First up, maybe for Jim, and you know, the question here is, should people from another department be washing scopes? And if they can, how long should they be trained consistently to be able to sign off on? Well, you know, reprocessing has taken a change in institutions over the course of time. Many times, most units still have reprocessing done within units. Others have been decentralized where the endoscopes, well, centralized, where the endoscopes go to a centralized location to be processed. Reprocessing personnel should be trained in the same fashion. If it's decentralized or centralized, they need to be trained on the individual scope models that are coming through their department as well. So my practice, just to cite a reference, is annual performance is done, annual competency is done. There's a spot check done every quarter to monitor their efficacy. And of course, whenever there's new models that are introduced or a breach has been noticed, new equipment is obtained, or IFUs change. Okay, and maybe along those same lines, Jim, you know, what is the expectation for endoscope techs to wear shoe coverings? Yeah, you know, shoe coverings are not considered PPE, though, however, they work in a wet environment. The potential for splash is there. So wearing a shoe cover is a additional protection for them. Many reprocessing staff, as well as clinical staff, have shoes that they wear only within the unit. Our reprocessing techs have their shoes. They wear them only at work. They protect them whilst they're at work. They remove shoe coverings. They place them on when they enter their reprocessing room and take them off when they leave the reprocessing room. So if you have very neat and tidy reprocessing staff, then, I mean, guidelines don't mandate they be worn. But if you have splashy, wet reprocessing staff, then it would enhance their safety. Okay, thanks so much for that, Jim. Now, this is a tricky question that maybe I think maybe all the panelists can answer. Can a patient sign an AMA form after being sedated earlier in the day? And has this been thought of as a valid legal document? So I don't know, TR, do you wanna have a go with that one? I think it's, you know, people, it was written into the document the way it was, mainly to, you know, allow for like a last kind of a Hail Mary sort of approach. Patients insisting on leaving, you can't stop them. You can't hold them against their will. So at least have them sign something before they go so that you have something to kind of point to, but obviously it's not ideal. We wouldn't accept an informed consent for a procedure with somebody after they've been sedated. So it's, you know, the whole thing is, it's kind of a murky area, but it's worth having something on file in case someone's really insisting on leaving. Yeah, what about yourself, Suneli? What would you do in this situation? Yeah, I mean, we actually, that is what we offer, the form. And, you know, to the credit of the post-op team, they don't usually offer it if the person's still sleepy, right? So it's only when someone's able to voice their thoughts does this even really come up. There have been scenarios where patients have just upright and left without signing anything. That happens obviously not as often, but then like, then you just document it, right? As TR was saying, you just document it and say, well, we were monitoring and then they weren't there anymore and we didn't lock the doors, you know? So what are you gonna do? We can't section 12 them. Yeah, and Kelly, what do you think? Have you encountered this and what have you guys done? Yeah, so it does come up. I think we all know that we've been in these situations. I would say we should all just really focus on the preparation and ensure when you're making those preoperative phone calls or when you're seeing the patient in the waiting room and they're not accompanied by someone to really drive into them that we may have to cancel this procedure if you do not have someone responsible to drive you home. And there have been moments where we have called, now I come from a hospital environment where we have resources like social work that can help us secure maybe like an amulet service or something like that, but I know that's not realistic for every endoscopy environment. But really focusing on saying, yes, you may take Uber or Lyft, however, you still need a responsible adult with you. And I know that's different for other environments, but in busier, more metropolitan areas where people don't have cars, we drive in, you can take public transportation, but you still need a person with you to accompany you to make sure you're safe. But that's all really focused on prior. And what do you think, Jim, what would you do? Well, first of all, I often found it mesmerizing that patients would sign a form AMA when they wanna go leave against medical advice anyway. So, but what we utilize, if the patient wants to leave, we go ahead and let them leave. We're not going to do anything to hold them. So usually, we try the Socratic method and talk to them, works the majority of the time, though there's always that individual that's going to wanna leave. So, let them go. Yeah, Sonali, I see that your hand's up. Did you wanna chime back in on this one? I actually, I wanted to ask a follow-up question. So, I've tried to offer, you do what you can, as Kelly said, ahead of time to identify the scenario. And there have been some patients who are fine going without sedation. And there were some where I was considering offering single agent, because there isn't any policy about single agent. You know, giving two of midaz, I think that they're gonna be okay afterward. And so, I'm curious what other people do. We don't have a policy yet, and we have differing opinions on how to manage that situation or whether to offer that. Yeah, that's