Guidelines for Safety in the Gastrointestinal Endoscopy Unit
Check out this great position statement and guideline by the American Society for Gastrointestinal Endoscopy (ASGE) on the key strategies to maintain safety in the GI endoscopy unit:
From the position statement: …Over the past 2 years, surveyors have called into question accepted practices at many accredited endoscopy units. Many of these issues relate to the Ambulatory Surgical Center Conditions for Coverage set forth by CMS and the lack of distinction between the sterile operating room and the endoscopy setting. The following is a summary of issues that have been faced by endoscopy units throughout the country along with the ASGE position and accompanying rationale.
In summary:
- Each unit should have a designated flow for the safe physical movement of dirty endoscopes and other equipment.
- Procedure rooms vary in size, with more complex procedures requiring greater space for more specialised equipment and, in some cases, additional staff.
- Before starting an endoscopic procedure, the patient, staff, and performing physician should verify the correct patient and procedure to be performed.
- A specific infection prevention plan must be implemented and directed by a qualified person.
- Gloves and an impervious gown should be worn by staff engaged in direct patient care during the procedure.
- The unit should have a terminal cleansing plan that includes methods and chemical agents for cleansing and disinfecting the procedural space at the end of the day.
- For patients undergoing routine endoscopy under moderate sedation, a single nurse is required in the room in addition to the performing physician.
- Complex procedures may require additional staff for efficiency but not necessarily for safety.
- At a minimum, patient monitoring should be performed before the procedure, after administration of sedatives, at regular intervals during the procedure, during initial recovery, and before discharge.
- For cases in which moderate sedation is the target, the individual responsible for patient monitoring may perform brief interruptible tasks.
- For cases in which moderate sedation is the target, there are currently inadequate data to support the routine use of capnography.
For those interested in designing or improving an endoscopy unit, this position statement is a must-read.
SOURCE: American Society for Gastrointestinal Endoscopy. The Role of Endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc 2014:79:191-201
http://www.asge.org/assets/0/71542/71544/4a572112-29a4-4313-8ab8-b7801e8f84e2.pdf
Consider Food Allergy Testing in Managing Eosinophilic Esophagitis
Food antigens can induce esophageal remodeling with fibrosis, which can resolve with appropriate food antigen elimination. Addressing food allergens in the treatment of eosinophilic esophagitis (EoE) is recommended and although allergy testing is common practice for pediatric gastroenterologists, many adult gastroenterologists are unfamiliar with the practice. A recently (online published) article provides in-depth guidance, including:
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Allergy testing for foods may be more useful in pediatric patients.
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The negative predictive values of tests for identifiable food allergies are generally higher than positive PVs.
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Patients with EoE are often highly atopic and have polysensitization to both food (particularly in children) and aeroallergens (particularly in adults).
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Ample evidence supports use of skin-prick or atopy-patch testing for building an elimination diet in children, but not in adults.
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Do not utilize food-specific panels using serum immunoglobulin E (or other immunoglobulins) in this setting.
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EoE recurs in >90% of pediatric patients after food reintroduction, and only 8% become tolerant of all their food triggers.
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Repeat endoscopic biopsy with histologic evaluation after sequential food reintroduction – do not rely on a positive test for food allergy.
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Consider the possibility of concurrent allergic diatheses in patients with EoE.
Studies recommend that one food or food group be introduced every 4 to 6 weeks with observation of clinical symptoms and a subsequent endoscopy if no change in symptoms occurs. A food trigger is identified based on the recurrence of symptoms and esophageal eosinophilia (≥15 eosinophils/high-power field) after reintroduction of a specific food group. Because patients typically have multiple food triggers, the process should be continued until all foods have been reintroduced into the diet or an acceptable diet is reached. Dieticians can play an important role in identifying possible cross-contamination of specific food items. Clearly, an integrated approach involving allergists, gastroenterologists, and pathologists is warranted in evaluating the possible role of food allergy in eosinophilic esophagitis.
http://www.cghjournal.org/article/S1542-3565(13)01302-5/fulltext
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