1. Efficient Endoscopic Practice Ryan D. Torrie, MD Taber, AB Canada November 4-5, 2011

2. Outline  Basics of efficient practice  Patient selection and referral process  Preparing the patient  Surviving scope day  The aftermath  Conclusion

3. Basics of Efficient Practice  Select appropriate patients  Ensure a smooth work flow  Efficiency in the OR  Manage pathology consistently  Ensure appropriate follow up  Quality assurance  Have some fun

4. Work Flow Patient Selection ReferralPre-op Scope day Follow up Reminder call RN/MD review

5. Patient selection and referral  How are patients referred  EMR “active rules” identifies screening patients  Patients recalled for appointment with MD  MD performs H&P  Referral form completed by MD  Urgent patients hand delivered

6. Physician Referral Form

7. OR Scheduling  Hospital staff book procedures  Clinic staff make reminder calls

8. Patient Preparation  Performed primarily by nurses in our program Basically a pre-op visit MD H&P reviewed by nurse OR history and paperwork completed Ensure appropriate labs and studies (ECG, Scr, INR) Select appropriate bowel prep (age, renal function)

9. Preoperative History

10. Patient Preparation Patient education performed by endoscopy nurse Bowel prep Managing meds Anticoagulation protocols Diabetes Mellitus 2 Informed consent reviewed and signed Complex or elderly patients (>75 yo) referred to MD

11. Clinic Consent

12. Scope Day  Pre-op area  1-2 nurses  3 bed pre/post op area  1 OR, 12-15 scopes per day  Procedure booked every 30 minutes  Intake sped along with office OR paper transfer  H&P reviewed by MD  Abbreviated physical exam and consent signed with MD

13. Preoperative History

14. Hospital Consent

15. Scope Day

16.  In the O.R.  MD administered versed/fentanyl  2 RN’s in O.R.  Excellent cleaning tech  Have enough scopes 1 per 150 scopes/year  Avoid distractions Everything stops when MD stops  Keep sedation to minimum  Often dictate at the end of day from OR record  cards for records

17. OR Record

18. Scope Day  Post-op  20-30 minutes in recovery  RN reviews D/C paperwork  Instructions to call in 10 days to review path  Significant findings reviewed by MD at bedside

19. Discharge Care Plan

20. Follow up  Manage pathology consistently  When cancer diagnosed cancer protocol activated in recovery room I notify family doctor personally Labs and imaging arranged immediately I take care of all surgical referrals  I review all pathology and recommend repeat interval  Interval entered in EMR  EMR generates call back for patients to my RN  Referral form taken to MD  Process repeated

21. Quality Assurance  Keep statistical records  Review quality indicators  Adenoma detection rate  Perforation, bleeding rates  Prep quality  Cecal intubation rate  Withdrawal time, turnover time, etc.  Patient comfort  Ensure patient safety  Constantly look for ways to improve

22. Conclusion  Select appropriate patients  Ensure a smooth work flow  Efficiency in the OR  Manage pathology consistently  Ensure appropriate follow up  Quality assurance