SHARING THEIR SECRETS We asked endoscopy facility managers how they keep their GI procedures running smoothly.

The challenge of running an efficient GI service lies in treating a high volume of patients with safety, efficiency and economy in mind. To assist you in your quest to achieve this rare trifecta, we asked your endoscopy colleagues to share the things that work well in their facilities.

1. Adhere to bowel-cleansing regimen. Inadequate bowel preparation is more than an inconvenience. Poor preps can result in missed lesions, aborted or incomplete procedures, and higher complication rates. At Philadelphia's Endoscopy Center of Pennsylvania Hospital, staff call patients the day before a procedure "right around the time the patient would begin the prep, to answer questions and improve compliance," says Stephanie Diem, BS, RN, the administrative director. "If we find out that the patient is not going to be well prepared, then we know we have to reschedule that colonoscopy."

2. Try split preps. Facilities experimenting with split preps — 2 liters of prep the night before colonoscopy and 2 liters on the morning of the procedure — are finding more flexibility with scheduling. "The patient can have breakfast the day before," says Diane Southern, RN, administrator at the Endoscopy Center of Ocean County and Toms River, N.J. "This way they don't have to go 2 full days without solid food. They begin fasting around noon the day before; take half their preparation in the evening and the rest the next morning, the day of the procedure." Ms. Southern's centers plan to study which bowel preparation regimens are easiest to follow while providing the best results. She's pretty confident split preps will come out on top. "We are finding patients' bowels are even cleaner than with the all-day fasting method and patients are less reluctant to schedule an afternoon colonoscopy," she says.

3. Make the most of the pre-procedure phone call. These calls can prevent surprises on the day of the procedure. In addition to giving bowel prep instructions and reminding patients about bowel prep compliance, double-check that necessary lab testing is complete, review current medications (such as anticoagulants and anti-diabetic agents), discuss the need for antibiotics and record the patient's sedation history. Be sure to confirm that patients will have drivers to take them home when discharged.

STILL MANUALLY CLEANING? Automatic endoscope reprocessors are faster and give you the assurance that the scope is clean every time.

4. Kick-start your day. Here's a scheduling pearl courtesy of Berry Sowell, CEO and administrator of the Dothan (Ala.) Surgery Center, to get each day off to a brisk start. Let your first GI patient on the schedule bypass pre-op and take her directly to the procedure room, where a nurse can perform paperwork and start the IV. "This frees up pre-op space out of the gate and lets pre-op staff prep other patients," says Mr. Sowell. To keep cases moving, place scopes outside each procedure room for the first 4 to 5 cases. To minimize discharge times, give patients water, not snacks or juice.

5. About those tardy patients. Have late-arriving patients come in 45 minutes before their procedure time. This way, if one is late, you can just take the next patient. To deal with no-shows, double-book a procedure every morning and afternoon to keep the room running in the event of a late cancellation or a no-show.

6. Assign docs bed spots. Put patients in bed spots, pre-procedure and post-procedure, by physician. This way, when anesthesia comes out for the next patient for their room, they know exactly which 2 bed spots to choose from. Likewise, when the docs come out post-procedure, their patients are always in 1 of 2 PACU or Phase 2 spots. In pre-op, place laminated signs that say "Dr. X Next Patient" on the over-bed table. This way, no one ever takes in or talks to the wrong patient.

7. Fast docs, slow docs. If you have 2 docs working, give the faster of the 2 a second room so you can have the next patient ready and waiting in the third room. Physicians at South Carolina Medical Endoscopy Center are encouraged to take their time with every patient to ensure they don't miss any adenomas. That means at least 6 minutes, and more optimally 8 minutes, to examine the colon. The longer it takes, the better the examination and the more polyps are discovered. "We measure ADR (adenoma detection rates) quarterly for all 25 physicians and we counsel those that are below 30 [percent]," says Stephen Lloyd, MD, PhD, medical director at the Columbia, S.C., center, and a passionate advocate of using ADR as a measure of a thorough colonoscopy. Recommended guidelines say ADR for each physician should be at least 25% in men and 15% in women. At Endoscopy Center of Ocean County and Toms River, cecal withdrawal times are recorded for peer review of physicians, says Ms. Southern.

8. Let the tech advance the scope. Several facilities let their GI techs or nurses assist with scope manipulation. The technician "drives," keeping a hand on the belly, while the physician "steers," says Ms. Diem. "It takes 3 to 6 months to train a technician to be adept at this. When it works well, when the physician and tech are in sync, it gives the physician more time to concentrate on the screen and on what's in the colon." Says Dr. Lloyd, "We have proven that having a technician advance the scope improves efficiency and quality and reduces complications."

9. Clean at bedside. Preclean at the point of use. Yes, good reprocessing starts in the procedure room. Immediately flush and wipe your scopes post procedure in the room to prevent drying. Wipe the scope of body fluid and debris, and rinse with soapy water in the room as soon as the doctor hands the scope back to the scrub. "You cannot high-level disinfect or sterilize if it's not clean," says Steven Gray, CRMST/CRCST, program specialist of sterile processing services at the Northern Arizona VA Health Care System in Prescott, Ariz. "If the manufacturer specifies to flush 90cc, then it must be flushed in one direction: out. I have witnessed a tech hook the syringe up and flush out, pull back and out again. This is not right. If there is debris left from brushing, you will not flush it out." Always leak-test scopes before putting them in a processor, says Debbie Amos, RN, CNOR, RNFA, director of surgical services at Sunnyside (Wash.) Community Hospital.

10. Have a dedicated reprocessing staff. Have only a few people who reprocess scopes in your facility and train them well. Give them the proper tools: physical setup and disposable supplies, says Debbie Hunt, RN, BSN, administrator of the Saratoga Schenectady Endoscopy Center in Burnt Hills, N.Y. "We use the same people to reprocess and clean our scopes. They have a very good routine and are very cautious with the expensive equipment. We have very few repairs. We sometimes go the whole year with no repair," says Michelle Fairley, RN, director of surgery at Iroquois Memorial Hospital in Watseka, Ill.

11. Use an automatic scope reprocessor. More than 9 out of 10 (91.7%) of the 109 endoscopy center managers we recently surveyed use AERs. Reasons most frequently cited: reduced human error and man-hours, increased turnaround and assurance that scopes are properly disinfected. "It's the only way to make perfectly sure the scopes are clean and decontaminated," says an assistant nurse manager.

"Manual reprocessing is very time-consuming," says a hospital infection preventionist. "With the auto reprocessor, we're able to do 2 scopes at once while the tech is manually pre-cleaning another scope." Adds Carol Saxton, RN, surgery director of Decatur County Hospital in Leon, Iowa, "While the machine is working on the scope, we can turn the room over and deliver specimens."

AERs provide peace of mind for many managers by documenting that high-level disinfection did in fact take place. "Computerized monitoring allows tracking of all cycle parameters, as well as patient information and reprocessing date and time," says Alexa Alessi, RN, BSN, CGRN, assistant nurse manager at the NYU Medical Center.