Abstract 10 Implementation of a Standardized Sedation Classification System to Improve Endoscopy Unit Efficiency: A Quality Improvement Project

Abstract

As the patient population becomes more complex, our inpatient endoscopy unit (GIU) has increased its dependence on the anesthesia (ANES) department to assist with monitored anesthesia care (MAC) sedation. However, ANES staff availability is limited and can result in delays in procedure start times or cancellations of non-urgent cases at our busy academic center. Formerly, our sedation planning (FS) relied on attending preference and experience, and was affected by ANES availability. Therefore, we introduced a standardized sedation classification system (SS) to more adequately identify cases able to be performed with moderate sedation (MS) and decrease reliance on ANES support. Our aim was to assess the efficacy of a new sedation classification system implemented to assist endoscopists in identifying cases for MS using the number of cases performed as the primary end point. We performed a retrospective analysis of patients referred for inpatient endoscopy to a single center (June—December 2015). ProVation inquiry identified cases scheduled. Prior to September 2015, patient sedation needs were based on attending preference and experience. The SS system was then introduced (Table 1). Clinical data was obtained during the old FS (June—August 2015) and new SS guidelines (October—Dec 2015). September was excluded for transition. Data collected included endoscopy records, sedation method, GIU schedules, and procedural complications. Cases performed in the intensive care unit, emergency department, or operating rooms were excluded. 1,431 cases were scheduled during the study period. 113 cases were excluded and 320 cancellations were reported. 998 total cases (mean age, 59 ± 16 years, 449 females) were performed. The mean number of cases performed daily were similar in both groups (8.01 FS vs 7.45 SS; P = .27). After SS implementation, the number of MAC cases and cancellations of non-urgent cases significantly decreased, while MS cases increased (Table 2). Overall complication rates were not statistically different in both groups (P = .42). Two patients in the FS cohort required intubation, 1 for hypoxia (started with MAC) and 1 for food impaction retrieval (MS). Six patients in the SS cohort (all MAC) were intubated for respiratory distress, laryngospasms, or bleeding. After SS, mean GIU start time improved by 36 minutes; and, on the days of least anesthesia availability (Wednesdays), the GIU started 1 hour 28 minutes earlier. The last MAC case of the day started a mean of 46 minutes earlier. A quality improvement project to improve endoscopy unit efficacy by implementing a new sedation classification system saw an increase in MS cases performed and a decrease in cancellations while not affecting the number of cases performed daily or rates of complications. The new system also resulted in earlier start times, especially on days of limited anesthesia availability.Table 1New Standard Sedation Classification SystemLevel 1: Requires MAC 1. Patient previously failed MS 2. Active medications that make sedation with MS difficult (ie, HIV medications, HCV medications, chronic narcotic use, chronic antipsychotic medications) 3. Left ventricular assist device 4. Complex or prolonged endoscopy (ie, deep enteroscopy, prolonged GAVE treatment) 5. Hypotension or hemodynamic instability 6. Active alcohol use, illicit drug use, or signs of withdrawal 7. Severe aortic stenosis (aortic valve area ≤ 1.0 cm2)Level 2: At discretion of endoscopy attending performing procedure 1. Perceived cardiac or respiratory instability 2. Complex medical history 3. Complex pathology requiring intervention (ie, variceal banding, large polyp resection)Level 3: Candidate for MS All other cases deemed safe for MS. These may be performed with MAC if anesthesiologist is available.GAVE, gastric antral vascular ectasia; HCV, hepatitis C virus; HIV, human immunodeficiency virus; MAC, monitored anesthesia care; MS, moderate sedation. Open table in a new tab Table 2Clinical DataFormer Sedation Systemn=521No (%)Standard Sedation Systemn=477No (%)P valueAge58.5 ± 15.959.4 ± 16.7Female260 (52.9)189 (44.0)No. of cases performed daily (mean)8.0 ± 2.87.5 ± 2.9.27MAC463 (88.9)386 (80.9).03MS37 (7.1)70 (14.7).01Cancellations186 (35.7)134 (28.1).02Complications (overall)9 (1.7)13 (2.7).42Intubation2 (0.4)6 (1.2).24Aspiration2 (0.4)1 (0.2).57Hypoxia3 (0.6)2 (0.4).55Inadequate sedation1 (0.2)4 (0.8).17Hypotension3 (0.6)1 (0.2).32Unit start time (mean)09:0508:29Unit last MAC case start time (mean)15:4314:56 Open table in a new tab