The Evolution of ERCP

The Evolving Role of the Endonurse

The advancement of technology and the shortage of nurses are strange bedfellows that have heightened the role of the endoscopy nurse.

Annette Wasielewski, RN, BSN, CNOR, manager of minimally invasive surgery at Hackensack University Medical Center, recalls a bygone era when the nurse had a much lower profile.

“The surgeon was king. The anesthesiologist thought he was king, and even though the nurse was the queen she was treated as a handmaiden. Well, we’ve gone from being their handmaiden to being their right hand. Many of the procedures that we are doing and the new technology require that the nurse in the room be very proficient.

Oftentimes they’re depending on us to give them what they need with the machines. I think that we’re working more and more hand in hand with the surgeon or the endoscopist. Those guys are going after and doing more and more. They really do depend on the person who is assisting them.”

Technology has taken off. “Every day there’s something new to learn. Nurses are becoming much more specialized within their field,” continues Wasielewski. “If you’ve got two or three ORs or endoscopy suites, it’s much easier for everybody to know everything. The experience is concentrated. If you’re in a very large OR hospital that does huge volumes of a particular procedure, everybody can’t learn everything. I think nurses are learning to specialize more.”

“I think what happens with the nursing shortage is that often you’re having fewer and fewer nurses in the department,”

says Donna Stanbridge, RN, minimally invasive surgery coordinator/ research assistant, McGill University Health Center, Montreal, and nursing course director for the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). “You may have one nurse who is running the whole area, and you have a lot of technicians. That is playing a role in competency. It depends on your philosophy. I think that yes, you can train people, but I think it’s hard sometimes to have one person responsible, overseeing everything and everybody.

Ideally, you would have more nurses; we just don’t have the numbers right now.”

The nursing shortage is a significant, acute issue. What is the right mix of staffing in a unit? “We tend to be very RN-heavy because RNs are able to multitask and perform at many different levels,” says Stan Branch, MD, director of the endoscopy unit at Duke University.

“With financial constraints, we have more of a mix of techs and nurses. And just like everywhere else, our nurses are getting older, and there aren’t enough young nurses coming in. The nurse’s role in endoscopy is pretty physical. It’s hard labor. We struggle with keeping adequately staffed.”

In addition to the paucity of nurses, there is a growing concern about the numbers of GI manpower in general.

“It’s a significant problem. Back in the early 90s we were told that we needed to cut our training programs in half,” says Branch. “Everybody thought that managed care was going to reduce the need for GI. A workforce study was done in the early 90s, and quotes were coming out saying gastroenterologists were going to be standing on corners with tin cups. Like most big programs in the country, cut our training programs in half. Now there’s a crying demand for gastroenterologists, because we can’t do all these screening procedures. We’ve got a waiting list that’s just ridiculous. How do we provide the healthcare providers to do all of this? Are we eventually going to be training midlevel people to do colonoscopy?

“There certainly are people doing endoscopy out there that you worry about. If a hospital grants you privileges, you can do whatever they grant you privileges for. There are certainly people doing endoscopy who haven’t been trained as gastroenterologists — that’s a very political issue. My worry is this: if more people get screened, more people are going to need colonoscopies who have got polyps that need to be removed.

How do we put the manpower out there?

There’s potentially going to be a doctor shortage in this country. There’s certainly a nursing shortage now.”

The big struggle for teaching hospitals, says Branch, is the lack of money and resources to train more people.

“We’re not getting money from Medicare to help pay for fellowships to help train people. We’re in the struggle of being told we need to compete and be efficient like private practice, and generate income for the teaching center, and do all of our academic missions. The manpower issue is a big issue. And for me, recruiting people who may want to go into gastroenterology in academics, it’s difficult. There are not that many people there, and the academic center just can’t pay what’s paid in private practice.”

Branch recognizes a corollary between medical malpractice and the low number of new docs entering the workforce. “I think people are more nervous. The cost is one thing, but the terror of being sued is a horrible thing for people to go through,” he says. “Fortunately, I’ve not experienced it, but I’ve seen it. That certainly is driving up the cost. We cover the malpractice for all of our trainees — and that adds $100,000 a year to our budget. Where do we get that?

Whose pocket does that come out of?”

Proper cleaning and processing of endoscopes is paramount in preventing nosocomial infection caused by both patient-borne and environmental pathogens, says Lawrence Muscarella, PhD, chief, infection control at Custom Ultrasonics, Inc., and editor-in-chief of The Q-Net Monthly. In February 2003, the Association of periOperative Registered Nurses (AORN) published its (Recommended Practices for Cleaning and Processing Endoscopes and Endoscope Accessories.1) These guidelines are inconsistent with guidelines published by other organizations, and has lead to confusion, says Muscarella. “It’s important that healthcare staff have guidelines that are consistent, and that send the same message and recommend the same practices. There was a multi-society guideline that was published in July 2003 that AORN endorsed.

