Sound familiar? Your docs devote long hours to meeting the ever-growing demand for colorectal cancer screening procedures, your GI nurses work efficiently and your infection control team has scope reprocessing down to an art form - yet you still can't keep up.
Some facilities are boosting their screening capacity by training advanced practice nurses to independently perform diagnostic endoscopy, specifically flexible sigmoidoscopy. A couple of facilities have even considered letting flex sig-trained nurses train for and transition to colonoscopy, a more complicated procedure.
Nurse endoscopy sparks heated debate. While 40 percent of respondents to an Outpatient Surgery reader poll believe advance practice nurses can safely do flex sigs, nearly 80 percent oppose non-physician colonoscopy. Read on to learn what colleagues at the front end of the nurse endoscopy practice curve have to say.
A matter of necessity?
While other clinicians and administrators debate nurse endoscopy from afar, Claudia Christensen, RN, CGRN, NP, prepares herself for another day of performing colonoscopies at the Alaska Native Medical Center in Anchorage. Patients come from the most remote regions of Alaska to seek colorectal cancer screening at the facility.
"This is not a nurse versus physician issue," she says. "It's a question of meeting our patients' needs." Her hospital system has seven surgeons, none of them gastroenterologists. Ms. Christensen says that a general surgeon performs as many screening colonoscopies at the facility as his schedule permits, but ANMC needed additional help.
Ms. Christensen performed more than 800 solo flexible sigmoidoscopies before receiving her colonoscopy training. She obtained permission from the Alaska Board of Nursing to develop a flex sig training program for ANMC nurses when she switched to colonoscopy.
"It's a necessity to train nurses to help increase screening rates among our patient population," says Ms. Christensen. "We were only able to screen about 15 percent before. Now, it's about half, between our colonoscopy and flex sig programs."
One study estimates the potential screening colonoscopy demand alone at about 2.6 million annual procedures nationwide. "Nationwide, there are more patients who need diagnostic colonoscopies than there are gastroenterologists to do them, and the problem is getting worse," says Annette Tealey, MS, RN, CGRN, CS, of the University of Wisconsin's GI Clinic in Madison, Wis. "At our center, the GI docs take on all the cases they can handle, come in on Saturdays, and we're still backlogged. What message does it send to patients that we educate patients about early detection, beg them to get screened and then wait-list them?"
Although not known for certain, it's believed that Ms. Christensen is the only advanced practice nurse in the United States performing colonoscopy. Non-physician sigmoidoscopy, however, has a relatively lengthy history in the United States. Advanced practice nurses have performed sigmoidoscopies since 1972, although the practice did not grow until the mid-1990s.1 However, even now, relatively few hospitals have nurse flex sig programs.
In fact, some of the respondents to our reader poll (see "Is Nurse Endoscopy Safe?" on page 32) were not aware that any nurses performed flex sigs. "I would like to know where nurses perform sigmoidoscopies," says Ellen Smith, RN, the director of surgical services at Morehead Memorial Hospital in Eden, N.C. "It's never been done at any hospital I've worked." She voices concern that sigmoidoscopy, like colonoscopy, is a specialized procedure with a "considerable learning curve and immense potential for harm."
Reader opinions on nurse sigmoidoscopy tended to be most favorable among those familiar with the literature on the practice. "There's no question that advanced practice nurses can do it. Numerous good studies in the literature have borne this out," says Edwin Montell, MD, a GI surgeon and a physician-owner of Hilo Gastroenterology Associates in Hilo, Hawaii.
Perhaps most notably, a randomized study by Philip Schoenfeld, MD, and colleagues compared 328 flexible sigmoidoscopies performed by gastroenterologists and nurse endoscopists.2 A gastroenterologist blinded to the identity of the first endoscopist performed a repeat sigmoidoscopy to determine the frequency of missed polyps. The result: The GI docs and nurses had virtually equivalent miss rates for adenomatous polyps (20 percent versus 21 percent), although the gastroenterologists typically inserted the sigmoidscope further than their nurse counterparts (61cm versus 55cm). There were no complications for any patients in the study.
