Ambulatory Endoscopy Center Research Articles

Designing Your Ambulatory Endoscopy Center: Lessons from Accreditation

Endoscopy-specific ambulatory surgery centers (ambulatory endoscopy center [AEC]) are the dominant site of service for independent community-based and academic gastroenterology practices in the United States. For most gastroenterologists, constructing a new AEC is the most complex and capital-intensive project that they will encounter in their careers. Much has been written about AEC design, primarily with regard to maximizing functionality and efficient throughput.1,2 However, regulatory considerations are another critical factor, because new AECs require certification to provide care to Medicare recipients and external accreditation as required by state and local jurisdictions or private payers.

Pediatric endoscopy across multiple clinical settings: Efficiency and adverse events.

BACKGROUNDEndoscopic procedures are becoming increasingly important for the diagnosis and treatment of gastrointestinal disorders during childhood, and have evolved from a more infrequent inpatient procedure in the operating room to a routine outpatient procedure conducted in multiple care settings. Demand for these procedures is rapidly increasing and thus there is a need to perform them in an efficient manner. However, there are little data comparing the efficiency of pediatric endoscopic procedures in diverse clinical environments. We hypothesized that there are significant differences in efficiency between settings.AIMTo compare the efficiency and examine adverse effects of pediatric endoscopic procedures across three clinical settings.METHODSA retrospective chart review was conducted on 1623 cases of esophagogastroduodenoscopy (EGD) or combined EGD and colonoscopy performed between January 1, 2014 and May 31, 2018 by 6 experienced pediatric gastroenterologists in three different clinical settings, including a tertiary care hospital operating room, community hospital operating room, and free-standing pediatric ambulatory endoscopy center at a community hospital. The following strict guidelines were used to schedule patients at all three locations: age greater than 6 mo; American Society of Anesthesiologists class 1 or 2; normal craniofacial anatomy; no anticipated therapeutic intervention (e.g., foreign body retrieval, stricture dilation); and, no planned or anticipated hospitalization post-procedure. Data on demographics, times, admission rates, and adverse events were collected. Endoscopist time (elapsed time from the endoscopist entering the operating room or endoscopy suite to the next patient entering) and patient time (elapsed time from patient registration to that patient exiting the operating room or endoscopy suite) were calculated to assess efficiency.RESULTSIn total, 58% of the cases were performed in the tertiary care operating room. The median age of patients was 12 years and the male-to-female ratio was nearly equal across all locations. Endoscopist time at the tertiary care operating room was 12 min longer compared to the community operating room (63.3 ± 21.5 min vs 51.4 ± 18.9 min, P < 0.001) and 7 min longer compared to the endoscopy center (vs 56.6 ± 19.3 min, P < 0.001). Patient time at the tertiary care operating room was 11 min longer compared to the community operating room (133.2 ± 39.9 min vs 122.3 ± 39.5 min, P < 0.001) and 9 min longer compared to the endoscopy center (vs 124.9 ± 37.9 min; P < 0.001). When comparing endoscopist and patient times for EGD and EGD/colonoscopies among the three locations, endoscopist, and patient times were again shorter in the community hospital and endoscopy center compared to the tertiary care operating room. Adverse events from procedures occurred in 0.1% (n = 2) of cases performed in the tertiary care operating room, with 2.2% (n = 35) of cases from all locations having required an unplanned admission after the endoscopy for management of a primary GI disorder.CONCLUSIONPediatric endoscopic procedures can be conducted more efficiently in select patients in a community operating room and endoscopy center compared to a tertiary care operating room.

