Gastroenterological Endoscopy. Группа авторов

the procedure room.

      Fig. 5.1 Example of a concept of an endoscopy unit with adjacent daycare unit. It is important to visualize pathways of patents, doctors, and staff for optimizing work flow.

      Fig. 5.2 Concept of the endoscopic suite in more detail consisting of procedure rooms (red), area for cleaning and processing of endoscopes (green), area for staff base, and changing of staff personnel (blue).

      For the endoscopists, it is important to define the endoscopic workflow beforehand. Who performs sedation (specialized staff, Nurse Administered Propofol Sedation [NAPS] nurses, anesthetist, second physician)? When and how is the procedure report created? Will there be a report given to the patient prior to leaving the unit, or will it be finalized after the patient leaves? According to the answers, the pathways (computer-based report generation location, printout, and signature) have to be developed. Similar pathways should be defined for equipment and material including endoscopes and working/break areas for the endoscopy staff. A close proximity between procedure rooms and cleaning and disinfection area is desirable. In this context, it is important to define how the contaminated endoscopes are transported back to the unclean area of the cleaning facilities and how the cleaned endoscopes are transported back into the procedure room. In many modern endoscopy units, a special closed trolley system is used for this purpose.

      5.5 Location of the Unit

      The strategic location of the unit is crucial and should be based on the number of inpatient and/or outpatient procedures. If the majority of endoscopic examinations are outpatient procedures, a location next to the outpatient department or day care unit is desirable (

Fig. 5.1,

Fig. 5.2), unless daycare facilities are fully provided for within the unit itself.^1,3 At many units, the majority of patients are ambulatory, with a significant minority arriving in wheelchairs or trolleys, or even on hospital beds. A suitable reception area is needed, as well as an area for patients to await endoscopy on trolleys, on which they will be transported directly into the endoscopy room. Changing facilities in or near this waiting area must be provided. The waiting area can also serve as the recovery area to which patients are returned after endoscopy, though it is advisable to have separate waiting and recovery areas. Waiting and recovery areas must also be provided with toilet facilities. After full recovery, ambulatory patients should await discharge in the reception area, which can also be occupied by relatives and friends. Waiting-room space can be calculated on the basis of eight chairs for each endoscopy procedure room. This is based on two or three seats for the waiting patient and family members, and two each for family members of the two patients in recovery and the patient undergoing the procedure.

      If outpatients and inpatients are treated, then simultaneous but separate patient flow pathways should be created (

Fig. 5.1). There should be an interview room where the details of the procedure prior to endoscopy and the results of endoscopy and further arrangements can be discussed in privacy with the patients and/or their relatives, as appropriate.

      5.6 Number of Rooms

      In general, upper and lower gastrointestinal (GI) tract endoscopies are separated, and thus there is a minimum of two endoscopy rooms even for a small unit. For larger units, approximately one endoscopy room per 1,000 examinations (diagnostic and low-scale therapeutic) annually is a rough estimate for capacity planning. The British Society of Gastroenterology recommends a minimum of 2 + 1 endoscopy rooms for 3,000 endoscopies per year.^3,4

      In larger units, the concept should also include a radiography unit and a multipurpose room for various procedures such as laser therapy, EUS, and emergency cases.⁵ Providing care for emergency cases has to be standardized and separated into those suitable for the endoscopy unit and those who should be treated in the intensive care unit or operating room. If a high volume of emergency and unscheduled cases are seen, then it is important to have at least one additional room for flexibility without interrupting the routine scheduled endoscopic program.³

      When additional techniques such as video capsule endoscopy and functional GI tests (manometry, breath test, absorptive tests) are planned and performed by the same staff, additional rooms for these tests and for reviewing capsule endoscopy should be planned for. In larger units or specialized centers performing 6,000 procedures (the 4 + 2 room model), a dedicated room for EUS, laser therapy, and photodynamic therapy should also be present.^{6,7,8,9,10,11,12,13,14,15,16}

      Therapeutic endoscopic procedures are increasingly time-consuming and result in lower productivity per room. Such interventional techniques as ESD, POEM, and double-balloon enteroscopy, which have longer procedure times, should be taken into account for workflow. There are recent reviews and published overviews on the time demands of the various endoscopic procedures, which have been validated.^8,9,17

      The amount of teaching that takes place in the endoscopy unit also has considerable impact on procedure performance time and can amount to as much as an additional 30% of time per procedure.

      Furthermore, the concept of report generation has to be considered (see below). If the report is generated immediately after the procedure with a computer-based documentation system, the time can be utilized for patient and room turnover. Thus, a single endoscopist could continuously work in one room. However, often the concept of switching rooms between procedures is applied. This increases the productivity of the individual endoscopist, but report writing and documentation might be less accurate. Capacity planning is important, and all calculations for procedure room capacity have to incorporate a realistic period (e.g., 10–15minutes) for cleaning and setting up the room for the next procedure.^6-16 However, capacity and productivity planning is often greatly affected by local characteristics (waiting time, in-house transportation, recovery facilities). Room productivity is a valuable quality measure for organization of the unit. However, productivity of a procedure room is also influenced by the availability of instruments (endoscopes) and the cleaning preparation cycles.

      5.7 X-Ray Requirements

      Besides ERCP and percutaneous transhepatic procedures, which depend on optimal X-ray imaging, several therapeutic endoscopic interventions such as dilation, placement of stents and probes, and double-balloon enteroscopy require radiographic guidance. If a unit requires more than 200 to 500 radiographic examinations per year, then a dedicated radiography room is recommended. In this case, either the third room in the 2 + 1 model should have such facilities or it should be possible in a separate additional room. Sharing X-ray facilities with other departments is possible, but there is a considerable loss of effective procedure time. Interventional ERCP strongly depends on the technical demands and optimal conditions of the procedure room. Movement of the endoscopy equipment to radiology should be minimized, and precautions are needed that when the equipment is moved it does not adversely affect the safety and performance.

      In most modern hospitals, a picture archiving and central storage system (PACS) is available, which allows digital archiving and distribution of X-rays. As PACS provides digital X-rays, high-quality monitors are needed to display the digital pictures in the various procedure rooms.

      5.8