Gastro-Intestinal Endoscopy Operational Policy. Consultant Nurse for Gastroenterology & Endoscopy. Director of Nursing

Transcription

1 Gastro-Intestinal Endoscopy Operational Policy Document Reference No: PTHB / TEP 061 Version No: 1 Issue Date: January 2018 Review Date: January 2021 Author: Consultant Nurse for Gastroenterology & Endoscopy Document Owner: Endoscopy User & Audit Group Accountable Executive: Approved By: Director of Nursing Executive Committee Approval Date: 10 January 2018 Document Type: Policy Clinical & Non-clinical Scope: PTHB Wide / Endoscopy & Theatre Service Specific Staff Group Powys Teaching Health Board is the operational name of Powys Teaching Local Health Board Bwrdd Iechyd Addysgu Powys yw enw gweithredol Bwrdd Iechyd Lleol Addysgu Powys

2 Version Control Version Summary of Changes/Amendments Issue Date 1 Initial Issue Jan 2018 Issue Date: Jan 2018 Page 2 of 55 Review Date: Jan 2021

3 Item Contents Page No. 1 Policy statement / introduction PTHB Endoscopy Unit Philosophy An overview of the Endoscopy Service in Brecon War 8 Memorial Hospital 2 Objectives and aims of the service 9 3 Definitions Guidance for patient care Privacy & dignity Consent Withdrawal of consent Uniform Decontamination Endoscopy reporting system Protocol for dealing with endoscopy reports and 14 endoscopy histology reports Communicating results Guidelines for the receipt, storage and administration of controlled and sedative drugs in the endoscopy unit Adverse events Complaints Guidance for Clinicians - Appropriate indications & policies for new referrals and surveillance endoscopic procedures Criteria for selection of patients suitable for endoscopy in 19 a community hospital Gastroscopy Colonoscopy Flexible sigmoidoscopy Protocol for patients on Warfarin / Clopidogrel requiring 27 endoscopy Antibiotic Prophylaxis for Endoscopy Advice for diabetics 29 4 Responsibilities Accountable executive Head of Department Other staff Key staff responsibilities 30 5 Access Brecon War Memorial Hospital Endoscopy schedule An outline of the administrative processes within the 32 endoscopy service : Referrals vetting and validation Unavailability Cancellations DNA s 37 Issue Date: Jan 2018 Page 3 of 55 Review Date: Jan

4 5.3 Prospective Validation of Planned (surveillance) 37 Procedures 5.4 Inpatients requiring endoscopy 38 6 Training and development Nursing / ODP Policy for monitoring endoscopic competence Consultants/ Endoscopists / Nurse Endoscopists 39 7 Service / Professional committees or groups Endoscopy User and Audit Group 40 8 Audit schedule 40 9 Service / department specific policies, procedures 42 and other written control documents 9.1 Department/ service intranet page Department/ service internet page Change control / review References / bibliography/ professional 42 organisations/ support or key contacts App. Appendices Page No. 1 Prague criteria for Barrett s Oesophagus 43 2 WAGE Management of Dyspepsia 44 3 Surveillance following adenoma removal 45 4 IBD BSG surveillance guidelines 45 5 Endoscopy pre-assessment checklist 46 6 Recommended pathway for upper endoscopy surveillance 48 referral 7 Recommended pathway for lower endoscopy surveillance 50 referral 8 OGD open access referral form 53 9 Bowel Prep Form 54 Issue Date: Jan 2018 Page 4 of 55 Review Date: Jan 2021

5 ENGAGEMENT & CONSULTATION Key Individuals/Groups Involved in Developing this Document Role / Designation Consultant Nurse for Endoscopy & Gastroenterology Professional Lead for Surgical Services Clinical Lead for Endoscopy Circulated to the following for Consultation Date May 2017 May 2017 May 2017 May 2017 January 2018 Role / Designation All endoscopists in PTHB who endoscope in Brecon War Memorial Hospital The theatre and endoscopy nursing team at Brecon War Memorial Hospital and Llandrindod Wells Hospital Administrative & managerial staff in endoscopy Strategic Decontamination Group Executive Committee Evidence Base Please list any National Guidelines, Legislation or Health and Care Standards relating to this subject area? BSG guidance for Gastro-Intestinal Endoscopy JAG key performance standards for Endoscopy NICE guidance for gastroenterology & endoscopy Issue Date: Jan 2018 Page 5 of 55 Review Date: Jan 2021

6 IMPACT ASSESSMENTS Equality Impact Assessment Summary Age Disability Gender Race Religion/ Belief Sexual Orientation Welsh Language Human Rights No impact X X X X X X X X Adverse Differential Positive Statement Please provide a summary of the outcome of your equality impact assessment. Risk Assessment Summary Have you identified any risks arising from the implementation of this policy / procedure / written control document? No risks identified If yes, note the risk/s and action taken to mitigate. If no please state no risks identified Have you identified any Information Governance issues arising from the implementation of this policy / procedure / written control document? None identified Have you identified any training and / or resource implications as a result of implementing this? None identified Issue Date: Jan 2018 Page 6 of 55 Review Date: Jan 2021