S311 Nipping It in the Bud – Patient Engagement and Prevention of Colorectal Cancer During the COVID-19 Pandemic: Results from a Quality Improvement Study

Introduction: Colorectal cancer (CRC) screening and surveillance colonoscopy declined nationwide during the initial surge of coronavirus infectious disease (COVID-19), including at our ambulatory endoscopy center at Emory Healthcare in the state of GA, which in August 2020 was designated as the "most likely" state where someone may be exposed to COVID-19. To improve show rates, we implemented a quality improvement project centered on patient engagement through which we addressed concerns regarding COVID-19, and the safety of colonoscopy. Methods: We contacted patients between the ages of 40-75 who were due for screening or polyp surveillance colonoscopy in August of 2020 via a telephone call through which we provided an overview of public health guidelines regarding COVID-19, safety precautions at our institution to minimize risk of transmission of COVID-19, including pre-procedural testing, social distancing guidelines, enforcing a universal masking policy, limited visitor policy, and vigorous surface disinfection. Post-procedure, patients completed a survey regarding the study phone call, and colonoscopy reports were reviewed. Results: 161 patients were contacted, of which 49% were white, 48.4% were African-American and 1.9% were Asian. 152 patients (94.4%), including 75 whites (49.3%), and 71 African-Americans (46.7%) completed their procedures. 91.8% agreed they received information about COVID-19 that they were unaware of; 91.1% felt safer about procedures after the phone call; 90.9% agreed that they felt less anxious about the risk of acquiring COVID-19; 70.3% agreed that they may not have come in for their procedures if they had not received the call. 206 adenomatous polyps, including 24 advanced adenomas (AN) (defined as ≥1 cm in size, adenoma with tubulovillous/villous histology or high grade dysplasia), and 1 locally invasive adenocarcinoma was found. Excluding the adenocarcinoma, there was no statistically significant difference between the proportions of African-American patients with adenomas when compared to the white patients (50.7% vs 57.3%, Chi-square statistic= 0.64; P-value= 0.41). Conclusion: Our study suggests that specific communication of pandemic related issues are key to reducing peri-procedural concerns about COVID-19. Although our cohort was small, the findings of ANs, and a cancer further reinforces that failure of timely CRC screening and colonoscopy will lead to a large burden of missed polyps and CRC, leading to increased morbidity and mortality from CRC.

Low Risk of COVID-19 Infection in an Ambulatory Gastrointestinal Endoscopy Center in Argentina

Background and Objectives. Since the onset of the COVID-19 pandemic, concerns have been raised regarding the risk of infection to both healthcare staff and patients during gastrointestinal endoscopy procedures. Given the importance of performing routine endoscopic procedures to an individual’s future health, we sought to estimate the risk of COVID-19 infection for healthcare staff and patients undergoing endoscopic studies at an ambulatory endoscopy center during the pandemic. Material and Methods. This is a prospective(and) analytical cohort study conducted in an ambulatory gastroenterology center located in the Autonomous City of Buenos Aires, Argentina. Patients undergoing different endoscopic procedures were evaluated for COVID-19 between April 14 and August 31, 2020. COVID-19 was also evaluated in all healthcare and associated staff during the same time period. The risk (cumulative incidence) of acquiring COVID-19 in all patients and staff was calculated. Results. Between April 14 and August 31, 2020, procedures were performed in 3,745 patients with a mean age of 51.12 years; 2,102 (56.18%) were male and 1,643 (43.82%) were female. Follow-up was completed in 3,492 patients, 18 of whom tested positive for COVID-19 standing for an incidence of 0.52% (95%CI 0.31 – 0.81%). Six (5.45%) out of 110 staff members were infected with COVID-19 (1 endoscopist, 4 endoscopy assistants and 1 administrative staff member). In this group, the incidence of positive tests for COVID-19 was 5.45% (95%CI: 2.03 – 11.50%). The increased rates of positive cases among our patients and healthcare professionals were respectively 7.9 and 23.6 times lower than in general population. Conclusion. During the study period, the proportion of COVID-19 infections in our ambulatory specialized in gastrointestinal endoscopy was low and much lower than that in the general population for both patients and healthcare professionals. Endoscopic procedures undertaken at this center were low risk, likely due to strict compliance with established pandemic protocols. Future studies should compare the risk of infection in the hospital setting.

