The complexity of endoscopy varies considerably from a very quick and safe diagnostic test to complex non-invasive surgery associated with considerable, but calculated, risk (eg ERCP, EMR and haemostasis). Broadly speaking the setting/location and local competencies should reflect this complexity and risk. Other factors to consider include whether the episode might just be a diagnostic test or a test associated with an evaluation of the patient’s symptoms and a recommendation on further management.
Equipment decontamination standards are the same wherever the service is provided. This requirement may mean endoscopy can no longer be reasonably provided in some locations or that it is not economically viable to set it up in other locations.
In any location it is essential that the service providers have undertaken an extensive risk analysis encompassing both frequent minor complications and the rarer, more clinically significant, adverse events. Any service should be able to demonstrate a clinical governance structure able to monitor and act on adverse events. Where necessary, the arrangements with local acute providers for transferring patients with potentially major complications should be clear to all.
The section is a glossary of terms defining endoscopy services in different settings with a broad outline of their defining features. Such definitions will facilitate the JAG Certification process and will aid the commissioning of new services.
Acute or General Hospital
- provides (and teaches) all the common diagnostic and therapeutic endoscopic procedures
- includes management of the highest risk cases
- provision for management of acute upper gastrointestinal bleeding
- in-patient facilities with 24 hour general surgical and anaesthetic support on site
Some smaller hospitals, with strong links to larger hospitals locally, may not provide teaching or some of the more complex procedures. Some of the most complex or uncommon procedures (and associated teaching) will occur on a regional basis.
Regional or Tertiary
A regional endoscopy service would provide a similar service to an acute hospital but also provide a service for the more complex and uncommon procedures. A regional service may have alternative expertise such as training, research or testing of new technologies.
Community Hospital or Treatment Centre
- a service for basic diagnostic endoscopy performed on an out-patient basis
- possibly some therapeutic procedures (such as removal of colonic polyps)
- a hospital setting with beds available for recovery of sedated patients
- sedation will be an option for patients treated in this setting
- case mix will be adjusted so that the highest risk patients (older patients with co-morbid disease) or those with special needs (eg children) will not have an endoscopy in this setting
The key factors to consider for community hospitals and treatment centres are safety, equipment and skill mix. Many community and treatment centre facilities will provide minor surgery and will therefore have anaesthetic support on an occasional (or less than 24 hour) basis. This will mean that there will be staff on site with some skills suitable to endoscopic procedures (e.g. recovery expertise) however, there are well-defined competencies unique to endoscopy that staff will need to be able to demonstrate. The equipment available will need to match the case mix and be suitable for managing complications arising from any anticipated interventions (e.g. clips for post polypectomy bleeding). There will need to be clearly defined referral protocols for dealing with more serious post procedure complications.
Office or Clinic
- performed outside of any form of hospital
- mainly if not wholly diagnostic service
- conscious sedation/local anaesthetic only. If sedation is used then there will need to be facilities for recovery and associated resuscitation equipment
- some procedures (such as biopsy and simple polypectomy) may be carried out
The cost of sustaining adequate decontamination services should be carefully weighed up against the volume of endoscopy likely to be undertaken in this setting.