an interesting practice technique to use anxiolysis versus sedation. So, we have done that before to just take the quote-unquote edge off for an upper or to get around the sedation being administered at a single-dose angiolytic agent. Yeah, in our own, like, again, maybe in the Canadian milieu, one, we're lucky it's not very litiginous, but to Tiara's point, I think it's good to have any documentation. And I think, so now you mentioned as well, like in these sort of cases, I might even have either myself or the fellow or the resident dictate a note in our electronic medical record, just detailing out what happened in the process. Sometimes it's also good with these EHRs that nurses have to sort of confirm, like for instance, consent was performed and all these sorts of things. And so, having that sort of layer of data to support you, if God forbid that comes up. And then secondly, I'll be honest, I very commonly will lean to unsedated procedures, much easier for colonoscopy than gastroscopy, funny enough. Like I think colonoscopy that's unsedated is sort of commonplace now, at least in Canada, whereas upper endoscopy, I think is more challenging for sure because of the gag reflex. So moving on with that, and obviously Mark, if I'm not doing your question justice, please just sort of chime in again, but maybe Sonali, is there any, what about staff and ergonomics? Is there any, like how much data is there around ergonomics and maybe the GI endoscopy unit? It's a great question, endoscopy, not much. So much of what I was pulling in was thoughts and observations from asking people in terms of the other considerations for people in the room. And I think a lot of that is from just like the ergonomics of office-based work of sitting at a desk. Like that's really where I was going off of, but there really isn't much literature. And so if any of you are interested in an area that is open for an opportunity for more work, go for it. Yeah, that's true. So here's another question. And I guess, again, this probably can go to all the panelists. In light of the supply chain issues we're having, specifically in the Northeast with respect to IV fluids, are there any thoughts on the panel regarding endoscopy with MAC or conscious sedation for outpatient procedures without running IV fluids? So what do you think, T.R.? What do you think about IV fluids with respect to endoscopy? I mean, I think it's feasible and I think people are definitely looking at doing that. Some places, just from my conversations with people around the country, some places when they work with anesthesia, the anesthesiologists or the CRNAs are not comfortable without doing the case without any IV fluids. But I think in a pinch, you can do it. You want to make sure people are hemodynamically stable and not dehydrated and tachycardic when they show up, but otherwise I think it's feasible. What about you, Sonali? At your center, are you guys, as a standard, giving all patients IV fluids, selective IV fluids, no IV fluids? Yeah, I'm glad this is brought up. This is one of our cases. This is great. It naturally came up. We actually were giving everyone IV fluids up until the hurricane. And knowing that that was a lot of our supply, we very quickly moved towards only doing fluids as needed. And this was in discussion with our, we were talking about the patient's IV fluids in discussion with our, we really pivoted very quickly by discussions with our anesthesia colleagues and our nursing colleagues and really everyone in the hospital leadership. And it's actually been like really great. We had done it, all of the sites at MGB, kind of we discussed it together. And over the course of that long weekend, we transitioned to hep blocking all patients for RN sedation cases and MAC cases. We had canceled a few high risk MAC cases the first few days, but then we've gone back to doing all the cases we were otherwise doing at blocking everyone and only giving IV fluids as needed. And the conversion rate from needing IV fluids, went from giving it to a hundred percent of patients to somewhere around five to 6% of our patients. It seems for RN sedation, less, a little bit more for MAC, but still pretty low. And so right now we feel comfortable about moving forward with this through the rest of the shortage. And I'm also hoping that this will just become our standard of practice. Why continue to use the fluids if you don't need to for every patient and just kind of go on demand. And then Jim and Kelly, maybe I have a question for you to follow that up. Like I comment, like we don't give fluids as a standard, only if it's felt to be needed. I would say the most common, and that's for like midazolam, fentanyl, conscious sedation. I would say the most common reason I get asked to give IV fluids is maybe to facilitate recovery for my nursing staff in patients who have received like high levels or high doses of conscious sedation. Jim and Kelly, what do you think about that? Like, what do you think are the drivers for maybe why we feel we need to give IV fluids? And is there even any evidence to suggest that we need to be giving IV fluids in these patients? I was thinking about this and there's a couple of positives that have come out of this. One, there tends to be a non-compliant hoarding and pre-making of IV fluid bags. And sometimes that's by anesthesia, sometimes that's by preoperative nurses, just for efficiency. So that's really never a good idea. And we all know that those practices are not good, but that tends to happen. So since this has stopped, now we are more compliant. And when we need fluids, we're spiking them at the time that's needed. And for recovery, one thing though, patients have noticed this and they've heard of this and they're feeling a little disappointed that they're not getting IV fluid that they think will be very helpful for them. And