S0539 Analysis of Reported Bowel Prep Scoring Utilizing a Nurse-Driven Two Week Pre-Colonoscopy Telephone Call in a Tertiary Care Ambulatory Endoscopy Center

INTRODUCTION: Colorectal cancer is the third most common cause of cancer-related death in the United States. Colonoscopy remains the optimal modality for detection and removal of precancerous lesions. Satisfactory bowel preparation remains an important component of polyp detection, removal, and safety. Unfortunately, 20–25% of all colonoscopies are reported to have unsatisfactory bowel prep. Multiple studies have shown that pre-endoscopy phone calls improve prep scores. However, these calls are typically 1–2 days prior to colonoscopy, possibly inducing sample bias with improved cleanliness scores due to pre-procedural drop-out. Additionally, many studies follow strict scripts that may not be feasible to reproduce in a real-world setting. This study aimed to evaluate the change in bowel cleanliness utilizing a nurse-driven phone call made two weeks prior to general colonoscopy. METHODS: Retrospective chart analysis of patients undergoing colonoscopy in general endoscopy rooms at random two-week intervals prior to and after the quality improvement (QI) initiative was performed. Primary aim was to evaluate change in endoscopist-perceived bowel cleanliness score (rated on a 1–5 scale (1 = unsatisfactory to 5 = excellent)). Secondary aim evaluated whether type of phone call (direct conversation versus voicemail (VM)) affected bowel cleanliness scoring. Two sample independent t-test and chi-square analysis evaluated groups. RESULTS: 218 patients (56.4% female) with mean age (55 ± 16 years) were evaluated before and after QI implementation. Baseline characteristics (age, sex, weight, BMI, need for extended prep) were similar between cohort/call (n = 70) and control/no call (n = 148) groups. Of those who received a phone call, 36 (51.4%) were spoken to directly, while 34 (48.6%) received a VM. Mean prep quality was similar between cohort and control groups (2.97±1.04 vs. 3.18±1.15, P = 0.21). Similarly, there was no significant difference in prep quality between phone call groups. CONCLUSION: Implementing an unscripted phone call two weeks prior to colonoscopy did not appear to improve bowel cleanliness. Additionally, there did not appear to be a difference between bowel cleanliness when calls consisted of direct conversation versus VM. Less strict interventions implemented at a longer interval prior to colonoscopy may not be as beneficial as those closer to scheduled endoscopy. Further research will evaluate whether it is the interval versus the type of information provided that most influences bowel cleanliness.Table 1.: Patient characteristics in control and cohort group. Prep quality scale (1 = poor/unsatisfactory, 2 = fair, 3 = adequate to identify polyps, 4 = good, 5 = excellent)Table 2.: Differences in perceived bowel preparation score between different types of phone calls

Outcomes of Universal Preprocedure Coronavirus Disease 2019 Testing Before Endoscopy in a Tertiary Care Center in New York City

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Impact of the COVID-19 pandemic on the workflow of an ambulatory endoscopy center: an assessment by discrete event simulation

Background and AimsAs community-based ambulatory endoscopy centers (AECs) across the nation are trying to reopen and safely resume outpatient endoscopic procedures after the unprecedented lockdown related to the coronavirus disease 2019 (COVID-19) pandemic, guidelines recommend pretesting and screening for COVID-19 along with other mitigation measures for the safety of patients and staff. The impact of such changes in the workflow of AECs on throughput and other performance indicators is largely unknown, although a significant reduction in revenue stream is expected.MethodsA discrete event simulation–based model was developed in the setting of a small to medium community-based single-specialty AEC to quantify the impact of COVID-19–related workflow changes on performance indicators and cost per case compared with the pre–COVID-19 baseline.ResultsIn the simulation model, post–COVID-19 recommended workflow changes significantly impacted the operational and productivity metrics and, in turn, adversely affected financial metrics. Overall, there was a significant decrease in staff utilization and consequent increase in total facility time, waiting time for patients, and cost per case because of a bottleneck at the time of preprocedure COVID-19 screening and testing while practicing social distancing. Strategies to minimize this adverse impact on productivity were assessed.ConclusionsPretesting and screening for COVID-19 as recommended by current guidelines will significantly impact the productivity and revenue stream of AECs. Urgent measures by payors are needed to adjust the facility reimbursement of endoscopy centers to ensure successful reopening and ramping up outpatient endoscopy services in these facilities already hit hard by the pandemic.

