| Abstracts from the 7th International Meeting of SIGNEA 1998 |
ENDOSCOPIC TECHNIQUES - CLIPS Introduction
Disadvantages Malfunction of haemoclip device during procedure
ENTERSCOPY Tova Podchlebnik3, RN, BA; Jacov Rattan4 l) Head Nurse, Head of
Department, Institute of Gastroenterology, Nutrition & Liver Diseases, Assaf Harofeh
Medical Center, Zerifin
BILIARY LITOTRIPSY: STATE OF THE ART Extraction of common bile duet stone is usually carried out spontaneously with balloon catheter or dormia basket. In case of giant stone or narrowing of the lower part of the common bile duet destruction of the stone should be performed locally. Mechanical litotripsy is the most common method. Immediately after endoscopie sphineterotomy, a specially designed dormia basket with only one wire component is passed through the biopsy channel then inserted into the common bile duet. Once the stone is grabhed, the litotriply could be performed by crushing the stone against a metallic shaft. Some devices require to withdraw the duodenoscope first before sliding the metallic shaft on the wire, other devices could be directly inserted into a large channel duodenoscope. In order to avoid impacted stone, some endoscopists use routinely this type of dormia basket. In some conditions, the stone fails to be trapped into dormia basket. Piczo-hydraulic probe could be used in order to crash the stone by hydraulic shock waves. Then the picces of stone are removed with routine basket. In few other cases, the direct access of the duct requires the use of a choledoscope via transhepatic route or with a mother-duodenoscope, baby-choledoscope system. Yag-laser or hydraulic device could be used to destroy the stone under endoscopie guidance. In very few patients, endoscope failure leads to leave in situ a naso-billiary tube then to use an extra-corporcal shock wave litotripsy. Endoscopie litotripsy is an important procedure in order to extract öarge stones. Its only drawbacks are the cost of equipment and the time consuming procedures. ENDOSCOPIC MUCOSAL RESECTION Startig with the ,,strip biopsy" of flat lesions in the
gastrointestinal tract, endoscopic mucosal resection (EMR) has become a well known
therapeutic procedure for special types of polyps and carcinomas. The development of the
technique was mostly done in Japan, obviously due to the high rate of early cancers in
this country. EMR is used to ensure the complete excision of flat adenomas or mucosal
carcinomas (T1a) with the aim of a curable resection.
Different combinations of the techniques are also in use. Histopathological workup of
the specimen should comment on free resection margin and on invasien depth. In some cases
a second intervention is necessary to ensure the complete removal of the lesions. Lesion
diameters of more than 20 mm and large sessile-type configurations seem to be associated
with incomplete removal.
INTRALUMINAL USE OF THE GASTROINTESTINAL TRACT Convex or linear scanning echoendoscopes have been recently introduced (3). With respect to the anatomic orientation and to the general overview of the structures, the linear (convex) approach appears to be inferior to the radial method. This is due to the limited scanning field (90°-180°), parallel to the long axis of the instrument. However, since the needle can be followed on the ultrasonography screen, it is possible to perform EUS guided fine needle aspiration biopsy (FNAB) of target lesions located within and beyond the gastric wall (Olympus GF-UM-30P). Furthermore the incorporation of a Doppler signal, with or without colorr may open new areas of investigation, such as the study of vascular abnormalities or of esophageal or gastric varices and collateral veins in patients with portal hypertension. Several types of small ultrasonic probes have been designed for the imaging of gastrointestinal structures (Olympus UM-lW, UM-2R/3R) (4). The main advantage of these probes, with a 7,5-30 MHz frequency range, is that they can be passed through the working channel of conventional endoscopes during upper and lower endoscopy, as well as in ERCP. High frequency miniprobes allow the visualization of mural gastrointestinal structures with much greater resolution, so that they can be useful to evaluate small and flat lesions such as early cancers. Anyway the depth of penetration is low, thus making the assessment of large tumors arid extramural lesions difficult.
ESOPHAGEAL AND GASTRIC MALIGNANCIES Esophageal cancer
OTHER ESOPHAGOGASTRIC CONDITIONS Gastroesophageal reflux and Barrett’s esophagus EUS seems to be an important supplement to endoscopy in reflux eshopagitis (RE) staging, as endoscopic findings are not always related to the progression of inflammation. Our group prospectively evaluated (16), by radial scanning echoendoscopy, 31 patients with endoscopically proven reflux esophagitis. We found that also mild esophagitis may cause the thickening of the entire esophageal wall and that there is a lack of correlation between the onset of symptoms and the degree of thickening. Anyway the role of EUS in the management of this disease remains still unproved, and further studies are necessary. The role of EUS in the management of patients with Barrett’s Esophagus (BE) remains largely unproved because it hardly detects very early stages of cancerous transformation of the mucosa. Srivastava et al. (17) found out that in patients with BE and dysplasia the esophageal wall thickening was not siqnificantly different from that measured in patients without dysplasia. The use of high frequency ultrasound transducers, capable of providing higher resolution images of the esophageal mural architecture, may be more useful in the evaluation and management of these patients.
Motility disorders EUS has been proposed for the evaluation of the lower esophagus wall in patients with achalasia, but the radial scanning echoendoscopes did not yield conclusive results (18). On the contrary, these Instruments may be useful in differential diagnosis from pseudoachalasia caused by esophageal tumors. The use of high frequency probes may prove more appropriate in this field because of their better resolution of the muscle layer.
Portal hypertension EUS allows the visualization of a large part of the portal venous system better than other non-invasive imaging procedures. Anyway its rote in the management of patients with portal hypertension (PH) has not been cleared up yet: while it is less suitable than endoscopy to detect esophageal varices, it better diagnoses gastric varices, differentiating them from submucosal tumors (4,19). Moreover EUS findings do not play a particular role neither in the assessment of variceal bleeding risk nor, as previously suggested, in the follow-up after variceal endoscopic sclerotherapy or band ligation (20). Doppler signal can be considered when transabdominal Doppler ultrasonography is nondiagnostic in those patients in which we suspect thrombosis of the portal venous system. Color Doppler Endosonography is also potentially useful to detect blood flow in gastric varices before and after cyanoacrylate glue injection.
PANCREATOBILIARY DISEASES Pancreatic cancer and neuroendocrine tumors EUS is highly accurate for the diagnosis and staging of pancreatic carcinoma and it is superior to other imaging methods such as US, CT, ERCP and MRI (4). Assessment of vascular invasion is crucial to determine cancer resectability: direct visualization of tumor growth in the vascular lumen and collateral vessels is probably the most reliable parameter in this sense. Anyway as inflammatory masses do not show a significantly different EUS aspect, the differential endosonographic diagnosis of cancer versus focal chronic pancreatitis may be difficult. The recent introduction of EUS-guided fine needle aspiration biopsy may be useful in this respect. Neuroendocrine tumors of the pancreas and of the gut may be difficult to detect by traditional imaging techniques: EUS appears to be 80% accurate in ultrasound-negative and GT-negative cases (4). EUS allows detailed visualization of the whole pancreas and almost the major parts of the gastric and duodenal walls: it is an important diagnostic tool for the preoperative localization of neuroendocrine tumors especially when used together with somatostatin-receptor scintigraphy.
GALLSTONES Gallbladder stones are usually diagnosed by transabdominal ultrasonography. However in selected cases, such as obese patients, EUS may detect sludge or small stones missed by US. Extrahepatic cholestasis is the best application, where EUS is more sensitive than US and CT (21). Stones in the intrahepatic duct, or in the right or left branch, and in the common bile duct can be localized, as well as ductal wall thickening.
LOWER GASTROINTESTINAL TRACT Colorectal carcinoma Rigid probes are the standard for intrarectal ultrasonography. An ultrasound colonscope with forward-viewing optics has been recently introduced to evaluate the entire large bowel, but its clinical utility still needs confirmation. Many studies showed EUS to be very accurate in the preoperative locoregional staging of rectal cancer (22), with an 80% accuracy for the T stage and 72% for the N stage. Scarce differentiation between T2 and T3, due to the inflammation around the tumor, is the principal drawback; on the contrary accuracy for T1 is very high (about 100%). As far as T and N stages are concerned, this technique appears to be superior not only to digital examination but also to MRI. Moreover ultrasound-guided biopsies of pararectal lymph nodes can be performed to help clinical decision making. According to Ramirez (23), postoperative rectal ultrasonography can detect local recurrence at an early, treatable stage. The method is more accurate than digital examination and sigmoidoscopy and it should be part of a regular follow-up program.
