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Rapid Responses: Rapid Responses published:
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Nurse Endoscopy - scoping the future
- Michael G Bramble (17 February 2009)
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Endoscopists-more questions than answers?
- Shjai Sebastain (28 February 2009)
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Impact on training and recruitment
- David G Samuel (4 March 2009)
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More of the same...ho hum
- Teresa T. Goodell (9 March 2009)
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Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)
- John G. Williams, Ian Russell, Dharmaraj Durai, Wai Yee Cheung, Amanda Farrin, Karen Bloor, Simon Coulton and Gerry Richardson (10 March 2009)
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Real Benefits of Nurse Endoscopists Not Demonstrated
- Tom Lee, Deepak Dwarakanath, The Nurse Endoscopy Team, North Tees and Hartlepool NHS Foundation Trust. (1 April 2009)
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Michael G Bramble, Medical Director James Cook University Hospital, Middlesbrough
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The article by Williams et al is a valuable addition to the evidence that nurse endoscopists are an effective and reliable resouce when it comes to the delivery of timely endoscopy services in an era when time to endoscopy impinges on numerous targets and Trusts depend an this resource to protect gastroenterologists from undue managerial pressure to meet those targets. Perhaps readers should be reminded that a huge amount of the colon cancer screening programme is being delivered by nurses and it would be deeply disturbing if nurses were less accurate than doctors at diagnosing lesions in patients undergoing such screening. The message must be that this is major success for the Joint Advisory Group (JAG), which brought all the relevant specialties together to agree a multidisciplinary approach to training, over ten years ago. Maybe other specialties can learn from such an approach no matter how how the obstacles appear to be when nurses challenge the traditional role of doctors in the diagnostic process Competing interests: Medical Director Previous Chair BSG Endoscopy Committe and Member of JAG 2000-2 |
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Shjai Sebastain, Consultant Gastroenterologist Hull and East Yorkshire NHS Trust Hull HU3 2JZ
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The article by Williams et al further puts the focus on the usefulness of highly trained nurse endoscopists in the UK ,who in the recent years have undoubtedly improved capacity. But there are more questions than answers from this trial. The trial, despite the claims of the authors, are not conducted to mirror the real day to day practice in most endoscopy units. First of all, the endoscpists were not blinded regarding which patient they are scoping on the list who was included in the trial and this is likely to explain the rather long 20 minutes average taken for a diagnostic endoscopy whereas most endoscopy units the time for a diagnostic endoscopy is much shorter. The use of both topical spray and sedatives for upper endoscopy in a significant proportion of participants is also not in line with the common practice. There is also no information regarding the number of endoscopic procedures per endoscopy session of the endoscopists and mix of procedures which may have impact on the variables used in the day one satisfaction survey. The authors also do not discuss the relevance of the significant differences in the `normal` endoscopies which may suggest over interpretation by one group which also correlates with the significantly increased number of biopsies taken by one group. Clearly both these will have impact on further follow up care and costs and may also potentially impact on the percieved satisfaction in the immediate post procedure satisfaction. The authors do not define their parameters for clinical effectiveness before concluding that that there are no differences in clinical effectiveness between the two groups of endoscopists. The impact of continuity of care which is an important aspect in patients undergoing endoscopic evaluation has also not been evaluated. Finally the conclusion that `confirms` that the quality of life improves after a normal endoscopy is against the results of a large number of trials which have proven the value of test and treat strategy as a safe and cost effective startegy for dyspepsia. Competing interests: None declared |
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David G Samuel, F1 doctor in gastroenterology Prince Charles Hospital CF47 9TD
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The conclusions that nurses may be more effective than doctors at performing endoscopic procedures is worrying and could easily become more prominent in years to come. Rota gaps are resulting in specialist trainees having to miss out on procedure session where their skills could be developed. Missing out on scoping chances means that when they do become consultants, their level of expertise may not be as good as their previous seniors. In addition, I feel that if the conclusions of the study are taken at face value by trusts and managers, it may result in increasing numbers of lists being performed by nurses. This will decrease the training opportunities for doctors. Nurse practicioners are becoming more popular as a resource, are available at most times of the day and do not have the same additional commitments as trainee doctors. I only hope that training for OGD etc... are protected to ensure that in future years, a study may show that doctors are as good if not better than nurses at performing these procedures. Competing interests: None declared |
