The Autonomous Endoscopy Unit DESIGNING IT FOR MAXIMUM EFFICIENCY

Jean Marmarinou, RN

ndoscopy is performed in operating rooms, clinics, emergency rooms, and outpatient E centers. Autonomous units dedicated to

endoscopic procedures are rare, but they are becoming increasingly popular. If designed appropriately, the autonomous endoscopy unit can meet a wide variety of patient needs.

This article discusses factors that need to be considered in the design of an endoscopy unit. The types of procedures and caseload determine the amount of equipment necessary for the unit. Space must be allotted for the instruments as well as their storage.

An autonomous endoscopic unit must include staff lounges, conference rooms, dictating areas, office space, waiting areas, and preprocedure rooms. Luxuries such as showers in the dressing area should be considered during the planning stage.

One of the primary factors in planning a unit is creating an efficient traffic pattern. In an optimal situation, the procedure rooms, cleaning areas, dictating areas, and holding areas are in close proximity to each other. Offices, lounges, conference rooms, and waiting areas may be on the perimeter. This reduces unnecessary traffic within the core of the unit.

Nurses must be involved in the design phase.

Jean Marmarinou, RN, CNOR, CGC, is the supervisor of the endoscopy unit at St Joseph Hospital, Houston. She received her associate degree in nursing from San Jacinto Junior College, Pasadena, Texas.

They can help develop effective traffic patterns and determine proper placement of utility outlets and assistance call systems.

Identijjing Procedures

0 ne of the first steps in the planning process is identifying unit objectives, including immediate and long-range needs of the

facility, physicians, staff, and patient population. Identifying the patient population is important because it also affects spatial arrangements. If there is to be both an inpatient and outpatient population, the unit must contain areas in which to admit and prepare the outpatients. The holding areas must be larger to accommodate additional space and staff.

Procedures. Many procedures are done in conjunction with endoscopy. The type of procedures influences the planning of the endoscopy unit in terms of equipment and space required. It also helps identify requirements for electrical circuits, special outlets, and radiation shields. The following are some of the procedures that can be performed in conjunction with endoscopy.

Percutaneous endoscopic gastrostomy. It re- quires a more extensive setup, and subse- quently more floor space, than a routine gastroscopy. Biliary procedures. Endoscopic retrograde cholangiopancreatography requires an elab- orate setup in addition to fluoroscopy. Pulmonary procedures. Bronchoscopy or iridium implantation require fluoroscopy.

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Fig 1. The larger room accommodates additional instrumentation for percutaneous endoscopic gastrostomy or for combined procedures. Note that the telephone, call systems, dimmer switches, oxygen, suction, and medical air are on the wall above the countertop, making the countertop accessible to the circulating nurse

The type of procedure also determines the size of room and utility specifications (Fig 1). Small rooms, approximately 10 x 17 feet, are sufficient for gastroscopy and colonoscopy procedures. Larger rooms, approximately 17 x 17 feet, are necessary for percutaneous endoscopic gastros- tomy procedures, laser procedures, and combined procedures such as gastroscopy with colonoscopy. In addition, when video equipment is used, the procedure must be performed in a larger room.

The type of procedures also helps determine staffing needs and the number of procedure rooms.

Cleaning Rooms

n endoscopy unit must include one or more cleaning rooms. If not cleaned A quickly and correctly, endoscopes clog

easily. Clogging is one of the most frequent factors contributing to high repair costs. In an optimal situation, cleaning areas are located between two procedure rooms. A sufficient number of cleaning

rooms should be planned to meet the needs of the unit. Size of the cleaning areas is dictated by the amount of equipment to be processed.

Cleaning areas should be easy to enter with contaminated instrumentation. Each area of the cleaning rooms (ie, contaminated, clean) should have a sink rather than one divided basin for cleaning or rinsing. Because forced air and suction are necessary for cleaning, each sink should be equipped with piped air and wall suction. Forced air and wall suction are better than large air cylinders because they do not require floor space.

Cleaning rooms should allow for flow of instrumentation from the contaminated area to the clean area, and finally, to storage. A physical barrier such as a partition can be used to separate the work areas. Exhaust fans that are mounted on the ceiling will ensure that the cleaning room is well-ventilated. Other factors to consider in designing cleaning areas are:

creating storage under counters (wall cabinets hamper movement with endoscopes),

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Fig 2. Sonic processor and automatic endoscope cleaners facilitate the cleaning process and prolong instrument life.

