Endoscopy Unit Efficiency Research Articles

LEAN Methodology to Improve Endoscopy Unit Efficiency in a Multi-subspecialty Ambulatory Surgery Center: A Pilot Study.

Background and objective Efforts to improve gastrointestinal (GI) endoscopy unit efficiency may lead to increases in colon cancer screening volumes. LEAN management principles applied to GI endoscopy unit practices may serve as a novel foundation for efficiency improvements.We conducted apilot study in an outpatient, hospital-based GI endoscopy unit with the goal of improving endoscopy efficiency by using LEAN principles Methodology A single endoscopist and anesthesiologist along with the nursing care team implemented changes to their practice based on LEAN principles. Efficiency metrics were tracked before these changes and after to assess for improvements. Results We observed statistically significant improvements in waiting room time (13.1 minutes vs. 25.6 minutes, p<0.001), recovery room duration (55.5 minutes vs. 61.8 minutes, p=0.01), total facility time (172.5 minutes vs. 196.1 minutes, p<0.001), and true completion time (19.7 minutes vs. 32.3 minutes, p=0.002) after the implementation of LEAN interventions. Conclusions A systematic and standardized approach using LEAN methodology canimprove GI endoscopy unit operational efficiency. Larger studies are needed to validate our findings and generalize the results to the field broadly.

Plan-do-study-act (PDSA) interventions to improve real-world endoscopy unit productivity.

Background and study aims The Plan-Do-Study Act (PDSA) ramp is a framework that uses initial small changes to build consensus and momentum for subsequent, iterative process improvement. Our aim was to study its impact on endoscopy unit efficiency and throughput. Methods Following a granular time-and-motion analysis to evaluate baseline performance (phase 1) we instituted successive interventions and measured their impact on core efficiency metrics including procedure volume and turnover time (phases 2-3). Results We identified that inefficiency in turnover of anesthesia-supported endoscopy was the most crucial issue. Implementation of a pre-procedure anesthesia visit in phase 2 reduced turnover time by 15.5 minutes (95% confidence interval 3.9-27.1 minutes). Subsequent changes (phase 3) including front-loaded procedure scheduling and parallel in-room preparation resulted in an 18% increase in procedure volume. Conclusions The PDSA ramp model is an effective means of assessing operational processes, developing novel interventions, and building consensus to improve the real-world productivity in a resource-conscious manner.

Prospective Randomized Comparison of Endoscopist-facilitated Endotracheal Intubation and Standard Intubation for ERCP.

Complex endoscopic procedures are increasingly performed with anesthesia support, which substantially impacts endoscopy unit efficiency. ERCP performed under general anesthesia presents unique challenges, as patients are typically first intubated, then transferred to the fluoroscopy table and positioned semi-prone. This requires additional time and staff while increasing the potential for patient/staff injury. We have developed the technique of Endoscopist-facilitated intubation using an endotracheal tube backloaded onto an ultraslim gastroscope as a potential solution to these issues and evaluated its utility prospectively. Sequential patients undergoing ERCP were randomized to Endoscopist-facilitated intubation or to Standard intubation. Demographic data, patient/procedure characteristics, endoscopy efficiency parameters and adverse events were analyzed. During the study period, 45 ERCP patients were randomized to either Endoscopist-facilitated intubation (n=23) or Standard intubation (n=22). Endoscopist-facilitated intubation was successful in all patients, without hypoxic events. Median time from patient arrival in room to procedural start was shorter in patients undergoing Endoscopist-facilitated intubation vs Standard intubation (8.2 min vs. 29 min, p<0.0001). Endoscopist-facilitated intubations were brisker than Standard intubations (0.63 min vs. 2.85 min, p<0.0001). Endoscopist-facilitated intubation patients reported less post-procedure throat discomfort (13% vs. 50%, p<0.01) and fewer myalgias (22% vs. 73%, p<0.01) than Standard intubation patients. Endoscopist-facilitated intubation was technically successful in every patient. Median Endoscopist-facilitated intubation time from patient arrival in room to procedural start was 3.5-fold lower and median Endoscopist-facilitated intubation time was over 4-fold lower than for Standard intubation. Endoscopist-facilitated intubation significantly enhanced endoscopy unit efficiency and minimized staff and patient injury. General adoption of this novel approach may represent a paradigm shift in the approach to safe and efficient intubation of all patients requiring general anesthesia. While the results of this controlled trial are promising, larger studies in a broad population are needed to validate these findings. NCT03879720.