7 Gastro-Intestinal Endoscopy Operational Policy 1. Policy Statement / Introduction This document sets out Powys Teaching Health Boards (PTHB) operational policy for gastrointestinal endoscopy. The operational policy gives patient related, clinical and administrative direction for the delivery of safe, effective and prudent care to patients undergoing endoscopic procedures. The operational policy is based upon the current evidence base for gastro-intestinal endoscopy provided by the British Society of Gastroenterology (BSG), Joint Advisory Group for gastro-intestinal endoscopy (JAG) and NICE, and forms part of the PTHB evidence for the JAG annual Global Rating Score (GRS) and JAG endoscopy service accreditation. GRS/ JAG domain and measures are noted in the policy to confirm adherence to the quality measures. We are grateful for all colleagues who provided comments on the draft version of our Operational Policy including GP representative, Consultant Endoscopists and Endoscopy User group. We are also extremely grateful to Dr John Green, Consultant Gastroenterologist at Llandough Hospital, Cardiff and Vale University Health Board who has allowed us to benchmark from their operational policy. We have endeavored to include all suggestions received, and hope that the policy reflects our unit philosophy and safe practices of work. The policies that are outlined within this policy are pertinent to all staff, including bank and temporary staff as well as trainees who work in the PTHB endoscopy units. We will contact all endoscopists and other staff and inform the Endoscopy User & Audit Group, PTHB where relevant to inform them of any changes in clinical guidance or local protocol that may arise before the next review this document in August PTHB Endoscopy Unit Philosophy (GRS domain Respect and Dignity 7.1, 7.6, Teamwork 14.1) Endoscopy is a highly technical procedural area where patients can feel vulnerable, the therefore unit strives to provide a non-judgemental patient focused environment. Our aim within the endoscopy unit is to effectively use resources and ensure patient safety by providing a high level of evidence based care throughout the patient journey. We endeavour to understand the patient as an individual and ensure their emotional, psychological, physical, cultural and religious needs and requirements are met. Communication is open and honest with all patients, relatives and staff, and conforms to high standards of confidentiality. All Patients are cared for by staff with the relevant knowledge and skills within a pleasant, friendly and informative environment. We believe in a strong ethos of multi-disciplinary team working; supporting and respecting our patients and our staff. We value everyone s contribution and performance in delivering high quality care for our patients. We use our resources responsibly and prudently, and communicate our outcomes effectively throughout our organisation and through the national regulatory bodies i.e. Endoscopy User and Audit Group (EUAG), Welsh Government and JAG. Issue Date: Jan 2018 Page 7 of 55 Review Date: Jan 2021

8 Patient needs are met in a dignified and caring manner during their stay in the Endoscopy Unit and equality, privacy and dignity are maintained at all times. Our Endoscopy units promote professional development for staff and welcome suggestions from staff, patients and relatives for ways to continually improve our service. 1.3 An overview of the Endoscopy Service in Brecon War Memorial Hospital (GRS domain Respect and Dignity 7.1, 7.3, 7.5, 7.8, Patient environment & equipment 9.1, 9.13, 9.15, Workforce delivery 15.1) The Endoscopy service at Brecon War Memorial Hospital (BWMH) is housed in the theatre and endoscopy suite (completed 2006) and has 1 procedure room. Llandrindod Wells & Brecon War Memorial Hospital are community hospitals with 1 adjacent theatre to the Endoscopy procedure room. The endoscopy facilities serve the local population of the South & Mid Powys Teaching Health Board (approximately 100,000). The population consists ethnically mainly of English, Welsh, Polish and Nepalese speakers. PTHB is committed to ensuring patients whose first language is not English receive the information leaflets for endoscopy, have information and reassurance during and after the procedure in their chosen language. PTHB discourage family from acting as interpreters and a list of interpreters is available at main reception. Leaflets are available for the main language groups as stated. Within the unit, a range of low complexity upper and lower GI endoscopic procedures are performed: diagnostic OGD, flexible sigmoidoscopy and colonoscopy, and minor therapeutic procedures including removal of polyp, APC. We have also developed a local service for gastro-intestinal physiology testing including hydrogen breath testing and high resolution oesophageal manometry and impedance and 24 hour ph testing. The patients that we see in our unit are referred by their GP and Consultant Surgeons or Consultant Nurse with a range of problems that require a full investigation, a detailed report and aftercare advice but do not require the specialist services of a District General Hospital. Any complex diagnostic or therapeutic endoscopic procedures, or patients with multiple co-morbidities are referred to the local District General Hospital in Merthyr Tydfil; Prince Charles Hospital, approximately 30 minutes drive south of BWMH. Cases are discussed at the monthly MDT meetings in Prince Charles Hospital as appropriate. BWMH is the local Centre for cystoscopy, there is approx. 1 cystoscopy list per month. BWMH conducts 1 list a month of Bowel Cancer Screening, delivered by visiting endoscopist, and as such is the designated local centre for the south Powys population. The medical endoscopists of BWMH have their substantial role in the Issue Date: Jan 2018 Page 8 of 55 Review Date: Jan 2021

9 local DGH Prince Charles Hospital, the BCS endoscopist in Carmarthen Hospital and the GP in a local practice. All have part time sessional commitments to BWMH. Advanced imaging equipment is available and is utilised for the detection and treatment of mucosal pathology and is utilised in many different diagnostic, therapeutic and surveillance procedures. There are a range of modern Pentax video endoscopes with integral narrow band imaging and zoom etc. All monitors are high definition. The equipment has a service contract. The equipment is on a rolling programme for replacement. The endoscopy lists are performed by JAG accredited Gastroenterologist, GP, Colorectal Surgeons and Nurse Endoscopist. The unit has a nursing team who work between theatre, day ward and endoscopy and have developed expertise in dealing with the nature of the endoscopic procedures and equipment and have attended endoscopy specific training courses. Our unit is staffed by highly qualified nursing and medical staff who are appraised annually and have their clinical practice assessed using a variety of methods such as competency assessment, observation of clinical practice using agreed tools, and review of personal development and performance. There is a nominated dignity champion in the unit. Nursing staff attend courses run by specialist providers such as the Welsh Endoscopy Nurse Training: ENDO 1,2,3 and Degree level courses, whilst the Endoscopists attend update training provided by the annual WAGE and BSG conference as well as those run by JAG. There are administrative and clerical staff housed near the unit who co-ordinate the lists and also work at the reception area. Managerially, the endoscopy service is in the PTHB South Locality. There is a monthly Endoscopy User and Audit meeting at 0800 on a Wednesday AM that is an open meeting for all staff to attend. Terms of reference are agreed and the agenda is set to reflect the GRS / JAG requirements and patient experience and to provide safety and quality updates. The audit cycle is set and active participation is encouraged in audit preparation and delivery from all staff. 2 Objective & Aims of the service Objectives the of Service: 1. To provide superior evidence based patient centred care via a team-based approach 2. To provide a local endoscopy service within Powys that meets the needs of the local population 3. To utilise all appointment slots to balance capacity and demand Issue Date: Jan 2018 Page 9 of 55 Review Date: Jan 2021