we've heard some of those comments over the last week or two, but it really has been a good thing and it's eliminated some waste because at least for the facility I'm working in, it would always be started in the pre-op area. And sometimes by the time the patient would get to the room, the anesthesiologist or the CRNA would say, you know what, actually I want LR instead. I don't want saline for this case. So really that would have been waste. So does it really help with recovery? It could probably, and I'm sure there are situations where it would, but I feel like going forward, this actually might make some big changes in our practice. With that in mind, Jim, like what's your approach right now with respect to like the steel water storage and irrigation and so on and so forth? Okay, I wanna go back to and expand on what Kelly said too. I think we have pushed PO fluids up to the NPO limit to ensure that patients are hydrated. So we make sure that they come to us in a better state of hydration. We're conserving IV fluids. We put in hep blocks. That was the practice back 40 years ago when I started endoscopy, no one received running fluids. They all got pushed. We never used. When we look at our patients that are not receiving drip IVs during a procedure and just using the push method, there's no increase in adverse effects or any increase in length of stay within the recovery room. So, I mean, I think these are articles that can be written that perhaps can be in conservative area in nature for practice. When it comes to irrigation fluid, fortunate for us, we have sufficient bottled fluid to run the programs for another period of time. Though we have in our meeting, I think on November, something to discuss alternatives when our water runs out and what we're going to do. We know that guidelines permit the use of alternative potable water sources for endoscope reprocessing, if it has to be done manually. When it comes to irrigation, we have a little bit more of a hangup from the MIFU of the manufacturer, but the manufacturer has released a statement saying that in this time of crisis, alternative methods could be employed. Look at a multi-discipline committee within your department of what to use. And preliminary thought is, if we move towards something than sterile water is that we're going to start with sterile water and we will use filter water for subsequent bottle refills in a clean method. Okay. Yeah, as you sort of pointed out, Kelly and Jim, like I think the situation is probably going to force us to pivot and I wonder what will come to life from that similar to maybe COVID and virtual care. So it's going to be interesting to see how this all plays out. Now, we have another question about reprocessing. It says, drawing scopes to buy special air dryers, is that possible in small or large practices? Do any studies that cultures were done without air dryer and with air dryer? And then essentially saying, you know, specifically these questions bearing in mind sort of, you know, fiscal restrictions and tight budgets and endoscopy. So Jim, what are your thoughts on that? Well, it's well documented that unfortunately, endoscopes do remain wet even after AER processing and the drying within the AER, it's not sufficient to dry the endoscope. Drying technologies have emerged that are quite compact. They're rather economical, and they do provide for sufficient drying of the endoscope. It all depends on how much cash is in the wallet of the amount of drying you wish to partake. You know, there's elaborate cabinets that have all sort of software that can regulate the cycle time and indicate which scopes are fit for patient use. So I think very few departments have the ability for personnel to run air through a scope for 10 minutes and alternative sources need to be found. And there are alternatives from Pintos to Lincoln Continentals. Okay. No, I'd love to hear everyone's opinion on this one, cause I've never thought of this question. And so, you know, the question is, staff have asked to use earbuds in the scope room. What do people think? Kelly, what do you think about people, I guess, I don't know what they're, is it for talking to people? Is it for listening to music? I have no idea. But what do you think about earbuds in the endoscopy room? Yeah, so this may not be a popular opinion. I think it's okay. And why do I think it's okay? Because we're holding them to a standard. They have 189 checkpoints. They, we're assessing that they're doing their job correctly. We're checking their competencies. And if it's for music and not conversations, I think it probably is okay. But that's my opinion. And I may be wrong. I just think if I was standing at a sink for eight hours, a little music might be nice and I can still do my job with music, just like we all can drive listening to music also. But then again, I may be wrong. It's just thinking of the employee. So Nellie, what do you think? I actually, I think I have two answers because it depends. If we mean the pre-processing room, I think I agree, actually. I mean, totally. Like there's not that much communication that needs to happen in the reprocessing room. That's not in front of patients. So they're not going to think someone's distracted. So I would be totally fine with that. If the question was more for the scope room, we actually, at our institution, are in the middle of establishing our cell phone policy, or maybe it went out last week, like very much at the edge of doing it because we did have some issues with, you know, not being sure if someone is distracted from delivering patient care. And so when patients are present, we don't want to give the impression of or actually be distracted from patient care. So in that setting, we've said no earbuds. We do have built-in speakers for music because I can't scope without music. And I think it's