1150 Safety, Feasibility, and Cost-Effectiveness of Pediatric Gastrointestinal Procedures at an Outpatient Endoscopy Center

INTRODUCTION: Pediatric endoscopic procedures are traditionally performed in hospital-based endoscopy centers or operating rooms due to safety concerns. However, the healthcare costs of these pediatric procedures are significantly higher in the hospital setting. Current healthcare environment necessitates safe, effective, and a cost-effective approach for pediatric endoscopic procedures. We implemented specific patient selection criteria for pediatric gastrointestinal procedures at our ambulatory endoscopy center. We report 15-month data on the safety and feasibility of performing pediatric gastrointestinal procedures at an outpatient endoscopy center. We also evaluated the cost of these procedures at our center compared to the hospital-based endoscopy centers. METHODS: We conducted a retrospective chart analysis of pediatric endoscopic procedures performed at our ambulatory center over the last 15 months (February 2018 to May 2019). Sedation was provided by certified registered nurse anesthetists using propofol. We used inclusion and exclusion criteria as defined by our QA committee. In addition to standard adult criteria for endoscopy, pediatric-specific criteria included: age &gt;6 years, weight &gt; 22kg, avoidance of documented anaphylactic reaction to soy or egg, and inclusion of ASA I or II only. Adverse events were defined as cardio-respiratory distress indicated by use of the bag and mask ventilation, airway intubation or transfer to a hospital due to respiratory distress. Cost analysis data were obtained from the NC Blue Cross Blue Shield treatment cost estimator tool which is based on historical BCBSNC claims data. RESULTS: Overall 316 pediatric patients underwent procedures at our endoscopy center, of which 271 underwent upper endoscopy and 90 underwent colonoscopy. The average patient age was 13 years (range 6-20 years) and 44% were males. 38% of patients met ASA I criteria. None of the patients experienced any adverse events. The average cost of upper endoscopy with biopsy at our center was $750 (+/-100) compared to $4000 (+/-500V) at the hospital. The average cost of colonoscopy with biopsy at our center was $1250 (+/-50) compared to $5000 (+/-500) at the hospital-based endoscopy center. CONCLUSION: Performing pediatric gastrointestinal endoscopic procedures at an ambulatory center is feasible and safe, as long as appropriate patient selection criteria are used. Performing pediatric procedures at an ambulatory center is highly cost-effective compared to performing procedures at a hospital.

Initial Experience of a Community Gastroenterology Practice with Ultraslim Colonoscopy

Colonoscopies are performed for cancer screening as well as for other diagnostic and therapeutic reasons. It is considered successful if cecal intubation is achieved and adequate mucosa is visualized. It is not always possible to achieve cecal intubation due to multiple reasons such as sharp angulation or fixed segments of the colon and stricture. A pediatric colonoscope (PDC) and an ultrathin colonoscope (UTC) are used as a tool to negotiate sharp angulation and the fixed segments of the colon because their small diameter allows easy movement. An ultrathin colonoscope is used at many practices as a rescue in situations where standard colonoscopes have failed. Our study highlights the use of an ultraslim scope in both rescue situations and as the initial colonoscope of choice in an ambulatory endoscopy center.

Safety and Feasibility of Pediatric Gastrointestinal Procedures at an Ambulatory Endoscopy Center

Safety and Feasibility of Pediatric Gastrointestinal Procedures at an Ambulatory Endoscopy Center

Safe Protocol and Technique for 7 Minute Orbera Balloon Placement in an Ambulatory Endoscopy Center

