Chapter 10 Day surgery and endoscopy
This chapter provides an overview of the evolution of day surgery and endoscopy in Australia, the process involved in providing these services, and the benefits for the patient, the facilities and health care in general. Opportunities for day surgery to reach its true potential are also discussed. Flexible endoscopic procedures are a large and increasing component of throughput in a day surgery unit and unique considerations are associated with them. The associated technology enables doctors and surgeons to diagnose and treat many different disease processes, sparing patients from traditional surgical interventions. These are examined, along with new roles that are emerging for nurses working in these areas.
The Australian Day Surgery Council (ADSC) (2004) provides accurate and internationally accepted definitions of day surgery:
More than a century ago Dr James Nicoll, a Scottish surgeon working at the Sick Children’s Hospital and Dispensary in Glasgow, published a paper in the British Medical Journal about his experiences of approximately 9000 paediatric surgical patients, most of whom he operated on alone in an outpatient setting (Jarrett, 1999). Nicoll believed that much inpatient treatment was a waste of hospital resources because the results obtained in the outpatient department were equally as good but at a fraction of the cost. He believed that carefully selected children recovered better at home, in the care of their family, provided that they were given the necessary education and information to care for their child postoperatively. He also believed that outpatient surgery was cost-effective and, that by removing children from inpatient beds, their treatment and recovery would be of a higher quality. Nicoll could not have realised then the impact that his practice would make in the mid-to-late 20th century, when the rising costs of health care created a trend to the performance of more surgery on an outpatient or day surgery basis. Nicoll is regarded as establishing the foundations for modern day or ambulatory surgery.
Like the impact that is attributed to Nicoll’s work, Hippocrates is noted to be one of the first people who attempted to see inside the gastrointestinal tract by inspecting the rectum with a candle. In 1795 Bozzini used a rigid sigmoidoscope. By the 1870s, Kussmaul was attempting to visualise the stomach with a rigid tube; however, it was not until 1932, when a semi-flexible instrument was designed by Rudolph Schindler to inspect the stomach, that flexible endoscopy began to move into its own domain. Hirschowitz, Curtiss, Peters and Pollard enhanced the design of these instruments in 1958 with their new fibrescope, using fibreoptic bundles to transmit the image. From this point, gastroenterology has evolved into what it has become today (Mays, 2003).
The advent of rapid development in endoscope design, along with procedural advancements, has created a demand for skilled personnel who can manage not only the patient but also care of the equipment. Specialised endoscopy units have developed as free-standing entities as well, as in hospitals, and practice within all of them is underpinned by clinical guidelines, professional standards and specific health department policies. These have been developed collaboratively and some of them are now mandated (Mays, 2003).
In the 1950s some day surgery was being performed internationally but the concept of a purpose-designed day surgery unit was not taken up until 1962, with the development of a hospital-based ambulatory surgery unit at the University of California, followed by the first free-standing ‘surgicenter’ opened in 1969 in Phoenix, Arizona (Jarrett & Staniszewski, 2006). In Australia, the first purpose-designed, free-standing day surgery centre was built in Dandenong, Victoria, in 1982, and the first free-standing centre on the campus of a public hospital at Campbelltown, New South Wales, in 1984 (Roberts, 2004). These were followed quickly by the development of other units around Australia.
Initially, this new concept generated little enthusiasm for changing the way health care was provided, as there was no incentive to change at that time. However, since the late 1980s and 1990s, a slow but steady growth of day surgery units has occurred in both the public and private sectors. These units have demonstrated their efficiency, combining good postoperative outcomes with high-levels of patient satisfaction. Factors contributing to the growth of day surgery have included: the continuing need to reduce extensive hospital waiting lists; the rising costs of health care in general; an increasing and ageing population demanding more surgical interventions; advances in surgical and non-surgical techniques and technology; the development of new, shorter-acting anaesthetic agents and drugs; and the commencement of national cancer screening programs.
The advantages offered by day surgery are listed below.
For most patients, spending minimal time in hospital is a great advantage and day surgery has become accepted as an alternative to lengthy hospital stays. Despite the obvious advantages of day surgery, there has been little encouragement from federal or state governments to increase activity rates. Roberts (2004) estimated that the potential for day surgery had increased from 50% to 75% (possibly more) of all operations/ procedures. However, statistical information from the Australian Institute of Health and Welfare (AIHW) (2007) shows that, in 1996–97, the rate of same-day activity, for all separations, was 44.7%. The rise in activity over the last 10 years has been approximately 1% per annum, as current statistics show (Table 10-1).