actually really important. But for everything else, we don't allow earbuds. Reprocessing room, I think that sounds fine. Yeah, unfortunately, our cell phone policy doesn't permit the use of earbuds by any staff on any circumstance. So unfortunately, we have piped in music so the staff can arbitrate who listens to what on what day. So that's our policy. It's unfortunate, but it's an overarching enterprise policy and, you know, it is what it is. Pierre, what do you think? Earbuds in the endoscopy room? Yeah, endoscopy room, I would say no. The scope reprocessing room, I would say yes. I think, you know, you're in the middle of that. We usually do have music playing. Sometimes the endoscopist is the person who chooses the music. Sometimes we let the staff, you know, choose it depending on the, you know, dynamic in there. But you need to be able to get somebody's attention quickly. You need someone to hand you a device or something when you're in a position. God forbid, you know, something's bleeding or something's going wrong. You need to be able to get someone's attention quickly. So, you know, when we do our MAC days, we have a nurse anesthetist in the room and a tech. And then we actually have a third medical assistant in there kind of helping with some of the documentation that has to occur during the procedure because the CRNAs are not trained in how to document a lot of the things that we want to document during the procedure, like ordering pathology and things like that. So even then it feels like there's opportunities for just conversation between all the staff. That can be sometimes difficult to get someone's attention to do, you know, to get help with what you need. So, yeah, I think attention is really key. There's also evidence from the ADR literature that if you engage the staff and just put all eyes on the screen, you can actually improve adenoma detection too, right? So let's try and get the staff to kind of help us be successful. Yeah, I tend to agree. Although I totally appreciate like the sentiments. I would be reluctant to have it in the indoor room. And again, probably maybe similar to you, Sonali, is maybe about the patient perception of what's going on in the indoor room and stuff like that. But I don't know, you never know. I like music though, so it's nice to have music in the indoor room. So we have maybe two last quick questions and then we might actually wrap up if everyone is okay with that. Sonali, I think you had actually brought this up a little bit before, but it's sort of analogous to some of our questions. So wondering, what's your PO status when prepping for let's say a colonoscopy or a gastroscopy? Do you adhere to after midnight, nothing by mouth, or do you allow up to clear, or do you allow clear fluids up to a couple of hours before the procedure? And do you think that's gonna have any impact maybe on IV fluid usage? Oh, I can go first and then I think we can round table. So this is a great question and we have a bit of a natural experiment going on between the different sites of MGB, being MGH versus Brigham and some of the other hospitals. We actually did always have that you can have liquids up until two hours before, there were clear liquids two hours before arrival time, so about three hours before your procedure. And then we actually started giving people like more encouragement to do so when the IV fluids thing happens. They were like, please drink up until two hours before your arrival time. And one of the other sites didn't say anything at all. And it seems like we're using the same amount of fluids in terms of converting to needing IV fluids. So I'm not sure if it made any difference and just more communication to people. And what about yourself, TR? Yeah, we are the same thing, kind of up to two hours or three hours, depending before the appointment time. And for those reasons, we'd like people not to arrive completely dehydrated. Helps with the IV placement. Yeah, yeah. We, yeah, go ahead, Neil. What about you guys? Yeah, no, same thing. Essentially, I think we're learning from experience and finding what makes, what's the best thing for patients is to Sally's point, hopefully helps with difficult IVs, hopefully decreases the use of IV fluids all around. I think it's good for patients. Jim, what do you think? Kelly, what do you think? Okay to drink up IV fluids or drink fluids, at least clear fluids, two hours before the procedure. Yeah, yeah. Same here. We also try to be descriptive and creative about the types of clear fluids and say, you know, you can have yellow, just avoid certain, you know, red color, broth and make sure that they have alternate types of fluid so they're not just simply stuck to water or Gatorade and give nice suggestions. Yeah, exactly. They can have clear tea, clear ice, I mean coffee. They can have carbonated beverages. They can have Jell-O, stay away from orange and red, you know, doesn't have to be water, but part of our instructions now are, you know, we're asking them to even at that two hour limit to drink 12 ounces of water. Okay, so maybe last question here, you know, I'd love to get everyone's opinion on this and then we'll wrap up, you know, what do people think about scheduling a lunch break whereby everyone goes on lunch break and their endoscopy room maybe pauses versus staggered lunch breaks? So maybe Jim, do you wanna, what are your thoughts on that? It's always been the endoscopist prerogative how they wish to run the room. So part of it is also based upon how's the staffing compliment within the unit? Can you run a room that the staff, the support staff can take a break if you need to change out? I know that you don't like to change the horse in midstream, but it keeps the provider happy because they can continue to scope. It keeps the staff happy, the supplement caregivers, because they can take