Anal canal Some authors suggested EUS could play a role for the staging and the follow-up of epidermoid carcinoma of the anal canal (24). After conservative, non surgical treatment, EUS can document a progressive decrease in tumor bulk even if distinction can not always be made between scar formation and local recurrence. Further prospective long term studies are required. Endosonography clearly delineates the muscular structures of the anal canal and for this reason it has been tested in the management of fecal incontinence (25). Anyway not always muscular function alteration shows a morphologic correlation detectable by EUS. On the other hand, in some incontinent patients, EUS proved to be more accurate than clinical and conventional physiological methods (manometry and electromyography) to detect external or intemal sphincter defects or both. It can be used also to evaluate the results of sphincter surgical reconstruction, especially when unsatisfactory.
REFERENCES
WHY QUALIFIED NURSING PERSONNEL IN ENDOSCOPY? As long ago as 1973 the British Society of Digestive Endiscopy (BSDE) issued a memorandum which stated that"A trained nurse is the ideal person to assist in the organisation of an endoscopy service and at the actual examination". The BSDE has long since merged with the British Society of Gastroenterology (BSG); we now refer to "qualified" rather than "trained" nurses – and endoscopy in the gastrointestinal tract has undergone phenomenal growth since 1972 so why do we need qualified nurses in endoscopy in the late 1990s? Qualified nurses are professionals, accountable for their own practice and responsible for the nursing needs of their patients and clients. To be capable of providing informed and appropriate care for people with problems requires understanding of concepts of health and wellbeing (HSC 1997). To become a qualified nurse in UK and other countries of the world one needs a broad based education and sufficient academiec achievements to gain access to a demanding university based diploma or degree course lasting 3–4 years. The European Union (EU) directive on this topic demands full time theoretical and practical instruction of a least 4,600 hours (Salvage 1998). In common with other countries the UK curriculum includes study of the biological sciences, psychology, sociology, law, social policy, philosophy, ehtics, research, communication skills, practical skills and management. Practical skills and application of theory to practice are recognised as essential and students gain practical experience in the full range of hospital wards and departments and in the community setting gaining knowledge of how the principles of nursing are applied to different care settings. On successful completion of the programme the qualified nurse is registered to practice nursing by the United Kingdom Central Council (UKCC), the regulatory body responsible for the standards of the profession. It‘s members are required to practice and conduct themselves within the standards and framework provided ba the "Code of Professional Conduct" (UKCC 1992). The mark of the professional has been described as the ability to observe and assess a particular situation and then to select the appropriate nursing response to meet the circumstances. Qualifying as a Registered Nurse is an impressive achievment (HSC 1997) leading to a satisfying career. Where endoscopy nursing is concerned it is starting point to futher training in this specific area. "As an accountable professional it is your responsibility to keep up to date and add to your skills. Registration is only the beginning" (UKCC 1992). Gastrointestinal endoscopy today includes a wide variety of diagnostic and therapeutic procedures, undertaken in a wide variety of settings in people of all ages, of different physical status and with a range of risk factors. Sedation using benzodiazepines sometimes supplemented with opioid drugs is coomon and there are serious risks attached to both procedures and drugs in some cases. In disgnostic oesophago-gastro-duodenoscopy (OGD) alone a recent survey (Quine 1994) showed a mortality rate of 1:2000 and a morbidity rate of 1:200. These figures are significantly higher in therapeutiv procedures and particularly ERCP. The common needs of all of these patients can be simly defined as a need for information and support coupled with safe and appropriate care. To provide the former, individualised to the needs of each patient, requires considerable skills backed by a sound knowledge not only of endoscopic procedures and their risks but also of the bilogical sciences, disease processes, psychology, sociology, law, social policy, philosophy, ethics and research. To provide the latter requires application of the principles of nursing usinf tools familiar in nursing and encompassed in the nursing process, assessment, planing, imlementation and evaluation of care. In fact the needs of people with problems requiring endoscopy are no different from those of people with any health and to provide informed and appropriate care for people with problems is exactly why people become qualified nurses! Although ensuring safe patient care with effective outcomes is the focus of all activity in endoscopy it is widely recognised that there are other essential functions in providing the service. It is appropriate that qualified nurses undertake aspects of other roles, for example:
CONCLUSION Esconomical and efficient provision of an andoscopy service is a multidisciplinary team responsibility and it is not within the remit of this presentation to discuss the roles of other members of this team. The role of the qualified nurse in this setting is varied, demanding and satisfying, however it must be remembered that "The registered nurse must, in serving the interests of patients, clients and the wider society, avoid any inappropriate delegation to others which compromises those interests" (UKCC 1992).
References British Society of Gastroenterology. (1989) Safe Working Practices for Gastrointestinal Endoscopy, Working Party Report. BSG, London Department of Health. (1997) Nursing. Health Services Careers, London Quine, M. A.; Bell, G. D.; McCloy, R. F. et al. (1995). Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety and sedation methods. GUT 1995; 36:463–467 Salvage, J. (1998). Taking the Lead. Nursing Times Volume 94, No. 18:32_33 UKCC (1992). Code of Professional Conduct. UKCC, London UKCC (1992). The Scope of Professional Practice. UKCC, London Bibliography Ravenscroft, M., Swan, CHJ, (1984). Gastrointestinal Endoscopy and Related Procedures. Chaman and Hall, London Shepard, M., Mason, J. (1997). Practical Endoscopy, Chapman and Hall, London Society of Gastroenterology Nurses and Associates Inc. (1998). Gastroenterology Nursing. A. Core Curriculum. Mosby, St. Louis, USA EDUCATION OF ENDOSCOPY NURSES AROUND
THE GLOBE doctors. There is only a handful of full time gastroenterologists but numerically more endoscopist made up by family practitioners, internist arid surgeons in 166 public arid private healthcare facilities. Out of which the majority are 35 goverment hospitals and a large number of standalone daytime doctor’s clinic (75 in all). There are another 50 classified as medical centres with inpatient numbers of between 2 to 240 beds. Endoscopy is relatively young in Malaysia with the first gastroscopy owned by a busy government surgeon who carried the scope in a suitcase while on call in 1976, and the first diagnostic ERCP at University Hospital in 1978. The early publicity on the need for nurse training in endoscopy came in 1988, the initiative having come from the private sector. There are 150 nurses involved in endoscopy, half of which are in full time endoscopy. Some endoscopy is still being done in operation theatre, We have very few endoscopy units in both private and public sectors, headed by a handful of skilled dedicated nurses, with units doing over 4000 procedures per annum, the range of procedures being no different from any busy centres in the world. These very same units offer an on-call emergency nurse rota. They have pulse oximetry and ECG recording during procedures, and some units tise only pharyngeal ariaesthesia with high patient turnover. Pre-endoscopy checks by nurses into fasting state, current medications, cardiac prosthesis, allergies and ensuring safe accompaniment homo after the procedure and all that impact on the patient safety may be actively practised and documented in a few units. Regular bacterialogical swabs from instruments and accesories are carried out in at least one unit, with close liaison of the hospital infection control officer. Each procedure is supervised by a SRN and one endoscopy assistant whose background may be a high school leaver, a state enrolled nurse or a male nurse who does not involve in drug administration, but skilied in safety observation like oral secretion suction, patient monitoring, biopsies, arid instrument disinfection. They also assist in Ph monitoring and othcr daycare procedures like liver biopsies arid IV therapies. They cope with difficult customers and impatient, demanding difficult endoscopist, and some hospitals offer in-house customer relation coping skills training to staff. Such mixed skill is a reflection of the manpower shortage and cost containment that afflict us here and elsewhere. Experience is gained on the job training. No formal certification, structured course or syllabus has as yet been worked out in both the private and public centres. Presently there is no national societies that are focus on endoscopy nurse training. We have four conferences held over the past ten years that hightlighted on eridoscopy nurse participation. Some Public hospitals have taken their own initiative to conduct training with assistance from equipment vendors. The latter remain the only source of "training" in disinfection at the point of sale arid some during after sales, but played no role if it was actually carried out correctly and consistently. Thus for the large part of endoscopy performed in Malaysia, in solo practice, the vendor provided the only link to some standard of care of instrument and disinfection of a few, usually diagnostic upper and fewer lower endoscopies daily. They are probably assisted by non-SRN because of cost and shortage of skilied personnel. The high turnover of staff in near full employment state meant the solo endoscopist will have to be highly motivated to maintain the standard of clean endoscopy with every change of staff. Even if the endoscopist is conscientious and wishes to send the staff for training, there exist no mechanism in government or university centres to accept them at this present moment. The problems surveyed above is probably true elsewhere in some parts of the world, with each trying to cope with its own handicap. At the local level, each centre must ensure the minimum standards of endoscopy are met by close supervision by experienced staff, each country through its national societies offer a regular training course, open to both private and public sectors and assisted by various vendors. We would welcome the world body’s assisstance by providing input of expertise or current practise and research endeavours at regional meetings.