Table 10-1 Current activity, all separations, 2005–06
| State/Territory | Day surgery activity |
| Victoria | 58.8% |
| Queensland | 56.9% |
| Western Australia | 55.2% |
| South Australia | 52.2% |
| New South Wales | 51.8% |
| Tasmania | not published |
| Northern Territory | not published |
| Australian Capital Territory | not published |
| Average | 55.3% |
The driving force to increase utilisation of day surgery principles in Australia is the Australian Day Surgery Council (ADSC), which is a multidisciplinary body of experts who have been responsible for setting standards and introducing clinical indicators, and who are involved with federal and state government on all aspects of day surgery (ADSC, 2004). The Australian Day Surgery Nurses Association (ADSNA) and the Gastroenterological Nurses College of Australia (GENCA) have also been instrumental in promoting best practice guidelines for ambulatory surgery and procedures, as well as providing educational opportunities for nurses working in day surgery and endoscopy settings. However, notwithstanding the utility of professional guidelines, they are not without limitations, as a systematic review described in Box 10-1 demonstrates.
Box 10-1 Systematic reviews of day surgery
Richardson-Tench, M., Pearson, A., Birks, M. (2005). The changing face of day surgery: using systematic reviews. British Journal of Perioperative Nursing, 15(6), 240–246.
This paper discusses the systematic reviews that resulted in the ADSNA publishing its best practice guidelines for:
The article highlights the lack of quantitative evidence to ensure best practice, noting instead that expert opinion underpinned many professional standards. Richardson-Tench et al (2005) strongly recommend the need for primary research in the above areas; it is not only relevant for day surgery practice but also for perioperative practice in general.
A steady increase in day surgery has been carried out internationally; however, this varies between countries, between and within regions, and in the types of procedures performed. Developed countries have performed better than developing countries as there are fewer barriers. Table 10-2 presents data on selected procedures extracted from a survey carried out by Toftgaard and Parmentier (2006) for the International Association for Ambulatory Surgery (IAAS). Table 10-2 shows that there are opportunities for growth in day surgery for some procedures in Australia, whereas for other procedures the limits appear to have been reached.
Table 10-2 Percentage of selected cases completed in day surgery settings by country
| Country | Arthroscopic menisectomy | Laparoscopic cholecystectomy |
| Australia | 81% | 2% |
| England | 70% | 3% |
| Germany | 32.5% | 0.5% |
| United States | 96.7% | 49.8% |
| Canada | 97.7% | 43.9% |
The availability of endoscopes has been instrumental in changing the face of day surgery, and has required surgeons/proceduralists to learn new skills. Similarly, surgeons have developed techniques of operating via smaller incisions. These techniques have led to less tissue trauma, less postoperative pain and quicker overall recovery from surgery. Advances in wound drainage systems allow the patient to be discharged with a small drain in situ (to be removed the next day). Diagnostic and therapeutic laparoscopy and other forms of endoscopy, removal of simple skin growths/cancers, repair of varicose veins, hernia repair, cataract removal, cystoscopy and in-vitro fertilisation are some examples of procedures commonly performed in day surgery settings.
The development of flexible endoscopes, along with the use of cameras that can be attached to them (resulting in the visualisation of the internal operative site on largescreen monitors), has resulted in a new range of procedures subsequently evolving. Flexible endoscopes are complex, long-lumened instruments that can be used to visualise the lungs, upper and lower intestinal tracts, biliary, gynaecological and urological systems. The small bowel has been difficult to visualise due to its length but this is improving as new technologies evolve, such as the double-balloon endoscope. There is also an ingestible capsule which, during its 8-hour transit through the small bowel, is able to take thousands of photographs. Although most endoscopic procedures are completed within the day surgery or endoscopy unit, lengthy procedures may require an extended or overnight stay for the patient to facilitate the process of monitoring that is required for patients undergoing small bowel investigations.
Another influence on the growth in day surgery procedures is exemplified by the National Bowel Cancer Screening Program. This screening initiative is a preventive measure to improve patient outcomes and to lessen health care costs by diagnosing bowel cancers earlier via a faecal occult blood test. This program evolved because of the development, firstly, of an effective, easy to administer, population-based faecal occult blood test. Subsequently, the Australian government implemented the National Bowel Cancer Screening Program in 2006 (MacLellan, 2006). It is anticipated that this will result in greater numbers of patients undergoing flexible colonoscopy to identify the cause of the bleeding from the bowel previously detected via faecal occult blood test.
