society of Gastroenterology Guidelineson the design of Endoscopy Units, were published in1990.25 In addition, specific Guidelines on the cleaningand disinfection of Endoscopes have been provided andthese include recommendations on how Units should bedesigned to handle the toxic agents used in disinfection.

District General Hospital Endoscopy Units have to dealwith the passage of an average of 100–150 patients/weekthrough the Unit, including emergency endoscopy,complex therapeutic procedures and in many cases, ERCP.In these circumstances, full time clerical staff working ina reception area, closely linked to a recovery areacontaining a mixture of 8 to 10 trolley beds and an equalnumber of reclining chairs, seems to be the optimumarrangement. The recovery area should be fully equippedto allow all sedated patients to be monitored using pulseoximetry. Facilities for measuring and monitoring bloodpressure should be readily available. Piped oxygen shouldalso be accessible for each trolley/bed.

Provision of Endoscopy Related Services in District General Hospitals 7

The Unit should be self contained and there should beease of movement of patients from the trolley/reclining chairarea to the Endoscopy Unit, using modern trolleys whichcan be tilted and can be ‘head-up’ or ‘head-down’ and allowpatients to be easily turned during Colonoscopy and ERCP.

Larger hospitals will need to have at least two (possiblythree with bronchoscopy) endoscopy rooms working sideby side. Ideally, one of these should provide for highquality pulsed digital fluoroscopy for ERCP, withappropriate resuscitative facilities, and x-ray support. Theendoscopy room should also have piped oxygen andsuction. One room may need to accommodate endoscopicultrasound as this investigation becomes more available.

Pulse oximetry, piped oxygen and suction, electronicblood pressure cuffs, and facilities for ECG monitoringshould be made available in the recovery area as well asin the endoscopy rooms.

All units should have full resuscitation facilitiesavailable including a cardiac defibrillator and emergencydrugs tray which includes any drugs which might beneeded for a cardiac arrest within the department.

The minimum size for an ordinary endoscopy room, isapproximately 7.5 metres x 3.5 metres. This allows astandard trolley to be turned within the Unit, the sitingof a light source/video processor on one wall and fixingof a video monitor opposite. In a room of this sizecupboards for hanging endoscopes can be providedtogether with a reasonable amount of work surface. Aseparate cleaning room is required with washing machinesand extraction facilities to satisfy COSSH requirements.The endoscopy room should be cabled for local areanetworks, wide area networks and ISDN.

Care should be taken to ensure sound from theendoscopy room cannot be transmitted to the patientwaiting/recovery areas. Windows are not required andmay positively be a disadvantage when proceduresrequiring transillumination are necessary (eg PEG andColonoscopy)

LightingAlthough windows are not required in the endoscopyroom, these are advantageous elsewhere and recoveringpatients should have access to natural light. In theendoscopy room itself there should be facilities to havevarying light levels ranging from bright to very subdued.Dimmer lights are ideal for background lighting whenthe main lights have been switched off.

SecurityEndoscopy units house a great deal of expensiveequipment and should therefore be regarded as areasrequiring a high level of security. This can be providedduring the working hours by having a reception areamanned by a full time clerk. At other times the unit mustbe secured with high quality door locks or code lockswhich will prevent easy access to an intruder.

STAFFING OF ENDOSCOPY UNITS

A core of highly trained, permanent staff is essential withclear lines of accountability to experienced management.The endoscopy service, which might also provide staff

and facilities for bronchoscopy and possibly cystoscopy,should have its’ own budget and be managed by adesignated Senior clinician working closely with the seniornon medical manager in the department with propersupport from the local Trust Finance Department.

Precise recommendations on the levels of staffing willdepend on the model of service provided, the followingare provided as examples. All nurses should have receivedbasic life support training.

MODEL A

� Patients attending the Endoscopy Unit will be admittedby an Endoscopy Nurse who will follow the patientthrough the Department. Assuming that the averageGastroscopy list will contain 10–15 patients, twonurses will be required in the reception/trolley area.

� In the Endoscopy Room, a minimum of 1 qualifiednurse and 1 trained assistant will be required, with afurther nurse/endoscopy technician being responsiblefor cleaning and disinfection.

� The recovery area should have at least 1 qualifiednurse and trained assistant to manage patients whoare returning from the endoscopy room

� Clearly, these numbers of staff will need to be increasedfor Units that have two rooms in action runningparallel lists. Under these circumstances the recoverynurse levels will be the same but 1 extra qualifirednurse and 1 extra trained assistant will be requiredfor the second room.