Jane Allaire, RN, CGRN, the assistant nurse manager at the National Naval Medical Center (NNMC) in Bethesda, Md., and a director of the Society of Gastroenterology Nurses and Associates (SGNA) was one of four nurse endoscopist prot'g's Dr. Schoenfeld trained in the mid-1990s. SGNA came out in 1996 in support of developing protocols for nurses to perform flex sigs for colon cancer screening (download updated standards and safety guidelines at www.signa.org/resources/FlexSigdoc.html).
Ms. Allaire helped develop the NNMC's nurse-performed flexible sigmoidoscopy program. As a first step, she recommends that interested facilities check with the state nursing board for the board's scope of practice position on nurse endoscopy. Most state nursing boards, she says, have no opinion or declaratory ruling prohibiting nurses from performing flexible sigmoidoscopies. In Ms. Christensen's case, she had to obtain permission from the Alaska board to develop ANMC's flex sig program.
Where does nursing practice end?
For every nurse who's interested in learning diagnostic endoscopy and physician who believes that at least flex sigs are safe in nurses' hands, there's a nurse, physician or administrator who believes it's beyond the scope of nursing practice.
"You must be kidding," says a physician-owner of an ASC group practice. "In the best of hands, I've seen complications. Where does the practice of nursing end?"
"These decisions are not nursing diagnoses, although perhaps some advanced practice nurses could handle it as a delegated responsibility," says Maggie Johnson, RN, CNOR, director for the Center for Outpatient Surgery in Sartell, Minn.
Others point to the liability question. "I have to ask why nurses would want to take on the responsibility - and potential liability - of diagnosing patients for colorectal cancer? We do hundreds of diagnostic endoscopies annually and things can and do go wrong. Flex sigs, much less colonoscopy, are physician functions," says a Virginia hospital surgical services director.
A Kentucky hospital OR director agrees, recalling a horrifying personal experience. As a young nurse, she assisted an especially talented surgeon in a procedure that resulted in a bowel perforation and gas gangrene. "It was bad enough assisting the surgeon - to have been the practitioner would have ended my career," she says. "Few nurses have the skill, experience and manual dexterity for flex sigs or colonoscopies."
Knocking on the door
Ms. Tealey has done about 3,700 flex sigs in about nine years at her hospital. She's heard cynics' arguments against nurse endoscopy before. Her reply? Properly trained nurse endoscopists provide an invaluable resource for GI physicians to manage caseloads. She would like to see the door opened for more nurses to learn and perform flexible sigmoidoscopy - and for opportunities to transition to colonoscopy scoping.
Nancy Eisemon, RN, CGRN, MPH, APN/CNS, of Central DePage Hospital in Winfield Ill., says that the switch to colonoscopy is possible, so long as physicians help champion the cause. "Evidence-based medicine drives changes in accepting unfamiliar practices. With colonoscopy, advanced practice nurses are still at the ground floor. We need physicians to take the lead supporting nurse education and training at their hospitals," she says.
Joan Brandt, RN, CGRN, the GI coordinator at Columbia St. Mary's in Mequon, Wis., who like Ms. Eisemon is certified to perform screening endoscopy, agrees. "Gastro nurses have the opportunity to work side-by-side with experienced gastroenterologists and have many learning opportunities. I see road blocks for nurses whose institutions and gastroenterologists don't encourage training and don't provide them opportunities to scope."
With flexible sigmoidoscopy declining in popularity in favor of diagnostic colonoscopy (see "Are Flex Sigs on the Way Out?" on page 34), Ms. Tealey wants to perform colonoscopy but, she says "there are still hurdles to clear."
More challenging than flex sigs
Many administrators and practitioners - even those who support the idea of advanced practice nurse flex sigs - express concern that colonoscopy may be more than they can handle. "I know that nurse practitioners perform flex sigs but only physicians should do colonoscopies because they're more invasive," says Diane Moore, RN, CGRN, of the Endoscopy Center of Northern Mississippi in Oxford, Miss.
"I'm convinced that nurse practitioners can do flex sigs but I simply don't believe in them doing colonoscopy or other types of endoscopy," says Bergein F. Overholt, MD, FACP, MACG, of Knoxville, Tenn. His rationale? Colonoscopy is much more technically challenging than flex sigs - with many patients, it's difficult to reach the cecum, he says, plus there is the risk of perforations and complications. Secondly, colonoscopy involves potential therapeutic interventions during the procedure, most notably polypectomies.
