Introduction
Gastrointestinal diseases are a significant health problem worldwide and have a substantial
impact on health care. Total expenditure for gastrointestinal diseases is $ 135.9
billion annually, greater than for all other common diseases, and costs are likely
to continue increasing [1].
The current dramatic revolution in the practice of endoscopists through emerging endoscopic
technology and new techniques has played an important role in screening, diagnosis,
and treatment of many digestive diseases. An estimated 17.7 million endoscopic procedures
are performed annually in the United States [1].
Today, endoscopic technology is developing continuously with various manufacturers
offering complex components that affect the purchase price of endoscopes. In Thailand,
an endoscope costs between $ 43,000 and $ 84,000, excluding the cost of the endoscopy
video processor and light source. The increasing use of gastrointestinal endoscopy
leads to hospital budgets being adjusted to allow for instrument damage and repair
[2].
An endoscopy center is typically composed of healthcare providers, such as endoscopists
and nurses, and an endoscopy suite. Education and training courses are important for
maintaining the quality of endoscopic care and services [3]
[4]
[5]
[6]
[7] especially among new practitioners [8]
[9]. The reduction in damage to instruments also has a beneficial influence on endoscopic
care due to less wasted time, economized costs, and the possibility that the quality
of healthcare service could be improved [10]
[11]. Training in understanding the endoscopic equipment, plus care and handling techniques
can be helpful in addressing these issues.
Currently, economic evaluations of health interventions are an interesting point for
many studies and publications by integrating the quality of care with the education
or created the statements or models [12]
[13]
[14]
[15]
[16]. Our hypothesis is that if the new endoscopists have a better understanding of the
instruments and handling techniques that reduce preventable causes of damage plus
the appropriate use of accessory instruments, and if the nurses and nurse assistants
had knowledge of the anatomy of the endoscopic structures allowing them to prevent
damage in technical endoscopic care, it will minimize unwanted costs and improve the
quality of endoscopic patient care. The aim of this study was to investigate the effects
of educational courses and training about basic endoscopic handling and care within
gastrointestinal endoscopic care and services.
Methods
We enrolled six new endoscopists, 13 endoscopy nurses, and nine nurse assistants who
worked in the Gastrointestinal Endoscopy Center, Thammasat University Hospital, Thailand,
in a training course for basic endoscopic handling and care, held between October
7, 2017 and November 25, 2017. A new endoscopist was defined as being in his/her first
year of training with experience of < 100 endoscopic procedures. Lectures were given
(45 minutes per topic) that addressed: (1) endoscopic components i. e. internal and
external endoscope anatomy; (2) causes of damage by using, washing, storing the endoscope,
and repair costs; (3) the appropriate use of accessory instruments like biopsy forceps,
injection needle catheter, polypectomy snare, and causes of damage from accessory;
(4) proper handling techniques and adequate endoscope care for durability; (5) hands-on
practice using a porcine stomach model for beginner covering procedures like polypectomy,
endoscopic mucosal resection, foreign body removal, glue injection and clipping, and
controlling bleeding using a computer simulator; and (6) hands-on practical endoscopic
care such as cleaning, disinfection, and storage following manufacturers’ guidance
for assembling and dismantling the endoscope and its accessory component and manual
and machine disinfection and cleaning. Details of the training are given in the Supplementary Material. The pretest and post-test with lecture topics were created by the experience endoscopists
and endoscopy nurses, developed from the retrospective data that were the causes and
pitfalls of the broken endoscopes in the Gastrointestinal Endoscopy Center. The pretest
and post-test constituted all topics of the lectures and hands-on in a training course.
The participants were required to pass the test by scoring ≥ 80 % and those who failed
were required to repeat the training course and hands-on practice until they passed.
Data regarding the type, cause of damage, cost, and timing of endoscopic repair were
collected prospectively (post-training) between December 2017 and November 2018 before
being compared with the retrospective (pre-training) data collected between October
2016 and September 2017.
When a defect was detected in an endoscope, the endoscopy nurse and an engineer checked
the instrument. The damages endoscope was sent for repair at a maintenance center
outside the hospital and repair time was defined as the period until the endoscope
was returned to the Gastrointestinal Endoscopy Center.
All data were analyzed using SPSS v.22.0 data (Statistical Package for Social Sciences,
SPSS Inc., Chicago, Illinois, United States). The study was approved by the Human
Ethics Committee of Thammasat University (Faculty of Medicine) with reference number;
MTU-EC-SU-0–184 /60.
Results
At the Gastrointestinal Endoscopy Center, Thammasat University Hospital, Thailand,
we performed 2,573 gastroscopies and 1,950 colonoscopies over the 1-year period from
October 2016 to September 2017 and 2,716 gastroscopies and 2,277 colonoscopies from
December 2017 to November 2018, using a total of 13 gastroscopes and seven colonoscopes.
All of the endoscopes were new and had been used for < 1 year. The procedures were
performed by six new endoscopists and 17 board-certified endoscopists from the Department
of Surgery and Division of Gastroenterology, Department of Internal Medicine, along
with 13 endoscopy nurses and nine nurse assistants.