10 4. To provide a prudent cost-effective service 5. To increase capacity by expanding at Llandrindod Hospital 6. To continue being a Bowel Cancer Screening Centre 7. To continue to be JAG Accredited (JAG accredited 2012) Our aims are simple. We want to provide an evidence based local service, in which we see patients quickly, provide increase choice for patients and deliver excellent outcomes. We believe that in order to provide the highest quality service, we need to make it as easy as possible for patients and their carers to comment and provide feedback. Properly shared, this creates a culture of learning and effectiveness, where staff can review and audit effectiveness and performance. 3. Definitions PTHB - Powys Teaching Health Board GP General Practitioner IC Ileocecal BCS Bowel Cancer Screening IBS Irritable Bowel Syndrome OWLD Online Waiting List Directory JAG - Joint Advisory Group on Gastrointestinal Endoscopy NICE National Institute for Health and Care Excellence NMC Nursing & Midwifery Council GMC - General Medical Council BWMH Breconshire War Memorial Hospital OGD - Oesophago-gastroduodenoscopy EUAG Endoscopy User & Audit Group APC Argon Plasma Coagulation AWENcf - All Wales Endoscopy Nurse competency framework GRS - Global Rating Scale HB Health Board THB Teaching Health Board TET Training the Endoscopists Trainers ASA American Society of Anaesthetics DNA Did not attend TTT Training the trainer BSG British Society of Gastroenterology AER Automated Endoscope Reprocessor WAGE Welsh Association for Gastroenterology and Endoscopy TCI To come in DGH District General Hospital ODP Operating Department Practitioner IBD - Inflammatory Bowel Disease FH Family History GAVE Gastric Antral Vascular Ectasia HIV - Human Immunodeficiency Virus CJD - Creutzfeldt-Jakob Disease LA Local Anaesthetic GA General Anaesthetic WAG Welsh Assembly Government EMR - Endoscopic Mucosal Resection NBI - Narrow-band Imaging NB - Nota Bene CLO - Campylobacter-like Organism Test CXR - Chest X-ray AXR - Abdominal X-Ray CT - Computerised Tomography MDT Multi Disciplinary Team USC Urgent Suspected Cancer cm - centimetre yrs Years CLD Clinical Referral Date PSC - Primary Sclerosing Cholangitis CRC Colorectal Cancer PMS - Property Management System The term Endoscopy literally means to look in and see, it can describe a variety of procedures: OGD / Gastroscopy - examination of oesophagus, stomach and duodenum Colonoscopy - examination of the large bowel Flexible sigmoidoscopy - examination of the left side of bowel Issue Date: Jan 2018 Page 10 of 55 Review Date: Jan 2021

11 An endoscopic procedure is described as either diagnostic - when a cause for patients symptoms may be discovered or therapeutic - where endoscopic treatment can be administered to ease a patients problem/disease, or to remove a pathology. JAG is a voluntary quality assurance process which sets a range of standards to ensure that safety, quality, patient outcomes, training and the environment meet the latest standards and can be evidenced. The unit supplies data on a wide range of indicators, called the Global Rating Scale, every six months. Our clinical quality processes are based around the key principles of the Global Rating Scale (GRS): Clinical Quality Patient experience Workforce Training 3.1 Guidance for patient care Respect, Privacy and Dignity (GRS domain Respect and dignity 7.1, 7.7, 7.9, 7.11, 7.12, Patient environment & equipment 9.4, 9.11, Teamwork 14.10) The unit prides itself on optimising our patients privacy and dignity throughout their time with us. Changes in practice are adopted from information received directly from patients via the suggestion box, patient satisfaction audit and from our patient representative on the EUAG. The Welsh Assembly s Health & Care Standards have been adopted within our service. No patient identifiable material should be easily visible to other patients or relatives at any point during the patient journey; from the time patients arrive in reception to discharge post procedure. This includes white boards and theatre lists. Only patients undergoing colonoscopy are changed out of their clothes - into gowns, just prior to their procedure. This is done in a private area, behind curtains in the day ward and patients can stay behind the curtains there if they wish. They change out of the gowns post procedure in private. There are toilets near all stages of the patients journey. Each procedure room has a sign on the door asking staff not to enter during procedures, unless there is an urgent reason. There are phones in the endoscopy theatres but these are on silent. Elsewhere every effort is made to talk about patient related information in a discrete manner. Additional equipment is sought if needed according to patient need e.g. hoists. There are 2 private admission rooms where staff obtain further details prior to the procedure and are utilised to provide additional privacy for vulnerable adults, to break bad news etc. post procedure. Toilets are nearby each part of the patient journey. Issue Date: Jan 2018 Page 11 of 55 Review Date: Jan 2021