S1481 Impact of Time-Motion Patient Flow Analysis on the Productivity of an Endoscopy Unit in a Large Safety-Net Health Center

Introduction: The COVID-19 pandemic disrupted health care delivery, particularly for high-volume procedural areas. To improve productivity in the Los Angeles County + University of Southern California Medical Center (LAC + USC) Endoscopy Unit, we initiated an iterative rapid cycle quality improvement process to identify inefficiencies and implement changes to our workflow. Methods: A time-motion analysis of patient flow through the LAC + USC Endoscopy Unit was used to construct a time-tracked flow sheet to track individual patients as they moved through the Unit. Data were collected weekly over 3 9-10 week phases, and intervening plan-do-study-act (PDSA) cycles were conducted to direct interventions for subsequent phases. Following phase 1 (9/1/21 to 11/9/21) we implemented targeted interventions at the start of phase 2 (12/1/21 to 2/1/22) and phase 3 (3/15/22 to 5/31/22). Phase 2 was focused on our anesthesia supported endoscopy room which requires greater resource coordination. Metrics were compared to published benchmarks. Linear regression was used to compare outcome parameters for the lean process flow improvement project. Results: Our phase 1 analysis showed operational delays in room turnover time for all procedures and pre-operative assessment and first-case on time start percentage for procedures supported by anesthesia, when compared to published benchmarks (Table 1). In phase 2 we implemented an intervention of combining pre-anesthesia visits with endoscopy teaching visits for patients designated to have anesthesia support. This significantly improved both turnover time and throughput for the anesthesia room (Table 1). In phase 3 we initiated a policy of preparing the first patient of the day in the procedure room which dramatically increased first-case on time start percentage. We further streamlined inter-procedure processes by simultaneously consenting, placing monitoring equipment and documenting in the time between procedures, leading to a greater than 20% increase in total procedure volume (Table 1). Procedure throughput for the anesthesia supported procedure room increased from 4.5 to 7 to 9 procedures per room per day for phases 1, 2, and 3 respectively (Table 1). Endoscopy Unit staffing remained unchanged throughout the study period. Conclusion: Time-motion analysis of patient flow may be used to perform targeted interventions with significant improvements in Endoscopy Unit efficiency. This may be achieved without costly interventions such as hiring additional support staff or faculty. Table 1. - Core Productivity and Efficiency Parameters of LAC+USC Endoscopy Unit Phase 1 FIRST INTERVENTION 12/1/2021: pre-anesthesia visit Phase 2 SECOND INTERVENTION 3/15/2022:First patient prepared in-room and streamlined inter-procedure processes Phase 3 Sep-2021 Oct-2021 Nov-2021 Dec-2021 Jan-2022 Feb-2022 Mar-2022 Apr-2022 May-2022 Total Procedures 539 556 450 511 467 501 504 647 612 Moderate Sedation 515 539 426 488 432 468 465 608 573 Anesthesia Supported 24 17 24 23 35 33 39 39 39 Mean Room Turnover Time (minutes - for anesthesia room) 45 (±40) 31 (±40) 30 (±24) First-Case On Time Start % (moderate sedation) 75.7% 78.3% 87.5% First-Case On Time Start % (anesthesia supported) 0% 0% 92.5% Anesthesia Room Throughput (mean # of procedures per day) 4.5 7.0 9.0

S1485 Increasing Inpatient Endoscopy Volumes Using the Model for Continuous Improvement