The training took place between October 7, 2017 and November 25, 2017, during which
no data were collected. Following our training course, the mean post-test scores overall
and for each category significantly improved with a mean score of 96.88 % and a pretest
score of 69.87 %. In addition, all participants passed the post-test by scoring higher
than 80 %; pretest and post-test scores are in the supplementary material.
The study revealed a total of 30 damaged endoscopes. It demonstrated the trend for
less total damage ([Fig. 1]) and lower costs ([Fig. 2]) in post-training outcomes than the data collected before the training course. The
results showed a significantly shorter duration required for repairing endoscopes
after training than during the pre-training period ([Fig. 3]).
Fig. 1 Cumulative amount of damage endoscope of pre- and post-basic endoscopic handling and
care training. Cumulative total amount of damaged endoscopes collected retrospectively
between a October 2016 and September 2017 compared with b prospective data collected between December 2017 and November 2018.
Fig. 2 Cumulative budget of pre- and post-basic endoscopic handling and care training periods.
Cumulative total amount of repaired endoscopes during a the pre-training period demonstrated and compared with b the post-training period.
Fig. 3 Cumulative duration of repairing endoscopies for pre- and post-basic endoscopic handling
and care training. Cumulative length of endoscopic repair was determined for a pre-training and b post-training courses.
The cost and repair time were different based on the type of endoscopes and the cause
of damage. Post-training results saved a total of $ 40,617.21 or £ 29,539.78 from
the budget as well as 1,218 days required for repairing endoscopes. The average cost
of repair was $ 5,421.09 or £ 3,942.61 per damaged endoscope and the average duration
of the repair process was 102.6 days per damaged endoscope. The main causes of damaged
endoscopes were endoscope leak and nozzle and channel blockage ([Table 1]). (Estimated exchange rate average November 30, 2017: $ 1 [United States] = Bt 32
(Thai) and £ 1 [UK] = Bt 44 [Thai]).
Table 1
Details of endoscopic damage before and after basic endoscopic handling and care training.
|
Pre-training (October 2016–September 2017)
|
Post-training (December 2017–November 2018)
|
|
|
|
Damage (n)
|
Damage (n)
|
P value
|
Total
|
|
Type of endoscope
|
|
|
12
|
7
|
0.283
|
19
|
|
|
7
|
4
|
0.303
|
11
|
|
|
19
|
11
|
0.145
|
30
|
|
Causes of problem
|
|
|
7
|
5
|
0.548
|
12
|
|
Cost
|
|
|
|
Difference
|
|
|
2,595,416.64
|
1,557,950
|
0.481
|
1,037,466.64
|
|
|
81,106.77
|
48,685.94
|
0.481
|
32,420.83
|
|
|
58,986.74
|
35,407.95
|
0.481
|
23,578.79
|
|
|
9
|
2
|
0.045
|
11
|
|
Cost
|
|
|
|
Difference
|
|
|
607,681.12
|
320,620
|
0.449
|
287,061.12
|
|
|
18,990.03
|
10,019.37
|
0.449
|
8,970.66
|
|
|
13,810.93
|
7,286.82
|
0.449
|
6,524.11
|
|
|
0
|
1
|
0.328
|
1
|
|
Cost
|
|
|
|
Difference
|
|
|
0
|
1,500
|
0.323
|
1,500
|
|
|
0
|
46.88
|
0.323
|
46.88
|
|
|
0
|
34.09
|
0.323
|
34.09
|
|
|
1
|
1
|
1
|
2
|
|
Cost
|
|
|
|
Difference
|
|
|
1,500
|
24,260
|
0.355
|
22,760
|
|
|
46.88
|
758.13
|
0.355
|
711.25
|
|
|
34.09
|
551.36
|
0.355
|
517.27
|
|
|
1
|
0
|
0.557
|
1
|
|
Cost
|
|
|
|
Difference
|
|
|
20,300
|
0
|
0.322
|
20,300
|
|
|
634.38
|
0
|
0.322
|
634.38
|
|
|
461.36
|
0
|
0.322
|
461.36
|
|
|
1
|
2
|
0.328
|
3
|
|
Cost
|
|
|
|
Difference
|
|
|
27,102.8
|
47,920
|
0.637
|
20,817.2
|
|
|
846.96
|
1,497.5
|
0.637
|
650.54
|
|
|
615.97
|
1089.09
|
0.637
|
473.12
|
|
Repair budget
|
Total cost
|
Total cost
|
p value
|
Difference
|
|
THB
|
3,252,000.56
|
1,952,250.00
|
0.361
|
1,299,750.56
|
|
USD
|
101,625.02
|
61,007.81
|
0.361
|
40,617.21
|
|
GBP
|
73,909.10
|
44,369.32
|
0.361
|
29,539.78
|
|
Total time (day)
|
Total time (day)
|
P value
|
Difference
|
|
Endoscope repair duration
|
2,123
|
905
|
0.007
|
1,218
|
Estimated exchange rate average as of November 30, 2017:
$1 (United States) = Bt 32 (Thai)
£1 (United Kingdom) = Bt 44 (Thai)
Discussion
With an increasing number of endoscopic procedures being performed, increased instrument
damage has become a concern. Damaged endoscopes affect hospital finances [11] and opportunities for patients who need to undergo endoscopy.