EDUCATION OF ENDOSKOPY NURSES AROUND THE GLOBE -
SITUATION IN EUROPE In Europe after completing basic nurse training and passing thc statc examinations, nurses arc able to work in endoscopy departments without compulsory further job spccific education. First training usually involves "on the Job training" with the support of a mentor. To enable nurses to fulfil the requirements of the job in endoscopy, various annual meetings and workshops have been offered locally and/or nationally since the early seventies to endoscopy nurses, facilitating them to share information and experiencc. Due to technical developments in endoscopy diagnosis and therapy, the necessity for specialist training in endoscopy nursing has become more and more important. Some European countries have already established specialist endoscopy training courses for now morc than tcn years. Speaking about post-basic education in nursing and comparing different models, there arc some definitions to be clarified:
Continuing training is defined as maintaining and updating knowledge and skills. It starts after passing the state exam and continues throughout the nurse’s professional life but does not lead to any formal qualification. There are a lot of opportunities of continuing training, e. g. congresses, meetings, study days or workshops.
Specialist training is defined as post basic training for specialised practice. It contains a study programme which provides knowledge and experience needed to ensure competence in the specialisation. The course leads to a special qualification which is officially and generally recognised. In some countrics this also includes a higher salary. Educational opportunities for endoscopy nurses vary from country to country. In Order to receivc comparable information from European different countries, a questionnaire was developed which dealt with the structure, content, organisation and recognition of endoscopy courses. The questionnaire was send to national representatives of 25 European countries. The questionnaire covered areas of length of courses/study days, content, number of hours of theoretical and practical lessons and national and/or official recognition. Of 25 countries circulated with the questionnaire, 22 numbers replied. Four main categorics of educational activities could be identified. Countries offer:
Countries having no specialist training courses in endoscopy nursing The analysis of the questionnaire has shown that six of 22 countries (Denmark, Greece, Luxembourg, Norway, Portugal and Switzerland) have not had any specialised courses for Endoscopy nurscs yet, but these countries; of course; offer a huge variety of continuing training in the field of Endoscopy.
Countries having specialist training courses in endoscopy nursing Specialist training for endoscopy nurses have been developed in 15 of 22 European countries. (Austria, Croatia, Czech. Republic, France, Finland, Germany, Great Britain, Hungary, Ireland, Israel, the Netherlands, Polen, Slovene, Spain, Sweden). The majority of these courses have been established for about 10 years. 50 to 420 students per country completed these courses. Caurses are organised by national endoscopy societies, nursing associations or ministry of health and education, by universities, high schools or academic hospitals. In 8 countries (53%) the courses are only focused on Gastroenterology, while courses in 7 other countries (43%) cover Gastronenterology as the focal point as well as Theoretic Medicine, Urology and some parts of surgery, orthopaedics and gynaecology. The curricula of the different courses have similar main items. They are: anatomy, physiology and pathophysiology, endoscopic techniques, nursing process, research and standards in endoscopy, environmental safety, hygiene and infection control, pharmacology, radiology, management, psychology and pedagogy, theory of rights, guidelines and regulations Concerning structure, duration and intensity a lot of differences and specialities can be contrasted. Therefore, courses can be slit up into two groups with courses having similar characteristics.
Short intensive courses Countries with short intensive term courses are: Austria, Croatia, Czech. Republic, Finland, France, Ireland, the Netherlands, Polen, Spain, Sweden. Characteristics of courses are: The duration of courses vary between 1 to 4 weeks. 6 courses (69%) concentrate on theoretical lessons; 4 courses (40%) oflier practice and visits in other endoscopy departments. A short examination has to be passed in 4 courses (40%). Only 3 (30%) courses lead to official recognition.
Long term, job accompanied courscs: Specialist training courses in Great Britain, Germany, Hungary, Israel and Slovene have a lot of similar characteristics: These courses are organised in a job accompanied form. They cover a longer space of time (from 10 weeks in Slovene to 2 years in Germany). The courses have theoretical as well as practical lessons, e.g. The German course covers 360 theoretical and 480 practical lessons. The British course include 3 weeks of theory and practice. Practical lessons are organised as practical training in other endoscopy departments. Students have to pass an oral, written and practical examination. In addition, several project tasks or written assignments, marked at diploma level, have to be carried out during the course. Students obtain an offcial recognition. In Great Britain courses are established at universities while in other the four countries societies and institutes organise courses.
In all questioned countries the employers usually have to finance the specialist courses by themselves: In the majority of countries the student is exempt from hospital duty during the theoretical and practical lessons but still receive a monthly salary. In most countries passing out from such courses for endoscopy nursing, does not automatically mean a higher salary. In Great Britain, the Netherlands and Germany, sometimes graduates have the chance to negotiate a higher salary. This strictly depends on the single hospital where the nurses work.
Courses in Planning Three countries (Austria, Belgium, Germany and Italy) are in the process of developing new models and curricula for courses which will be established within the next fcw years. Usually the national society of endoscopy nurses took the initiative. Working parties have already been established, in co-operation with official bodies (e. g. ministries of health / education). Austria and Italy plan to establish long term courses of one year containing 830 or 1700 hours theory and practice, covering all fields of endoscopy (gastroenterology, Thoratic Medicine, Urology, Gynaecology, Orthopaedics). In Germany a new curriculum has been developed combining operation theatre and endoscopy nursing containing 720 theoretical lessons and 2400 hours in practice. In Belgium a short intensive course of 1 week with 45 hours focused on Gastroenterology have been developed.
Legal situation In each European country a lot of different legal regulations concerning education have to be taken into account. In addition, European bodies also develop recommendations and guidelines which are or will be important while establishing specialist training courses. The "Permanent Committee of Nursing on the EU (PCN)" positively influence, restrict or regulate educational activities and developments on the national level. The "Advisory Committee on Training in Nursing (ACTN)" published "Recommendations on Continuing and Specialist Training". These recommendations also have to be taken into account in each European country while creating and establishing specialist training.
Conclusion For more than ten years specialist training courses in endoscopy nursing have been established in a lot of European countries. We have a huge variety of models and specialities. There are some important questions for the future which we have to clarify.
ESGENA has already startes to collect and interchange information from all over Europe. European guidelines for education in endoscopy will be defined. In co-operation with its national members. ESGENA will work towards a European curriculum and official recognition. The positive feedback of students confirms the necessity of specialist training in endoscopy:
Continuing as well as further education is important to update and increase endoscopy nurses’ knowledge and to gain acceptance and official recognition. The complex and ever developing high technology and nursing need of endoscopy requires highly trained and qualified nurses.