De Jong et al. (2006) discuss the role of day surgery in a variety of surgical specialties for frequently performed procedures, and recommend that more complex procedures be introduced in the near future. However, careful patient selection remains the key to success.
Over the last two decades, significant improvements in anaesthetic techniques have been made owing to the availability of more refined, shorter-acting anaesthetic agents with minimal side-effects. Volatile inhalational agents, such as sevoflurane, desflurane and isoflurane, are popular, and propofol is now commonly used because its properties are such that patients recover rapidly following its use. Total intravenous anaesthesia (TIVA) is ideal for some procedures (Raeder, 2006) and local infiltration, with or without peripheral or regional nerve blocks, may be used and provide good pain relief intra and postoperatively. Fentanyl is another drug with a rapid onset and short duration, making it ideal intraoperatively as well as postoperatively, where it provides excellent analgesia (Gupta, 2006). The variety of antiemetic drugs currently available allows for more effective control of postoperative nausea and vomiting than previously (Bustos et al., 2006; Langton & Gale, 2007).
Equipment used by the anaesthetist has also markedly improved. The laryngeal mask airway has replaced the endotracheal tube for the majority of patients having a general anaesthetic. More sophisticated monitoring equipment records all events and data throughout the anaesthetic and allows for early warning of untoward events, facilitating early intervention. Raeder (2006) states that, ‘The most important aspects of quality in an optimum anaesthetic technique are rapid and clear headed emergence, no postoperative pain, no postoperative nausea or vomiting and absence of any perioperative side effects or discomfort’ (p 186).
Patient acceptance of and satisfaction with day surgery is consistently high, providing that their expectations of the experience are met, namely:
The ideal facilities are specifically designed to provide a relaxed, non-threatening, hotel-like ambience where patients receive individualised care. Day surgery is particularly suited to children, who are separated from their parents for as short a time as possible. Given a choice, most paediatric patients and their families would choose day surgery over an inpatient stay (Davidson & Sale, 2006).
However, expectations can be problematic to manage if patients are not given the correct information and explanations during the preoperative consultation. The day surgery experience can seem like a ‘production line’ and patients can feel they are being rushed through the system (Richardson-Tench et al., 2005). Adequate education and care will alleviate these problems, and must be combined with good communication between day surgery and/or perioperative/endoscopy staff, and patients and their families/carers.
Even though patient acceptance of the day surgery experience is mainly positive, acquiescence with the bowel preparation for lower endoscopic procedures can be problematic. Many patients inform staff on admission to the day surgery unit that they were unable to complete the bowel preparation. This is due to its unpalatable nature and/or quantity of medications to be consumed, combined with the (frequent) onset of headache, hunger and diarrhoea caused by the preparation. This, together with the perceived embarrassment associated with the procedure, prevents a number of patients attending for colonoscopy. It is important to educate patients adequately about these matters and their subsequent management prior to the event. This education enhances their overall experience and improves compliance with the necessary preparation. It is often the gastroenterological specialist who gives this information to private patients, which nursing staff reinforce when telephoning the patient on the day before to confirm admission time the following day. Adequate bowel preparation is vital to the success of the procedure and, if this is not completed as directed, then patients need to be aware that the procedure may produce suboptimal results or even be cancelled (Dix, 2007).
Careful selection and assessment is paramount to successful day surgery and endoscopy, and many factors need to be taken into account in making a decision. It is strongly advised that each facility adopt a team approach to establishing written criteria for patient assessment and selection. This means that all who may be involved in the care of the patient—surgeons, doctors, anaesthetists, nurses, social workers, diabetes educators, pain management consultants, physiotherapists—should be involved. Ensuring this involvement results in all stakeholders taking ownership of the criteria developed, and consequently abiding by them. The criteria should address, but not be limited to, suitability of the procedure, significance of medical history, the minimal physical and anaesthetic assessments to be undertaken, and how the evaluation of social circumstances will be determined. The criteria are then used throughout the selection and assessment process, allowing those patients who do not meet the criteria to be referred for treatment as an inpatient.
Traditionally, patients have been selected following the American Association of Anesthesiologist’s (ASA) physical status classification system, whereby patients classified as ASA 1 and 2 were deemed appropriate for day surgery. This classification is presented in Table 2-2.