At our Endoscopy Center, patient care is managed by a number of health care professionals.
One important task in the mission of the university hospital is training of endoscopists
and we add six new endoscopists every year. The endoscopic procedures that these doctors
learn to perform present opportunities for instrument damage [4]
[8]
[9]. Other health care providers, nurses, and nurse assistants are also crucial in maintaining
the quality of endoscopic care [6]
[7]. Together with patient care, nurses and nurse assistants play important roles in
endoscopic care, particularly in terms of cleaning, disinfection, and storage. Previous
studies have reported that improved education and training of personnel have resulted
in a 35 % reduction in instrument damage [10].
Our training course enrolled all new endoscopists, as well as all nurses and nurse
assistants who work in our endoscopy center. The educational program was composed
of sessions on personal awareness of endoscopy handling and manipulation, correct
choice and accessory instrument usage, and strict adherence to cleaning, disinfection,
carriage and storage, according to the recommendations of the endoscope manufacturer.
An endoscopic hands-on workshop focused upon handling techniques for new endoscopists,
focusing upon endoscopic technical care for nurses and nurse assistants.
Our institute performs approximately 2,500 gastroscopies and 2,000 colonoscopies per
year, using 13 gastroscopes and seven colonoscopes. The present study found a decrease
in the number of damaged endoscopes and resultant savings in the cost of repair. According
to our analysis, post-training saved a mean of $ 5,421.09 or £ 3,942.61 per damaged
endoscope, translating to total repair budget savings of $ 40,617.21 or £ 29,539.78
in 1 year. This is significant for our institution and could also be realized by other
endoscopy units with limited budgets, especially given the current economic situation.
The total cost of training courses for this study was estimated at $ 2,187.5 or £ 1,590.9.
Consideration of the multiple viewpoints by integrating the clinical practice with
cost and value analysis is one of the concerning priorities for creating an evidence
base towards education for the best benefit to the healthcare system [17]
[18]
[19].
Endoscope damage can be divided into preventable and non-preventable causes. Preventable
damage can be prevented with proper care and handling techniques. On the other hand,
non-preventable damage occurs due to deterioration over the lifetime of the endoscope.
The results of this study showed all causes of damage. Nozzle and channel blockage
was the most common cause of damage to endoscopes in the pre-training period. The
reasons are due to not checking the endoscope before use, presence of tissue, foreign
objects, or debris during service, not flushing the channels after use, and not cleaning
the scope as soon as possible after the procedure. There was a particularly significant
decrease in nozzle and channel blockage, which likely was due to improved care in
endoscopic usage, cleaning, and technical care after a training course. However, the
repair budget also was reduced after training, therefore, damage to the different
types of endoscopes might have been affected by the cost of the repair. Also, differences
in repair duration in the pre-training and post-training data may be one of the limitations
of this study. This study was conducted in a single center with a small group of participants,
over a short time, and with a limited number and type of endoscopic procedures. Further
studies are required to evaluate and confirm the results of this study in multiple
centers and more categories of endoscopy, such as endoscopic ultrasound (EUS), enteroscopy,
and endoscopic cholangiopancreatography (ERCP).
Our study also showed the mean duration of repair was 102.6 days per damaged endoscope.
The shorter duration of repairing endoscopes in the post-training period may be explained
by the indirect effect of reducing the number of damaged endoscopes, which is the
most likely cause of nozzle and channel block. However, when considering the cost
of repairs at this point, it was found that the amount was reduced but not statistically
different. In addition, this study did not analyze the degree of damage that might
affect the duration and cost of repair. The conditional effect of minimizing the duration
of endoscopic repair could be increased opportunities for endoscopic use for gastroenterology
patients, and thereby, improvements in the quality of patient care. Although our education
and training course revealed a decrease in total damage post-training, it is important
to note that the rate of damage increased once again in the last month of the post-training
period, which might suggest forgetfulness or a relaxation in diligence. This should
be investigated to inform post-training strategies to enhance skills retention over
the long term [20]
[21]
[22]. In this study, the post-course feedback was not analyzed; that might be another
limitation. Better outcomes may have been achieved if the training intervention was
reinforced with reminders while endoscopic procedures were being performed.
Conclusions
The financial impact of endoscopy services is increasing steadily due to more expensive
accessories and procedures, which have widened the scope of practice. Training before
handling costly and delicate instruments such as endoscopes is an a priori condition
that should be the norm for every endoscopy practice. This study underscores the magnitude
of potential savings, which is an interesting detail from a financial and cost-effectiveness
point of view. Still, there is little added value from a scientific vantage point.
Training for doctors and nurses handling endoscopic equipment is mandatory and beneficial
from medical and financial points of view.
We therefore recommend refresher training courses and support for educational programs
and workshops for health care providers in the Gastrointestinal Endoscopy Center.
Basic endoscopic handling and care training plays an important role for endoscopists,
nurses, and endoscopy facilities in avoiding unwanted and broken endoscopes, which
can benefit both hospital finances and endoscopy services.