Nevertheless, it contains recommendations that are different from AORN’s recommended practices for reprocessing endoscopes. There’s really no need for the confusion, and as a result you can get variations in the standard of care and increases in the risk of patient injury.

“If nothing else, the professional organizations need to send consistent messages. One thing that would be important is whenever writing a guideline, first review other organizations’ guidelines, and use them as a template.

Deviations from a guideline may be acceptable, but only if compelling evidence- based rationale is provided. I see deviations and inconsistencies in recommendations that have no rationale for going off in their own direction — I’m not really clear on why this happens.”

Concern, says Muscarella, lies in AORN’s recommendation that endoscopes should be dried only before storage and after high-level disinfection (or after a tap water rinse) using a 70 percent to 90 percent ethyl or isopropyl alcohol rinse followed by forced air. “This recommended practice is arguably incomplete and may fall short of AORN’s laudable goal to establish an ‘optimal level of practice’ and to achieve ‘optimal outcomes for patients undergoing operative and other invasive procedures.’

“AORN does not recommend drying the endoscope between patient procedures after either high-level disinfection or liquid sterilization,” continues Muscarella. “Nor does AORN recommend drying the endoscope before storage and after liquid sterilization or a sterile water rinse. Instead, to minimize the risk of nosocomial infection due to bacterial colonization in the endoscope’s internal channels during overnight storage or idle ‘down-time,’ AORN recommends reprocessing every endoscope immediately before its first use of the day (and immediately before each subsequent use throughout the day.) But this early morning practice can be time-consuming and prohibitively expensive, making it impractical for many endoscopy centers.

“This is an issue that needs to be resolved, particularly in the operating room setting. What is the position: do endoscopes need to be dried or not?

There’s inconsistency in published guidelines,”

says Muscarella. There is no reason to reinvent the wheel: “Just follow SGNA’s (Society of Gastroenterology Nurses and Associates) all-inclusive recommendation, which is evidence-based and recommends drying the endoscope after every reprocessing cycle, whether between patient procedures or before storage, and irrespective of the water quality or label claim of the endoscope reprocessor. If this is done, bacterial infections linked to contaminated endoscopes are unlikely to be reported.”

Another hot spot, says Muscarella, is reprocessing errors. It is essential that the staff is adequately funded, sufficiently educated and that a quality control program is in place to make sure that all of the necessary endoscope reprocessing steps are being done and that a disinfectant of the appropriate concentration is used.

“When there are different endoscope models coming in to be reprocessed, maybe the technician has been trained on the bronchoscope, which has only one channel.

But that doesn’t help the technician to know how to process an ERCP endoscope, which has four internal channels the same technician is likely to be reprocessing.

Different endoscope models require different training. Plain and simple.”

Muscarella cites another recurring issue that has many implications to the standard of care: “Hospitals typically will monitor the disinfectant only once in the morning before the first patient. They usually don’t monitor it after every patient throughout the day, which they probably should be doing. Let’s say they’re doing 15 procedures a day. It can be argued that they then should be monitoring the disinfectant 15 times, but hospitals generally do it only once. The problem is, if they do it first thing in the morning on a Monday and it’s fine, and then they check it on a Tuesday and it fails, that means that the results are only as good as the previous passing test, which was Monday morning.

“Let’s assume worst-case scenario:

Monday’s first patient was okay, because you tested the disinfectant before the first patient. But it could have failed just prior to the second patient. You have to assume that. So the second through the fifteenth patients could have been exposed to potentially pathogenic microorganisms.

What does the hospital do? Does it let this go under the radar and not do anything about it? Or does it notify each patient?

This happens a lot more than people think. It’s an example of a quality control that probably should be in place.”

What do the guidelines say? “They kind of skirt the issue,” says Muscarella.

“They say to monitor the reusable disinfectant just once a day or more if needed, depending on the volume and workload and the number of scopes being reprocessed. But that’s vague—not everyone knows what that means.

“I get a lot of calls from hospitals that say they didn’t monitor the disinfectant.

Or they switched from one disinfectant to another and thought that the soaking times and temperatures were the same.

Then they found out later they weren’t the same. There’s an example of some kind of quality control that goofed.

People tend to think that in endoscopy you have a lot of room to work with. I disagree. Patient safety must come first.”

“The care and cleaning of the scopes are a big, big deal,” says Linda Hylind, BS, RN, endoscopy clinical nurse and research clinical nurse, Johns Hopkins University, and regional president elect of the Canadian Society of Gastroenterology Nurses and Associates (CSGNA). “A vital part of infection control is having a company come in and do competencies once a year on their equipment, going through everything with the staff and making sure everything is being cleaned properly. Inservices are key. If you get a new scope with a new attachment, does everyone know how it works and how to clean it? Education and infection control go hand in hand.”

Still, Hylind is optimistic that things are headed in the right direction. “You see a lot more being published on infection control in endoscopy. I think it’s coming up to the forefront. I think everybody is trying to be on the same wavelength.”