Introduction: Orbera is an FDA approved endoscopically placed device for temporary weight loss in patients with BMI >27.FigureFigureFigureMethods: Between June 2016 to February 2017, 40 patients were evaluated and scheduled for balloon placement. The average BMI was 46.87 (37.2-60.97), mean age 46.62 (61-28 y/o). All patients were instructed to follow a non-vegetable diet for 1 week prior and liquid diet 2 days before the scheduled placement. All the procedures were performed in an accredited ambulatory endoscopy center by a single gastroenterologist with advanced therapeutic training and 25 years of experience, under propofol sedation. All patients were placed on a non-rebreathing mask at 100% oxygen while in the holding area until the patient was taken to the procedure room and sedation started, when it was switched to a nasal cannula set at 3 liters per minutes. The patients were also pre-medicated with 8 mg of ondasetron, glycopyrrolate 0.1 mg and hydrocortisone sodium 40 mg by intravenous route before the sedation with propofol. After the initial endoscopy to clear the stomach from pathology that can preclude the Orbera placement and to aspirate any remaining fluid, an over insuffl ation technique was used in the stomach and continued until the removal of the scope in order to create a good intra gastric pressure gradient to facilitate the passage of the balloon catheter through the EGJ and avoid coiling in the esophagus. Once the balloon is placed in the body of the stomach it is crucial to gently and slowly pull on catheter a bit under endoscopic surveillance until the catheter is in a straight position (not coiling in the stomach). That will allow the easy passage of water to fill the balloon in a faster and more efficient fashion. The balloons were filled up to 600 ml, a careful inspection is performed to see if there are any leaks. Complete aspiration of the air in the stomach is also preformed until we could see the stomach around the balloon. Results: In all cases the Orbera balloon was successfully placed in 7 minutes from scope in, to scope out without any complications or any episodes of oxygen desaturation, or the need for endotracheal intubation in an ambulatory setting. Conclusion: Orbera balloon can be safely and quickly placed in an ambulatory basis following this technique in an appropriate and controlled environment.

Eight Minute Technique for Orbera Gastric Balloon Removal

Introduction: Orbera is an endoscopically placed intra gastric balloon approved by the FDA for short term weight loss with an average of 31% pounds excess weight loss. Many centers perform removals under general anesthesia with the use of an over tube, making the procedure a longer and more costly one. Methods: A single therapeutic gastroenterologist successfully removed 12 Orbera balloons from June 2016-March 2017 at the ambulatory endoscopy center under propofol sedation only, with the Orbera system removal kit. All patients were placed in a non-rebreathing mask at 100% oxygen in the holding area until sedation was started, when a nasal cannula at 3 Lt/min was placed for the procedure. All patients were instructed to follow a liquid diet for 48 hours prior to the removal date. The needle was marked at 4 cms and 6 cms apart from the tip before passing it through the scope. Once the balloon was in front of the scope, the needle was introduced up to the 6 cms mark. It is very important to keep the needle straight and with no more than 2cms between the balloon and the scope to avoid kinking the catheter. Once the aspiration flow becomes slow the catheter is pulled out until the next mark, this is very important to avoid pulling out the aspiration catheter prematurely before complete deflation. Once the edges of the balloon evidence that a complete deflation was achieved, the grasp forceps from the extraction kit are used. It is critical to place the forceps deep into the more pronounced edge of the balloon and to avoid exposure of the esophagus to the metal, the forceps are pulled to the very tip of the scope before retrieval of the balloon. Results: All 12 balloons were successfully removed in an average scope in to scope out time of 8 minute. There were no complications. All the patients had >95% oxygen saturation for the entire procedure, without the need for general anesthesia. Conclusion: Orbera balloon can be safely and quickly removed by adhering to a protocol of using a non-rebreathing mask pre procedure to avoid hypoxemia in those patients, keeping the puncture catheter within the two marks at 4 and 6 cms apart, to safely move the aspiration catheter without early removal of the catheter before fully deflating the balloon, keeping a straight catheter position with no more than 2 cms between the balloon and the scope and achieving a firm entire grasp of the more pronounced deflated edge and keeping the forceps and balloon at the tip of the scope, pulling until it is out.

