GdGpwwaGasttta

tpscapcic

caCtrdsHnssspnGt

C0d

w

STANDARDS OF PRACTICE

Minimum staffing requirements for the performance of GI endoscopy

This is one of a series of statements discussing the use ofI endoscopy in common clinical situations. The Stan-ards of Practice Committee of the American Society forastrointestinal Endoscopy (ASGE) prepared this text. Inreparing this guideline, a search of the medical literatureas performed by using PubMed. Additional referencesere obtained from the bibliographies of the identifiedrticles and from recommendations of expert consultants.uidelines for appropriate use of endoscopy are based oncritical review of the available data and expert consen-

us at the time the guidelines are drafted. Further con-rolled clinical studies may be needed to clarify aspects ofhis guideline. This guideline may be revised as necessaryo account for changes in technology, new data, or otherspects of clinical practice.This guideline is intended to be an educational device

o provide information that may assist endoscopists inroviding care to patients. This guideline is not a rule andhould not be construed as establishing a legal standard ofare or as encouraging, advocating, requiring, or discour-ging any particular treatment. Clinical decisions in anyarticular case involve a complex analysis of the patient’sondition and available courses of action. Therefore, clin-cal considerations may lead an endoscopist to take aourse of action that varies from these guidelines.

Staffing requirements for the performance of GI endos-opy should be based on what is needed to ensure safend proficient performance of the individual procedure.urrently, staffing may vary as determined by local prac-

ice, regulatory (federal, state, and local) and accreditationequirements, patient characteristics, and the type of en-oscopic procedure being performed. The Joint Commis-ion and the Accreditation Association for Ambulatoryealth Care do not define the specific qualifications orumber of staff required. Rather, they generalize that thetaff be adequate in number with appropriate training andupervision.1,2 The level of education and training of thetaff can vary, including registered nurses (RNs), licensedractical nurses (LPNs), and unlicensed assistive person-el (UAP). Some UAP undergo additional training in theI endoscopy unit and are often referred to as GI assis-

ants or GI technicians. While the physician is performing

opyright © 2010 by the American Society for Gastrointestinal Endoscopy016-5107/$36.00

oi:10.1016/j.gie.2010.02.017

ww.giejournal.org V

endoscopic procedures, the endoscopy suite staff has 3major responsibilities that include, but are not limited to,patient monitoring, documentation, and technical assis-tance.3 Technical assistance includes such activities as ap-plication of abdominal pressure, manipulation of endo-scopic accessory devices (eg, forceps, snares, balloons,bougies, cautery devices), manipulation of endoscopes(eg, maintaining endoscope position while the endosco-pist performs complex tasks), and cleaning and prep-aration of endoscopes. Accreditation organizations rec-ommend that endoscopy unit staff receive trainingappropriate to their responsibilities and document main-tenance of competency periodically (eg, annually). Objec-tive evidence pertaining to the relationship between en-doscopy unit staffing levels and patient outcomes islacking. Therefore, recommendations are based primarilyon expert opinion and clinical experience.

ENDOSCOPY WITHOUT SEDATION

The majority of GI endoscopic procedures performedin the United States are performed with sedation. How-ever, sigmoidoscopy and transnasal endoscopy are oftenperformed without sedation. Sometimes colonoscopy isalso performed without sedation. In this setting, 1 endos-copy staff member is required to assist with various tech-nical aspects, such as obtaining biopsy specimens. Anappropriately trained UAP, LPN, or RN may perform thesetasks.

ENDOSCOPIST-DIRECTED SEDATION

For those patients receiving moderate sedation for en-doscopic procedures, the physician must perform a pre-procedural assessment to determine the suitability of thepatient for sedation and then formulate a sedation plan.Under the supervision of the physician, the RN preparesand administers sedatives while monitoring the patient’svital signs, comfort, and clinical status to detect any intra-procedural complications.4 Once the patient’s level of se-dation and vital signs are stable, the RN may performminor, interruptible tasks (eg, biopsy or polypectomy).5-7

In patients who require more intensive or prolonged en-doscopic interventions (eg, difficult polypectomy, EUS/FNA, ERCP), a second assistant, who may be a UAP, LPN,or another RN, should assist in the procedure to allow theRN administering moderate sedation to remain focused on

patient monitoring rather than technical assistance.

olume 72, No. 3 : 2010 GASTROINTESTINAL ENDOSCOPY 469

bdprptrt

EP

wpsamtUm

R

1

2

3

4

5

Minimum staffing requirements for the performance of GI endoscopy

4

In some endoscopy units, deep sedation is performedy the administration of propofol by an RN under theirection of the physician endoscopists.7 However, thisractice may be restricted by local or state regulations. Theesponsibilities of this primary RN should be limited toatient monitoring and administration of sedation underhe guidance of the physician.5,7 A second assistant isequired for technical assistance during the procedure inhis setting, who may be a UAP, LPN, or RN.