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Teresa T. Goodell, assistant professor and ICU nurse Oregon Health & Science University, 97239
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I believe the question regarding whether nurses should perform endoscopies (although we apparently can do so safely and effectively) is a bugaboo; there is no reason why nurses cannot safely and reliably perform screening endoscopies, as this and prior studies have shown. At least in the U.S, nurses are not requesting privileges to perform endoscopic treatments or to evaluate treatment success in people with diagnosed GI illnesses. Rather than impinge on physician practice, nurse endoscopists could free specialist physicians to do the treatment and evaluation functions they ought to do. This is one in a growing cadre of studies demonstrating the safety and effectiveness of nurse-delivered medical screening and treatment. Often, such studies have shown superior satisfaction among patients. I hypothesize this is attributable to nurses' superior communication and interpersonal skills, a topic taught in nursing educational programs and reinforced in practice. This advantage puts nurses in an ideal position to provide an expanded scope of services in the U.S. and elsewhere, statistically non-significant trends observed in the current study notwithstanding. Competing interests: None declared |
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John G. Williams, Consultant Gastroenterologist /Professor of Health Services Research Swansea University SA2 8PP, Ian Russell, Dharmaraj Durai, Wai Yee Cheung, Amanda Farrin, Karen Bloor, Simon Coulton and Gerry Richardson
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This response raises a few issues which can be clarified. Firstly, this study was conducted in 2002/03. As a pragmatic trial the procedures and practices used by participating units were not modified. The average time taken for diagnostic endoscopy was the time from one extubation to the next and so reflected the between-patient activities in the participating units. It was not just the time for which each patient was intubated. We have noted that the combined use of topical spray and sedatives is out of line with BSG recommendations but it was clearly common practice at the time the trial was conducted. Recent evidence suggests that it is more comfortable for patients (Evans LT, Saberi S, Kim HM, Elta GH, Schoenfeld P. Pharyngeal anaesthesia during sedated EGDs: is “the spray” beneficial? A meta-analysis and systematic review. Gastrointest Endosc 2006;63(6):761-6). We did not collect details of every list, which indeed may be different between doctors and nurses and impact on post-procedure satisfaction. Pressure on space prevented us discussing the fact that nurses tended to diagnose endoscopy as normal less often than doctors and take more biopsies than doctors. This is further discussed in the full report on the study which is available on the HTA website at: http://www.hta.ac.uk/project/1155.asp Clinical effectiveness is clearly defined as quality of life at one- year and there was no difference between the two groups in this primary outcome. Our finding of an improvement in this quality of life at one year is reflected in other studies including the ENIGMA study http://www.hta.ac.uk/project/957.asp. It does not run counter to the known benefits of test and treat strategies, which also lead to improved quality of life. We thank Dr Sebastain for raising these issues and giving us the opportunity to clarify them. John Williams and Dharmaraj Durai Competing interests: None declared |
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Tom Lee, Endoscpy Research Fellow University Hopsital North Tees, Stockton on Tees, TS19 8PE, UK., Deepak Dwarakanath, The Nurse Endoscopy Team, North Tees and Hartlepool NHS Foundation Trust.
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The MINuET trials and the associated editorial do not demonstrate the most important benefits of nurse endoscopists whilst making debatable conclusions based on questionable endpoints. Attributing impact on quality of life at one year to a single endoscopy is speculative. Endoscopies do not occur in isolation but are part of the patient’s journey that includes other consultations, tests and treatments. These factors will impact more on quality of life than an endoscopy and are unlikely to be influenced by the endoscopist. The most important benefits of nurse endoscopists relate to productivity and flexibility within an endoscopy unit and the continuity they provide to an endoscopy service. Within our unit 6 nurse endoscopists work alongside 15 consultant endoscopists.52% of the lower GI endoscopy workload is performed by nurse endoscopists. Their roles have expanded to include endoscopy training, performing bowel cancer screening colonoscopies, providing a PEG service, running an iron deficiency anaemia clinic, coordinating the polyp surveillance database, coordinating the Barretts registry and providing an IBD service. Their flexibility ensures the unit runs to its optimal capacity; this is of crucial importance in meeting the 2 week, 18 week and 31/62 day targets. Caecal intubation rates and other measures of endoscopic quality and safety are comparable between nurse and medical endoscopists. We could not provide a high quality endoscopy service without nurse endoscopists. These benefits can not be demonstrated by a randomised trial. Competing interests: None declared |
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