12 There are 6 recovery bays (with curtains and monitoring) and a second stage seating area. Relatives can wait in the patient waiting area if possible & appropriate, but are not allowed into the recovery area. Conversations with relatives (if agreed by the patient) take place in the admission rooms. It is assumed that all patients wish to have their clinical care discussed in private unless they ask to have relatives with them Consent (GRS domain Comfort 3.1, 3.7 Consent 8.1, 8.2, 8.4, 8.5, 8.11, 8.12, 8.13 ) Consent is a process not a single action and begins at time of referral for endoscopy. The referrer will explain the proposed endoscopic procedure and discuss the benefits and risks of the procedure so that patients can make an informed choice. For lower GI endoscopy fitness for bowel prep will be assessed. Within the endoscopy information booklets for each procedure, issues regarding the benefits and risks of the procedure are detailed including a realistic expectation of the discomfort of the procedure. A range of choice of sedation is available, including none, up to general anesthetic. The booklets are reviewed and amended annually according to latest evidence based guidance. Consent signatures will be taken on the day of the procedure, in the admitting room, by the endoscopist. Opportunities are given at several points for patients to ask questions about the intended procedure. See the THB s consent policy for an overview of the consent process that the organisation has adopted and what should be done in situations where patients are unable to give informed consent etc. Family / friends etc should not be used as interpreters. Refer to THB policy regarding the usage of interpreter services such as Language line. All signatures for consent are obtained before the patient enters the procedure room. The THB consent policy is available on the PTHB intranet and in the unit. Nursing staff discuss the findings of the procedure with patients afterwards and give an aftercare leaflet with a copy of the endoscopy report. A follow up plan is provided. The leaflet explains precautions that should be undertaken after the procedure, gives an outline of adverse effects to be vigilant of and who to contact if they occur (in hours the endoscopy unit and otherwise the emergency services e.g. MIU to whom they should present their copy of the endoscopy report) Withdrawal of Consent During Endoscopic Procedures (in accordance with BSG guidelines for Consent 2016) (GRS domain Consent 8.2, 8.9) Definition A situation where a patient requests verbally or by non-verbal means for a procedure to be stopped (e.g. patient says take it out doctor, I can t stand the pain during a Issue Date: Jan 2018 Page 12 of 55 Review Date: Jan 2021

13 colonoscopy, or patient forcibly grasps a gastroscopy and tries to remove it during a gastroscopy) And where a member of staff in the endoscopy room raises a concern that the patient is conscious of what is happening, and has sufficient awareness to want the procedure stopped Action during Endoscopy procedure 1. The staff member raising the concern should tell the clinician in charge usually the endoscopist performing the procedure) that he/she believes that consent is withdrawn. 2. The procedure is stopped 3. The clinician in charge will address and discuss concerns and make a decision to either: a. Pause and increase sedation or analgesia, or alleviate discomfort by other means (eg withdrawing colonoscope loop) b. Terminate procedure immediately if the patient wishes the procedure to be discontinued. If clinician in charge decides to continue the procedure without remedial action, and thus overriding the views of patient and other staff members, then he/she must state clearly the reason for the decision (e.g. in his/her opinion patient is not sufficiently aware to recall discomfort, or patient s safety would be seriously compromised by stopping procedure) 4. In the case of significant disagreement between staff, there must be senior review after procedure (see below) Action after a patient withdrawal of consent during an Endoscopy procedure 1. The senior endoscopy nurse present at procedure notes the withdrawal of consent in the patient record & completes an endoscopy adverse event form 2. After recovery patient is asked to complete a discomfort score and feedback on procedure 3. If patient is distressed regarding procedure, the endoscopist must also speak to the patient 4. If there was a significant disagreement between clinician in charge of procedure and endoscopy staff in theatre, and in their opinion patient safety was significantly compromised or unnecessary distress was caused, then senior medical review must take place with discussion with both endoscopist, and nursing staff, (and patient if appropriate) before patient leaves unit, or within 24 hours. A HB DATIX clinical incident form should also be completed. 5. This will be discussed at the EUAG / monthly meeting to generate an action plan. Issue Date: Jan 2018 Page 13 of 55 Review Date: Jan 2021

14 3.1.4 Uniform All staff working within the clinical environment, who come into contact with patients, should wear theatre scrubs at all times. This also includes those working within the decontamination area. There are separate male and female changing rooms with a range of scrubs available, just across the corridor from the unit these are secured by a key-fob Decontamination (GRS domain Patient environment & equipment 9.2, 9.5, 9.8, 9.9, 9.10, 9.12, 9.14) The BSG and JAG decontamination guidelines are available in the unit and on the Endoscopy part of the PTHB intranet. A detailed SOP document and competency training for all staff is available in the unit. (See Decontamination policy for endoscopy PTHB) Endoscopy Reporting system (GRS domain Quality 4.6) The EMIS Health system is used in BWMH. The password and initial training are given to all new endoscopists. A report must be generated for all GI endoscopic procedures that are performed. All fields should be completed from the drop down list. This ensures procedural, operator and follow up details can be recorded to aid patient care. It also captures key audit data. The image capture system should be used to take pictures of any pathology seen but also should be used to demonstrate that the caecal pole / IC valve / terminal ileum / retroflexion in the rectum, J maneuver in the stomach, 2 nd part of duodenum have been reached or achieved Protocol for dealing with endoscopy reports and histology reports (GRS domain Results 6.5, 6.6, 6.7, 6.8, 6.9 ) Endoscopy requests (i.e. via GP / Consultant letters or endoscopy request forms), should clearly state the referring clinician. A copy of the endoscopy report should be sent to the referring clinician immediately after the procedure. The endoscopy report should contain a clear management plan within the free-text comments section. If the management plan is dependent on biopsy results, this should be documented. The management plan requires the endoscopist to understand the clinical background to the endoscopy request (which should clearly ask a question (e.g. what is the cause of this patients diarrhoea?, are there polyps present? ) or request an action (e.g. remove this polyp). The management plan should indicate appropriate follow-up plans based on current guidelines (e.g. normal colonoscopy; symptoms likely to be due to IBS; symptomatic treatment; no hospital follow-up, surveillance colonoscopy in 3 years. Issue Date: Jan 2018 Page 14 of 55 Review Date: Jan 2021