NDOSCOPY WITH AN ANESTHESIAROVIDER

In patients undergoing endoscopic procedures forhich an anesthesiologist or certified RN anesthetist isroviding sedation, the anesthesia provider has the re-ponsibility of monitoring the patient’s vital signs, comfort,nd clinical status. In this situation, one endoscopy staffember is required to assist the endoscopist with the

echnical portion of the procedure. This person may be aAP, LPN, or RN. However, the presence of an RN is notandatory in this setting.

ECOMMENDATIONS

. It is recommended that unsedated endoscopic proce-dures be staffed with a minimum of a single assistant,who may be a UAP, LPN, or RN.

. It is recommended that for endoscopy with moderatesedation, a single RN may administer sedation underphysician supervision and assist with the technical por-tion of the endoscopic procedure, provided that thesetasks be interruptible.

. It is recommended that complex endoscopic proce-dures (eg, difficult polypectomy, ERCP, EUS/FNA) bestaffed with a second endoscopy assistant. This individ-ual may be a UAP, LPN, or RN.

. It is recommended that if an RN administers deep se-dation under physician supervision, then staffingshould include a second endoscopy assistant. This in-dividual may be a UAP, LPN, or RN.

. In the setting of sedation administered by an anesthesia

provider (ie, anesthesiologist or certified RN anesthe-

70 GASTROINTESTINAL ENDOSCOPY Volume 72, No. 3 : 2010

tist), it is recommended that staffing include an individ-ual dedicated to endoscopic technical assistance. Thisindividual may be a UAP, LPN, or RN.

REFERENCES

1. Joint Commission on Accreditation of Healthcare Organizations. Stan-dards for Ambulatory Care. Oakbrook Terrace, IL: Joint Commission Re-sources; 2009. P. 293.

2. Accreditation Association for Ambulatory Health Care. AccreditationHandbook for Ambulatory Health Care 2009. Skokie (IL); AccreditationAssociation for Ambulatory Health Care: 2009. P. 32.

3. Petersen BT. Promoting efficiency in gastrointestinal endoscopy. Gastro-intest Endosc Clin N Am 2006;16:671-85.

4. ASGE/SGNA Joint Position Statement. Role of GI Registered Nurses in theManagement of Patients Undergoing Sedated Procedures 2004. Avail-able at: www.sgna.org. Accessed November 15, 2009.

5. Practice guidelines for sedation and analgesia by non-anesthesiologists.Anesthesiology 2002;96:1004 –17.

6. Cohen LB, DeLegge MH, Aisenberg J, et al; AGA Institute. AGA Institutereview of endoscopic sedation. Gastroenterology 2007;133:675-701.

7. Standards of Practice Committee of the American Society for Gastroin-testinal Endoscopy, Lichtenstein DR, Jagannath S, Baron TH, et al. Seda-tion and anesthesia in GI endoscopy. Gastrointest Endosc 2008;68:815-26.

Prepared by:ASGE STANDARDS OF PRACTICE COMMITTEERajeev Jain, MD, FASGESteven O. Ikenberry, MD, FASGEMichelle A. Anderson, MDVasundhara Appalaneni, MDTamir Ben-Menachem, MDG. Anton Decker, MDRobert D. Fanelli, MD, FASGE, SAGES Rep.Laurel R. Fisher, MD, FASGENorio Fukami, MDTerry L. Jue, MDKhalid M. Khan, MD, NASPGAN Rep.Mary L. Krinsky, DOPhyllis M. Malpas, RN, CGRN, SGNA Rep.John T. Maple, DORavi Sharaf, MDJason Dominitz, MD, MHS, FASGE, Chair

This document is a product of the ASGE Standards of Practice Committee.This document was reviewed and approved by the Governing Board of

the American Society for Gastrointestinal Endoscopy.

www.giejournal.org