However, Gudimetia and Smith (2006) noted that the ASA classification is a simple, albeit crude, evaluation of chronic health and further add that patients with a ranking of ASA 3 do not experience more complications in the medium-to-late recovery period or problems after day surgery. They therefore recommend that patients who are classified as ASA 1–3 should be considered suitable for day surgery unless they have other contraindications, and that some patients classified as ASA 4 may also be acceptable for day surgery under local anaesthetic.
A variety of models are available for preoperative patient assessment. The most commonly used model internationally is one that utilises a nurse who is experienced in all aspects of day surgery practice using a well-structured medical/health questionnaire, following completion by the patient of a physical and social questionnaire at least 1 week prior to surgery. The ideal interview is a face-to-face meeting with the patient and carer (if possible), which also provides the opportunity for physical assessment, and preoperative diagnostic and other tests to be carried out, and for information sharing and education to occur. An anaesthetist should be available for referral or advice as necessary. Where distance is a problem, the assessment may be carried out by telephone, followed by a mail-out of written information. The preoperative assessment needs to ensure that:
This information, once gained, and following the proscribed criteria, enables identification of those patients who are suitable, those who may be suitable following further assessment, and those who are unsuitable and must be referred for inpatient admission.
Routine screening tests are expensive and of no clinical benefit. Investigations should be based on the findings of the preoperative patient assessment and evaluation (Gudimetia & Smith, 2006). This assessment and evaluation may have already been conducted by the medical specialist prior to the day of the procedure and the appropriate tests ordered as relevant to the patient’s current medical history. It is therefore necessary to ascertain which, if any, tests have been completed and to ensure that the results are made available once the patient arrives at the hospital/facility and prior to the surgery or procedure.
Whether patients are interviewed/assessed face to face or via telephone, several details needs to be ascertained.
Demographic details, which include confirming the patient’s name, home address and other relevant details, must be obtained. Age may be a factor as some facilities have either upper and/or lower age limits. A consent form that indicates the correct procedure must be completed. An incomplete consent form should not be accepted and steps must be taken to rectify this before the day of surgery. If this is not possible, it must be rectified prior to the surgery or procedure.
Recording of baseline observations should occur where possible. Recording of weight and height should occur if pertinent, and always for children. Obesity is an increasing problem in Australian society and the decision to apply a weight limit (calculated on body mass index or BMI) is a matter to be decided by the team and subsequently included in the criteria for admission to the individual facility. Obesity is a predictor of adverse events in day surgery, specifically, respiratory events (along with smoking and asthma) (Langton & Gale, 2007).
A review of the list of the patient’s current medications should take place and include identifying the use of herbal and complementary medicines, as these are now commonly used and can cause adverse effects in patients undergoing anaesthesia and surgery. It is imperative that patients undergoing an endoscopic procedure (like many other procedures) and taking aspirin, anticoagulants or non-steroidal anti-inflammatory drugs are asked to cease these several days prior to the procedure (Robertson, 2005).
A medical history is important as many patients have chronic or concurrent medical conditions, such as cardiac disease, liver disease, pulmonary disease, hypertension, diabetes mellitus or latex allergy. In these cases a specific clinical pathway should be initiated, indicating the necessary preoperative tests and patient management throughout their surgical experience. Those patients with an artificial heart valve or other prosthesis may also require prophylactic antibiotic therapy (Robertson, 2005).
Anaesthetic evaluation is particularly important in patients identified as having previous or family problems with anaesthesia and includes patients who have a known (or possible) difficult airway, a history of malignant hyperthermia, sleep apnoea or those with drug and egg allergies. The anaesthetist should always be consulted for specific advice, although few of these difficulties will preclude day surgery (Gudimetia & Smith, 2006). Recommendations provided by the Australian and New Zealand College of Anaesthetists (ANZCA) on the pre-anaesthesia consultation indicate that all patients must be seen by an anaesthetist prior to anaesthesia and surgery to ensure that the patient is in an optimal state of health, and to facilitate the planning of anaesthesia along with appropriate discussion and consent for the anaesthesia, and related procedures (ANZCA, 2003, PS7). This consultation may be at the initial patient interview following referral by the nurse but prior to the day of surgery or on the day of surgery but prior to the patient going to the operating or procedure room. The final decision on patient suitability for day surgery is made by the anaesthetist.