15 The histology request should have the endoscopist recorded as the consultant or nurse endoscopist, to ensure that reports come back to the endoscopist s secretary and is passed to the endoscopist. If the endoscopist is on leave etc. other endoscopists will review the histologies to ensure there are no urgent results. The endoscopist will act on all results on the day of review. All histology reports must be seen and acted on within 5 working days of receipt. This is the responsibility of the endoscopist. If there is a suspicion of malignant histology the result is sought by the patient booking team daily from Prince Charles Hospital pathology department. A referral to the MDT team, including the appropriate Clinical Nurse Specialist at Prince Charles Hospital will be made at time of endoscopy. On receipt of a histology result confirming malignancy an immediate referral to the appropriate MDT at Prince Charles Hospital is made Communicating results (GRS domain Results 6.1, 6.3, 6.4, Aftercare 12.1, 12.2, 12.3, 12.4, 12.5, 12.6, 12.7) All cancer pathology are referred to the upper or lower GI MDT at Prince Charles Hospital, Merthyr, Cwm Taf Health Board. Patients are informed on the day of the procedure of the suspicion or finding of cancer unless it is not in the interests of patients and this is documented in the patient record. A copy of the endoscopy report, including the follow up plan, and procedure specific aftercare advice (including 24 hour number for advice) is given to the patient on discharge with explanation. Patients are informed from who, and when results of specimens will be available. If a copy of the endoscopy report is not given to the patient the reason must be documented in the patient record. A copy of the report is sent to the referrer and patient GP on the day of the procedure Guidelines for the receipt, storage and administration of controlled and sedative drugs in the endoscopy unit Ordering and Delivery of Medications Controlled drugs must be requisitioned in the controlled drug order book and the requisitions signed in full by an assigned nurse from the endoscopy unit. The name of the nurse should also be printed on the requisition. Controlled drugs must be checked on arrival in the endoscopy unit, with the order book signed in full and records of date, serial number of requisition, quantity received and new stock balance entered immediately in the controlled drug register by the person receiving the delivery. The person receiving the controlled drugs must be a Issue Date: Jan 2018 Page 15 of 55 Review Date: Jan 2021

16 registered nurse. The entry must be witnessed and signed by a second registered nurse. Drug Storage Controlled drugs must be stored in a lockable cupboard, permanently fixed to a wall. Access to the cupboard & keys should only be by the nurse in charge of the endoscopy theatre. The appointed nurse in charge is responsible for the safe custody of controlled drugs. Drug checks Controlled drugs must be checked theatre every day prior to the start of the first list by two qualified members of staff: ODP / nurses. The check has to be entered in the controlled drug register. All controlled drugs should be checked in each theatre at the end of the final list of the day by two qualified members of staff. The check must be entered in the controlled drug register. Preparation of Medicines Drugs must only be drawn up into a syringe by the person administering the drug, after checking each ampoule and its expiry date. Each syringe must be clearly labelled with the approved name of the medicine and strength in mg/ml or mcg/ml. The drugs can then be administered after confirming the patient s allergy status and baseline observations. This entire process must be witnessed by a second person (preferably the endoscopy assistant) as per guidelines. Additional medications required during the procedure During a procedure, top ups of sedation/analgesia or additional drugs eg Buscopan may be required. It would be unsafe and unrealistic for the endoscopist to halt the procedure to administer them. In this situation, the nurse caring for the patient may administer these drugs on the instruction and under the supervision of the endoscopist. If a drug has to be drawn up then the ampoule must be checked with the endoscopist. The nurse should also have completed the local training for intravenous drug administration. Following the procedure The person administering the medications must confirm that the amount of drug left in each syringe at the end of the procedure corresponds to the amount of drug given to the patient. Both the ampoules and syringes must be reviewed by a second person. Any remaining drug not administered, must be disposed of in the endoscopy room (sharps bin or sink), witnessed by a second person. Issue Date: Jan 2018 Page 16 of 55 Review Date: Jan 2021

17 The controlled drug register must be signed at the end of each individual procedure by the person administering the drug and a registered nurse, after confirming that the dose of drug administered has been correctly documented. It is not acceptable to complete the controlled drug register for all patients at the end of the endoscopy list. No crossings out or alterations are allowed in the register. If errors are made, they should be marked entered in error and a new entry made. Ampoule damage/spillage of contents If a drug ampoule is damaged or the contents spilled, the incident and destruction of the drug must be recorded in the controlled drug register and signed by two nurses/ ODP (or nurse and doctor). NB: if stock reconciliations do not balance at any point, the matter should be reported to the nurse in charge immediately Adverse Events (GRS domain Safety 2.1, 2.3, 2.10) If any of the adverse events that are listed below are encountered (by any member of staff) then a Datix form is completed and submitted through the usual PTHB channels. Separate decontamination incident forms are present in the cleaning rooms. The unit clinical nursing manager should be informed, and where appropriate a PTHB clinical incident form should be completed. These are collected and reviewed during the monthly EUAG meetings where they are discussed and action plans are determined. Any bleeds or complications admitted after an endoscopic procedure will be entered as an adverse event and the original endoscopist will be informed. All adverse events are responded to and actioned within 3 months of a report. Endoscopy Adverse Event Definitions Use of flumazenil, naloxone or other reversal agent Any patient requiring an agent to reverse the effects of sedation at any point during the procedure or stay within the endoscopy unit Use of midazolam > 5mg or fentanyl > 100mcg Any patient given sedation in excess of the quantities stated above Perforation Any patient with an upper gastrointestinal or colonic perforation (including those treated endoscopically) Bleed caused by endoscopy requiring blood transfusion Issue Date: Jan 2018 Page 17 of 55 Review Date: Jan 2021

18 Any bleed occurring after biopsy or any therapeutic procedure requiring a blood transfusion Bleed caused by endoscopy requiring hospitalization Any bleed occurring after biopsy or any therapeutic procedure requiring an unplanned hospital admission (even if blood transfusion is not required) Persistent hypoxia Persistent fall in oxygen saturation levels below 90% (despite oxygen therapy) Persistent hypotension requiring treatment Any persisting hypotensive episode requiring intravenous fluid resuscitation or premature termination of the procedure Unplanned admission Any patient requiring admission to hospital due to unforeseen events (eg: complications of the procedure or unplanned admission for monitoring post sedation) Unplanned operation Any patient requiring operative intervention following an endoscopic procedure (eg: for perforation or uncontrolled haemorrhage) Unplanned radiology or radiological intervention Any patient requiring radiological imaging to exclude perforation (eg: CXR, AXR or CT imaging) or intervention to treat uncontrolled haemorrhage Withdrawal of consent Any patient who withdrawals consent during the procedure but who the endoscopist does not appropriately terminate the procedure (see withdrawal of consent guidelines) Cardiac arrest call Any patient for which a cardiac arrest call is required Any accidental injury Any accidental injury occurring (eg: diathermy pad burn) Drug administration error If an incorrect drug is administered to the patient or if there is any discrepancy in the dose of drug given or number of drug vials recorded. Procedure performed by unapproved personnel Any personnel undertaking a diagnostic or therapeutic procedure for which they are not accredited or appropriately supervised. Any person handling controlled drugs without appropriate training or authorisation Equipment failure Issue Date: Jan 2018 Page 18 of 55 Review Date: Jan 2021