� Allowing for holiday/annual leave and sick leave, theaverage department running a single endoscopy room,will require a minimum of 6 wte staff, one of whomwill be the senior nurse responsible for managing thedepartment. These numbers will need to be increasedto 9 wte staff in Units where two rooms are runningparallel lists on a regular basis.

� For ERCP the number of nurses and trained assistantsrequired per room is 3.

� In Departments in which nurses undertake endoscopy,additional nursing hours will be required to replacethe routine work that would have been undertakenby the nurse endoscopist.

� In this self-contained model, the Unit will usually havea devolved budget for the purchase of endoscopeaccessories and to cover the revenue costs of staff.

� As stated previously, it is likely that economies of scalewould be achieved by merging the purchasingrequirements of separate DGH Departments, but theEndoscopy Unit should have a clear policy for therepair and replacement of endoscopes, with rollingcapital requirements being clearly identified, andincluded in business plans.

� It is extremely important that the skill mix ensuresthat all the staff are able to assist with complexprocedures.

� The day to day running of the Unit should be in thehands of a Senior Nurse Manager who would usuallybe a highly experienced endoscopy nurse.

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� It will be the responsibility of the ConsultantGastroenterologists in the Department and the SeniorNurse to ensure that endoscopy is conducted safelyby properly trained staff and that the quality criteriastated previously, are fulfilled. Regular audit must takeplace, and it is strongly recommended that theDepartment’s Management Committee meet at leaston a monthly basis to ensure that quality control andbudgetary planning are properly performed.

MODEL B

An alternative arrangement for endoscopy is that thistakes place in a hospital’s Day Unit where the admissionof patients is dealt with by permanent Day Unit staff, butthe Gastrointestinal Endoscopy takes place in a separateroom and this is where the Endoscopy Unit staff will bebased. The requirements for permanent endoscopy staffin this Model, are slightly less than Model A, but wouldstill require at least 4 wte, and is probably less satisfactorythan Model A.

FACILITIES FOR TRAINING

Specialist Registrars in Gastroenterology and in GeneralSurgery now require formal training in gastrointestinalEndoscopy.19 The Joint Advisory Group (JAG) hasproduced specific recommendations on the quality criteriathat Endoscopy Units will have to fulfil to be recognisedas training departments. Probably the most importantaspect of training is the direct supervision of trainees byexperienced endoscopists, but “hands-off” experience canbe gained, both in diagnostic and therapeutic procedures.Training departments, as a minimum, will require videoendoscopy systems, and secondary monitors in adjacentseminar rooms or offices, usually with voice linkage.

Trainees are required to keep an annual record of theirendoscopic experience and all training units must provideadequate computerised endoscopy record systems.Increasingly these will be systems linked to the hospital’smain patient Master Records System rather thanstandalone PCs.

Ideally, it is recommended that the offices of theGastroenterology Department will be based close to theEndoscopy Unit and here there should be a mini librarycontaining up to date Gastroenterology Journals andtextbooks, and again a PC Workstation linked to Medline,the Cochrane Database and the Internet.

Liaison with other departments

We recommend that at least fortnightly meetings shouldtake place to review the Department’s x-rays and biopsyspecimens and ideally there should be a departmentalmeeting jointly held with the gastrointestinal surgeons,pathologists and radiologists, at least once per month.There should be clear responsibility for the organisationof departmental meetings, which should form the basisof departmental audit, evidence-based practice and clinicalgovernance. Indeed in larger departments, a clinician withspecific responsibility for clinical governance should beidentified. Collaborative peer review with Colleagues inadjacent units should be encouraged.

OTHER GASTROENTEROLOGICAL SERVICES TOBE PROVIDED IN THE DISTRICT GENERALHOSPITAL

The provision of these services will depend on the specificneeds of the local population and of the Physicians andSurgeons with a GI interest. What needs to be providedwill also depend on the availability of other proceduresat Regional and Sub-Regional level.

All Gastroenterologists require access to OesophagealPH and Manometric testing. In many regions these areconcentrated in one or two centres which perform asufficient number of procedures to provide reliable andreproducible results. Many District General Hospitals donot have this facility, but have good relationships with aregional centre, which can provide a rapid reliable service.

The provision of Oesophageal PH and Manometrictesting within a DGH will almost invariably requireadditional funding for a Specialist Nurse and/orTechnician. These personnel will also often performHydrogen breath testing on these Units.

Many District General Hospital Departments nowprovide carbon-13 urea breath testing for H.pylori,although the funding of this service often depends onresearch support. It is recommended that negotiations takeplace with Primary Care Groups to build the cost ofH.Pylori testing into Service Agreements

Core Services provided by Service Departments

1 A full range of barium studies should be providedalong with diagnostic and therapeutic ultrasound,spiral CT scanning and easy access to MRI.

