A survey of the practice of after-hours and emergency endoscopy in Canada

1Internal Medicine, University of Manitoba, Winnipeg, Manitoba; 2Canadian Association of Gastroenterology Clinical Affairs Committee, Oakville, Ontario; 3Division of Gastroenterology, Department of Medicine, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia; 4Division of Gastroenterology & Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton; 5Pediatrics, Queen’s University, Kingston, Ontario; 6Community Health Sciences, University of Manitoba; 7University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba Correspondence: Dr Harminder Singh, Section of Gastroenterology, University of Manitoba, 805-715 McDermot Avenue, Winnipeg, Manitoba R3E 3P4. Telephone 204-480-1311, fax 204-789-3972, e-mail singh@cc.umanitoba.ca Received for publication May 28, 2012. Accepted June 4, 2012 Most of the endoscopies performed after regular work hours (ie, ‘after-hours’ endoscopies) are performed for emergent indications such as gastrointestinal bleeding, esophageal food bolus impaction or cholangitis. Such emergency endoscopies generally involve performing the procedures on acutely ill patients often with hemodynamic instability that requires therapeutic intervention, as well as other comorbidities with risk of cardiorespiratory compromise. Recent Canadian and international guidelines have recommended appropriate staffing for emergency endoscopy as essential, but the appropriate level of staffing is not well-defined in any of them (1,2). In a previous survey, focused primarily on sedation practices for colonoscopy across Canada, we found 97% of the respondents had at least one trained endoscopy nurse present during routine endoscopy (3). Anecdotally, several hospitals have recently withdrawn the services of trained endoscopy nurses for after-hours endoscopy (communication from Canadian Association of Gastroenterology [CAG] members from Ontario). However, there are no systematically collected data on the practices for after-hours endoscopy in Canada or in other jurisdictions. We conducted a survey to determine the staffing, practice patterns and level of satisfaction for after-hours endoscopy in Canada. The survey was performed on behalf of the CAG Clinical Affairs committee in accordance with its mandate to document and improve care for Canadians with gastrointestinal disorders. originAl ArtiCle


MEthoDs
The survey instrument was developed by the authors and first distributed to the members of the Division of Gastroenterology at the University of Manitoba (Winnipeg, Manitoba) to establish content and face validity.Modifications were made based on the responses and comments on the pilot assessment.
The final survey instrument consisted of six pages and 35 items divided into two sections (ie, demographics and after-hours endoscopy care practices).The demographics section included questions on primary specialty, province of practice and population of practice location.The second part included questions regarding after-hours staffing patterns, site of after-hours endoscopy, time allocated for emergency endoscopy, personnel reprocessing the endoscopes, access to propofol sedation and intensive care unit beds, acceptance of patients from other facilities, availability of endoscopic retrograde cholangiopancreatography (ERCP) call schedule and satisfaction level of the endoscopists for the current arrangements for after-hours endoscopy.
A link to the web-based survey was sent by e-mail to all clinical members of the CAG in February 2011.A reminder was sent four weeks later to improve the response rate.The e-mails were sent by the CAG National Office.All responses were anonymous and the investigators received no information that would identify the respondent or their site of practice.
Survey responses were collated in an Excel spreadsheet (Microsoft Corporation, USA).Cross tabulation was performed using SPSS version 19 (IBM Corporation, USA).Standard descriptive statistics were used to describe response frequency.The χ 2 test was used to compare categorical variables and a two-sided P<0.05 was considered to be statistically significant.The endoscopists' satisfaction with the current arrangements for after-hours endoscopy at their primary site was assessed on a 10-point Likert scale and the responses categorized as low (1 to 4), moderate (5 to 7) and high (8 to 10) satisfaction.A priori, it was planned to compare variations in practice among gastroenterologists (GIs) performing endoscopy in different regions of Canada, between pediatric and adult GIs, and between university and community hospitals.To ascertain regional variations, the comparison was performed among Ontario (ON), Alberta (AB), British Columbia (BC) and all the remaining provinces.
The present project was approved by the Ethics Board at the University of Manitoba.

REsults
Of the 422 potential respondents, 168 (40%) responded.The response pattern across the country reflected the CAG membership, apart from a slightly higher response rate from BC (Table 1).Fifty-eight per cent (n=78) of the respondents practised primarily in university hospitals, which is comparable with the 56% (n=238) of the CAG membership practising in university hospitals.Of the 168 respondents, 139 (83%) were adult GIs, 18 (10.7%)were pediatric GIs and the rest (5.6%) were hepatologists, internists and/or family physicians.Only those performing after-hours endoscopy are included in the rest of the presented results.