19 Any piece of equipment or device that fails (eg: endoscope or cleaning equipment) Any other medication related complication Any other medication related complication not encompassed above Any other endoscopy related complication Any other endoscopy related complication not encompassed above Complaints & feedback (GRS domain Patient involvement 13.1, Patient involvement 13.3, 13.4, 13.5, 13.6) Complaints will be received and processed in accord with the WAG s Putting things right complaint policy (April 2011). This is available in the unit. Any complaint received by the directorate or clinicians etc. that relates to endoscopy will be discussed at the next EUAG / monthly JAG meetings, and actions taken accordingly. Patient can feedback about the service in a variety of ways: verbally, via cards, feedback in the patient book and via the patient satisfaction survey. 3.2 Guidance for clinicians - Appropriate indications & policies for new referrals and surveillance Endoscopic procedures Criteria for selection of patients suitable for endoscopy in a community hospital (GRS domain Safety 2.5) The main consideration is to ensure appropriate patient selection for a community endoscopy service to also includes ward referral. The criteria applies to adult patients over the age of 16 (patients between the age of would be deemed competent of giving informed consent (Fraser and Gillick competence). The following patients are deemed to be suitable to undergo endoscopy procedures within a community setting: 1. Diagnostic endoscopy. 2. ASA grade I, II. ASA grade III if medically assessed by the consultant as fit. 3. Minor therapeutic procedures including EMR of polyps < 2cm, APC. 4. Low risk, low complexity procedures and patients. Patients with the following risk factors would require a medical assessment on the day of endoscopy prior to the procedure: 1. Known allergies including complication following GA, LA or sedation 2. Known HIV / risk of CJD 3. Current anticoagulation therapy Issue Date: Jan 2018 Page 19 of 55 Review Date: Jan 2021

20 4. Insulin dependent diabetics 5. Uncontrolled hypertension Patients with the following risk factors are to be referred to the local DGH for endoscopy. Myocardial infarction within the last 3 months Internal defibrillator / pacemaker if diathermy is to be used CVA in last 3 months Known haemophilia Severe immunodeficiency e.g. cardiac transplants Poorly controlled epilepsy, or recent seizure in past month Known severe chronic liver failure / impairment Known large aortic aneurysm Suspected oesophageal varices / known varices Unstable angina Big, complex polyps over 2cm or if the polyp is in a difficult site e.g. right colon The endoscopist and nursing / ODP assisting team meet before each list for a team brief to discuss any potential problems, complex patients or need to access additional equipment or services Gastroscopy (OGD) (GRS domain Appropriateness 5.1, 5.4, 5.5) Appropriate criteria for Open Access Gastroscopy (see PTHB Gastroscopy referral form appendix 8) Based on the Upper GI cancer NICE guidelines 2015, Position statement BSG, ACPGBI, AUGIS Patients with dyspepsia are accepted for direct gastroscopy from GPs (as agreed with representatives of primary care) if they have: 1 Alarm features: (USC/ Urgent indicators) Persistent/progressive dysphagia Upper abdominal pain and unintentional weight loss >3kg Iron-deficiency anaemia (Post menopausal Females & all Males). Consider colonoscopy at the same time. Haematemesis / Melaena Persistent vomiting & weight loss Upper abdominal mass Suspicious Radiology (barium meal, CT etc) 2 Age over 55 and other risk factors: (Routine indicators) FH of upper GI cancer Previous gastric surgery Previous gastric ulcer Issue Date: Jan 2018 Page 20 of 55 Review Date: Jan 2021

21 Pernicious anaemia Continuing need for NSAIDs Unresolved dyspepsia (see Appendix 2: All Wales Dyspepsia Guidelines) 3 Age over 55 and diagnostic uncertainty (again a Routine indicator) (n.b. This is more debatable, and a clinic appointment may be more appropriate) All others consider H pylori testing, trials of acid suppressant therapy or see in clinic, on ward or send back to referrer. Other referrals for Gastroscopy Other indications that may be appropriate are the items in black, those in red are considered more complex and will be referred to the local DGH include :- Odynophagia Varices assessment (in a patient with Portal hypertension etc) Placement of PEG (see section A1.D) Removal foreign bodies Removal of (selected) lesions e.g. polyps (especially big or flat polyps) or early cancer Dilatation of strictures or achalasia Palliation of malignancy by stent, APC, alcohol injection etc. Treatment of vascular lesions eg angiodysplasia, Gastric Antral Vascular Ectasia (GAVE) Follow up of previous disease eg MALTOMA. (Intervals for OGD surveillance individualised) Surveillance ulcer healing / varices see below Insertion of Endoclips for Precise Radiotherapy planning in Oesophageal cancer Endoscopic Mucosal Resection or Endoscopic Submucosal Dissection for Dysplasia within Barrett s Oesophagus or Gastric Dysplasia or Early Adenocarcinoma of the Oesophagus or Stomach Mapping & assessment or follow up of patients pre and or post EMR and or RFA Indications for Follow Up Gastroscopy Ulcer Healing Typical Duodenal ulcers do not require repeat OGD s due to the extremely low risk of malignancy. Eradicate H pylori if CLO test +ve. Consider carbon urea breath test/faecal antigen if recurrent symptoms after treatment. Gastric (GU) and Oesophageal Ulcers (OU) should be biopsied - unless actively bleeding / coagulopathy. Treat with full dose PPI continue up to the day of repeat OGD. Issue Date: Jan 2018 Page 21 of 55 Review Date: Jan 2021

