Saffron Walden Community Hospital - Curlew Endoscopy Unit
Background and Introduction
The demand for Endoscopy in recent years has increased. Gastroscopy is the most common NHS day case procedure (British Society of Gastroenterology 2001) and now that the new National Bowel Cancer Screening Programme has been introduced this demand will continue to rise inexorably. The Trust’s vision for local health services includes developing access to local care by focusing on those services that do not require the resources of a general acute hospital. The development of the primary care endoscopy service at SWCH is to ensure patients avoid unacceptable waits for appointments while at the same time offering choice and quality of care in the appropriate setting.
The endoscopy service at SWCH has been in operation since October 2002. It was recognised that the rising demand and the need to ensure service quality and efficiency required additional resources in the form of a specially commissioned endoscopy area, the Curlew Unit with the appropriate staffing skill mix. The unit opened in November 2005.
Philosophy
The basic principle for the service is based on the requirement to provide “seamless” process of healthcare for patients with Gastrointestinal (GI) problems so that they have direct access to endoscopy services. GP’s are well placed to select patients for such investigations (BSG 2000) although referrals can be via a number of routes, including Consultants, Clinics and the ward. The benefits to patients are the reduction in the number of visits to the acute hospital by eradicating inappropriate referral and follow up, and facilitating rapid access, diagnosis and treatment.
Description of Service and Component Parts
The elements of the Endoscopy unit include a Theatre and associated scope cleaning area, two recovery bays, a waiting area and reception as well as clinical and non clinical support facilities. The Theatre is capable of supporting all forms of Endoscopy and offers a good Diagnostic Service. Currently Flexible Sigmoidoscopy, Colonoscopy, Gastroscopy and insertion of Percutaneous Endoscopic Gastrostomy tubes (PEG) are available. It is hoped that as the unit expands in the future such procedures as Cystoscopy and Bronchoscopy may be offered.
The Unit is staffed by experienced Endoscopists and Nurses. The Endsocopists are either Medical (Dr’s) or trained Specialist Nurses. They have all undertaken a formal training course in approved centres. They also undertake ongoing training to update skills relevant to practice in order to remain compliant with the Joint Advisory Group (JAG) Guidelines. They are expected to maintain a personal audit of performance including the number of procedures performed. The Specialist nurses are registered with the Nursing and Midwifery Council (NMC) and abide by the NMC professional code of conduct. They have considerable experience in the area of Endoscopy and within their expanded role run clinics and perform procedures in other hospitals. They contribute greatly to the provision of the service in this area.
The Nursing team resource the process from beginning to end ensuring that there is a continuity of care, safety and efficiency. All staff working within the unit receive “in-house specialist training” and attend regular study days and courses to update their practice. As Endoscopy is an invasive procedure nurses who assist must be properly trained in the use of Scopes, the administration of the drugs used and the management of the patient both normally and in an emergency situation. Senior Staff should hold a current Immediate Life Support certificate.
The cleaning process of the scopes is essential to the provision of the service. It is a specialised procedure using computerised machines supplied by a firm called Sterilox which also gives its name to the solution used for decontamination. This system has replaced the use of noxious chemicals and is safe to be used by all staff. Specific training is given on the use of the equipment and the company themselves offer regular residential training courses so that all cleaning staff are kept up to date both in technique and available products. Staff have fundamental training in the care and handling of the endoscopes and they are required to adhere to COSHH regulations and abide by the trust Health and Safety and Infection Control Regulations.
Organisational and operational
- Pre admission pathway – The majority of patient referrals are taken from general practitioners from within West Essex. GP’s from further afield, for example south Cambridgeshire and East Hertfordshire can access the facility. It is very important that the initial patient selection is correct. The unit has no immediate access to an acute hospital and therefore cannot accept patients who are at risk or compromised prior to the procedure carried out. It is also not possible to accept children under 16 years of age. In addition, the endoscopist may refuse to carry out the procedure on any patient who’s medical condition has worsened since referral, or who is suffering from a previously undisclosed medical condition. Initially patients are booked to attend the clinic when the referral form arrives with the staff. They are telephoned at home and after an explanatory discussion a convenient appointment date is fixed. A pre admission pack is sent to the patient within an enclosed hospital contact number should the patient need to ring. In practice this happens frequently and it is therefore very important for the appropriate staff to have knowledge of the procedure. Stable Diabetic patients and those receiving Warfarin, Iron or Proton Pump Inhibitor drugs are sent guidelines as to how to manage their condition prior to the procedure. Physically disabled patients can also be accepted into the unit as all staff have current manual handling training and there is a hoist available if necessary.
- Admission Procedures – Each patient is allocated a hospital number prior to arrival and a correctly labelled folder with a full set of admission forms. The admission nurse will complete these with the patient as well as reviewing the completed health questionnaire which the patient brings with them. Basic observations are carried out by the nurse and a blood sugar level recorded for Diabetic patients. Every patient is given an identity bracelet. The nurse should also discuss sedation with the patient allowing them to make an informed decision. As Endoscopy is an invasive procedure the patient is required to give express written consent. The patient has the right to be given sufficient information to allow an informed decision to be made. This should include enough information to ensure they understand the nature, consequences and any substantial risks of the proposed procedure and what if any alternatives are available. The patient has the right to withdraw consent at any time, and in this case the hospital protocol should be followed. If a patient requires sedation prior to the procedure being carried out a venflon cannula is inserted by an appropriately trained person and secured safely.
- Record keeping – Documentation is designed to provide a quick and accurate method of recording a patient’s care whilst in the unit. This should include patient details, a health questionnaire, a pre- procedure record, a procedure record, a recovery record and discharge details.
- Endoscopy procedures – Flexible Sigmoidoscopy and Colonoscopy – these procedures involve the passage of a flexible endoscope into the large bowel and advancing the endoscope to the anatomical level of the splenic flexure or caecum. These procedures facilitate biopsy and polyp removal as well as visualisation of the colonic mucosa.
Gastroscopy – this procedure involves the passage of a flexible endoscope into the oesophagus, stomach and duodenum. Two routes can now be offered for this procedure – trans-nasally or orally. It facilitates visualisation of the mucosa and provides opportunity for biopsy and to recommend progression onto therapeutic procedures if necessary.
Insertion of Percutaneous Endoscopic Gastrostomy Tube – this procedure involves the insertion of a tube directly through the mouth via the endoscope into the stomach. It is then passed through the stomach wall to the outside and is used to give liquid balanced feed to patients unable to eat in the normal way.
- Discharge – The minimum criteria for safe patient discharge has
been formalised by the Royal College of Surgeons of England (1993). These are: stable vital signs, ability to leave the unit as the patient entered, toleration of oral fluids, ability to void urine, minimal nausea, adequate analgesia and appropriate aftercare. Post procedural advice is given to the patients and/or the escort, and a written report of the findings to be delivered to the GP. Information as to how and when to access any biopsy results is given.
If the patient has had sedation the venflon is removed and the site dressed. All documentation is signed and dated by the endoscopy nurse responsible and the time of leaving the unit recorded.
- Reporting – all reports of results are returned to the Endoscopist who performed the procedures and he then actions these appropriately.
- Follow up – in certain circumstances patients require repeat procedures in order to monitor their condition. Those requiring urgent treatment are referred to the acute sector via the GP who will place them on the fast track system.