Abstract 11 Assessing the Success of a Multidisciplinary Quality Improvement Initiative to Improve Outpatient Screening Colonoscopy Bowel Preparation

The quality of screening colonoscopy preparation is dependent upon pre-procedural bowel preparation. An abundance of poor and fair bowel preparations during screening colonoscopies at our tertiary care, a university ambulatory endoscopy center, prompted a quality improvement (QI) initiative to enhance screening colonoscopy quality and efficiency. A multidisciplinary team comprising Gastroenterology faculty and fellows, endoscopy nurses, and procedure schedulers was assembled. Current scheduling workflow, screening colonoscopy bowel preparation protocols, patient informational handouts, and relevant published literature were reviewed. Several changes were implemented: prescribed bowel preparations were standardized into 1 of 2 choices ‘Standard Bowel Prep’: split-dose 4L polyethylene glycol solution, or ‘Miralax Plus Prep’: 5 days of polyethylene glycol 3350 (MIRALAX) 17g twice daily plus the Standard Bowel Prep. The latter was chosen for prior poor bowel preparation, opioid use, or chronic constipation. Standardized dietary instructions were used; patients were asked to avoid corn, beans, and vegetables for 3 days. A simple, colorful, pictorial description of a clear liquid diet was designed. The procedure schedulers and endoscopy nurses received additional training on educating patients about effective bowel preparation, with the use of newly designed visual aids. Endoscopists applied the validated Boston Bowel Preparation Score (BPSS) to grade the bowel preparation immediately post procedure. χ2 test for proportions and paired t-test for means were used to test for statistical significance. Records of 776 consecutive patients who had screening colonoscopy between January—August 2016 were reviewed; 388 prior to the QI initiative implementation date (April 21 2016), and 388 post-intervention. Males and females were equally represented (388 each). Post intervention, the mean Boston Bowel Preparation Score (BBPS) was 7.3, corresponding with excellent bowel preparation. Over half (52%) of post-intervention bowel preparations received a perfect score of 9. There was a significant increase in optimal (good + adequate + excellent) bowel preparations (63.3% to 82.4%), and a corresponding drop in fair (23.8% to 13.9%) and poor (13.9% to 3.6%) post-intervention. The number of aborted procedures because of suboptimal bowel preparation decreased from 13 pre-intervention to 5 (P = .03; Table 1). The mean procedure duration of screening colonoscopies without polypectomy was significantly lower post-intervention compared with pre-intervention group (from 16.4 minutes to 15.1 minutes; P = .04). This QI initiative demonstrates that a multifaceted approach to improving the quality of colonoscopy preparation can be executed in a brief time. The multidisciplinary team implemented standardized bowel preparations, dietary counseling, and pictorial dietary reinforcement, which improved the quality of screening colonoscopy bowel preparations and reduced both the number of aborted procedures as well as duration of screening colonoscopy without polypectomy.

406 - Assessing the Success of a Multidisciplinary Quality Improvement Initiative to Improve Screening Colonoscopy Bowel Preparation at a University Ambulatory Endoscopy Center

406 - Assessing the Success of a Multidisciplinary Quality Improvement Initiative to Improve Screening Colonoscopy Bowel Preparation at a University Ambulatory Endoscopy Center

Clipping prevents perforation in large, flat polyps.

AIMTo determine if prophylactic clipping of post-polypectomy endoscopic mucosal resection (EMR) mucosal defects of large, flat, right sided polyps prevents perforations.METHODSIRB approved review of all colonoscopies, and prospective data collection of grasp and snare EMR performed by 2 endoscopists between January 1, 2010 and March 31, 2014 in a community ambulatory endoscopy center. The study consisted of two phases. In the first phase, all right-sided, flat polyps greater than or equal to 1.2 cm in size were removed using the grasp and snare technique. Clipping was done at the discretion of the endoscopist. In the second phase, all mucosal defects were closed using resolution clips. Phase 2 of the study was powered to detect a statistically significant difference in perforation rate with 148 EMRs, if less than or equal to 2 perforations occurred.RESULTSIn phase 1 of the study, 2121 colonoscopies were performed. Seventy-five patients had 95 large polyps removed. There were 4 perforations in 95 polypectomies (4.2%). The perforations occurred in polyps ranging in size from 1.5 cm to 2.5 cm. In phase 2, there were 2464 colonoscopies performed. One hundred and sixteen patients had 151 large polyps removed, and all mucosal defects were clipped. There were no perforations (P = 0.0016). There were no post-polypectomy hemorrhages in either phase. An average of 2.15 clips were required to close the mucosal defects. The median time to perform the polypectomy and clipping was 13 min, and the median procedure duration was 40 min. Five percent of all patients undergoing colonoscopy in our community based, ambulatory endoscopy center had flat, right sided polyps greater than or equal to 1.2 cm in size.CONCLUSIONProphylactic clipping of the mucosal resection defect of large, right-sided, flat polyps reduces the incidence of perforation.