Social factors are also important. Patients who are unable to make satisfactory arrangements for travel and/or do not have a responsible carer to accompany them, take them home after surgery or their endoscopic procedure, and provide care postoperatively, are deemed unsuitable for day surgery. Other factors to be considered include the distance that patients have to travel from home, the times at which they need to travel (e.g. the elderly driving at night), the availability of help locally (e.g. a nearby hospital) and access to a telephone. If distance is an issue, local motel accommodation may be an option as it is much cheaper than an overnight hospital bed. Special consideration must be given to elderly and infirm patients as they may require community health services post discharge. If they are to undergo colonoscopy, they may also need hospitalisation prior to the event to assist with bowel preparation. Many elderly patients experience dizziness and weakness during this period and are susceptible to falls. Closer monitoring is reassuring to these patients and allows them to relax and attend the procedure in an unstressed state.
In some cases, carer support will be required for more than 24 hours post discharge. For example, a mother of pre-school children who has undergone a laparoscopy will almost certainly need someone to assist with the daily tasks of caring for her family beyond the first postoperative day. Patient compliance with the requirement for a carer is greatly enhanced when the reasons for this are explained. Generally, the majority of patients will have someone who can provide care and support; however, alternative arrangements must be considered when patients themselves are also the sole carer of another reliant person, for example, those with a spouse who has dementia. It is important that these patients are given any additional assistance to enable them to attend the hospital and then be supported while resuming their own role once they have returned to the home environment.
Information and education are essential. Patients have a right to be fully informed on all aspects of the day surgery process and this should be done both verbally and in a written, easy-to-understand format. Information may also be provided by video and through internet access. Use of an interpreter may be required and written information may need to be provided in several languages. Most units now have well-developed patient information brochures. In many cases, carers must also be privy to and fully understand this information. Failure to provide information, particularly related to pain management, personal hygiene and emergency contacts, are among the most significant sources of patient dissatisfaction with day surgery (Richardson-Tench et al., 2005).
Castoro et al. (2006) recommend four different information leaflets. These are outlined in Boxes 10.2-10.5. The information contained in brochures needs to be specific to the individual day surgery unit and requires regular review to ensure that it is current and written in a format that is easily understood. It should not include jargon or medical terminology and should be aimed at the level of an average reader. Regular patient satisfaction surveys should be conducted and used to improve the quality of the day surgery service, including the quality of the information given.
Box 10-2 Booklet construction: Day surgery general information leaflet
A second section provides the following:
Castoro et al. (2006). Reproduced with permission.
Box 10-3 Booklet construction: Day surgery unit instructions and procedures
Castoro et al. (2006). Reproduced with permission.
The information provided should answer questions about patient expectations and requirements, including what to wear and items to bring in, such as diversionary materials. Pre-assessment instructions and procedure checklists should also be included.
Box 10-4 Booklet construction: Procedure-specific information
Castoro et al. (2006). Reproduced with permission.
Box 10-5 Booklet construction: Information for caregivers
Castoro et al. (2006). Reproduced with permission.
It should also provide any specific information the caregiver needs to know regarding a specific procedure, such as:
On the day of surgery, the patient should be well-prepared and undergo routine admission procedures as per unit/facility and surgeon-specific protocols. This includes establishing that the patient has fasted appropriately (Tudor, 2005). Staggered admissions are the ideal but may not be possible in some facilities. Immediate preoperative preparations may need to be carried out, such as the instillation of local eye drops or wicks for ophthalmic patients (Kirby, 2005) and the use of antiseptic solution on the operative site of patients undergoing orthopaedic surgery. Clipping of the body hair may also be necessary and should occur either immediately prior to or on entry to the operating/procedure room. Allergy bands must be securely placed, as needed. Sedative premedication is rarely given in day surgery, and in many units patients walk into the operating/procedure room.
Where appropriate, assessment of the colonoscopy patient’s completion of the bowel preparation is crucial because inadequate preparation may compromise visualisation and identification of relevant pathology. In this case, it is probable that further attempts will be made to clean the bowel, which may include the use of one or two small enemas or a bowel washout if the patient is still passing formed faeces. The patient may also need some form of rehydration, as many complain of headaches, which are due to dehydration and electrolyte imbalance caused by some types of bowel preparation (Dix, 2007). These patients, anecdotally, usually feel much better with this treatment. Fasting is essential for patients having gastroscopy or similar, upper gastrointestinal procedures. These patients are often being assessed for reflux problems and the incidence of aspiration can be much higher with this cohort of patients (Grant et al., 2007).