EDUCATION OF AN
ENDOSCOPY NURSE IN THE UNITED STATES Prior to entering the gastroenterology endoscopy specialty a registered nurse must have an active license to practice in the state she is seeking employment. It is preferred that the R. N. have at least two years medical/surgical clinical experience, and be cardiopulmonary resuscitation certified. After employment comes orientation. Orientation is a process of intensified learning prior to the R. N. assuming responsibilities. The probationary period varies and can be from 6 weeks to 3 months. This individualized process assigns a preceptor to the orientee. The nurse is introduced to physical facilities, personnel, job descriptions, etc. The preceptor ensures that a structured program is implemented based on the identified learning needs of the orientee. The orientee is expected to complete the endoscopy competencies within the probationary period. When all items of the endoscopy competencies are met, a documentation of completion is signed and dated by the nurse, the manager, and the preceptor. The nurse is then competent to fulfill her job functions. SGNA certification is encouraged after a minimum of two years full-time or its part-time equivalent of 4000 hours. Testing validates an individuals qualifications and knowledge within the specialty practice. This voluntary process was developed to recognize the nurses desire for professional achievement and promote excellence within the specialty.
EXPERIENCES WITH COMPUTERS IN ENDOSKOPY Objective: Upon completion of this presentation, the participants will be able to discuss the applications of computers in an endoscopy setting. VI. Documentation A. Endoscopy Reports B. Nursing Documentation C. Staff Competencies D. Computerized Medical Record E. Image Documentation II. Communication A. Letters/Reports to Referring Physicians B. E-mail III. Data Collection/Aralysis A. Endoscopy Unit Statistics B. Equipment/Accessory Inventory C. Endoscope Utilization and Repair IV. Research A. Cyberqueries B. Benchmarking C. Surfing the Internet V. Presentations/Meetings A. Powerpoint B. Smart Boards VI. Marketing A. Websites
ERGONOMICS IN ENDOSCOPY Postural disorders are by no means a new problem, in 1713 Rammazzini who was an Italian physician and author of "De Morbis Artificum" thought to be the first text relating to occupational medicine , described the problems of scribes who were working in cramped and poor conditions , this led them to suffer from disorders of the wrists and forarms and in the worst cases led to paralysis of limbs through the centuries that have followed postural disorders have been identified in various groups of trades and professions, these include foundry workers , drummers locksmiths, organists and many more.
The current situation The Health and Safety Executive (HSE) who are tasked to police health and safety issues within the UK reported that in the year 1996 musculoskeletal problems were the most frequently reported (593000 cases) Nurses were among the highest proportion of these cases . The HSE had previously noted in its dlsaussion document regarding the introduction of the Manual Handling Regulations 1992 that "For many years Legislation and guidance on manual handling have concentrated on the weight of the load, it is now well established that the weight of the load is only one and some times not the main considoration affecting the risk of injury, factors such postural requirements and frequency and duration of handling need also to be considered."
WHAT ARE THE PROBLEMS? Damage to cervical region The neck is made up of 7 small vertebrae , these do not have to transmit large amounts of weight, however they are very moveable which allows us a good field of vision. The cervical vertebrae arc vulnerable to injury by external force such as whiplash or head injury. The neck is very able to hold the head erect but when it tries holding the head at one of its extremes of motion it will very quickly tire Demonstration. Many tasks performed in enterology require the head to be bent forward this increases the pressure on three cervical discs arid makes the small muscles work very hard. The effects of this are neck tension, neck stiffness and headaches but in the long term this can lead to disc and joint degeneration .
Table height During the act of standing the weight on each vertebrae is shared between the disc and the intervertabral joints, any forward bending of three lumbar spine places additional pressure on the disc . Any increase in the disc pressure greater than that created by standing erect tends to squeeze the fluids out of the disc arid increases the likely hood of disc damage. Bending forward 20 degrees from a central erect position increase the pressure on the disc by 70% .
Shoulder injuries The shoulder joint differs from other joints in its structure in that, unlike other joints that have strong ligaments that surround and support them, the shoulder joint has a nest of muscles known as the root cuff. This nest of muscles allows added flexibility and good control of the shoulder in many different positions . Unfortunately the muscles the root cuff are small and can be damaged by poor positing, injuries to the shoulder are often difficult to manage they are very painful and debilitating.
Muscular fatigue This occurs when muscles are over used, it results in reduced power of the muscular contraction arid a reduction in muscular power, when a muscle works continuously it has sufficient energy for s short period oftime.
Thus - Maximum force can be sustained for about one second
Head of table
RECOMENDATIONS We are now aware of the problems what can be done to prevent them? Good risk assessment at unit level, look at the tasks completed and evaluate how they can be done more safely, include consideration of space and working environment, Ensure that equipment is serviceable and will adjust in height, an extra monitor on the other side of the room may be of value check the depth of sinks, to ensure excessive bending is not required what training is being provided in correct manual handling, can aids be used to reduce the strain on Staff Use time between cases to loosen off tensed muscles, by gentle rotation and stretching exercises Ensure staff are aware of the problem, invariably postural disorders that are noted early respond well to treatment, where as those left unattended be come chronic ailments that can be career threatening Remember that painful shoulders and limbs are not an occupational hazard to be ignored. KINESTHETIC - FROM
LIFTING TO MOVING "Kinesthetic" is formed from Greek words "Kinesis"=movement and esthetic = beauty, harmony or perception. It therefore means perception of movement or moving in harmony. Known is the concept as "perception of kinesthetic" with contact, including proprioception and positional perception.
The Inventor The American psychologist Lenny Maietta and the American dancer Frank Hatch developed the concept of kinesthetic and together with Nurse Susanne Schmidt established the programme "Kinesthetic in nursing care". This programme is suitable for all areas of nursing care.
Principals Kinesthetic is based on the following principals or basis:
Interaction People use three forms of interaction (or communication) when dealing with each other:
Its about getting patients to move, usually interaction is one-sided: The patient does nothing and the nurses do it all. They lift the patients and literally wait on them hand and foot, resulting in back complaints or other injuries. The nurses learn on the kinesthetic courses how to support movement, e.g. to develop movement together and simultaneously. Patients going in for examination are either flustered or sedated. In both cases there is a deterioration in communication and it is also hindered. Perceptions by means of senses can be restricted: without glasses, without hearing aid and without teeth understanding will be difficult. For such patients movement can be supported by specific contact. Specific contact in the right place in the appropriate ways gives very clear information as to which movement is required. Movement can be written with a physical value, namely of power x time x room. Take the workplace, using an "endoscopy" as an example: The room is in darkness or is dimly lit, with an examination bed, time is limited as in all areas of nursing, everything has to happen quickly. Elderly patients especially find it hard when we do not adapt to their speed. These conditions therefore often lead to the nurses needing a lot of power because the patient is moving but is not being supported.
Anatomy Kinesthetic dedicates special attention to contact. For support of movement it is important that the patient is handled in the right position. Kinesthetic sees (or perceives) the body, as a composition of masses and parts inbetween. The masses are compact and are in relatively firm areas: head, thorax, pelvis as well as legs and arms. They can take on power and act as a lever making them very suitable to support movement. The parts inbetween are the moveable, elasticity zones: throat, waist, inguinal regions, axillas. When moving they should not be held firm otherwise movement will be restricted or blocked. Two dimensional and three dimensional movements are made possible by employment of the parts inbetween, which means by skilful use of physics and physique of a patient’s body lifting Dr carrying does not need to be implemented.
Simple and Complex Functions Everybody in every situation automatically adapts their "suitable" position, e.g. when eating or when sleeping. For example endoscopy: In this situation the patient has to take on an exact position which is suitable for an examination and stay in it throughout the whole examination. Positioning help is provided for this. Unfortunately it is hard work to reposition the body correctly on the examination bed, should it slip during positioning. How can the body be repositioned in the required position without exerting too much strain? When observing a healthy person walking down the street, one leg always bears the body’s weight, whilst the other is relieved from the strain and engages the direction of movement. Then the weight is transferred to the second leg as the first leg swings forward. At the same time the thorax and arms move diagonally, shifting to the pelvis and legs (masses and moment balancing). This is also the basic principal: By stacking the masses over a supporting point there is a possibility of managing diagonal as well as turning movements. In each body position there is a possibility of motion without effort.
Effort as Communication Means When supporting movement, the kinesthetic expert works with tension and force. The word "effort" is usually associated with energetic activities. Tension and force applied in the fitness studio, working out on the equipment, here people sweat and suffer to train their muscles. The movement of people by tension and force is elegant and light when using kinesthetic for support of movement. The secret is hidden in the inneraction of the participants, the room usage and with correct and helpful contact.