Top down or Bottom Up? Does the Order of Bidirectional Endoscopy Matter?

Introduction: Same day bidirectional endoscopy (EGD and colonoscopy) is frequently performed for screening and to evaluate various GI conditions. There is debate surrounding the optimal sequence for the procedures. However, there is little data comparing the safety of the two approaches - EGD then colonoscopy (E-C) vs colonoscopy then EGD (C-E). AIM: to assess whether there are any differences in adverse events between the 2 approaches to bidirectional endoscopy: E-C vs C-E in a large ambulatory endoscopy center (AEC). Methods: Data for the study were retrospectively obtained from a large AEC from Feb 2012 until June 2016. A total of 8,611 bidirectional endoscopies were performed (3,444 E-C and 5,167 C-E). CRNA delivered propofol was used for all procedures. All patients were ASA 1 to ASA 3. We recorded adverse events using data from peri-procedural incident reports, follow up phone calls (24 hours post procedure) and reporting of adverse events by physicians. We compared the frequencies of adverse events (cardiac arrhythmia or hyper/hypotension, laryngospasm, aspiration, post procedure bleeding, desaturation, post procedure pain/nausea, post procedure fever and splenic injury) between the 2 models of bidirectional endoscopy using chi square analysis. Results: Total adverse events in the E-C group were 36 (1.0453%). Total adverse events in the C-E group were 22 (0.4258%). The difference was statistically significant with a p value of .00058. Frequency comparison of subgroups resulted in a statistically significant p value of < .05 in 2 subgroups, aspiration (p=.0302) and fever (p=.0135). Average ASA of adverse events in the E-C group was 1.94 compared to 2.22 in the C-E group. There was no data available on BMI or mallampati scores. Conclusion: In a large AEC with over 8,600 bidirectional endoscopies over a greater than 4 year period of time, there was a statistically significant difference in total adverse event rate when comparing order of bidirectional endoscopy. There were greater rates of adverse events with EGD then colonoscopy compared to colonoscopy then EGD, particularly aspiration and fever. Further prospective evaluation of contributing factors, both patient and procedure specific, is warranted.Table 1: Frequency of Adverse Events

The Initial Management and Endoscopic Outcomes of Dyspepsia in a Low-Risk Patient Population.

Dyspepsia is frequently encountered by primary care providers (PCP) and gastroenterologists (GI). While esophagogastroduodenoscopy (EGD) may be useful, current guidelines suggest a proton pump inhibitor (PPI) trial and H. pylori (HP) test-and-treat before EGD for low-risk patients. This study aimed to evaluate pre-EGD management and endoscopic outcomes in this population. This was a retrospective cohort study of low-risk dyspepsia patients (age ≤55, no alarm features) undergoing EGD at an ambulatory endoscopy center from January 2011 to March 2012. Adherences to initial management guidelines (PPI trial and HP test-and-treat strategy before EGD) were compared between PCP and GI. Endoscopic and pathologic outcomes were assessed for all patients. Statistical analyses were performed using Chi-squared test (categorical variables) and Student's t test (continuous variables). This study received IRB approval (2011P001715). A total of 309 low-risk patients underwent EGD for dyspepsia. Only 202 (65.4%) had HP testing, and 220 (71.2%) were trialed on any dose/length PPI pre-EGD, with no differences between PCP and GI. PPI exposure was similar between groups for all dose/duration except for trials ≥8weeks of any dose (46.9% GI vs 34.3% PCP, p=0.03) and high dose (32% GI vs 18.7% PCP, p=0.01). Overall, only 178 (57.6%) patients had both HP testing and any PPI exposure pre-EGD (56.6% GI vs 59% PCP, p=0.73). Significant pathology was rare, with gastritis (46.6%) and HP (17.2%) being most common. No malignancy was found. A significant proportion of low-risk dyspepsia patients did not receive any PPI trial or HP testing before EGD. Within this population, significant finding on EGD was rare, supporting the current noninvasive initial management guidelines for dyspepsia.

