Nurse endoscopists increase staffing options

GI nurses perform colorectal cancer screenings

An aging population means more patients seek tests such as screening sigmoidoscopy for colorectal cancer. While this is a procedure commonly performed by a physician, some facilities are utilizing the skills of gastroenterology nurses to perform the procedure in an effort to improve efficiency and patient care.

The primary benefit of a nurse handling the screening exam is that it frees the physician to handle more acute cases, says Irfan Hussain, MD, chief of gastroenterology at Kaiser Permanente in Denver.

"Another benefit is that a nurse endoscopist who has screening sigmoidoscopies as a major part of the job will perform a lot more of the procedures than a physician who just occasionally has a patient that needs the screening exam," he says. "The benefit to the patient is that practice makes perfect, and the nurse who does this every day will have better skills than a physician who performs the test 10 to 15 times each year."

Outcomes from a nurse’s performance of the screening are just as good when physicians perform the procedure,1,2 says Hussain. "In our own lab, our review of the nurses’ cases showed that no lesions were missed in 1999, and since the program began in 1996, we’ve found only two missed lesions," he adds. The Kaiser Permanente nurse endoscopists see more than 3,000 patients each year, he says.

Patients also benefit because nurses tend to spend more time educating the patient, making sure they are aware of the patient’s pain level, and talking with the patient during the exam, says Jane Allaire, RN, CGRN, nurse specialist at the National Naval Medical Center Endoscopy Lab in Bethesda, MD.

The disadvantages may include reimbursement issues and state boards of nursing that do not allow a nurse to perform the procedure alone.

"Medicare reimburses for screening sigmoidoscopies performed by a medical doctor or a doctor of osteopathy only," says Nancy S. Schlossberg, BSN, RN, CGRN, president-elect of the Society for Gastroenterology Nurses and Associates (SGNA) in Chicago. Because the American College of Surgeons and the American College of Gastro-enterologists in Chicago recommend flexible sigmoidoscopy screening for colorectal cancer beginning at age 50, there is a population covered by private payers that may provide patients for nurse endoscopists, she adds.

A facility that is considering the use of nurse endoscopists should survey the managed care companies with which it has contracts to determine if the procedure will be covered if a nurse performs it, suggests Schlossberg. The issue of whether reimbursement is reduced with a nurse endoscopist is negotiated on a payer-by-payer basis, she says. The advantage to payers is that patient access to the test is increased at a lower cost to the payer because a nurse’s time is less expensive than a physician’s time, she adds. Even with Medicare, Schlossberg says she has been told that sometimes a facility fee may be charged even if the nurse performs the procedure. Investigate all of these reimbursement issues because contracts differ, she suggests.

Another area that must be investigated before pursuing a screening program with a nurse endoscopist is your own state licensing board, says Allaire. A 1997 survey conducted by the staff at the Naval Medical Center found only seven state nursing boards approved screening sigmoidoscopy as a nursing practice. They were in Arizona, Maryland, Massachusetts, Nevada, Pennsylvania, Washington, and Wisconsin.

There were, however, 23 state boards that said the practice might be possible based on the state’s decision-making model for scope of nursing practice, Allaire adds. Because nursing boards are constantly updating their regulations, check current practice regulations as you evaluate a screening program, she recommends.

Once you have addressed financial and regulatory issues, the key to a successful nurse endoscopist screening program is to hire the right nurses and provide a comprehensive training monitoring program and well-defined protocols, says Allaire. (See protocol, inserted in this issue.) Guidelines, protocol examples, and training recommendations are available from SGNA, says Allaire. (See resource box, p. 76.)

"The best nurse for this type of program is a gastroenterology nurse who is already familiar with the anatomy and has been assisting physicians with the procedure for years," says Allaire. Also, a gastroenterology nurse is familiar with infection control procedures and care of the equipment, she adds.

Kaiser Permanente requires that nurses have at least five years in gastroenterology, says Hussain. "A great deal of learning takes place in a GI lab that makes it possible for a gastroenterology nurse to handle flexible sigmoidoscopy." That means the training program can focus on the nurse’s goal of performing without direct physician supervision rather than the basics of scopes, he adds.

The best training programs utilize a combination of study, observation, supervised procedures, and ongoing review by physicians, says Allaire. (See training program, at right.) While the numbers of supervised procedures may differ from facility to facility, the SGNA recommends a minimum of 25 before the nurse performs the procedure with no direct supervision. The Naval Medical Center requires 50 procedures to be supervised, and Kaiser Permanente requires 75 to be supervised.

"It means new areas for nurses to expand their skills," Allaire says.

References

1. Maule WF. Screening for colorectal cancer by nurse endoscopists. N Engl J Med 1994; 330:183-187.

2. Sturgess RP, O’Toole PA, McPhillips J, et al. Percutan-eous endoscopic gastrostomy: Evaluation of insertion by an endoscopy nurse practitioner. European Journal of Gastro-enterology & Hepatology 1996; 8:631-634.

For more information about nurse endoscopists performing screening for colorectal cancer, ontact:

Debbie Lantz, RN, Nursing Supervisor, Kaiser Permanente, 20th Ave. Medical Center, 2045 Franklin St., Denver, CO 80205. Telephone: (303) 861-3639. Fax: (303) 861-3679.

Jane Allaire, RN, CGRN, Nurse Specialist, Division of Gastroenterology, National Naval Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889. Telephone: (301) 295-1312. Fax: (301) 295-4599. E-mail: jaallaire@cs.com.

Nancy S. Schlossberg, RN, CGRN, President-elect, Society of Gastroenterology Nurses and Associates, 401 N. Michigan Ave., Suite 2200, Chicago, IL 60611-4267. Telephone: (757) 640-1452.

For guidelines and other reference material to create a program for nurses to perform flexible sigmoidoscopy for screening purposes, contact:

Society of Gastroenterology Nurses and Associates, 401 N. Michigan Ave., Suite 2200, Chicago, IL 60611-4267. Telephone: (800) 245-7462 or (312) 321-5165. Fax: (312) 527-6658. E-mail: sgna@sba.com.