Introduction: Inpatient endoscopy volumes can affect patient care at many levels in a hospital system. At our academic center, inpatient procedural volume efficiency is 65% (defined as the number of completed procedures compared during the designated in-patient endoscopy time period). As a consequence, excess procedures are being completed on-call or on weekends. Our aim was to increase procedural volume by one (14%) additional procedure completed/day over a 12-month period. Methods: An interprofessional team of Gastroenterology fellows and staff along with endoscopy nurses and managers was created to investigate throughput concerns. Baseline data was collected via direct observation and completion of a time study over 2 months. Subsequently, a process flow diagram was completed. A combination of root cause analysis tools (ie, Ishikawa diagram and Pareto chart) were then utilized to identify areas for improvement. A delay in procedural start time was identified as a strong culprit for reduced efficiency. Potential PDSA (plan-do-study-act) cycles included: early physician handover start time, constructing a standardized patient procedure list, and improving timeliness of patient transfer to the endoscopy suite. Results: Baseline data identified that the first case start time was delayed by 51 min when our actual start time is 08:00 am. Our first PDSA cycle involved a 15-minute earlier physician handover start time. PDSA cycle #1 reduced our mean procedural start time to 08:49 am [UCL: 104 minutes; LCL: −5.4 minutes]. Our second PDSA cycle, involved the standardization of a planned procedural list and mandate for the first procedure to be esophagogastroduodenoscopy (EGD). PDSA cycle #2 reduced start time reduced to 08:29 am [UCL: 69.6 minutes; LCL: −12.4 minutes]. Our third PDSA cycle, involved utilizing the standardized procedural list to pre-emptively organize timely patient transfer to account for delays secondary to hospital portering services, which reduced the mean start time further to 08:22 am [UCL: 52.0 minutes; LCL: −8.0 minutes] (Figure 1). Conclusion: Using the model for continuous improvement we were able to increase procedural volumes by one (14%) per day. The most effective intervention included developing a standardized procedure list and mandating the first case as an EGD minimizing delays due to inadequate or incomplete bowel preparation.Figure 1.: A statistical process control chart (SPC) demonstrating baseline data on endoscopy procedural start time and interventions (PDSA #1, PDSA #2, PDSA #3) that were effective in reducing the delay in procedure start time and resulted in a subsequent increase in endoscopy unit efficiency.

Badge sign-in and report cards improve first case start times in gastrointestinal endoscopy: A prospective quality improvement study.

Background and study aims First case start (FCS) time is often a key metric used to gauge efficiency in an endoscopy suite. There are limited data on tools and methods to improve the FCS time in the endoscopy suite. Methods A prospective observational cohort study was conducted in an academic tertiary care endoscopy suite examining the effect of badge sign-in (Period 2) and badge sign-in coupled with report cards (Period 3) compared to an initial observational period (Period 1). Results After the badge sign-in reader was introduced in P2, the unit experienced a mean time savings of 5 ± 18 minutes in FCS delays compared to P1 ( P = .03). In P3, an 8 ± 17-minute time savings in FCS time delay was observed compared to P1 ( P = 0.0006). Sign-in compliance significantly increased for the overall unit between P2 and P3 (49 % vs. 59 %, P = .002). Increases in first case on-time start (FCOTS) rates compared to P1 were observed for the unit, with a 14% absolute increase in P2 ( P < .0001) and a 17 % absolute increase in P3 ( P < .0001). FCS delays for on-time badge sign-ins were significantly lower compared to FCS delays for missed badge sign-ins and late badge sign-ins ( P < .0001). Conclusions The use of badge sign-in and report cards improve endoscopy unit efficiency as it can increase FCOTS rates and decrease FCS time delays.

Efficiency in the Endoscopy Unit: Can We 'Turn Around' Room Turnover? An Observational Quality Improvement Study.