Surroundings The 6th principal of kinesthetic lies in the surroundings. One side of the room should be left for the movement of the patient and the supporting person, e.g. the examination bed, where possible should be accessible from all sides and not "walled in" by equipment. It must also be long enough and wide enough. On the other hand the surroundings should be laid out so that the patient can feel relaxed and feel well during examination. The feeling of safety and security amongst others go hand in hand with the above. I must not be afraid of falling off and feeling uncomfortable. Optimisation for positioning an individual can be learnt on the kinesthetic course.
Conclusion Kinesthetic in nursing care gives the possibility to develop easy and pleasant movement for patient and nurse alike. The course teaches the basic principals of kinesthetic, movement can be experienced here and literally made "conceivable". This knowledge protects both the patients and nurses from injuries and light injuries causing an unpleasant feeling.
DATA MANAGEMENT IN DIGESTIVE ENDOSKOPY Data generated during endoscopic procedures include adminstrative data of the patient and of the examination itself on one hand and medical data on the other hand which consist of text data, i.e. the description of findings and the diagnosis proposed by the endoscopist performing the examination and more recently, images that are captured directly from the endoscopic workstation. The fast advances made over the last decade in the field of personal computers (PC) and the development of videoendoscopes over the same period have open the way for new applications in digestive endoscopy. Their goal is primarily to improve the communication of data between users of endoscopy systems. Circulation of data will benefit to patient care but also to education, both primary and post-graduate and training, as well as it will finally results in cost savings and in a better management of digestive diseases. Since videoendoscopes have been available quite recently, the interest of gastroenterologists for such questions has been raised over the last few years. However, this activity of standardization and exchange of medical data is ongoing since many years in other fields like radiology. Why do we need to standardize endoscopic data? Standardization supposes that information will be produced in a common way by different operating systems. This means that each of these systems will be able not only to export objects in the standard format but also to import them without altering their intrinsic quality. There are many reasons for promoting standardization of endoscopic data. In clinical practice, diagnosis and therapeutic decisions are more and more based on the results of varions procedures, including endoscopy. The patient’s folder contains thus a number of images and data that need to be properly archieved, stored arid retrieved. The idea of using computers for this purpose is not new but all attempts to create large systems encompassing all the data related to one patient have so far failed. The electronic health record remains an unsolved problem. By contrast, information systems limited to one or some modalities of investigation of the patient may offer adequate services in many cases. So, radiology information systems are now offered by manufacturers together with their equipments. There is a need for equivalent systems in endoscopy. The solutions offered by the manufacturers should be independent of their workstations and interoperability should be ensured. Therefore we need standardization of data formats. Starring from this, the material produced and easily accessible will promote:
What do we need to standardize? Endoscopic data ccmprise images and text, containing a number of data (Table 1). These data include patient-, procedure- and findings/diagnosis-related items. Images are now part of the endoscopic reports although most of them do not contain images so far because including images into the report requires either expensivc or technically adavanced solutions. Endoscopic images are characterized by their colour frame and usually the presence of multiple lesions on them. Moreover, not all the information gained from an endoscopic procedure is documented with images. This means that the report has a key function in the transmission of information. Contrary to radiologists, gastroenterologists have first concentrated on the standardization of terms describing the endoscopic findings, in this field, OMED has promoted standardization far before most of other organisations, with the tremendous work done by Professor Z. Maratka during decades in the Terminology Committee. But an endoscopic report also contains data on the reasons why an examination was performed, on the final diagnosis and recommendations made by the endoscopist at the end of the procedure to the referral physician... Therefore, the need for a revised version of an endoscopic thesaurus became obvious over the last five years. On the other hand, the fastly broadening use of electronic images has imposed the use of standards for exchange of images. Some exchange formats are becoming standards de facto because they are used by huge and powerful organisations mastering the information technology. These image formats (JPEG, TIF, TGA, EPSF, GIF... ) are not only used in medical applications and the medicai field is a too restricted market to impose an additional and specific format. However, exchange of medical images has some specific requirements. To meet these requirements, the efforts of the American College of Radiologists and of the National Electric Manufacturers Association have resulted in the production of a common transfer protocol that allows the systems to exchange data. This system has been named the DICOM (Digital Images Interchange and Communication in Medicine). From its initial basis in radiology, the DICOM has expanded to endoscopy and now to all visible light modalities producing images: dentistry, ophthalmology, pathology... One must well understand that the DICOM is not an image format by itself but rather a shell which allows the acceptor systems to recognise all the informations contained in an object because these data have been organized in a structured way by the sending system and because these systems are able to recognize this structure. How can we standardize the endoscopic data? To standardize text data, we need to use thesauri and vocabularies that organize the various diseases and endoscopic findings in common terms. There is a number of these vocabularies based on the international classification of diseases (ICD-9 arid ICD-10), on pathology findings (SNOMED) or aggregating various vocabularies (UNMLS of the National Library of Medicine in the USA). As said before OMED promoted standards terms for endoscopy in the past. This effort was a real pioneer action. However, it did not take into account the various elements of an endoscopic reports and the terminology proposed suffered of being too detailed and offering many double entries (redundant terms) describing one unique lesion, e.g. malignant stenosis versus stenosing tumour. Starring from the definitions proposed by the OMED terminology, the group of experts committed by the European Society for Gastrointestinal Endoscopy (ESGE) proposed a "Minimal Standard Terminology" of about 150 terms that covers 95 % of endoscopy procedures. It contains lists of terms for oesogastro-duodenoscopy, colonoscopy and ERCP, arranged by main locations (oesophagus, stomach, duodenum, colon...) and describing the reasons for performing an endoscopy, the endoscopic findings, each term being specified by the use of various attributes and the endoscopic diagnosis, made at the end of the procedure. This "Minimal Standard Terminology" meets the criteria of a practical use in computerized databases and allows the transfer of data between systems. Transfer of images should be based upon the Visible Light supplement of the DICOM. This supplement uses the main features of the DICOM 3.0 exchange protocol for radiology images plus a number of items specifically needed to describe the colour frame of the endoscopy picture. We must succeed in achieving a committment of all manufacturers of endoscopic workstations to provide systems which will be DICOM-compliant. But we must recognize that endoscopy is far from reaching such an integration. It will be possible only if users and producers combine their efforts. To be effective, standardization must allow the circulation of the whole information obtained during an endoscopic procedure. This information includes the images and the surrounding information. There is currently no standard organizing this type of composite objects. The structure of object-oriented databases is perfectly adapted to this purpose but they use different format. Therefore the ESGE has initiated a research project that has been funded by the European Commission and which is intended to integrate text and images in objects based on the DICOM format and using the "Minimal Standard Terminology" for description of the content. The Gaster project will also produce a database of referenced endoscopic images that will be used later on for education and for supporting the promotion and the dissemination of these standard protocols (Figure 1). Similar actions are funded by the NIH in the USA. All these efforts will certainly meet and merge into the action launched by the DICOM Organisation for building of a "Structured Report" module to be added to the DICOM format. Creating a common frame for structuring medical reports would be a major advance for the actual use of standards in daily practice. However, standards will be used by the community only when their use will become transparent to the common user. When you call a Australian friend on the phone from Europe, you don’t care about the interoperability of telecommunication systems between the two countries. However the fair process of the call is based on the standards used by the various operators to link their networks. This is the goal of all the people involved in this research and definition work around the DICOM. As practitioners, we must participate actively in order to secure that developed standards will actually meet the criteria of a fair clinical practice.
Table 1. Data Elements of an Endoscopic Report
Figure 1 Organisation of endoscopic data for generation of the endoscopic report. Use of standard formats for exchange of data G. I. INFECTIONS WHAT ABOUT
PATIENTS AND STAFF? Thank you for asking me to participate in this mornings session, devoted to the topic of infection in Gastrointestinal Endoscopy. As this is the first presentation of the session and my title is "G. I. Infections, What about Patients and Staff". I have decided to approach this in the following way and that is to consider Pathogens, Problems and Processes. In the next twenty minutes I will present some information regarding the infection risks associated with Gastrointestinal Endoscopy. The problems of ensuring that the risk of transmission of infection patient to patient, patient to staff or staff to patient are minimised and the processes designed to address the significant challenge posed by the design and range of endoscopes and accessory items.