Fig 3. Open shelving accommodates the light source, electrosurgical unit, and heat probe. Grommets and outlets under the counter make the equipment more accessible.

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Fig 4. The suction apparatus can be placed in a lower cabinet, which removes it from the

patient’s view and enhances the room’s appearance.

Fig 5. Locks provide additional security when endoscopes are hung from hangers.

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locating drawers close to each sink for storing cleaning supplies (eg, gauze sponges, applicators), and creating adequate counter space for soaking pans. Optimally, different soaking pans should be used for the upper and lower gastrointestinal endoscopes and pulmonary endoscopes. Additional pans are required for the rinsing process.

Counter space also is required for small, tabletop steam sterilizers, which are used to sterilize accessory items such as biopsy forceps and snares. Space also is needed for automatic endoscope cleaners, sonic processors, and flash sterilizers (Fig 2). If this equipment can be located in one large, central cleaning area, ancillary cleaning areas can be designed adjacent to the procedure rooms.

Innovations in automatic endoscope washers have facilitated the cleaning process. This equipment uses approximately the same floor space as a washing machine.

When designing the cleaning area, it is important to get professional input on electrical and plumbing requirements because the require- ments may vary.

Procedure Room

esigning the room where the endoscopic procedures will be performed is the next D step. With proper planning, cabinets and

open shelving can enhance the work space and make equipment more accessible (Fig 3). Part of the countertop can be designated as the endoscope setup area, and the open shelving beneath this area can house the light source and electrosurgical unit. To ensure that equipment is properly ventilated, the lower cabinets should be at least 25 inches deep and wide enough to allow two to three inches on each side of the equipment. Adequate space must be planned for in advance to handle changes in equipment size and shape. The following are some tips that we found to be useful.

Canisters can be placed in lower cabinets to make the room appear neat, and by installing proper holders, the canisters are more stable (Fig 4).

Grommets should be placed in the rear of shelves and cabinets to eliminate exposed cords and allow access to the countertop wall suction An aperture in the cabinet door allows, suction tubing to be passed through to the light source during procedures. Oxygen, suction, aind medical air are placed on the wall above the countertop to make the countertop imore accessible to the circulating nurse. Medical air is higher grade than regular piped air. Monitoring devices are placed on the countertop adjacent to the head of the stretcher. The devices include an automatic blood pressure device, pulse oximeter, and electrocardiogram monitor. Telemetry eliminates the need for additional cords to the stretcher. To increase storage areas, peg boards can be used to store biliary stents, balloons, and guide wires. Not only does it save space, it makes these item highly visible.

Each endoscopic room should contain a hand washing sink, which is placed away from the electrical equipment area and the procedure area. An ideal location for a sink is near the linen storage cabinet.

Storing endoscopes, One central location for endoscopes is ideal, if space permits. The cabinets should be tall enough to accommodate the longest endoscope, and they should be wide enough so that each endoscope can be removed without disturbing adjacent endoscopes or hitting the cabinet wall. For additional security, endoscope hangers should be used with individual locks (Fig 5). Biopsy and grasping forceps also can be hung on the hangers, but they must be a sufficient distance from the floor.

Liners for closets should be resistant to moisture and easily cleaned. The closet itself should be vented to Ieduce fume accumulation from the disinfectant. Hangers for accessories allow adequate drying and prevent obstruction during the procedure

nfumination. Proper illumination enhances endoscopic procedures. Recessed lights with dimmer capabilities offer good visualization without extssive light Additional lights under

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light sources electrosurgical unit heat probe procedure carts

video equipment lasers endoscope washer sonic processor sterilizer endoscope hangers soaking pans for each clean

Equipment for Endoscopic Unit

Procedure room

room electrocardiogram monitors automatic blood pressure

pulse oximeter infusion pumps portable oxygen crash cart

monitor

as designated as designated 1 per two procedure rooms Minimum of 1-dependent on use and number of emergency