22 Stop Aspirin / NSAID s where possible, also Biphosphonate (OU) A CLO test should be taken for GU s, eradicate H pylori if positive Repeat OGD within 2 months until healed or evidence of malignancy n.b. a non healing ulcer may warrant a surgical referral on a case by case basis Some patients scoped for a significant GI bleed may need to be re-scoped at a suitable interval as per the endoscopist s discretion Gastric Polyps (see BSG 2010 guidelines Consider biopsying all polyps seen (if clinically appropriate). Also biopsy intervening mucosa in patients with hyperplastic / adenomatous polyps. Look carefully for other lesions if a gastric adenoma is found, consider using NBI / dye spray. Always do a CLO test Polyps with dysplastic foci, adenomas and those that are symptomatic should be considered for removal. Please discuss via the Upper GI MDT Eradicate H pylori if detected in patients with hyperplastic and adenomatous polyps Repeat OGD in 1 year after removal of high risk polyps eg adenomas Barrett s Oesophagus The current best practice to detect early lesions of high grade dysplasia and carcinoma is careful inspection with high resolution white light endoscopy. All reporting should be as per the Prague C&M classification and WAGE and BSG guidelines on Barrett s Oesophagus. (see appendix 1) The Endoscopist should ensure optimal mucosal visualisation by cleaning the thick mucus layer and air bubbles with suitable mucolytics. Suggested agents include N acetyl cysteine and simethicone all of which have been demonstrated to improve visualisation. There is a suggestion that the time spent on inspecting Barrett s epithelium (Barrett s inspection time) has a correlation with the lesion detection. At present we would advocate four quadrant biopsy every 2cm and separate biopsies from any visible lesion (e.g. nodule/ ulcer etc.) as per the Seattle protocol for all cases. The yield may improve in future with targeted biopsy aided by one of the emerging endoscopic techniques. Acetic acid 3% is readily available and there is a reasonable degree of evidence to suggest that routine use within Barrett s surveillance may improve detection of focal abnormalities (used as spray on the Barrett s segment with close endoscopic visualisation for early loss of the whitening effect usually seen with Acetic acid and taking targeted biopsies from these areas). Other digital enhancement techniques (e.g. NBI, FICE & i-scan) and magnification may be used in addition depending on the experience and expertise available locally but should not replace the standard protocol outlined above. Issue Date: Jan 2018 Page 22 of 55 Review Date: Jan 2021

23 All patients with Barrett s oesophagus should be on treatment dose of PPI. Anti reflux surgery should be considered if reflux is not controlled with medical management after ph studies and manometry. All patients with intestinal metaplasia should have endoscopy every two years and surveillance can be stopped at the age of 75 in line with other areas of screening in UK though cessation of surveillance should be discussed with individuals as appropriate (see upper GI surveillance form appendix 6). For low or high grade dysplasia refer immediately to the Upper GI Surgical Services in Prince Charles Hospital to take over the patient care and for discussion in the Upper GI MDT Colonoscopy (GRS domain Comfort 3.6, Appropriateness 5.1, Consent 8.3) Open access colonoscopy is not performed at BWMH. Patients having colonoscopy require full bowel preparation. This must be taken into consideration for the elderly or those with co-morbidity. If significant large bowel pathology that will affect patient management is suspected, a minimal prep CT colonogram is the investigation of choice (discuss with the Cwm Taf radiology department). A patient s fitness for bowel prep, and renal function is confirmed and documented on the PTHB bowel prep form, (see appendix 9) prior to the dispensing of the prescribed bowel prep. Special precautions are required for patients taking Clopidogrel or Warfarin / other oral anticoagulants or those with metal heart valves. CT pneumocolon may be more suitable than colonoscopy. Please discuss with a colonoscopist or radiologist if there is any doubt. C02 insufflation is in use for all lower GI procedures and Entonox is available for patient comfort. It is very difficult to produce an exhaustive list of when a colonoscopy is indicated and when it is not. It should be remembered that the procedure can be uncomfortable and has documented complication rates (e.g. perforation 1 in 1000, problems related to sedation up to 1 in 100 etc.) these are a greater worry in the elderly and those with significant cardio-respiratory compromise. Colonoscopy is generally not an appropriate test (because of a very low yield) for patients with abdominal pain alone, long standing constipation alone or patients under 40 with typical IBS symptomology and no alarm features. It should also be avoided in a patient with colonic perforation, recent Myocardial Infarction etc. Indications where colonoscopy may be appropriate include :- Issue Date: Jan 2018 Page 23 of 55 Review Date: Jan 2021

24 Iron Deficiency Anaemia (nb in premenopausal women this is usually due to menstrual loss) - see updated BSG Guidelines Patients should also be considered for OGD at the same appointment. Chronic Diarrhoea (lasting for >4 weeks, stool culture negative.). Always take biopsies for this indication. Faecal calprotectin is a useful test in patients <45 with diarrhoea (+/- other non alarm abdominal symptoms) if normal then lower GI endoscopic investigation is of very low yield, should be consider if raised (but nb may still be normal in this setting). Altered blood PR in some cases may have had normal flexible sigmoidocopy (with fresh blood loss) or OGD (with melaena) Abnormal Radiology (CT colonography) Assessment of IBD extent and activity Polyps found on sigmoidoscopy (see later) Family History of polyps / Bowel cancer (per advice Genetics) Surveillance procedures (polyps, post cancer surgery, IBD - see later) Colonoscopy Follow-up Policy including surveillance (see PTHB lower GI surveillance form appendix 7) These guidelines are to direct follow-up of at-risk patients undergoing lower GI investigations. They are not all evidence-based, but represent what is current practice at this centre. Further evidence will clarify the position, and these guidelines are likely to be further modified in the future. Indications for follow up :- Colonic Polyps Family History of CRC / polyps Post Cancer Resection Inflammatory Bowel Disease Colonic Polyps (Updated BSG guidelines 2010) All adenomas should be removed. If a clear colon; i.e. good views and no polyp is not definite at the time of colonoscopy, repeat colonoscopy soon (i.e. within weeks). If polyps are found at flexible sigmoidoscopy, patients should routinely be considered for a full colonoscopy subsequently unless co-morbidity precludes this. Post Cancer Surgery (from ACP / NICE guidelines) Full colonoscopy if not done before surgery should be done within 6 months of operation (unless normal CT pneumocolon). If no other lesions / polyps seen (and no other adverse risk factors eg FH CRC, IBD etc) then repeat colonoscopy within 1 year following surgery and every 5 years thereafter if normal. Issue Date: Jan 2018 Page 24 of 55 Review Date: Jan 2021