Risks of Infection and Pathogens What are the risks and mechanisms of infection and what do we know? Flexible Endoscopy is a common clinical procedure and the infection rate following it is thought to be small. Oase reports and surveys over the last 20 years confirm that endoscopic procedures do occasionally cause cross infection.
(l) Silvis et al This slide reflects that in 1976 infection rates were quoted at one per 10 thousand cases and that infection was more offen associated with ERCP than other procedures. In the 1980’s concem regarding Human Immunodeficiency Virus (HIV) highlighted the Problem of potential serious disease transmission if suitable precautionary measures were not adopted in endoscopic practice. Contaminated equipment may Cause infection in three ways: i, Transmission of pathogenic organisms from one patient to another, the commonest examination being Salmonellosis. (2) ii, Transmission of infection such as Hepatitis B from patient to staff via blood, needle stick injury. iii, by the introduction of opportunistic organisms, which colonise endoscopic and ancillary equipment on storage or from general hospital environments and water supply. This previously related to ERCP procedures but now with an increasing use of disinfecting machines it is rapidly becoming a more general Problem. During the 1980’s much work was undertaken, leading to the publication of many national and international recommendations, including a Working Party Report presented at a previous World Congress of Gastroenterology in Sydney in 1990. (3).
(4) Spach, Silverstein and Stamm 1993 reviewed transmission of infection during gastrointestinal endoscopy and bronchoscopy. In the absence of data from any large prospective studies looking at post endoscopy infections, stated that the risk was small as long as these recommended guidelines for cleaning and disinfecting equipment were followed. However, vigilance is required as the transient nature of endoscopic procedures with no detailed follow up of patients may contribute to significant under reporting.
Routes of Transmission and Pathogens. This next slide shows the pathogens which have been associated with infection and possible routes of their transmission. There is still only one reported of transmission of Hepatitis B occurring after gastrointestinal endoscopy. (5) Birnie et al. 1993 - GUT. This followed needle stick injury, and other risks associated with viral transmission of Hepatitis B or HIV remains small, as these virus’s are ready killed by many disinfectants used in endoscopic disinfection procedures.
Problems. (l) Patient related Let us now look at some of the problems. To have an adequate disinfection policy, we have to consider that all patients are at risk. Many infections are latent and we can only adopt a universal practice. We therefore need to employ adequate antibacterial and antivirat agents. We need to disinfect before and after every use and all guidelines are agreed that thorough manual cleansing of all equipment prior to disinfection is the most important step. We need to treat any known AIDS patients or others who are immuno compromised as being more susceptible to infection from both ordinary pathogens and organisms not ordinarily considered pathogenic. Additionlly such patients also harbor unusual atypical bacteria, for example cyptrospiridia, which are hard to eradicate from equipment, thereby posing a relatively minor risk to patients with normal immune systems but a more serious threat to other immuno compromised patients. Another route of transmission is autologous infection, the patients own organisms. In this is example bacteria can enter the blood stream during procedures, which I will describe later, as the gastrointestinal tract is not sterile and this can give rise to septicemia or endocarditis. This type of infection can be minimised by good technique and the appropriate use of antibiotic prophylaxis in high risk groups.
Procedure related risks So what types of procedures have been implicated. Infection risks are higher in therapeutic procedures and where tissue trauma has occurred and antibiotics need to be considered. Additional risk factors are patients immune status, the presence of any intrinsic ineffective foci, such as peridiverticular abscess during colonoscopy, pancreatic pseudo cysts and biliary stasis in ERCP patient with duct obstruction, also the Passage of the gastrostomy tube through the mouth and the oesophagus during placement of PEG feeding devices may require appropriate antibiotic prophylaxis. Sclerotherapy can result in both localised mediastinal infections or brain abscess.
Universal Precautions Elements include safe practice, safe environment. As in many other clinical areas, risks to staff from patients in the endoscopy setting are mainly those that come through continuous contact with body fluids, either directly or by handling contaminated equipment. The adoption of what is called universal precautions displayed on this slide and care and respect for colleagues in the safe disposal of any sharps including particularly varices injection needles, careful handing of spiked biopsy forceps is recommended. The appropriate use of gloves, protective aprons, visors and Hepatitis B immunation of staff are now accepted as being mandatory. The most important barrier and protection of staff is there own skin integrity and any wounds or abrasions should be covered with waterproof dressings. The safe disposal of clinical waste is part of good practice.
Problems (2). Disinfectant related Schematic Dlagram of Eridoscape Channels Disinfectant requirements The design of fibreoptic and video endoscopes is a microbiologists nightmare. This slide showing the internal channels also shows that there is use of many differing materials, the complexity of the internal channels and some inaccessible parts make sterilisation by heat impossible and high level disinfection using chemicals is the most frequent method of decontamination but such chemical disinfectants have to have a wide range of antimicrobial activity. Also because of the speed of turn around of patients in endoscopic practice there must be rapid speed of action, not to be inactivated by the presence of organic matter, be non irritant, non toxic, non allergenic, non corrosive and have good stability and of course be relatively inexpensive. The hunt goes on for such a perfect solution but the most commonly used are aldehydes and although these are efliective in killing organisms they have undesirable effects on staff who come into contact with them. Personal protective wear, the use of respirators when filling machines or making up solutions and proper ventilatory controls to remove fumes are in many countries subject to legislation (6). Surveys carried out in both Britain and America show risks to staff from sensitisation and allergic response. Common symptoms reported in surveys that have been undertaken arc of; headache, rhinitis, conjunctivitis, dermatitis, cough, excessive tiredness, nasal bleeding and asthma. So whilst suitable alternatives solutions are sought the advice has to be to minimise risk to staff by using a closed disinfecting process, adequate fumes extraction, wearing of Viton or Nitrile rubber gloves when in contact with the disinfectant and wearing of eye protection. It is also important that risks to staff are monitored by Occupational Health or other professions with extensive record keeping as problems may be delayed for up to 30 years. In Britain a working party looked at the use and surveyed the problems of using aldehydes. (7) B SG GUT 1993. 34, 1641-1645 )
Problems (3). Process related The next slide shows an example of a closed system which has both benefits and problems in minimising risk. The introduction of disinfection machines has reduced exposure to hazardous chemieals but has brought with it additional concerns. Machine advantages are a consistent system and a more reliable reproducible decontamination process, compared to one conducted manually and also they are more convenient for staff They reduce the likelihood of eye, skin and respiratory exposure to disinfectants. However, machines also have disadvantages and require themselves to be regularly maintained to ensure that their tanks, pipework, strainers, filters and all other parts of the machine are free from deposits, biofilm and limescale. Processed endoscopes may have been recontaminated during the rinsing cycle, either from the machine itself or from the water supply, therefore the machine chosen should have the ability to internally disinfect all pipe work and fluid pathways in each cycle but, psuedomonas aeruginosa as said before and other gramnegative bacteria plus atypical microbacteria have been isolated from machines and rinse watet. These have lead on occasion to infection or pseudo infection and identitication of myctobacterium chelonae which is extremely resistant to gluteraldehyde requires alternative disintfecting agents with a chlorine base or peracetic acid to be used for machine disinfection to rid the biofilm.
What about rinse water? This should be fresh each time and available in quantity. A build up of disinfectant will occur if rinse water in reused and this may transfer toxic residues to the endoscope causing irritation of patient mucosa. There has been a reported case of chemical induced colitis at colonoscopy (8 & 9) or irritation to the endocopists eyes.