More and more procedures, especially in the realm of general surgery, are becoming minimally invasive. Vascular surgeons are turning to endoscopic procedures, using stents instead of bypass grafts when possible. In orthopedics, smaller incisions are used in joint replacement.

“As technology keeps progressing, we’re doing more and more through areas of access that are less and less,”

says Wasielewski. “The images we had when they first started doing the gallbladders were minimal at best. There was always an issue with light, and you couldn’t see as clearly. Today we’re using digital cameras and getting tremendous vision, and for many procedures we actually can see better doing it laparoscopically than the surgeon can in doing an open procedure. We can get right up there. You have a magnified image.”

The new frontier in therapeutic endoscopy is minimally invasive surgeries, says Branch.

“Taking things that have been and are presently in the surgical realm, can we do some of those things in a less invasive way with endoscopy? I think those things are coming down the pike. Some of the fundoplication therapies are already approved. Though the data to support those is not as good as everyone would like. I think that’s still in evolution.

“Other areas of endoscopy are potentially improving our abilities to make diagnosis of malignancies, or pre-malignant lesions. Barrett’s esophagus is a good example — are there ways endoscopically to screen Barrett’s more efficiently or effectively and try to find areas that are premalignant or have a high chance of malignancy?

If we can pick those things up earlier, we can provide better treatment.

“Endoscopy is a diagnostic tool that will evolve into a therapeutic tool,” continues Branch. Take for example, endoscopic ultrasound. “EUS is primarily a diagnostic tool now, but we’re beginning to do more with it — what therapies we can do using EUS, at least as a guide. And whether eventually we can use high frequency ultrasound (HIFU) as a therapy.”

Branch notes that there have been advances in new imaging techniques using different wavelengths of light to help screen for malignancies or premalignant lesions.

“In the past we’ve sprayed dyes on things to see if we could separate where the tissue is pre-malignant or not,” he says.

“There are newer ways of looking at how light reflects back. As the endoscope and the processor are emerging with the computer world, you’re starting to be able to look at what information you can get back from a chip, and how can you process that information. When this all started out, you’d look through a fiber-optic bundle, and what you saw with your eyes is what you saw. It’s evolved, and now it’s all predominantly video chip-driven. Now, can we get higher definition with these video chips and maybe subtract a wavelength out, or pick up a wavelength that we normally don’t see with our eye? And does that tell us more about the lining, and is this lining developing changes that could be pre-malignant? Can we do something about it at an earlier point?”

Bard Interventional Products has developed an incisionless therapeutic option for the treatment of GERD called the EndoCinch™suturing system.

Endoluminal gastroplication works by creating plications, or pleats, at the lower esophageal sphincter (LES).

Performing the procedure has been shown to significantly improve symptoms and regurgitation while reducing or eliminating patients’ dependence on acid controlling medications.

It works like this: the EndoCinch device, like a tiny sewing machine, is attached to the end of a standard, flexible endoscope. The suturing system allows the physician to place a suture near the LES. Two stitches can be placed and tied together to create a pleat near the LES and treat symptomatic reflux.3

Although standard endoscopes provide some magnification, the resolving power is insufficient for observing subtle mucosal details. Magnification endoscopy, with or without dye spraying, has been developed for this purpose, allowing fine topographical details to be seen. Magnification has been primarily studied in the colon using dye spraying to clarify abnormalities already seen by conventional endoscopy. Using dye spraying, experts can differentiate adenomatous versus hyperplastic polyps.

Where are we going? Stanbridge sees a need for integration between the different facets of the healthcare team.

“I think one of the things that is going to change drastically over the next decade, for social reasons as well as just because we need to change it because of safety and error, is that there will be a lot more interdisciplinary ties,” she says. “There will me much more of a team environment.

People are going to start to work together more.

“I’m seeing more joint educational events, and things that are happening in nursing in general. I think that the development of ties between the professions is going to change over the years. That’s something that needs to happen. And it’s starting to.”

That melding of disciplines can be facilitated by getting out there, getting involved, and talking to your peers.

“If you really want to look at endoscopy, one of the key things is networking,” says Hylind.

“Networking and communicating with other people, other hospitals, other parts of the country to see what people are doing. That way you know what’s going on out there. If you have a problem or a question, there are experts out there somewhere.”

Branch also foresees integration between disciplines. “What I envision between two and five years down the road is that we move more toward GI imaging centers,” he says. “If the technology for virtual colonoscopy or computer-regenerated colonoscopy via an MRI or CTE advances, that can be the screening tool. Right next door you turn what’s been predominantly screening colonscopy into therapeutic colonoscopy. Patients come through and if they’re found to have a polyp, you just wheel them next door, do a colonoscopy and take the polyp out.

“We’ve got to figure out how to be service-oriented for our patients,” he says. “How do we start thinking a bit out of the box? Traditionally, things have been more compartmentalized:

this is the department of radiology, that’s the department of medicine. We really need to look more disease-specific, and who needs to work together to take care of the patient. I see those things starting to meld with time.”

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