Quality assurance in endoscopy nursing

Risk factors for underestimation of patient pain in outpatient colonoscopy

BACKGROUND

Adequate management of patient pain and discomfort during colonoscopy is crucial to obtaining a high-quality examination. We aimed to investigate the ability of endoscopists and endoscopy assistants to accurately assess patient pain in colonoscopy.

METHODS

This was a single-center, cross-sectional study including patients scheduled for an outpatient colonoscopy. Procedure-related pain, as experienced by the patient, was scored on a verbal rating scale (VRS). Endoscopists and endoscopy assistants rated patient pain likewise. Cohen's kappa was used to measure the agreement between ratings and logistic regression applied to test for potential predictors associated with underestimation of moderate-severe pain.

RESULTS

In total, 785 patients [median age: 54 years; females: n = 413] were included. Mild, moderate, and severe pain was reported in 378/785 (48%), 168/785 (22%), and 111/785 (14%) procedures respectively. Inter-rater reliability of patient pain comparing patients with endoscopists was κ = 0.29, p < .001 and for patients with endoscopy assistants κ = 0.37, p < .001. In the 279 patients reporting moderate/severe pain, multivariable analysis showed that male gender (OR = 1.79), normal BMI (OR = 1.71), no history of abdominal surgery (OR = 1.81), and index-colonoscopy (OR = 1.81) were factors significantly associated with a risk for underestimation of moderate/severe pain by endoscopists. Young age (OR = 2.05) was the only corresponding factor valid for endoscopy assistants.

CONCLUSIONS

In a colonoscopy, estimation of patient pain by endoscopists and endoscopy assistants is often inaccurate. Endoscopists need to pay specific attention to subgroups of patients, such as male gender, and normal BMI, among whom there seems to be an important risk of underestimation of moderate-severe pain.

Discharge following sedation for endoscopic procedures: a best practice implementation project

OBJECTIVES

The aim of this project was to promote best discharge practice in sedated patients following endoscopic procedures in an endoscopy tertiary center in Shanghai, China.

INTRODUCTION

Discharge of sedated patients is the final stage of the endoscopic procedure. Healthcare providers must ensure patient safety through timely and appropriate discharge from endoscopic procedures.

METHODS

A clinical audit was undertaken using the JBI Practical Application of Clinical Evidence System tool. Eight audit criteria that were representative of best-practice recommendations for the discharge of sedated patients following endoscopic procedures were used. A baseline audit was conducted, followed by the implementation of multiple strategies that were determined by the key stakeholders. The project was finalized with a follow-up audit to determine change in practice.

RESULTS

Improvements in practice were observed for all eight criteria. The most significant improvements were for the following criteria: an organizational policy exists for patient discharge after endoscopy, minimum discharge criteria are established, minimum discharge criteria are met before the patient is discharged (each from 0% to 100% compliance), patient received written and verbal discharge instructions (from 12% to 100% compliance), and discharge care plan is documented in the patient's medical file (from 0% to 88%). Criteria 4 (discharge is authorized by an appropriate staff member), 6 (staff member is appropriately trained and educated) and 7 (patient is accompanied by a responsible adult) achieved the least improvement in compliance rates, as baseline measures already showed a high degree of compliance. Overall, there was improvement in compliance for all best-practice recommendations.

CONCLUSIONS

The project demonstrated positive changes in the discharge care of sedated patients following endoscopic procedures in an endoscopy tertiary center in Shanghai, China. A formalized organizational discharge policy is currently in place and a continuous cycle of audit and re-audit will need to be carried out in the future to keep the quality at a high and steady level.

Development of a Nurse-Led Competency-Based Program for Therapeutic Endoscopy: The Formation of the Nurse Product Procedure Group

Therapeutic endoscopy is emerging as an innovating alternative to gastroenterology surgery. Due to the increase in new technologies, endoscopy clinical staff require ongoing education to develop safe, competent practice for new equipment and supplies. Maintaining competencies with new equipment and supplies can be challenging. This article illustrates the development and implementation of a continuous educational program for endoscopy clinical staff at a major academic medical center. An initial needs assessment of staff education and competency led to the multidisciplinary plan for continuous education. Development of the Nurse Product Procedure Group enabled endoscopy staff to standardize care and maintain competency in advanced therapeutic procedures. The Nurse Product Procedure Group offers various pathways of learning to meet clinical staff's individual learning needs. Over a 5-year span of implementation, staff satisfaction of education and resources improved. Key implementation elements of the Nurse Product Procedure Group include monthly staff education, resource development, multidisciplinary collaboration, cost savings, outreach education, and external collaboration with national and international gastroenterology professional organizations and societies.

Management of Colorectal Cancer Patients Undergoing a Colonic Stenting: A Multidisciplinary Team Approach

Colonic stent procedure is one of the best therapeutic medical interventions for managing a colorectal cancer patient with large bowel obstruction. This is a retrospective study that evaluated data from the past 10 years; it examined the epidemiological and clinical data of patients with colorectal cancer undergoing a colonic stent procedure. In addition, this study prospectively evaluated the nurse's roles during a colonic stent procedure, and at the same time, it explored the patient's satisfaction with the procedure at the Hospital Universitario Central de Asturias (Spain). The results revealed that for the last 10 years, a total of 102 patients underwent a colonic stent procedure. Male patients outnumbered female patients by 2:1. The palliative group consisted of patients with multiple cancer metastases, elderly patients, and patients with other comorbidities, whereas the preoperative group comprised those patients with fewer comorbidities and no multiple cancer metastases. Survival time in the palliative group was 3 months without any aggressive treatment, whereas patients with a favorable condition and fit for surgery after a colonic stent procedure had a survival time of 28 months. In the prospective study, nurses implemented care in terms of a multidisciplinary team approach of safety culture that included patient safety, equipment safety, and environment and procedure safety. Therefore, the level of patient satisfaction was high. In conclusion, management of a colorectal cancer patient undergoing colonic stenting performed at the Hospital Universitario Central de Asturias has high technical and clinical success, and it is a quality procedure that includes a multidisciplinary team approach.

Needs assessment survey for simulation-based training for gastrointestinal endoscopy nurses

The optimal performance of gastrointestinal (GI) endoscopy nurses is required for patient safety and quality improvement. The aim of the present study was to assess the educational needs for simulation-based training for Korean GI endoscopy nurses using importance-performance analysis. A cross-sectional survey was conducted with 238 Korean nurses from 25 endoscopy units. The educational needs of these nurses were identified using the 35 item clinical competence importance-performance scale. Exploratory factor analysis of the scale identified the following eight factors: emergency care, patient monitoring, evidence-based practice, documentation and referral, patient safety, nursing process, patient assessment, and infection control. A significant overall mean difference was identified between importance and performance for all eight factors, with emergency care showing the largest difference. It was also ranked the highest priority for continuing education in the importance-performance analysis matrix. Therefore, simulation-based training should focus on enhancing emergency care competence for GI endoscopy nurses to improve patient safety and quality of care.

Setting up the Pediatric Endoscopy Unit

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.