People problems - Processes, People and Protocols Having discussed pathogens and processes, let us now look at the human element and People in relation to infection risk. If we have approved and recommended processes and infection is transmitted, then it may be for the following reasons i, either inadequate cleaning of equipment, inappropriate or ineffective disinfection, or failures to follow protocols this could be a people related brake in the chain. What evidence is there of the latter? A National Survey of the physicians and nurses attitudes towards endoscope cleaning and the potential for cross infection was conducted by (10) Foss and Monogan (reference Gastroenterology Nursing 1992). They found that risks of cross infection may be attributed to variable cleaning practices. The failure to clean scopes before placing them in disinfectant, abbreviated overall cleaning times, in consistency of disinfection of immersion times and all this compounded by unreliable automatic disinfectors. Variations in practice and deviation from protocol usually have a people element. Accessories have also been implicated with a case report of Hepatitis C. Transmission was thought to be by biopsy forceps used in consecutive colonoscopies examinations where the forceps had not been sterilised between consecutive cases. However, there were also other breaches to recommended procedures reported alongside this incidence. reference (11 & 12). Time, training and motivation are key factors to maintain and improve standards. Triere will also be a gap between what should be done and is done, but supervision of processes, personal accountability and further research and larger studies may be required to provide the evidence of the true risks of infections to patients or staff. Environmental factors, water supplies, equipment design and the provision of more accessories items, many of which may be disposable, need to be considered, for further research work, and of course there is a cost consideration to be made. Whilst we feel comforted that infection risks may be minimal, endoscopy plays an essential role in the management of gastrointestinal disorders and its benefits far outweigh the occasional complications which arise. Further work needs to be continuously done in this area. The recognition of new antibiotic resistant infections is one which causes some concem but recent repotts at the American Gastroenterology Nurses Meeting (13) would suggest that although some pathogens are now becoming resistant to known antibiotics, there is no evidence that they are not susceptible to the disinfectants used in common practice. However, I would suggest in conclusion that we all need to remain vigilant in this very important area.
REFERENCES
INFECTIONS: WHAT
ABOUT PATIENTS AND STAFF - HEPATITIS Medical professionals clearly are at increased risk to acquire viral hepatitis. On the other hand there is also much concern that patients might become infected either via diagnostic or therapeutic procedures or by an infected health care worker. What is the evidence for such widespread fear? Being a health care provider is a risk factor for hepatitis B (HBV) and hepatitis C (HGV) which accounts for roughly 5% of all viral hepatitis cases. For hepatitis B transmission via blood and blood products is well documented and transmission via bloody fluids, semen, saliva and vaginal fluid is possible es HBV can be detected in these compartments. In contrast, transmission via urine and feces is unlikely because HBV has not been detected in this material. What are the routes for HBV after occupational exposure? Most prominent is the direct percutaneous injury: the risk is estimated to be somewhere between 2 % and 40 % depending on the level of viremia in the patient. Transmission via contact with injured skin or mucosal surface or transmission via a bite has been documented but is such a rare event that the risk can not be estimated. Transmission via aerosolized blood has not been documented. The risk after a needle stick from a HBV-infected source patient depends on his serologic state: HBsAg-positive, HBeAg-positive patients who usually have high viremia carry an estimated risk for transmission as high es 40%, whereas in HBsAg-positive, HBeAg-negative patients usually having low viremia the risk for transmission is 2% only. In contrast, HBV transmission risk by a needle stick from a HBsAg-negative patient is 0%, although there are some rare cases in which HBV-DNA can be detected in HBsAg-negative patients. HBV-infection after occupational exposure should not be a question of much concem anymore, because there is a very effective active vaccine against HBV available, which has a protective efficacy of 98 to 100%. If someone is not vaccinated - and everybody should be vaccinated today - hyperimmunoglobulin prophylaxis should be given within 24 hours of the accident. The efficacy of this measure declines sharply when there are more then 3 days between exposure and prophylaxis. However, the protective efficacy even given shortly after exposure is between 75 and 80% only. What about Hepatitis C and the occupational exposure risk? Transmission has been documented by blood and blood products and seems to be possible by body fluids, semen, vaginal fluid and saliva: HCV has been found in those compartments. HCV is not detected in urine and feces. After percutaneous injury the risk has been estimated to be between 3 and 10%. Transmission by contact with injured skin or mucosal surfaces has not been documented but seems to be plausible. Overall health care workers are at a slightly increased risk for anti-HCV positivity as compared to blood donors, anti-HCV positivity increases with the number of years spent in professional life. What can we do to prevent Hepatitis C infections? Unfortunately, there is no active immunization as yet and passive prophylaxis is not effective. The only thing we can do is to take general precautions. Place needles, lancets, sharp instruments in safe containers, do not recap needles, and sterilize all reuse equipment. What about infection of the patient by an endoscopic procedure? In 1997 a well-documented case of transmission of hepatitis C via colonoscopy appeared in the New England Journal of Medicine. A couple with documented normal ALT levels and no anti-HCV had routine colonoscopy on the same day. 3 months later an hepatitis-like illness occurred and both converted to anti-HCV positivity. An Investigation was started and the staff members of the endoscopy unit were found to be anti-HCV negative. However, the same day the couple had had colonscopy a third patient who had been anti-HCV positive with high viremia was endoscoped. Virus isolates of the presumed source patient and both index patients were compared: all three had genotype 1b and a 100% homology in nucleic acid sequence was found in the NS3 region of the virus indicating that the Hepatitis C viruses of the source patient and the two index patients were identical. In addition, it was found that all three patients had multiple biopsies during the procedure, that the same colonoscope was used in all patients, and that all three procedures where performed with in 2 % hours. Review of the disinfection procedure revealed two severe shortcomings: first, no brushing of the instrumental channel was done and remaining tissue can impair the disinfection procedure. Second, neither the forceps nor the diathermic loops were autoclaved. The authors of this report conclude that the failure to adhere to the recommended disinfection procedure resulted in transmission of HCV via colonoscopy. There are some other reports concerning transmission of Hepatitis C via endoscopy. A study investigated 39 patients with chronic hepatitis C in whom gastroscopy was performed. The authors investigated the washing fluid used to rinse the channels immediately after gastroscopy and found HCV-RNA in two of the 39 cases. After proper disinfection no HCV-RNA was found. This indicates that failure in the disinfection procedure might result in transmission of HCV. Another study investigated whether a previous endoscopy is a risk factor in anti-HCV-positive patients and found that 4 % of anti-HCV-positive patients had a history of endoscopy and even 7.2 % had endoscopy with biopsy. Another study done in volunteer blood donors in France, looked for the development of anti-HCV-antibodies between two subsequent blood donations: in 57 blood donors seroconversion to anti-HCV was detected during follow-up. 20% of those seroconverters had an endoscopy between the two last blood donations. This finding prompted the French blood transfusion centers to exclude from blood donating everyone who had an endoscopy during the previous six months. What about Hepatitis B? There is just one documented case of transmission of HBV via endoscopy. The source patient was HBsAg-positive, HBeAg-positive and the cleaning procedure reported by the endoscopy unit was okay. On the other hand, there are twelve papers dealing with HBV transmission and endoscopy investigating a total of 394 patients exposed to endoscopes used on HBsAg-positive patients immediately before and no infection could be documented. What can we do to prevent infection with hepatitis viruses during endoscopy ? Meticulous adherence to the guidelines for prevention as proposed by the European Society for Endoscopic Gastroenterology is mandatory. It is preferable to use an automatic disinfecting machine for washing and disinfection of endoscopes. If the procedure has to been done manually it is critical to do a mechanical cleaning with brushing of the channels. Flushing the internal channels with detergents and flushing it with water and air and do a disinfection with 2% glutalaldehyd for 10 minutes by fully immersing the endoscope in the solution and filling all channels. The endoscope should then rinsed with clear water and air-dried. All the accessory instruments used should be either for Single-use only or be autoclaved or disinfected, lnjection needles should be either for single-use only. However, the most important thing we have to do is to implement a proper quality control scheme of disinfection procedures in our units.