Adult versus pediatric Gis (table 2)
Although most of the GIs had at least one registered nurse present for after-hours endoscopy, a trained endoscopy nurse was available all of the time for only two-thirds of adult GIs and for only 12% of pediatric GIs; 25% of the adult GIs and 65% of the pediatric GIs had no on-call endoscopy nurse.Furthermore, 22% of the adult GIs and 88% of the pediatric GIs had no set amount of time reserved for emergency cases in the daytime endoscopy schedules.Most GIs were able to arrange an endoscopy within 24 h of deciding that an endoscopy was indicated.Approximately 14% of the adult GIs clean and reprocess endoscopes themselves or with the help of their house staff.
All (n=17) of the pediatric GIs practised at university hospitals.Most of the pediatric GIs (70%) performed after-hours endoscopy in operating rooms, had an anesthetist present (65%), access to propofol sedation (94%) and intensive care unit beds (94%).However, only 12% of the pediatric GIs were highly satisfied with the current arrangements for after-hours endoscopy compared with 53% of the adult GIs (P<0.01).

university versus community hospitals (table 3)
A higher proportion of the respondents practising in university hospitals performed after-hours endoscopy in emergency rooms (91%) or intensive care units (91%) than those in the community hospitals.As can be expected, most endoscopists in the community hospitals performed endoscopy without house staff.A majority (58%) at the community hospitals had the endoscopes processed in the central processing units.Approximately one-third of transfers from other hospitals were received by the endoscopy team in the emergency rooms of either type of facility.A small minority (7%) at the community hospitals were unable to perform emergency endoscopy within 24 h.Even at the university hospitals, only one-half of the endoscopists had an on-call schedule for ERCPs.There was no significant difference in the satisfaction rating between endoscopists at university and community hospitals.

Regional variation (table 4)
Endoscopy nurse assistance outside the endoscopy units was available less often in ON than in the other provinces.The site of the performance of after-hours endoscopy also varied significantly across the country.Interestingly, two registered nurses were present more frequently for after-hours endoscopy in the rest of the country than in the three provinces analyzed separately.Trained endoscopy nurses were available almost all the time in AB and the rest of the country but only for approximately one-half of the after-hours endoscopy procedures in ON and BC.A much higher proportion of respondents from BC had the endoscopes processed in central reprocessing units than in the other provinces.A lower proportion of respondents from ON were able to perform more than 75% of emergency endoscopies within 24 h.In ON, only a minority of the respondents performed after-hours endoscopy in the endoscopy suite where daytime procedures were performed.Furthermore, assistance by trained endoscopy nurses was available less often outside of the endoscopy units in ON.A much higher proportion of endoscopists in AB (84%) were highly satisfied compared with one-half or less in the other provinces (P=0.01)

DisCussion
Results of the present survey suggest that there are large regional differences in the practice of after-hours endoscopy in Canada.The findings in ON and BC are concerning in that only one-half of the respondents have a trained endoscopy nurse present at all times for after-hours endoscopy.
The staff assisting during the performance of endoscopy provide several vital functions.These include administration of sedation, patient monitoring, documentation and technical assistance (4).The technical assistance includes manipulation of endoscopic accessory devices, such as cautery devices, proper deployment of endoscopic clips, and other hemostatic equipment and manipulation of the endoscopes, while the endoscopist performs complex tasks (5).The need for appropriate technical assistance is more common during emergency procedures when hemostatic interventions are performed at a much higher rate than during the regularly scheduled procedures.Yet, paradoxically, more endoscopists have well-trained assistants available during the regularly scheduled procedures than for after-hours endoscopy!One of the potential reasons for such wide variations in staffing for after-hours endoscopy may be the absence of specific guidelines for staffing for procedures performed after-hours.Recent Canadian guidelines recommended that "endoscopy facilities should have the technical and personnel resources required by national and/or regional standards to complete all planned procedures safely and effectively" (1).However, there are few national and/or regional standards for staffing for endoscopy, particularly for after-hours endoscopy.Therefore, we recommend that the CAG develop a position statement with regard to the minimum staffing requirements for performance of gastrointestinal endoscopy in Canada; this should be developed with input from patients and accreditation agencies.In 2010, the American Society for Gastrointestinal Endoscopy issued a position statement for staffing during gastrointestinal endoscopy, but did not specifically address after-hours or emergency endoscopy (5).
Another potential reason for differences in staffing patterns is that few studies have objectively evaluated the effect of differences in staffing on important patient outcomes.A single study reported that the presence of experienced nurses increased the polyp detection rate during routine screening colonoscopy (6).Similar studies are urgently needed, especially in these uncertain economic times when there may be impetus to reduce/minimize staffing levels.
Our survey found that one in 10 endoscopists or their residents are reprocessing the endoscopes themselves.We hope the hospitals are ensuring such physicians are receiving adequate and regular