BackgroundEndoscopy units are being challenged to provide timely and quality care, despite limited resources and an ever-growing patient population. Decreasing procedure time is unlikely to create sufficient time savings and may compromise quality. Non-procedural factors, such as room turnover, are important contributors to efficiency and represent an ideal target for quality improvement efforts.AimsThe objective of this quality improvement study was to identify practices that will improve endoscopy unit efficiency at our centre. The specific aims were to (a) understand practices at local hospitals that contribute to room turnover efficiency and (b) examine the magnitude and sources of variation in room turnover efficiency across endoscopists and nurses at our centre.MethodsInterviews were conducted with team leads at five local hospitals. Routinely collected data from our centre were analyzed to understand the magnitude and variation in efficiency by provider and reasons for delays. Non-procedure time defined as ‘patient 1 scope out’ to ‘patient 2 scope in’ was our primary measure of efficiency.ResultsOver the 12-month period, 750 outpatient procedures met inclusion criteria. Median non-procedure time was 19 min (interquartile range: 16–22 min). The variation attributable to endoscopists was 14.7% compared to 80.4% for unmeasured factors.ConclusionsThe variation that remains unexplained by our model suggests that unmeasured factors play a substantial role in endoscopy unit efficiency and that our current endoscopy records are not capturing important contributors to efficiency. The next phase will involve focus groups and direct observation with the goal of identifying these unmeasured factors.

Analyzing and Improving Endoscopy Unit Efficiency in an Academic Tertiary Care Facility

Background and Aims: Demand for endoscopy continues to increase, and it is critical to identify factors limiting practice efficiency. The aims of our study were twofold: to identify major bottlenecks in our workflow, and to quantify differences between scheduled procedure times (SPT) and actual procedure times (APT) at our high-volume academic tertiary care endoscopy center. Methods: We categorized and quantified reasons for delay to the start of the first case of the day through our electronic medical record. To compare SPT and APT, we collected data on all endoscopies from May 2019 to February 2020 and determined mean time discrepancies of our ten most frequently performed procedures. Results: The mean preoperative time was 67 minutes. A median of 27 minutes were spent with nursing for preoperative documentation. 74% of first cases started late, and approximately 10% of inpatient cases rolled over to the next day. The most common factors were patient and gastroenterologist tardiness, causing mean delays of 35 and 22 minutes respectively. 48% of cases went over their SPT. Inpatient esophagogastroduodenoscopy (EGD), colonoscopy, and endoscopic retrograde cholangiopancreatography (ERCP) went a mean of 21.3 (p&lt;0.01), 19.4 (p&lt;0.01), and 15.8 (p&lt;0.01) minutes over their SPT, respectively. Outpatient colonoscopy and ERCP went a mean of 5.23 (p&lt;0.01) and 19.7 (p&lt;0.01) minutes over their SPT, respectively. Conclusion: Potential targets to improve inefficiency include patient and GI physician tardiness and reducing nursing preoperative documentation time. Inpatient procedures including EGD, colonoscopy, and ERCP along with outpatient colonoscopy and ERCP were significantly delayed and would benefit from additional scheduled time. Keywords: Endoscopy; Quality improvement; Efficiency

Propofol compared with bolus and titrated midazolam for sedation in outpatient colonoscopy: a prospective randomized double-blind study

The safest and most efficient method of sedation for outpatient colonoscopy remains unclear. This study aimed to compare the efficiency and safety of bolus administration of midazolam compared with titrated administration and propofol administration for patients undergoing outpatient colonoscopy. We randomly divided patients undergoing colonoscopy into the propofol group, bolus midazolam group, and titrated midazolam group. We compared total procedure time, induction time, recovery time, and discharge time among the 3 groups. We also compared patient satisfaction and the incidence of adverse events. In total, 267 patients (89 in each study group) were enrolled during the study period. Patients in the propofol group had a shorter total procedure time (39.5 vs 59.4 vs 58.1 minutes; P< .001), induction time (4.6 vs 6.3 vs 7.6 minutes; P< .001), recovery time (11.5 vs 29.5 vs 29.2 minutes; P< .001), and discharge time (20.6 vs 34.9 vs 34.7 minutes; P< .001) than patients in the bolus midazolam group and titrated midazolam group. Patients in the propofol group reported higher degrees of satisfaction than patients in the bolus or titrated midazolam plus meperidine groups (9.9 vs 9.6 vs 9.6 [P= .007] and 4.9 vs 4.7 vs 4.8 [P= .008], respectively). Adverse events were not significantly different between groups. In this randomized trial, propofol was superior to bolus or titrated midazolam in terms of endoscopy unit efficiency and patient satisfaction during outpatient colonoscopy. (Clinical trial registration number: KCT0002805.).