NOSOCOMIAL INFECTIONS AND MULTI-RESISTANT BACTERIA Many pathogenic micro-organisms arc becoming resistant to antibiotics. This reflects selection, due to the extensive use of antibiotics for treating people, and the use of antibiotics in farming and animal husbandry. The spread of resistant organisms between people is much easier in the confines of a huspital, where sick people are in close contact with each other, and share facilities and equipment. However, it has been shown in studies that resistant organisms are being identified and spread in the community away from a hospital setting (examples include resistant tuberculosis and streptococcus pneumoniae). These resistant pathogens are a challenge to the progress in controlling emerging infection and concern at government level is being shown internationally. In the United Kingdom the "Hause of Lords Select Committee on Science and Technology" has just reported on this topic. British concern is also paralleled in other countries. The USA, Southern Europe, Japan and South East Asia report more problems caused by resistant bacteria in both hospitals and in the community. This reflects the extensive over-use of antibiotics worldwide, and means that the treatment of infections is offen more difficult and expensive alternative intravenous antibiotics have to be used. This increases the length of time of hospitalisation resulting in:
Annual expenditure incurred from drug resistances in the USA is estimated to approach $ 4 bilIion and is rising (1995 USA Government data). A recent study carried out in the USA (Archibold et al. 1995) looked at data compounded from 8 American hospitals to compare the occurrence of antibiotic resistance in hospital with that in the community. They looked specifically at:
It is not surprising that the conclusion of this work states that:
From this study we can assume that increased care and intervention in hospital equals a tilgher risk of infection causcd by resistant microbes and therefore more risk of cross-infection with resistant microbes to other patients and staff. Patients seen in Gastroenterology Units will be referred from a variety of settings, including hospital Inpatients and patients from the community. These patients entering your department are likely to have unsolved medical problems whilst others will be waiting for confirmation of diagnosis. However, there is no doubt that many of these patients will be infected or colonised by bacteria that have an increased resistance to antibiotics. Antibiotic drugs are used to treat infection and this slide shows how some of these drugs attack micro-organisms.
Action of Antibiotic Mechanism for Resistance The resistant mechanism can be classified into 3 types (explain slide):
Information is passed on to other bacteria in 3 ways:-
When antibiotics do kill sensitive bacteria the resistant bacteria have more space, more food and more resources to multiply. Therefore inappropriate antibiotic treatment can benefit the resistant bacteria, who can strengthen their colonies once the opposition has been knocked out.
"RISK FOR PATIENTS AND STAFF: HELICOBACTER
PYLORI (Hp)" Fifteen years ago, the Australian pathologist Robin Warren discovered the gramnegative bacterium Hp and , moreover, did recognize its pathogenetic potency for the gastric mucosa resulting in gastric disease. At his visit to Vienna in 1997, he told us the fabulous story of discovery and identification of the microorganism. In fact, Robin Warren did discover the bacterium some 4 years before - in 1979 - but could not find credit among his colleagues. To prove Hps pathogenicity for humans Barry Marshall, a young Australian medical doctor, performed an heroic experiment of "selfcontamination". Especially this part of the story sounded like a fairy tale and particularly may contribute to our actual topic of "risk for patients and staff". In order to document a causal relationship between Hp infection and gastritis Barry Marshall underwent a baseline gastroscopy with mucosal biopsies showing regular gastric mucosa. Afterwards he drank a solution of bacterial bouillon provided by the microbiologist, but nothing happened. Gastroscopy continued to show regular mucosa. Determined upon convincing the "non-believers", B.M. contaminated himself by drinking a bouillon of bacteria again, stronger in concentration and bigger in volume than before. Fourteen days thereafter he fell ill with symptoms of severe gastritis, which histologically turned out to be Hp associated. Finally his experiment was a success! However, because of persistent severe symptoms like vomiting, weight loss and exsiccation he treated himself with antibiotics and recovered. In 1983 the first report of "Campylobacter pylori associated gastritis" was published in "The Lancet". What is the message from this "true story": seemingly, it is not easy to get successfully infected, as shown in this particular case of an adult man. As you will hear in a minute, age of patients and mode of infection may be of considerable impact for infection and, moreover, for colonization of the bacterium. If we focus on the endoscopic staff the risk of contamination is likely to be very low as long as standard conditions of hygiene are strictly followed. These include not only correct handling of instruments but also thorough wasting of vomited material of patients, which may be a major source of infection. Reports of literature with respect to the Hp prevalence of medical staff as compared to non-medical persons are conflicting, Austrian data collected in 1992, however, did not show any difference between these groups. The risk of the patient at gastroscopy may be different as there are reports of infection following endoscopic procedures. A background of inappropriate disinfection of the endoscope and its associated instruments, however, could not be excluded in these cases. Altogether, correct performance of hygienic standards is essential for minimizing the risk of Hp infection or transmission in an endoscopic setting. This statement is agreed upon by the microbiologists, also. What do we really know today about the risk associated with an Hp infection? First of all, there is little doubt on the oral route of infection, i.e. we swallow the bacterium with contaminated food or, more attractively, with infectious saliva at the occasion of french kissing. High prevalence of Hp infection is found in low social-economic groops of populations all over the world. Epidemiologic data suggest that infection is very likely to occur during childhood and in young adults before the 25th year of life. Prevalence in developing countries in Africa and Asia figures as high as >80%. Both, bacterial factors responsible for effective mucosal colonization as well as host factors of susceptibility are poorly understood. Secondly, with respect of pathophysiology of Hp infection, there is good evidence, that the germ colonizes within the mucous layer above the epithelial lining but does not invade the gastric epithelial cells. It is equipped with an incredible amount of enzymes, the most important of which is urease. By its action a cloud of urea is built up around each Hp enabling it to live, to produce and secrete cytotoxins and cytokines. By these humoral substances reactive inflammation is induced in the gastric mucosa, which consists of lymphocytes, plasmacells and neutrophils infiltrating and, to a variable degree destructing the gastric glands. The human immune system cannot, in general, respond sufficiently this bacterial attack and chronic infection results in every case. Serological antibodies of IgG type are produced but cannot eliminate the germ but serve as diagnostic marker for ongoing infection. Thirdly, the spectrum of Hp associated disease is determined by virulence factors of the infectious agent and the immunologic answer of the host, respectively. It ranges from minimal type B gastritis to classical peptic ulcer disease and MALT (mucosa-associated-lymphoid tissue) - type lymphoma. Its role in the carcinogenesis of gastric cancer still remains to be determined in prospective studies even if the WHO in 1994 did declare the Hp as "class I carcinogen". Fourthly and fortunately, the Hp can be killed by combined antisecretory and antibiotic treatment according to a well established schedule mostly including amoxicillin, clarithromycin and / or metronidazole or bismuthyl. The peculiar term of "eradication" of Hp derives from the latin word "radix" for "root" and the suffix "e" instead of the latin "ex" which means "to pull out", translating alltogether in "to pull out the roots of Hp from the gastric mucosa". Many clinical trials resulted in an eradication rate of >90% after a 7 days treatment course. In addition, follow up of patients documented cure of peptic ulcer disease after Hp eradication one year after therapy but relapsing peptic ulcer in those who remained Hp positive. Moreover, Hp reinfection rate turned out to be about 2.4% per year as calculated from a successfully treated group of patients during a five year follow up. However, meanwhile primary resistance of the germ against metronidazole and clarithromycin is rising and figures out 35% and 10%, respectively, in Austria. First cases of amoxicillin resistance are reported from South America. Therefore, indication for Hp eradication should be restricted to
As the number of reports on reflux-oesophagitis following Hp eradication is increasing, the indication in cases of non-ulcer dyspepsia should be made with caution and should be based on histological evidence of gastritis with considerable activity. Otherwise, especially patients with disturbances of gut motility will suffer from gastro-oesophageal reflux disease after Hp therapy. Another unanswered question is to treat or not to treat patients on longterm NSAIDs (non steroidal antiinflammatory drug), because there is some evidence from literature that Hp colonization may help against NSAID side effects on gastric mucosa. In summary, at the end of the millennium, Hp discovery revolutionized our understanding of gastrointestinal pathophysiology and the therapy of some lifethreatening gastric diseases. Nevertheless, many unsolved issues will keep the gastroenterologists busy also in future.
SOCIETY OF INTERNATIONAL GASTROENTEROLOGICAL The Society of Gastroenterological Nurses and Endoscopy Associates (SIGNEA) is a multinational network of Nurses and technicians who work in the fields of endoscopy and gastroenterology. SIGNEA has been formed so nurses and technicians in these fields can make contact with colleagues and share information to keep abreast of the lazesz clinical and technical development in gastroenterology
Goals
Membership Benefits Newsletter Individual membership in SIGNEA entitles you to a biannual newsletter (sponsored by Wilson-Cook). You are invited to contribute by submitting articles to the editor. National member country organizations receive a number of copies for distribution among their members in addition to the copies received by individual members in that country. The newsletter contains articles of clinical interest, news from member countries, contact names and products/teaching aids available from member countries and notices of forthcoming conferences of interest.
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