2 Isotope studies – these will include gastric emptying,SEHCAT absorption, white cell and HMPAOscanning.

3 PathologyClose links with Histopathologists andMircrobiologists are essential, with provision forassessments of specimens obtained by biopsy andcytological examination. Gastroenterological surgeonswill also require access to frozen section techniques.

4 MicrobiologyThis department should provide facilities for theinvestigation of infectious diarrhoea, culture ofintestinal and liver biopsies and serologicalinvestigation of gastrointestinal and hepatic disease.

5 Biochemistry/HaematologyThese departments will be closely involved in theinvestigation of gastrointestinal diseases, includinghormone secreting tumours, haemochromatosis, andthe monitoring of the response to treatment of patientswith malignancy.

VISION OF GASTROINTESTINAL AND RELATEDSERVICES IN THE NEW NHS

All Clinicians are now required to take part inmanagement and Gastroenterologists are no exception.

Provision of Endoscopy Related Services in District General Hospitals 9

Clinicians within the department should be identified whowill be responsible for the organisation of businessplanning and contract negotiations. It should berecognised that these skills are an essential part of thedepartment’s activities.

THE NEW NHS26

Gastroenterology Units will be required to have clearguidelines and protocols agreed with their Primary Carecolleagues for the management of most commongastrointestinal conditions and these are likely to includethe implementation of care pathways. Gastroenterologistswill also have to work closely with their colleagues, bothat Health Authority and hospital level and on drug andtherapeutic committees to ensure that funding is identifiedto allow the introduction for newer treatments for whichthere is good evidence to support an effective role. In thisrespect, the cycle of business planning becomes even moreimportant and it is likely that Gastroenterology Units aswith all other departments, will have to prioritise theinvestigations and treatment that they can provide withintheir budgets. It is to be hoped that these can be agreedon a national basis.

In future, it is probable that the organisation of serviceswill relate to populations of at least 500,000. In thesecircumstances, endoscopy sub-specialization is likely tooccur with not all consultants performing ERCP orColonoscopy. Closer co-operation between neighbouringacute hospitals will be necessary with the sharing ofexpertise and equipment, and mutually supportive peerreview and audit.

DEMAND FOR ENDOSCOPY SERVICES

As the numbers of trained endoscopists and endoscopyunits have increased in the last decade, the demand forGastroscopy in particular has increased inexorably, withthis procedure now being the most commonly day caseprocedure constituting 12% of all NHS day caseadmissions.27 Approximately 530,000 endoscopies areperformed each year at a cost to the NHS of £50 million.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 FlexibleSigmoidoscopy.11

These services have proved to be very successful inreducing waiting times for Gastroenterology OutpatientClinics, but have placed a considerable burden onEndoscopy Units having to deal with increasing demand,with most units reporting normal Gastroscopies in 25%–40% of patients undergoing endoscopy.28

The introduction of Guidelines and Protocols governingreferrals for endoscopy, should lead to a reduction in theproportion of negative findings. It is stronglyrecommended that Endoscopy Units work very closelywith their local Health Authority and Primary CareGroups to establish clear criteria for referral using thebest available contemporary evidence.

APPENDIX5

Bronchoscopy and Endoscopy

Emergency general medical care requires the support ofupper gastrointestinal endoscopy, sigmoidoscopy,colonoscopy and bronchoscopy. Each acute generalhospital must have a fully equipped endoscopy unit,staffed by experienced nurses or operating departmentassistants, with apparatus for continuous cardio-respiratory monitoring. There should be mobileequipment for use elsewhere in the hospital. The use ofanaesthetic services must be provided for and built intocontracts for this service.

Endoscopy should always be available within twelvehours of request. There should be a rota of available andexperienced physician or surgeon endoscopists andexperienced endoscopy assistants which identifies their24 hour availability. Whenever possible, informed consentmust precede endoscopy/bronchoscopy.

There should be an endoscopy unit portering servicefor the protection of sedated and often ill patients andtheir rapid transfer back to a safe environment.

A record of endoscopy findings must be made on thepatient’s notes, as should a record of complications ofthe endoscopy. A system must be in place for making theresults of endoscopy immediately available to the referringmedical team.

CORRESPONDENCE

to Dr IG Barrison at gastrosach@hotmail.com

BSG Working Party10

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28 Hungin AP, Thomas PR, Bramble MG et al. Whathappens to patients following open access gastroscopy?A study from general practice. Br J Gen. Pract1994:44:519–21.

ACKNOWLEDGEMENTS

The authors wish to thank Mrs D Findley for typing themanuscript of this document.

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