A148 EFFICIENCY IN THE ENDOSCOPY UNIT: CAN WE ‘TURN AROUND’ ROOM TURNOVER?

Abstract Background Endoscopy units across Canada are being challenged to meet the growing demand for procedures despite limited resources, highlighting the need to optimize endoscopy unit efficiency. Earlier studies have found that non-procedural factors, such as room turnover, represent an ideal target to improve efficiency. Aims The objective of this research project was to identify practices that will improve efficiency for routine outpatient gastrointestinal (GI) procedures at Sunnybrook Health Sciences Centre (SHSC). There were 2 sub-aims: 1) to understand practices at Toronto hospitals that shorten room turnover time and 2) to describe the variation in room turnover time at SHSC. Methods Sub-aim #1: A survey of endoscopy units at five other Toronto hospitals was completed. Questions were designed to gain a better understanding of routine practices and any initiatives undertaken to improve room turnover efficiency. Sub-aim #2: Median room turnover time from April 2018 to March 2019, defined as ‘patient out’ to ‘patient in’, was reported in an anonymized fashion for the following categories: 1) by endoscopist, 2) by nurse, and 3) by unique endoscopist-nurse pair. Only data from routine outpatient endoscopic procedures (e.g. colonoscopy, gastroscopy, flexible sigmoidoscopy) were included. In order to evaluate turnover times by endoscopist-nurse pair, consecutive cases not performed by the same pair were excluded. Procedures affected by patient- and transportation-related delays were also excluded. Results Of the five centers surveyed, three allocated 5 minutes for turnover and two allocated 10 minutes. All centers reported tracking turnover time and four centers reported undertaking initiatives to decrease turnover time such as involving a flow team, hiring team attendants, and sharing performance data. Over the 12-month period, 2504 routine outpatient GI endoscopic procedures were performed at SHSC, with 803 cases meeting inclusion criteria. Median turnover time for the unit was 6 minutes, ranging from 5 to 9 minutes across endoscopists, 5 to 7 minutes across nurses, and 3 to 10 minutes across unique endoscopist-nurse pairs (Figure 1). Efficiency of endoscopist-nurse pairs did not correlate with the number of cases performed as a pair over the 12-month period. Conclusions Endoscopy room turnover times at SHSC are similar to those reported by other local centers, with important variation across endoscopists and nurses. The next phase of this study will involve directly observing each of the most and least efficient individuals and pairs and recording common practices. It is anticipated that these findings will enable us to identify efficient practices that should be incorporated into standard operating procedures and training for endoscopy room personnel. Funding Agencies None