Management procedures and care of the patient intraoperatively must follow recommended nursing and health department standards, and best practice guidelines for perioperative nursing. In addition to the standards of ACORN (2006) and the Perioperative Nurses College (NZNO) (2005), endoscopy nurses follow the GENCA guidelines (2003), together with the relevant Australian and New Zealand Standards, such as those that apply to cleaning, sterilisation and disinfection methods (Standards Australia, 2003, AS/NZS 4187). These documents govern practice for endoscopy patient care and reprocessing of endoscopic equipment, and form the basis of risk management in endoscopy and all perioperative settings.
Explanation of the procedure to reinforce information given previously, along with reassurance and clear directions about positioning, monitoring and other procedural events, will alleviate patient anxiety and improve intraoperative compliance. This applies to many types of surgery, especially when procedures are completed under local anaesthesia. Some public hospitals do not use the services of an anaesthetist during endoscopy when drugs such as fentanyl and midazolam are used for sedation. These are administered by the registered nurse under the guidance of the proceduralist.
The same safety standards apply for postoperative care as for inpatient surgery throughout each stage of the recovery process.
In stage 1 recovery, the patient is unconscious and requires one-to-one nursing care. Close monitoring is required (see Ch 9). Before transferring to stage 2, the patient must have regained consciousness, have stable vital signs and be able to obey verbal commands. Medication for pain and postoperative nausea and vomiting is given either intravenously or intramuscularly. Patients need to be observed for temperature changes, haemorrhage, distension or a rigid abdomen, breathing difficulty and excessive pain following endoscopic procedures, as these could indicate an adverse event, such as bowel perforation. Other, procedure-specific observations must also be instigated.
During stage 2 recovery, the patient is awake and oral medication can be taken to control pain and postoperative nausea and vomiting. The blood pressure is 20 mmHg above or below the pre-anaesthetic level and oxygen saturation is over 92% on room air (Awad & Chung, 2006).
With the improvements in anaesthesia management and the ability of the anaesthetist to eliminate postoperative complications (particularly pain and postoperative nausea and vomiting) a new concept of ‘fast tracking’ is now being explored. This allows patients to bypass stage 1 recovery and proceed directly to stage 2 recovery provided they meet certain criteria. This concept has merit but requires further research and validation to ensure patient care is not compromised (Awad & Chung, 2006).
During stage 3 recovery, the patient is ambulant and meets the criteria for discharge home. The modified ‘postanaesthesia discharge scoring system’ (PADS), introduced by Chung in 1995, is the most commonly used criteria for assessing ‘home readiness’. This system is based on giving a score to each of five major criteria, namely, vital signs, activity level, presence of nausea and vomiting, pain and surgical bleeding. A patient with a score of 9–10 is considered to be ready for discharge home (Awad & Chung, 2006).
Before final discharge, a simple checklist should be completed (Table 10-3). Discharge of the patient may be nurse initiated providing there are agreed protocols in place.
Table 10-3 Patient discharge checklist
It is normal procedure for follow-up telephone calls to be made to patients the day after discharge to check that they are recovering and coping well, that they are satisfied with the treatment they received and so that they have an opportunity to ask any further questions. Many facilities also telephone patients again 3–4 days postoperatively to check on progress. All follow-up calls should be documented and evaluated as part of the unit/facility quality improvement and risk management program.
A key aspect of risk management in day surgery and endoscopic settings is prevention of nosocomial infections. While most aspects of sterilising and disinfection have been dealt with in Chapter 5, this section deals with the unique considerations of endoscopic instruments. These may be reprocessed within the endoscopy or day surgery unit or they may go to a separate sterilising department. Technical staff involved in this specific activity need to be adequately trained and deemed competent prior to engaging in this work. Irrespective of the location of the day surgery or endoscopy unit, nursing staff employed there must be conversant with all aspects of patient care, and have an understanding of instrument cleaning, maintenance, reprocessing and infection control issues. In endoscopy units, it is important to have dedicated personnel to work with the medical specialists/proceduralists because of the highly specialised and often complex nature of the procedures and equipment (Mays, 2003).
Flexible endoscopic instruments are complex and expensive. Some of their numerous accessories are also expensive and many of these are designed for single use, adding further to costs, both financial and environmental. When purchasing the equipment used in the endoscopy unit, patient safety as well as the best possible equipment affordable or available are often key determinants. Consequently, care of that equipment is of the utmost importance.