their break. So we leave it up to the prerogative of the endoscopist. Where we do get a hang up is the anesthesia staff. They always seem to be, you know, we gotta take our break now. So they're the ones that usually muddle up the situation, but usually they come around when they realize they're gonna get done ahead of time. And Kelly, what do you think? Do you think it's gonna be good for morale of the unit? I don't, I actually don't. I've been in facilities where there has been a scheduled lunch break and one that continues on and just gets a break team. And I do think that for efficiency and staff preference, the break team works better. Because it's sort of planned out ahead of time with anesthesia, with the staff. Now, I don't know how physicians always feel about this because I'm thinking, how are you handling this very long day sort of snacking between cases? And I feel for the endoscopist, but for the staff, it seems that they like the break team better. Also for delays, if it's not the same endoscopist for the entire day, sometimes that set lunch break could delay somebody else. If there's a different team or a different endoscopist in the afternoon. So for my experience, I don't think that that's a better way, but always worth a trial. Everything's always worth a trial. And so then I guess TR and Sonali, maybe TR first, maybe give your viewpoint from the endoscopist. Do you want lunch break or no? Well, when I started working at KP, which was like almost 25 years ago, the evolution of endoscopy had been really through the medical clinic schedule. So we always had a lunch break and oftentimes one endoscopist in the morning, different endoscopist in the afternoon, kind of splitting the day. We've experimented with trying to run what we call the continuous day where we'd have a break team. And it created like huge nightmares for the managers in terms of staffing. There was a little wiggle room if somebody called in sick, really needed like all those people. And we also would have department meetings over the lunch hour. And if the endoscopist are tied up scoping, then they can't really participate. So we've kind of gone back to like a natural lunch break. For ergonomic reasons, we do try and like split the day as often as we can. So people are only scoping for a half day because we've had times where, half the department has had some sort of limitation. Now I will say we're all salaried and we're not running like a fee-for-service practice. So that may change the way the incentives are operating kind of in our setting versus people who are just trying to scope for dollars and generate as much revenue as they possibly can. And Sonali, what do you think? Yeah, we've always done staggered breaks for the team and endoscopists have just grabbed snacks in their pockets in between. And I guess that's just what I'm used to. I think I can see the morale of having a team break together but in terms of our schedules, we're just able to get more cases done this way. And so it seems to work out fine for us. And our turnover time is slow enough and for our really sick patient rooms so that you get enough time to eat something in between as the endoscopist. Yeah, I think for myself, speaking probably both for nurses and for myself, I like getting my day done. But to TR's point, invariably you're gonna get fatigued throughout the day. And so one of the things that even in our unit we sometimes will do, it's variable, but we'll actually have sort of morning and afternoon endoscopist. So you just try to decrease some of that fatigue throughout your day. So I think that's it for questions. I'll give it back to Eden. It has been a wonderful day. Do our course directors have any final comments before I do the final housekeeping to wrap us up? You can go ahead. Yeah, I'll just, and I really enjoyed this. We have this virtual space for our very large endoscopy community in this, which is really wonderful to hear from all of you. And I think we're all working towards the same goals. It's just really great to have these conversations about issues that we all deal with. And it's always very thought provoking to see what other sites do. So I'm glad I had an opportunity to participate. And I hope you also feel like this was a good Saturday for you. Yeah, and I think, thanks so much, obviously, to all the speakers that gave amazing talks. And obviously, Eden, for always the queen of organization, because this course does not happen without Eden, for sure. And I think it's just, this content can sometimes be daunting, but I think TR said it best in one of his talks where he said, just the fact that you're here probably tells you that you're very engaged with respect to improving quality. So I think you've already taken the first step to sort of working in that direction of providing high quality endoscopic care for your patients. Beautiful how we all lean on each other. This has just been a wonderful day. It's absolutely my favorite way to spend a day as a quality course. So congratulations on a wonderful course. Our thanks to the faculty and to you, our participants. As a reminder, each of you will have ongoing access to the recordings from the course via GI Leap, ASG's online learning management system, when they're available in roughly three to four weeks. The course evaluation is now available in GI Leap. And once you complete it, you can download your certificate. If you need assistance logging into GI Leap, please email quality at ASG.org. We may get back to you on Monday, but just go ahead and email us. You can complete the evaluation on Monday as well. This concludes the improving quality and safety in your endoscopy unit course. We hope this information is useful to you and your practice.

endoscopy

scope reprocessing

patient discharge

procedural ergonomics

hydration

staff safety

IV fluid management