You can tell a lot about an endoscopy center by looking in an unlikely place: the waiting room. If you spot patients wearing ID bands sitting in the waiting room after the first few cases of the day, you can be pretty sure that all the scopes and stretchers are in use, and that the sole automated endoscope reprocessor is occupied, as is the only restroom. Yep, another case of GI gridlock caused by poor facility design and not enough equipment.

For each of the 40 or so GI rooms I helped design and equip, and guide through certification and accreditation, I kept the same goal in mind: Patients should be in and out of the facility in about 90 minutes. Here are 5 tips to keep the patients flowing — instead of making a U-turn at the registration desk and backing up into the waiting room.

1. Have enough restrooms. Anyone who's had a bowel prep knows the importance of a restroom. No pun intended, but not having enough restrooms can clog your schedule. I'd suggest at least 1 for the waiting area and at least 2 in the admitting area. Remember, patients might still be eliminating from the prep when they arrive for check-in. While we're on the subject, instruct your admit nurses to screen patients by asking if they're cleared out — and don't take the patients' word for it. If a patient has to use the restroom during the admitting process, tell him not to flush so the nurse can see for herself if it's clear. Let the doctor know if there are formed particles. You don't want to wheel a patient into a procedure room and open supplies only to find out that the doctor can't do the case because the patient is not adequately prepped.

2. Buy enough scopes. At about $30,000 apiece, GI scopes will be your biggest equipment expense. How many will you need? I've never bought less than 10 scopes (7 colonoscopes and 3 uppers) to start a center. Case mix is extremely important if you have a limited number of scopes. Ask each of your docs how many slots he can realistically fill in a day or a half day (they tend to overpromise). Let's assume a 70:30 colonoscopy-to-upper endoscopy ratio. If we allow 15 minutes for an EGD, 30 minutes for a colonoscopy and 45 for a double procedure — and about 45 minutes for reprocessing, which involves leak testing, manual cleaning and reprocessing through the AER — you likely won't run out of scopes:

• if you schedule a colonoscopy every half hour and an endoscopy every 15 or 20 minutes, and
• if you stagger the schedule accordingly — first an EGD, then 2 colonoscopies, then an EGD.

Those are big ifs. Here's one more: If you schedule 4 EGDs in a row, you'll need a 4th upper in order to avoid delays. To give you an example, let's say the EGD scope you use for the first case of the day at 7 a.m. gets to decontamination at 7:25 a.m. That scope won't be free to use again until 8:10 a.m. If you schedule an EGD for 8 a.m., you'll need a second upper scope. But if you schedule colonoscopies for 7:30 a.m. and 8 a.m., and a EGD for 8:30 a.m., you can use the same upper scope that you used on your first case.

A quick word on what scopes you should buy. I've never worked with a doctor who didn't know exactly what instruments he wanted, from the brand of scope to the kind of biopsy forceps.

3. Install enough AERs. Speaking of sterile processing, I recommend you install 2 automated reprocessors in your reprocessing room. You can run an AER with 1 scope, but it's obviously more efficient to run it with 2 scopes. But there will be times when you'll need to run the AER with just a single scope in it to keep the schedule moving. That's why you'll want a second AER. Plus, it's smart to have a backup in case one needs service.

Keep in mind that AERs vary in size. Give your architect the dimensions of the AER(s) you want when you plan your decontam room. The room's dimensions might eliminate certain models or force you to move some cabinetry around. Plus, you'll need to know where to plumb in drains and water lines. Finally, make room for a scope cabinet/room where you'll hang your scopes after processing.

4. Outfit the procedure room. It's easier if you dedicate a shelled-out or in-use procedure room for GI, but if you're planning to convert an OR to a GI suite once or twice a week, you'll have a new set of challenges.

• Pace. GI cases are scheduled every 15 or 30 minutes and patients remain on the same stretcher from admit to procedure to recovery, so you'll likely need to buy a few more stretchers.
• Space. Where will you move all the pieces of equipment you'll have to clear out of the OR? It's a long list that includes the OR bed, Mayo stand, back table, ring stand, IV pole and anesthesia machine.
• Monitors. Then there's the question of where to place the monitors. If the tracks of the OR's overhead lights won't let you suspend monitors from the ceiling, you'll have to place them on audio-visual carts. The oxygen, nitrous and suction hanging from the ceiling could also interfere with GI cases.

Equip each room with 2 monitors — one for the doctor and one for the nurse/technician assisting the physician in handling the scope, biopsy forceps and snare. Unlike most ORs, GI rooms routinely have a small sink as part of the cabinetry. You'll need an in-room cabinet (glass door or stainless steel) to store your supplies, such as towels, suction, 4x4s, K-Y Jelly, IVs, IV tubing, medications and specimen containers.

5. Create a comfortable space. Yes, you want to provide patients with a pleasant setting, but don't skimp on what I call "non-revenue-generating spaces," such as lockers and break rooms for staff. And don't forget about the people who drove your patients and are taking a few hours out of their day. Invest in comfortable waiting room chairs for patient escorts. In one center, I put sofas with pillows in the waiting room. The doctors didn't much care for it, but the escorts were comfortable. The chairs in one center were so uncomfortable that escorts routinely went next door to another doctor's office to sit on chairs with padded arms.

Consider the privacy of patients when they're registering. A doorway that leads to a couple cubicles off of the admit area is a nice touch. GI patients will be hungry and thirsty after their procedures. In your recovery room, you'll want to serve individually packaged saltines or graham crackers, and a juice box, bottle of water, or can of ginger ale or 7 Up.

My last piece of advice: Visit a GI center — not a competitor! — to see what good patient flow looks like. If there's a traffic tie-up in the waiting room, you'll have a pretty good idea what caused it. OSM