The equipment required for endoscopy includes:
All facilities benefit from having written policies, procedures and protocols in place.This assists in ensuring all equipment is properly cared for and maintained, and in accordance with the manufacturers’ recommendations. Broadly, it will include the following activities.
Many chemicals are involved in the reprocessing of endoscopes and it is important that they are handled correctly and in the manner and concentration for which they were designed. Usually a detergent/enzymatic agent is used in the ‘pre-clean’ phase and a biocide during the disinfection/sterilisation period. As noted earlier, technical staff responsible for reprocessing flexible endoscopes (in fact, all surgical instrumentation) must be adequately trained in the care and handling of equipment and understand the importance of high level chemical disinfection. The provision of ongoing education, particularly when newer endoscopes and other instrumentation are introduced, is necessary.
Flexible endoscopes need to be hung at full length to allow for excess moisture to drain away. When not in use, they require storage in purpose-built, well-ventilated cabinets that allow for good air flow. They should never be stored within a box or suitcase while still wet. Some hospitals have designed and installed systems that force air through the endoscope continuously when it is not in use.
Documentation is a crucial aspect of endoscope care. All stages of the process that each endoscope undergoes during cleaning, reprocessing and sterilisation must be recorded, and a copy of this record included in the patient’s medical record. This data must also be retained at unit level. This is essential to facilitate tracking in the event that a look-back review is required by the health department. This will occur if routine microbial testing reveals a contaminated endoscope, in which case it becomes essential to identify all patients on whom the contaminated endoscope has been used (see below).
Endoscope reprocessing is an activity that must only be completed by personnel who are adequately trained. Most breaches of infection control have been attributed to inadequate manual cleaning of these instruments (GENCA, 2003). As there is no way to visualise the effectiveness of the cleaning of internal endoscopy channels, it is imperative that personnel adhere to the manufacturer’s recommendations, and the guidelines and recommended practices developed by organisations such as the Gastroenterological Society of Australia (GESA), GENCA and the pertinent Australian and New Zealand standards. Additionally, certain measures provide validation for this process. These measures include completing routine, periodic microbiological testing of endoscopes, which will alert endoscopy personnel to the presence of microorganisms (or biofilm) within the instrument’s channels. This process is very specific and, if testing shows the presence of microorganisms, the potential for cross-contamination and infection in patients exists (GENCA, 2003). If this occurs, the state or national health department is contacted, and patients may be recalled and tested for hepatitis B and C, and human immunodeficiency virus (HIV), if necessary (GENCA, 2003). This is traumatic for patients, their families and the personnel involved in the reprocessing of the equipment; however, it is crucial to the effective management of any potential acquired infection.
As part of the accreditation process it is essential that day surgery and endoscopy facilities constantly monitor performance, clinical outcomes and patient satisfaction. Clinical indicators for day surgery recommended by the ADSC and endorsed by the Australian Council on Healthcare Standards (ACHS) (2006) include monitoring the incidence of:
Other indicator sets that may also be used are related to anaesthesia, endoscopy, ophthalmology and oral health (ACHS, 2006). Frequent evaluation and continuous improvement on all aspects of day surgery and endoscopy are essential to ensure a first-class service to the community.
A number of new, advanced roles are emerging within perioperative settings, most of which are addressed in Chapter 12. Two roles, however, are specific to endoscopy and day surgery settings, and are already in evidence. These roles are those of the nurse endoscopist and nurse sedationist. These roles have evolved because, like other countries (Sprout, 2000), Australia does not have enough gastroenterologists or surgeons to cope with the amount of work generated by national bowel screening programs and growth in the range of endoscopic procedures available.
The role of nurse endoscopist is an important, nurse-led development and encompasses diagnostic endoscopy (Smith & Watson, 2005). Careful selection of nurses for this training is vital; only a small number of nurses will wish to develop such skills and/or have the necessary aptitude. The nurse endoscopist is an autonomous, Nurse Practitioner level role with a minimum academic requirement of a Masters degree. This is a relatively new role in Australia, with only one nurse known to be practising currently. Overseas, where the role developed more than a decade ago, it initially involved the incumbent performing an accurate endoscopic examination while maintaining patient safety and comfort, and conducting patient education within a cost-effective framework (Sprout, 2000). However, within a decade in the United Kingdom nurse endoscopists were also providing interventional procedures, such as oesophageal dilatation, percutaneous endoscopic gastrostomy (PEG) tube insertions, variceal injections, banding and endoscopic ultrasounds. They also complete full colonoscopic procedures and are not limited to flexible sigmoidoscopy only.