547 Increasing Endoscopy Unit Efficiency: It's Time to Take Control

INTRODUCTION: Operational flow is an important factor in relation to efficiency in an endoscopy center. There are opportunities for improvement in efficiency while keeping the standards of quality. We performed a time flow analysis in our outpatient endoscopy center to identify workflow improvement opportunities. METHODS: We evaluated 616 patients who underwent EGD and colonoscopy. We analyzed preop prep time, procedure time, room turnover, recovery room time, total time in unit, and physician arrival time. These times were compared to efficiency benchmarks identified in the limited literature available. A process map was documented to illustrate patient flow and to assess redundancies and non-value added steps (Figure 1). Post-intervention data was collected on 381 patients. RESULTS: Pre-procedure nursing time exceeded benchmark intervals for both EGD and colonoscopy (Table 1). This was due to lack of documentation if the patient could not be reached during precall assessment 5 days prior to procedure requiring the nurse to obtain the information on the day of endoscopy. 2/3 of nurses did not have EMR access to be able to chart the medical history prior to patient arrival. In addition, IV was placed prior to the restroom visit delaying procedure start time while physician was ready to proceed. Doubles were allotted only 30 min block times and progressive delay was noticed increasing pre-procedure wait time. Physician start time was delayed 26% by an average of 12 min (Figure 2). This was due to clerical tasks, staff questions, and operational tasks. Encounter forms were reformatted to be user friendly for nursing documentation. All nurses were given EMR access in the event where patient was not reached prior to procedure. Pre-call assessment changed from 5 to 7 days prior to procedure to increase probability of reaching patients. Patients were offered restroom break prior to IV placement. Block times for doubles were extended from 30 to 45 minute block times . Recovery room delays with EGDs were attributed to oversedation by a single nurse anesthetist who was educated regarding propofol usage. Physician delays remained essentially unchanged (Figure 2). CONCLUSION: With our interventions, we reduced pre-procedure time by 8 mins for EGDs and 7 minutes for colonoscopy. We improved recovery room time. Delays related to physician behavior remain unchanged. Our next step is to address physician arrival times will be to post results of physician start times on a weekly basis at our endocenter.

Anesthesia-administered sedation for endoscopic retrograde cholangiopancreatography: monitored anesthesia care or general endotracheal anesthesia?

The decision to undertake monitored anesthesia care (MAC) or general endotracheal anesthesia (GEA) for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is influenced by many factors. These include locoregional practice preferences, procedure complexity, patient position, and comorbidities. We aim to review the data regarding anesthesia-administered sedation for ERCP and identify the impact of airway management on procedure success, adverse event rates and endoscopy unit efficiency. Several studies have consistently identified patients at high risk for sedation-related adverse events during ERCP. This group includes those with higher American Society of Anesthesiologists class and (BMI). ERCP is commonly performed in the prone position, which can make the placement of an emergent advanced airway challenging. Although this may be alleviated by performing ERCP in the supine position, this technique is more technically cumbersome for the endoscopist. Data regarding the impact of routine GEA on endoscopy unit efficiency remain controversial. Pursuing MAC or GEA for patients undergoing ERCP is best-approached on an individual basis. Patients at high risk for sedation-related adverse events likely benefit from GEA. Larger, multicenter randomized controlled trials will aid significantly in better delineating which sedation approach is best for an individual patient.

Improving First-Case Start Delays in a Tertiary Care Academic Endoscopy Unit

Increasing emphasis on quality of care, as well as performance-based reimbursement have placed the spotlight on improving healthcare efficiency. As demand for GI procedures continues to increase, resources like physical space and personnel remain unchanged. Despite this, the literature is sparse with regard to improving efficiency in the endoscopy unit. First-case start delay is a known endoscopy efficiency metric. In our study, we look at the impact of implementing a patient check-in protocol on first-case start delays in our hospital-based endoscopy unit. A multidisciplinary team, consisting of endoscopists, anesthesiologists, unit manager, and administrators, was created in August 2018 with a focus on improving efficiency. Our initial goal was to improve first-case start delays. Beginning September 1st 2018, specific pre-procedure assessment end times were assigned to the care team for the first case. Fellows completed assessing the patient thirty minutes prior, nursing fifteen minutes prior, anesthesia ten minutes prior, and the endoscopist five minutes prior to the scheduled start time. First-case start delays, defined as the difference between the in-room and scheduled start times, were measured pre- and post-intervention for five GI faculty endoscopists (study group). Delayed cases were defined as any case with a first-case start delay of ≥5 minutes. The control group consisted of private GI endoscopists and colorectal surgeons, who were not part of the protocol. One hundred data points pre-intervention, and all data points for close to 3 months post-intervention, were collected for the study group. Three months of pre- and post-intervention data was collected for the control group. Statistical comparisons were made using a paired t-test (means) and Fisher’s exact test (proportions). A p-value of <0.05 was considered statistically significant. In the study group, the average first-case start delay was 19 minutes pre-intervention. This decreased significantly to 6 minutes post-intervention (p<0.001). In the control group, the average delay was 18 minutes pre-intervention and 19 minutes post-intervention. For the study group, on-time starts increased significantly from 13% to 45%, while delayed cases decreased significantly from 69% to 20% (p<0.001) post-intervention. In the control group, on-time starts remained at 20% pre- and post-intervention, while delayed cases increased from 67.5% to 80%. A standardized pre-procedure process resulted in significant reductions in first-case start delays in our endoscopy unit. This study highlights the use of multidisciplinary teams and the feasibility of implementing simple interventions that can have dramatic effects on endoscopy unit efficiency. It also illustrates the importance of establishing and monitoring reliable efficiency metrics in endoscopy.

