EFFICIENT ENDO Some of the nation's busiest GI centers share the secrets to their success.

The hospital GI department? Take the elevator to the basement, hang a left and head down the cinderblock hall. If you pass radiology, you've gone too far.

Debbie Hunt, RN, BSN, remembers the cramped, dimly lit hospital GI unit all too well. Its inefficiencies, too. She was a hospital GI nurse for 20 years until 2004. That's when she helped open the Saratoga Schenectady Endoscopy Center in Burnt Hills, N.Y., a sleek, 10,000-square-foot, freestanding facility that has skylights, windows and elbow room throughout. She's got 11 physician-owners, a part-time colorectal surgeon and more patients — a record 11,000 last year — than you can shake a scope at. They're at near capacity, most days running 3 full procedure rooms from 7 a.m. until 4:30 p.m., and a fourth room until noon.

How do they do it? Here are a few keys to success from some of the country's busiest GI centers.

ENDO ROOM SUPPLIES
What's in Your GI Turnover Pack?

ECONOMICAL AND EFFICIENTGI turnover pack contains all of the supplies you need for a case.

Linda W. Frix, RN, BSN, CAPA, the clinical director of the Northern Virginia Surgery Center in Fairfax, Va., shares the contents of her custom disposable GI turnover packs.

• A very small packet of lubricant. They used to use a larger tube, but ended up wasting most of it. "Remember, you have to discard the tube after using it for 1 patient," she says.

DOUBLE DUTY Convert your GI pack to a drawstring bag to transport used scopes.

• 500cc plastic basin
• gown
• 2 pre-packaged scope-cleaning brushes
• Contoured sponge with the center impregnated with enzymatic solution for pre-cleaning scopes in the procedure room. This saves you from having to store and pour from the large jugs of enzymatic solution in the procedure room, she says.

"Our custom packs significantly reduce turnover and prep time," says Ms. Frix. "There's no retrieving the individual contents of the pack before each case."

After pre-cleaning in the procedure room, everything is tied up in the green wrapper, which converts to a drawstring bag for safe transport into the scope room.

1. Staffing
Looking back, Ms. Hunt says she took 2 invaluable things with her when she left the hospital GI unit to serve as the administrator of the outpatient endo center: a solid clinical background and a talented group of handpicked colleagues she pulled from area hospitals.

"The one thing they all shared? They're really good independent workers who also work well as a team," says Ms. Hunt. "When you've got the right mix of people, your patients will notice and your efficiency will soar. Things just flow better."

There's plenty you can do to promote teamwork. For starters, says Ms. Hunt, make sure everyone has clear expectations and clear assignments. She remembers how the assignments weren't clear at the busy hospital unit, how 3 or 4 prep and recovery nurses were mixed together, how whoever happened to see the patient's chart on the counter would admit the patient. As she says, "People need to be told, 'This is what you're going to do. You're in charge of this.'"

Rather than assign 3 nurses to recovery and tell them to divvy the work amongst themselves, assign a PACU nurse to each procedure room. If Dr. Jones is doing 14 cases in 1 room, he knows that he'll have 1 nurse recovering his patients in 1 assigned area. "Our docs like knowing which beds and nurses are assigned to their patients. It takes a lot of the confusion and mystery out of things," says Ms. Hunt.

Her GI staffing formula: 3 nurses per doc — 1 in the room, 1 in prepping and 1 in recovery. Add a dash of teamwork, and the schedule will hum without making patients feel they're on an assembly line.

"Work as a team," says Kristine Bedford, RN, BS, clinical director of the Endoscopy Center of Marin in Greenbrae, Calif. "If the recovery room is less busy and the pre-op needs help, then help out, even if it's only to get a warm blanket for the patient. While one patient is changing, we interview the next. While that one is changing, we're starting the other's IV. Any way we can, we utilize our time. When it's slow, RNs file."

Ms. Hunt schedules 4 techs per day: 1 works in the reprocessing room all day, 1 turns over procedure rooms 1 and 2, 1 turns over procedure rooms 3 and 4, and 1 rotates between prep and PACU, making and moving stretchers, walking patients to the bathroom and getting them juice.

At the Harbin Clinic Endoscopy Center in Rome, Ga., procedures are scheduled every 30 minutes for 2 endoscopists, from 7:30 a.m. to 11:30 a.m., and from 1 p.m. to 4:30 p.m. The staffing model depends on the type of anesthesia being administered, says Nurse Manager Bobbi Freeman, RN, CGRN.