Others say colonoscopy is just too unpredictable a procedure for non-physicians and point out the additional complication that unlike flex sigs (which can be done unsedated), colonoscopy requires conscious sedation. "I worked in endoscopy for 15 years. Some colonoscopies are very easy and some very difficult. Unless it was a re-exam, how would you know?" asks Deborah Womble, RN, CNOR, the administrator of Children's West Surgery Center in Knoxville, Tenn.
Dr. Montell likens his perspective on gastroenterology nurse colonoscopy to most anesthesiologists' views of CRNA anesthesia. "Certainly, advanced practice gastro nurses can learn the technical skills in a few hundred cases just like the MDs. But they'd need to be supervised by an MD to make medical judgments and carry out treatments," he says.
Donna Holt, RN, is even more emphatically opposed to solo nurse colonoscopy. "I say no, no, no! Under no circumstances would I accept a nurse performing a complete colonoscopy at my facility. I've seen too many cases where that would be criminal, in my mind. Only a board-certified gastroenterologist whose credentials I've checked can perform colonoscopy," says Ms. Holt, the administrator and director of nursing at the Strand Gastrointestinal Endoscopy Center in Myrtle Beach, S.C.
Lengthy learning curve
Ms. Christensen agrees that colonoscopies present quite a challenge and are more difficult than flex sigs. She performed 50 supervised colonoscopy cases before her experience doing 180 solos to date. "There's definitely a learning curve. It took me about 75 to 100 cases before I started feeling comfortable," she says. With some patients, she has a hard time getting to cecum and she says that her patient population often has particularly difficult colons to navigate due to high rates of diverticulosis and lengthy colons.
What's more, she says, polypectomies can be tricky, "particularly if the polyp is in a difficult fold. It's definitely tougher than doing a small polyp biopsy in a flex sig case." Over time, she's gained more skill and comfort with the therapeutic element of colonoscopy. Ms. Christensen reports that she has not had any bowel perforations, complications or sedation-related problems. When faced with an especially complicated case, she gets help from one of the ANMC surgeons.
"Our care model is rather unusual. We're a regional facility serving a population scattered remotely over a region one and a half times the size of Texas," she says. "The native Alaskan population suffers colon cancer at twice the rate of the general U.S. population but are among the least likely to obtain early diagnosis. Our physicians recognize this and they've been tremendously supportive. Everyone's goal is to get the best outcomes."
Are changes on the horizon? In a study published in Gastrointestinal Endoscopy in 2001, Douglas Rex, MD, and David Lieberman, MD, wrote, "There is evidence that non-physicians can perform flexible sigmoidoscopy at the same level of competence as physicians. However, there is little published experience regarding colonoscopy. 'Further study is needed before colonoscopy by non-physicians can be recommended." 3
Dr. Rex does not anticipate a sea change, however. "Training nurses is not under [wide] consideration and I don't envision any endorsement of nurse-performed colonoscopy in the future," he says. "The reality is that there is no available short-term mechanism to significantly increase the number of fully-trained, competent colonoscopists."
How then can facilities compensate for colonoscopy provider shortages and control costs? Among other suggestions, Dr. Rex proposes reducing the use of colonoscopy for post-cancer surveillance exams and increasing the cancer screening efforts currently applied to other tests such as flex sigs. Secondly, he says that block scheduling, allocating two procedure rooms per colonoscopist and considering a gastroenterology nurse-administered sedation program in lieu of anesthesiologist or CRNA care can help increase productivity and volumes while holding down some of the cost.
In the meantime, Ms. Allaire predicts an increased role for nurse endoscopists, even if solo colonoscopy is not likely in the cards. "The population at risk for colon cancer continues to grow. Nurse endoscopists are valuable assets to help screen more of these patients."
1 Maule WF. Screening for colorectal cancer by nurse endoscopists. N Eng J Med 1994;330:183-187.
2 Schoenfeld P, Lipscomb S, Crook J, Dominguez J, Butler J, Holmes L, Cruess D, Rex D. Accuracy of polyp detection by gastroenterologists and nurse endoscopists doing flexible sigmoidoscopy: a randomized trial. Gastroenterology 1999;117:312-318.
3 Lieberman D, Rex D. "Feasibility of colonoscopy screening: Discussion of issues and recommendations regarding implementation." Gastrointestinal Endoscopy. November 2001: p. 558.