Issue Highlights

Issue Highlights

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

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

Tu1011 Physician-Directed Bolus Sedation for Colonoscopy Improves Endoscopy Unit Efficiency and Safety

Tu1011 Physician-Directed Bolus Sedation for Colonoscopy Improves Endoscopy Unit Efficiency and Safety

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

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

Bolus Administration of Fentanyl and Midazolam for Colonoscopy Increases Endoscopy Unit Efficiency and Safety Compared With Titrated Sedation.

Guidelines recommend slow titration of sedatives for moderate sedation. Bolus sedation, in which a larger weight-based dose of medication is given upfront, has been shown in a single trial to be beneficial. We evaluated the effects of bolus sedation on procedural safety, efficiency, and patient experience. We performed a retrospective analysis of colonoscopies performed between April 2010 and April 2011 at Duke Medical Center. Colonoscopies before October 2010 were performed with nurse-directed titration of sedative (n= 966); colonoscopies performed after October 2010 were performed with physician-directed administration of bolus sedative (n= 699). We compared sedation and recovery times, medication doses, and adverse events between groups. We also compared patient satisfaction in a subset of patients from each group. Data were compared using the chi-square test for categorical variables and Wilcoxon rank sum test for continuous and ordinal categorical variables. Patients in the bolus group had a shorter sedation time (6.0 min) than patients in the titration group (13.0 min; P < .01) and a slightly longer colonoscopy time (25.0 min vs 24.0 min in the titration group; P < .01). Recovery time did not differ significantly between groups (53.0 min in the bolus group vs 52.1 min in the titration group; P= .07). Patients in the bolus group received lower weight-adjusted doses of fentanyl (1.71 μg/kg vs 1.89 μg/kg in the titration group) and midazolam (0.065 mg/kg vs 0.075 mg/kg in the titration group). A smaller proportion of patients in the bolus sedative group developed hypotension (12.7% vs 17.9% in the titration group; P < .01). These findings persisted even after adjustment for baseline patient age, race, sex, smoking status, alcohol use, body mass index, and American Society of Anesthesiologists' classification. In a retrospective study of patients undergoing colonoscopy, we found that compared with titrated administration of sedative, bolus dosing improves endoscopy unit efficiency and safety and decreases the amount of sedative required. This benefit does not come at the expense of the patient experience.