1 per procedure room 1 per unit (may share with OR) 1 per unit 1 per unit 1 per unit 1 per endoscope 1 per upper gastrointestinal; 1 per lower gastrointestinal; 1 per

pulmonary; 1 per accessories; 1 per rinsing per procedure room; 1 per bed in postanesthesia care unit per procedure room; 1 per bed in postanesthesia care unit

procedures

per procedure room; 1 per postanesthesia care unit per unit per stretcher per unit

1 per unit 2 per unit (linen and supplies) Dependent upon available space-an extra two to four stretchers if

storage space is available. We perform a patient’s procedure on the stretcher on which he or she is brought in from the holding area.

some instruments and promotes efficiency in setup.

computer with printer storage carts stretchers

stainless steel carts

wheelchairs 2 per unit

One per extra set of instrumentation-this affords safe storage of

stretcher wheelchairs electrocardiogram monitor automatic blood pressure

monitor pulse oximeter crash cart portable oxygen call systems and emergency

piped in oxygen and

medication station lockers desk and chairs

calls

suction

Holding room

1 per bed space 2 per holding area 1 per holding area 1 per holding area

1 per holding area 1 per holding area 1 per stretcher 1 per bed space

1 per bed space

as space allows for outpatient belongings

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the cabinet make it easier for the staff to care for specimens and instrumentation. A combination of these light arrangements provides illumination even during a blackout.

Equipment, Instrumentation

he final step in designing an autonomous endoscopic unit is to select proper T equipment. Identifying equipment needs is

part of the initial design process. Developing the shopping list is important and makes the unit more efficient. (See “Equipment for Endoscopic Unit.”) Our minimal list of equipment and endoscopes does not allow for much downtime. We consider

the following endoscopes essential: colonoscopes (2); gastroscopes (2); bronchoscopes (2); sigmoid- oscope (1); duodenoscolpe (1); and lecturescope (teaching attachment for flexible endoscopy) (1). Endscopic accessories include grasping forceps (2), biopsy forceps (2), and an assortment of valves, hoods, mouth pieces, and brushes.

Other factors to evaluate are the types of procedures to be performed, the scheduling procedures, and physicia.n preferences. Providing quality patient care andl efficient service is one of the goals of the endoscopy unit. Implementing forethought and careful research will promote these goals. 0

Stress Leading Cause of Missed Workdays Stress causes American workers to miss an aver- age of 16 days on the job each year, according to a survey by the Gallup Organization, Inc, that was reported in the Nov 10, 1989, issue of American Medical News. Stress, along with anx- iety and depression, costs businesses and employ- ers billions of dollars each year in lost wages and for treatment of related disorders.

Some of the respondents said that problems caused by stress contribute to decreased produc- tion, lower employee morale, and alcohol and substance abuse. Managers also responded that 13% of their employees suffer from symptoms of depression: difficulty in concentrating, loss of energy, loss of interest in work, and trouble sleeping.

The cost of occupational disability related to mental problems averages $8,000 per case, according to Robert M. A. Hirschfeld, MD, the chief of the Mood, Anxiety and Personality Dis- orders Research Branch of the National Institute of Mental Health, Rockville, Md.

If the problems continue, Gallup officials pre- dict that stress and depression will dominate the field of occupational disease in the 1990s. Dr Hirschfeld recommends that businesses add men- tal health coverage to group insurance policies.

Outcomes Management Systems Developed Quality Quest, a subsidiary of a think tank in Minneapolis. is developing an outcomes manage- ment system ta track the effect of medical care on patients over time. “lie system will measure a patient’s clinical condition, functional status, and satisfaction with care, according to an article in the Nov 5, 1989, issue of Hospiruk. It also will be able to isolate the experience of individual patients by diagnosis, tre,atment, or provider group.

Believing that the outmmes management con- cept will increase in popiularity, the American College of Physician Executives, Tampa, is devel- oping a curnculum to train physicians. It will teach physician executives the philosophy behind the concept, how to implement an outcomes management system in their organizations, and how to interpret data and take corrective action.

Patient satisfaction also is important to the concept. To this end, a scientist at the Institute for the Improvement of Medical Care and Health, Boston, has developed a patient satisfac- tion survey. It it being tested to determine how patient satisfaction can be incorporated into out- comes management. Health care organizations can use the survey as long as they report back to the think tank regarding how they are using it.