On conscious sedation days, there are 2 admit nurses (1 for each doc), 1 float admit nurse, 2 discharge nurses (1 for each doc), 2 scope nurses (1 for each doc), 1 tech to turn over admission/recovery rooms and 1 tech to reprocess scopes. On propofol days, it's the same, but with a CRNA added in the procedure room, to administer propofol.

Staggering start times throughout the day may help you meet staffing needs by ensuring staff are present during peak patient care times, says Jim Collins, practice manager at the Cleveland Clinic, adding that part-timers can fill open spots on the schedule.

2. Scopes
A case should never be delayed because a scope isn't available. If that's happening at your facility, you need to either look at what's going on in reprocessing or consider buying more scopes.

"I can probably count twice the number of times a doctor has been at my door saying that he's waiting for a scope," says Ms. Hunt. Her center uses 3 high-level disinfection automated reprocessors and doesn't hesitate to buy more scopes when they're needed.

An additional factor in the equation for operating an efficient endoscopy unit is having the equipment and supplies necessary to perform the scheduled procedures readily on hand, says Mr. Collins. "The unit must have the appropriate number of endoscopes in inventory to perform the day's procedures without causing procedural delays."

To minimize procedure times — scope-in to scope-out — place scopes outside each procedure room for the first 4 to 5 cases, says Frank J. Chapman, MBA, chief operating officer of Asheville Gastroenterology Associates in Asheville, N.C.

It's also helpful if every endo room is designed exactly the same so that all rooms have the same supplies in the exact same locations. "There should be no reason to leave the room to go get something," says Mr. Chapman.

STAFFING PEARL Assign a PACU nurse to each procedure room. GI docs like knowing which beds and nurses are assigned to their patients.

3. Scheduling
Patients don't always arrive on time for their GI procedures. Sometimes they cancel without notifying you. If this is a problem at your facility, consider double-booking a procedure every morning and afternoon to keep the room running in the event of a late cancellation or a no-show, says Mr. Collins.

Have patients come in 45 minutes before their procedure time, says Ms. Bedford. "If one is late, take the next patient," she says. It's standard to schedule 30-minute procedures. If you have 2 docs working, give the faster of the 2 a second room, so you have the next patient ready and waiting in the third room, says Ms. Bedford.

Have a tech call patients the day before and try to get all their information over the phone. Having your charts prepared a day in advance is a real time-saver on the day of the procedure, says Ms. Freeman. Pre-procedure phone calls also add a personal touch to the patient experience and decrease patient anxiety, says Mr. Collins. These calls can also prevent surprises on the day of the procedure. Double-check that necessary lab testing is complete, and remind patients about bowel prep compliance, NPO status, and taking their diabetic, heart and blood pressure meds before procedures. Finally, be sure to confirm that patients will have a driver to take him home when discharged.

To increase the unit's efficiency on the day of the procedure, you can complete many activities when a procedure is scheduled, says Mr. Collins, including patient education about the procedure, bowel preparation instructions, review of current medications (such as anticoagulants and anti-diabetic agents), need for antibiotics or lab work before the procedure, and sedation history. "Obtaining this information will assist in the reduction of cancelled or delayed procedures," he says.

At the Harbin Clinic Endoscopy Center, the average admission time is 12 minutes. Each of the 2 doctors has an admission nurse assigned to him. Plus, there's a floating admitting nurse moving in and out of the 4 admission/pre-op rooms. This nurse turns the rooms over and starts the IVs while the admission nurses focus on charting, assessment and the EMR, says Ms. Freeman.

To minimize discharge times — from the end of the procedure (scope-out) to when the patient meets discharge criteria — give patients water, not snacks or juice. "Give patients 15 minutes to sleep and then have their ride come in the recovery room," says Ms. Bedford.

You want patients to pass gas soon after the procedure, says Ms. Freeman. "This reduces the chance of cramping or abdominal pain in recovery," she says. "We often apply minimal abdominal pressure and ask the patient to bear down to encourage passage of gas. We try to do this before the family member enters the room as sometimes patients are embarrassed."

To kick-start your day, take the first patients directly to the procedure room and bypass pre-op. "The nurses in the GI procedure rooms will perform paperwork and start IVs," says Berry Sowell, CEO and administrator of the Dothan (Ala.) Surgery Center. "This frees up pre-op space out of the gate and lets pre-op staff prep other patients."