Anesthesia administration, procedure prep studied
Sixty percent of participants in a second study on diagnostic colonoscopy, who also had participated in the first study, saw a significant decrease in some aspect of their procedure times. The 2002 study conducted by the Institute for Quality Improvement (IQI), a subsidiary of the Wilmette, IL-based Accreditation Association for Ambulatory Health Care. It included data collected by 42 organizations on 952 cases performed between February and April of 2002.
"Our pre-procedure time dropped by 50% from the first study," says Linda Ray, administrator of the Shreveport (LA) Endoscopy Center. Ray attributes her facility’s pre-procedure time of 15 minutes to a variety of changes they’ve made. "We collect all of our information at the time we schedule the colonoscopy, so when the patients arrive, we’ve already pre-certified them, verified insurance information, and prepared the forms they need to sign," Ray says. Although patients are instructed to arrive 30 minutes prior to their procedure, they often just sign their consent forms and are taken directly to a procedure room, she adds.
Another big change that affects pre-procedure time is that the physicians are scheduled for the entire morning, afternoon, or day in the center, Ray says. "When they are here, they don’t cover call, schedule procedures in another location, or see patients in the office," she points out. This system keeps cases on schedule, Ray adds.
The median pre-procedure time for all participants was almost 33 minutes, down from 37 minutes in the 2001 study, but that time can be affected by how early or late patients arrive, says Naomi Kuznets, PhD, director of the IQI. "Overall, the decrease in different aspects of procedure times is encouraging," she says.
Although average procedure times increased slightly, there were proportionately more polyps found per procedure (90% for 2002 and 84% for 2001), and of these, proportionately more were removed (93% for 2002 and 85% for 2001), Kuznets says. The average discharge time decreased from 46.2 to 39.2 minutes, she adds.
Sometimes the short procedure time and rapid operating room turnover can cause problems in the discharge area, says Tracey E. Carrigan, RN, BSN, CNOR, administrative director of Texas Midwest Surgery Center in Abilene. "Our turnover time between cases is so rapid that our physicians weren’t able to get to recovery in a timely manner to discharge patients," she explains. This contributed to the discharge time of almost 70 minutes, she says. "We already knew this was a problem before the IQI study was complete because we were seeing complaints on our patient satisfaction surveys about how long they had to stay following a colonoscopy," Carrigan says.
To address the problem, Carrigan’s staff now walk the patients from Level 1 recovery area to a Level 2 area where the patient’s family is allowed to join the patient. "The physician then calls the Level 2 area and talks by conference call to the patient and family members, while a nurse listens as well," she says. "This process means that the physician doesn’t have to leave the operating room area but can still explain everything," she adds.
If patients don’t feel comfortable talking to the physician by phone, the physician comes to meet with them in the Level 2 area, she explains. This change has created a dramatic decrease in the amount of time patients wait to see the endoscopist, she says. "I’m embarrassed to admit that some patients would wait up to two hours," she says. "Now our patients typically wait no more than 30 minutes before the physician talks with them."
Carrigan’s multispecialty same-day surgery program handles about 580 cases per month, with only 60 colonoscopies per month. Because there is no team dedicated to colonoscopy and nurses don’t see enough to develop an expertise in the procedure, Carrigan utilizes a certified registered nurse anesthetist (CRNA) to administer anesthesia. "I can’t expect my nurses to give and monitor drugs with which they’re not familiar, and I also don’t want to have a double standard in my operating rooms, where some patients get CRNAs and others are monitored by nurses," she says. "I realize that a CRNA is a luxury and the cost is not always reimbursed, but this is our process."
Endoscopists, RNs, and combinations of the two comprised 70% of the anesthesia administrators in the study. CRNAs represented 9% of the anesthesia administrators, anesthesiologists were used in 8% of the cases, and certified gastroenterology registered nurses (CGRN) or a combination of RNs/CGRNs were used in 3% of the cases. (Editor’s note: Regulations governing the administration of anesthesia differ from state to state. Not all states allow RNs to administer anesthesia in hospitals and surgery centers.)
Carrigan’s facility was one of only five programs that used a CRNA as the designated anesthesia monitor, and the five programs represented 7% of all the cases included in the study. Of the 952 cases, 66% had an RN as the designated monitor, and 9% had an anesthesiologist as the monitor.
IQI’s studies change slightly each year, with questions added as concerns of participants and review committee members are addressed, says Kuznets. "We added a question about discomfort with bowel prep because some people thought the discomfort of the prep would affect a patient’s willingness to repeat the procedure," she says.
While only 11% of patients reported severe discomfort and 30% described the prep procedure as not comfortable, there was no correlation between these numbers and the number of patients saying they would not repeat the procedure, she adds. As IQI staff members plan the next colonoscopy study, a question related to removals and biopsies may be added, Kuznets says.
"There are no guidelines as to when the endoscopist removes or biopsies a lesion," she says. "Some endoscopists remove and biopsy as the scope goes into the colon, and some [remove and biopsy] as the scope comes out," she says. Because there are no guidelines, Kuznets contends that gathering this information will add some additional valuable clinical data to the study.
Copies of the study are $50 each. To order a copy of the 2002 Colonoscopy Study, contact: Institute for Quality Improvement, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091-2992. Telephone: (847) 853-6060.Web: www.aaahciqi.org.