In Australia and New Zealand, Nurse Practitioner legislation provides the framework for the development of the nurse endoscopist role. Additionally, as Waters (1998) noted, collaborative relationships with medical colleagues are necessary so that this specialised role can evolve. Mutual responsibility for patient care within the framework of the different disciplines is essential and can only occur through trust, confidence and respect for all areas of expertise. This will only happen when current beliefs about discipline boundaries are revoked, and all stakeholders are open to working in unity to the common goal of achieving positive patient outcomes.
This is also the case in point for the emerging role of the nurse sedationist. Halliday (2006) identifies new tasks and responsibilities for those nurses who take on this role within the endoscopy unit. Advanced assessment skills, a greater understanding of the relevant pharmacology and advanced life-support techniques are critical for this nursing role, and these should be acquired via formal training. Currently, endoscopy units within New South Wales and other parts of Australia use appropriately qualified and prepared perioperative nurses who give the sedation and subsequently manage the patients (Jones et al., 2006). Nurse sedationists work within various guidelines and clinical protocols and their outcomes of care are consistent with the data from the United States and Switzerland (Rex et al., 2005). Within the Australasian context, the role will require an extensive number of hours of advanced practice working with a mentor, such as an anaesthetist or gastroenterologist, along with the other requirements needed to be a Nurse Practitioner, if it is to evolve fully. Additionally, the varying perspectives of several key stakeholders and the guidelines each produce to support (or countermand) the role and activities of the nurse sedationist will need reconciling (ANZCA, 2007; Jones et al., 2006). This work is ongoing.
In summary, the nurse endoscopist and nurse sedationist are examples of the nursing profession developing its identity and forging new career paths. These roles are also necessary for the retention of highly skilled registered nurses who might otherwise travel overseas to expand their knowledge and skills. Issues such as formal training programs, reimbursement and recognition need to be addressed.
It is clear that the future for increased day surgery and endoscopy in Australia, with or without extended recovery capabilities, has a major role to play in the delivery of health care services in the future. The Australian government (2006), as part of its ‘broader health cover’ legislation, has introduced a new Private Health Insurance Act (2007) and the distinction between day surgery facilities and private hospitals has been removed. Further, accreditation will become compulsory, at least in Australia.
NSW Health (2007) and the Victorian Department of Human Services (2007) are two examples of state departments that outline reasons for, and supply toolkits to assist in, implementation of extended day surgery services. These policies will actively encourage an increase in day surgery and enable performance of more complex procedures in the future. For many reasons, variations exist in clinical practice among specialists, hospitals and states, and benchmarking would assist to promote greater consistency on a national basis. Those surgeons, proceduralists and anaesthetists performing more complex procedures need to monitor, evaluate and publish outcomes as encouragement to others, and all facilities should have a responsibility to undertake research to improve patient outcomes continually and ensure best practice. The lack of formal training in day surgery and clinical education for medical students in day surgery should be a priority for medical schools as students have little exposure to surgical conditions being treated as day cases. Learning in this environment is essential for clinical skills development (Roberts, 2004).
Dedicated and free-standing facilities totally committed to day surgery, including endoscopy, are the best performers and should be encouraged in future planning or redevelopment projects. Day surgery will continue to increase because it is a safe and financially viable alternative to inpatient treatment, and the rising costs of health care alone will force acceptance of it as one of the solutions to increasing surgical demand.
You are working in the preoperative assessment clinic and Mrs Schmidt, age 45 years, presents as a stable, insulin-dependant diabetic for a diagnostic laparoscopy the following week.
Mr Williams, age 32 years, has undergone a repair of a left inguinal hernia under general anaesthetic and is getting dressed. He meets the discharge criteria and tells you he feels ‘great’. You are unable to contact his carer and realise that Mr Williams’s car is parked outside. He firmly declares that there is nobody else who can pick him up. You now suspect that Mr Williams has no carer and intends to drive himself home. This is a problem that has previously occurred in your unit.
Mr Moroni, a young fit man, attends the endoscopy unit and informs you he has not taken all of his bowel preparation. Further, he states he is still passing formed stools.
Mrs Crane has had a colonoscopy today following a positive faecal occult blood test, which she underwent recently as part of the National Bowel Cancer Screening Program. The gastroenterologist has advised her that a suspicious lesion was found in her sigmoid colon and biopsies have been taken for pathology testing. Mrs Crane is very distressed by this news and, further, has no family with her.
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