Clinical Outcomes With Nurse-led Colonoscopy Surveillance
Clinical Outcomes With Nurse-led Colonoscopy Surveillance
Background A nurse practitioner-led colonoscopy surveillance service was introduced to improve appropriateness, validation and compliance with the National Patient Safety Agency safety alert and British Society of Gastroenterology consensus guidance for bowel cleansing agents.
Objective To determine the clinical outcomes and efficacy of this new service.
Design and patients A 4-month prospective audit of patients due to attend for surveillance colonoscopy.
Setting Royal Liverpool University Hospital.
Intervention A new nurse practitioner-led surveillance service reviewed all patients before listing.
Outcomes Clinical outcomes, service efficiency and cost effectiveness.
Results 224 Patients (median age 68 years, 52% male, and median American Society of Anesthesiologists (ASA) 2) were assessed and 34% had medical factors influencing their colonoscopy. 37% patients were discharged without a colonoscopy, 17% deferred (median >2 years), 6% had died while on the register and the remaining (40%) had their procedure at the agreed interval. The 30-day and 6-month all-cause mortality was 0% for those fit for colonoscopy, compared with 5% and 14%, respectively, for those deemed unfit. The did-not-attend (DNA) rate was reduced from 7.6% to <1%. With 95 patients not requiring a colonoscopy a potential £40 000 saving to the primary care trust was made.
Conclusions The nurse practitioner-led surveillance service has been invaluable for guideline adherence and medical management of patients before colonoscopy. In addition, it potentially avoided procedural all-cause mortality in these patients. It has proved to be efficacious with reduced DNA rates and over one-third of patients assessed did not require a colonoscopy.
Two categories of guidance/guidelines have been issued recently, which have major implications for surveillance practice and processes for colonoscopy in the UK. The first, recently published by the British Society of Gastroenterology (BSG) and National Institute for Health and Clinical Excellence ruled on changes in surveillance intervals and categories The second, issued by National Patient Safety Agency (NPSA) and the BSG consensus groups, provided guidance on the safety of oral bowel cleansing agents. These latter guidelines had a number of recommendations which should be considered before issuing oral bowel cleaning agents—namely, all patients should be clinically assessed and risk stratified for the appropriate bowel cleansing agent before their procedure; oral bowel cleansing agents should be prescribed and dispensed by authorised personnel; patients should give verbal and written information for use of the bowel preparation; renal function should be ascertained before the procedure; medication for diuretic patients should be reviewed; use of angiotensin receptor blockers, ACE inhibitors and the presence of specific comorbidities such as advanced liver disease, CCF and chronic kidney diseaseshould be ascertained. Compliance with these safety guidance has been particularly challenging for the surveillance patients requiring colonoscopy.
Consequently, we introduced a new nurse practitioner-led colonoscopy surveillance service to improve compliance with these guidelines/guidance. In addition, this service manages the surveillance patients on the register, preassesses all patients, performs surveillance colonoscopy, collaborates with and educates the interested parties.
The aim of this prospective audit was to determine the clinical outcomes and efficacy of this new service.
Abstract and Introduction
Abstract
Background A nurse practitioner-led colonoscopy surveillance service was introduced to improve appropriateness, validation and compliance with the National Patient Safety Agency safety alert and British Society of Gastroenterology consensus guidance for bowel cleansing agents.
Objective To determine the clinical outcomes and efficacy of this new service.
Design and patients A 4-month prospective audit of patients due to attend for surveillance colonoscopy.
Setting Royal Liverpool University Hospital.
Intervention A new nurse practitioner-led surveillance service reviewed all patients before listing.
Outcomes Clinical outcomes, service efficiency and cost effectiveness.
Results 224 Patients (median age 68 years, 52% male, and median American Society of Anesthesiologists (ASA) 2) were assessed and 34% had medical factors influencing their colonoscopy. 37% patients were discharged without a colonoscopy, 17% deferred (median >2 years), 6% had died while on the register and the remaining (40%) had their procedure at the agreed interval. The 30-day and 6-month all-cause mortality was 0% for those fit for colonoscopy, compared with 5% and 14%, respectively, for those deemed unfit. The did-not-attend (DNA) rate was reduced from 7.6% to <1%. With 95 patients not requiring a colonoscopy a potential £40 000 saving to the primary care trust was made.
Conclusions The nurse practitioner-led surveillance service has been invaluable for guideline adherence and medical management of patients before colonoscopy. In addition, it potentially avoided procedural all-cause mortality in these patients. It has proved to be efficacious with reduced DNA rates and over one-third of patients assessed did not require a colonoscopy.
Introduction
Two categories of guidance/guidelines have been issued recently, which have major implications for surveillance practice and processes for colonoscopy in the UK. The first, recently published by the British Society of Gastroenterology (BSG) and National Institute for Health and Clinical Excellence ruled on changes in surveillance intervals and categories The second, issued by National Patient Safety Agency (NPSA) and the BSG consensus groups, provided guidance on the safety of oral bowel cleansing agents. These latter guidelines had a number of recommendations which should be considered before issuing oral bowel cleaning agents—namely, all patients should be clinically assessed and risk stratified for the appropriate bowel cleansing agent before their procedure; oral bowel cleansing agents should be prescribed and dispensed by authorised personnel; patients should give verbal and written information for use of the bowel preparation; renal function should be ascertained before the procedure; medication for diuretic patients should be reviewed; use of angiotensin receptor blockers, ACE inhibitors and the presence of specific comorbidities such as advanced liver disease, CCF and chronic kidney diseaseshould be ascertained. Compliance with these safety guidance has been particularly challenging for the surveillance patients requiring colonoscopy.
Consequently, we introduced a new nurse practitioner-led colonoscopy surveillance service to improve compliance with these guidelines/guidance. In addition, this service manages the surveillance patients on the register, preassesses all patients, performs surveillance colonoscopy, collaborates with and educates the interested parties.
The aim of this prospective audit was to determine the clinical outcomes and efficacy of this new service.