A Patient Flow Analysis: Identification of Process Inefficiencies in a Tertiary Care Endoscopy Center

Introduction: Gastrointestinal endoscopic procedures are essential in the evaluation and treatment of gastrointestinal diseases. An aging patient population and emphasis on preventative care and surveillance have contributed to an increased demand for endoscopy. One potential approach to increase supply of endoscopy services is to improve the efficiency of endoscopy units. However, there is limited literature on the range of endoscopy unit efficiencies. The goal of this study was to identify the etiology of endoscopy delays in our endoscopy unit.Figure 1Figure 2Methods: Retrospective analysis was conducted of endoscopy suite data from April 1, 2015 through October 30, 2015 to identify the origin of delays. An observational arm further characterized the retrospective data. Results: A total of 1296 procedures were performed during this time period. Colonoscopies comprised 49% (635) of the procedures, EGD contributed 19% (244), EGD/colonoscopy 7% (85), ERCP 6% (77), upper EUS 8% (106), and upper EUS/ERCP 1% (16). All other procedures made up the remaining 10% (133). On average, the flow time (arrival to endoscopy unit to arrival in the recovery room) was 159.1 ± 63.0 min. The main bottleneck of the operation was identified as the preparation time (waiting room to procedure room) which took on average 113.9 ± 60.3 min. An additional major bottleneck was room turnover (patient exiting to next patient entering the same procedure room) with a mean turnover time of 36.5 ± 29.1 min. To isolate the exact cause of the delays within each bottleneck, a direct observation period was conducted from December 2015 to January 2016 (Table 1).Table 1: Direct observation dataLinear regression demonstrated that the flow time increased as the day progressed (r = 0.29; p < 0.05). Analysis of the variation between physicians shows that physicians have an impact on the overall flow time of the patient (p < 0.05). The type of procedure also had a significant impact on endoscopy unit efficiency (p < 0.05). Conclusion: Endoscopy units have unique operational characteristics and identification of process inefficiencies can lead to targeted quality improvement initiatives. These baseline data will be essential for future resource optimization and have identified unique opportunities for process improvement at our endoscopy center. We recommend all endoscopy units undertake efficiency analysis to determine bottlenecks and help increase patient satisfaction and decrease healthcare costs.

The Utility of Mobile Application Technology to Analyze Efficiency And Improve Operational Performance in the Endoscopy Unit

Introduction: The principles of operations management and healthcare information technology (IT) may be used together to evaluate and enhance operational performance in endoscopy centers. Previously, our group published the largest publically available endoscopy unit analysis. This “time and motion” assessment was done via data collection using a paper chart flowsheet.(1) In this study, we aim to implement a mobile app software solution and test its ability to gather endoscopy unit data and analyze efficiency in the endoscopy unit. Ultimately, we hope to validate the use of a mobile app to analyze endoscopy unit efficiency in order to perform targeted operational interventions to reduce overhead cost savings. Methods: The study was conducted over a 5-week period at a UCLA outpatient community-based endoscopy center. Endoscopy unit staff members were each given an iPad device to input operational check points involving patient flow through the endoscopy unit in real time. A variety of performance metrics were tracked for efficiency, including the True Completion Time (TCT) (scheduled procedure start time to the time the patient exited the room post-procedure), on-time starts (endoscope entry occurring within10 minutes of the scheduled time of procedure), and mean delay (time from this 10-minute mark to endoscope entry) for all cases studied. Results: We analyzed 168 patients who underwent a total of 249 procedures during the study period [42 EGD, 154 Colonoscopy, 51 EGD+Colonoscopy, 2 Flexible Sigmoidoscopy]. A total of 5 endoscopists were included in the study. The TCT was 47 minutes and room turnover time was 10 minutes across all cases studied. Ninety three percent of procedures had on-time starts, with a mean delay of 2 minutes. The average procedure duration was 39 minutes. Conclusion: The use of mobile app technology is a feasible method to implement real-time tracking and management of operational efficiency in the endoscopy center. This technique of efficiency analysis offers potential advantages compared to paper charting including automation and the potential for real-time data analysis and workflow modifications. This software-based technology may facilitate the implementation of large-scale operational efficiency and process improvement projects aimed at enhancing workflow. (1)Kaushal, et al. “Using efficiency analysis and targeted intervention to improve operational performance and achieve cost savings in the endoscopy center.” Gastrointest Endosc 2014;79:637-45.Table 1: Average Time Benchmarks, all cases studiedFigure 1