Comparison of Sedation Practices in GI Endoscopy Between Ambulatory Endoscopy Center and GI Lab in Hospital

Comparison of Sedation Practices in GI Endoscopy Between Ambulatory Endoscopy Center and GI Lab in Hospital

Sa1510 Large, Flat, Right-Sided Polyps in a Community Ambulatory Endoscopy Center. Incidence, Pathology, and Outcomes of EMR

Sa1510 Large, Flat, Right-Sided Polyps in a Community Ambulatory Endoscopy Center. Incidence, Pathology, and Outcomes of EMR

Do CRNAs Need On-site MD Anesthesia Supervision for Safe Propofol Sedation in an Ambulatory Endoscopy Center (AEC)? A Comparison of Two Sedation Models: CRNA Alone and CRNA with MD Anesthesia Supervision in 99,818 Consecutive Procedures: ACG Auxiliary Award

Purpose: Propofol use in AEC's is increasing in use, driven by multiple factors such as increased patient satisfaction and improved efficiency. Given the concern for complications due to propofol's narrow therapeutic window and impaired patient response with deep sedation, it is administered by anesthesia personnel. Currently the labeling on propofol states it “should be administered only by persons trained in the administration of general anesthesia.” Current options would include an MD anesthesiologist in each procedure room, a combination of a CRNA in each procedure room and an MD anesthesiologist overseeing several CRNAs (CRNA+A) or a CRNA in each procedure room without an MD anesthesiologist (CRNA) on site. There is little data comparing safety outcomes of these models. Aim: To assess if there are any significant differences in adverse outcomes between two different anesthesia models: CRNA+A vs CRNA in a large AEC. Methods: The data for the study were retrospectively obtained from a large AEC over a 55-month period (October 2008 through May 2013). A total of 99,818 consecutive endoscopic procedures performed by gastroenterologists, all using MAC anesthesia with propofol only were included. Between 10/6/08 to 2/10/12, these were performed with the CRNA+A model (70,436 procedures). Subsequently, the CRNA model was adopted from 2/13/12 until 5/31/13 (29,382 procedures). All patients were ASA 1 to ASA 3. We recorded adverse events using data from incident reports during and immediately after the procedures, follow up phone calls typically performed 24 hours post procedure and reporting of adverse events by individual physicians. We compared frequencies of adverse events (aspiration, desaturation with intervention, laryngospasm, cardiac arrhythmia or hyper/hypotension, perforation and splenic injury) between the two models of MAC anesthesia using chi square analysis. Results: Aspiration rates were .020% and .027% with CRNA+A and CRNA, respectively. Desaturation (with intervention) rates were .075% and .078%. Laryngospasm rates were .024% and .041%. Cardiac event rates (arrhythmia and hypo/hypertension) were .020% and .020%. Perforation rates were .011% and .003%. Splenic injury requiring splenectomy rates were 0% and .003%. There were no procedurerelated deaths. None of the frequency comparisons resulted in a statistically significant p value of <.05. Conclusion: In a large AEC with nearly 100,000 total procedures, there were no differences in adverse outcomes using two different propofol sedation models: CRNA alone and CRNA with MD anesthesia supervision. CRNA-administered propofol anesthesia is safe in an AEC. MD anesthesia supervision does not significantly impact safety outcomes with propofol in an AEC.Table 1: Frequency of adverse outcomes