25 If additional polyps then follow polyp protocol. Generally, colonoscopy should be continued up until aged 75 and stopped if clean colon (average life expectancy is then <15 years no proven benefit continuing with surveillance ). A decision to continue beyond this age or stop earlier should be discussed with the patient and documented in their records. Family History of CRC / Polyps (see BSG Document Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups 2010 for more specific information Those with FH and no symptoms should be referred to Genetics for formal risk stratification & further advice. For the so called Moderate Risk individuals and families who do not fit into the known Mendelian syndromes below, usually undergo 5 yearly surveillance. This should be discussed individually as above rather than presumed as a number of individuals with a family history often have an near average population risk due to the relatives either not being first degree, numbers of relatives affected being small or affected at a late age or not actually being affected with bowel but other cancers. Conversely it is important to bear in mind that those already on a surveillance program due to a familial risk of any degree will be excluded from the Bowel Screening Program as part of the agreed exclusions by BSW. Those seen by Genetics will have been given individualised advice as to the time intervals between colonoscopies. Typical advice for those with defined conditions would be :- FAP Gene carriers - flexi sig every 1-2 years from puberty (or as advised by Genetics). Colonoscopy at age 40 if flexi sig does not show distal polyps. Known FAP - refer for colectomy HNPCC At risk Family members - colonoscopy to the caecum every 2 yrs after age 25 Peutz - Jeghers Colonoscopy start aged 18yrs, perform every 2-3 years All others consult Genetics for guidance Inflammatory Bowel Disease (BSG Guidelines 2010) If Ulcerative colitis (not proctitis only) or Crohn s colitis for > 10 years then do a colonoscopy to assess extent. Issue Date: Jan 2018 Page 25 of 55 Review Date: Jan 2021

26 List for colonoscopy with 4 proximal and 4 distal pouch biopsies suggested in BSG guidance. Post colectomy surveillance of pouch / rectal mucosa Annually - If previous dysplasia or cancer, PSC, persistent atrophy or severe inflammation of pouch 5yearly - for others Colonoscopy tattoo protocol- suspected colorectal cancer (updated Nov 2014) Flexible Sigmoidoscopy (GRS domain Appropriateness 5.1) Indications for flexible sigmoidoscopy include Rectal Bleeding (see guidelines on page 28) Palpable rectal mass Assessment of colitis activity Issue Date: Jan 2018 Page 26 of 55 Review Date: Jan 2021

27 Assessment of pouchitis Left sided polyp (only) on radiological imaging Follow up to assess site of previous distal EMR /polypectomy Suitable patients for Flexible Sigmoidoscopy Direct access service Rectal bleeding with a change in bowel habit to looser stools and/or increased frequency of defecation, persistent for 6 weeks. Any age patient Rectal bleeding persistently without anal symptoms in patients aged over 50 Other patient groups not suitable for direct flexible sigmoidoscopy. Refer with letter:- Definite palpable right-sided abdominal mass or rectal mass at any age: Urgent referral to colorectal surgical clinic Change of bowel habit to looser stools and/or increased frequency of defecation, without rectal bleeding and persistent for six weeks in patients aged over 60: Urgent referral to medical gastroenterology clinic Rectal bleeding in patients under age 50: Refer to surgical or medical gastroenterology clinic Protocol for patients on Warfarin or Clopidogrel requiring endoscopy (BSG 2016) (GRS domain Safety 2.4) Patients are informed in the patient information booklets that if they are taking anticoagulants they should contact the endoscopy department prior to their procedure. The pre-assessment carried out by the endoscopy receptionist also enquires whether any anti-coagulants are taken, and if so the patient is referred to a qualified nurse for further advice. The Nurse will advise the patient to contact their GP for advice. Please see overleaf for the guidelines for the management of patients on warfarin or direct oral anticoagulants (DOAC) undergoing endoscopic procedures. Issue Date: Jan 2018 Page 27 of 55 Review Date: Jan 2021

28 Issue Date: Jan 2018 Page 28 of 55 Review Date: Jan 2021

29 3.2.6 Antibiotic prophylaxis for endoscopy (BSG 2009) (GRS domain Safety 2.4) Antibiotic prophylaxis is no longer recommended for the prevention of infective endocarditis in patients with cardiac risk factors who undergo diagnostic or therapeutic endoscopy. Any patient with severe neutropenia (<0.5) or profound immunocompromised e.g. haematological malignancy, prior therapeutic endoscopy to be referred to PCH Advice for diabetics (GRS domain Safety 2.4) If patients are identified as having diabetes in the clerical pre-assessment process (appendix 5), they are advised by a staff nurse / ODP to phone their GP who will give advice on an individual basis (based largely on NICE guidance Management of adults with diabetes undergoing surgery and elective procedures ). Patients are booked first on the AM endoscopy list. Blood glucose levels are taken along with routine observations on admission and if there is any clinical concern it is raised immediately with the endoscopist. Post procedure blood glucose levels are taken immediately post procedure and 1 hour post procedure if applicable. If patients become unwell the endoscopist is notified immediately. Staff have training on how to recognize signs of hypoglycaemia / hyperglycaemia. The endoscopy unit has a blood glucose monitor & staff have had training on how to operate it. Daily checks are performed on the blood glucose monitor. 4. Responsibilities All staff must be familiar with & demonstrate an understanding of the relevant parts of this Endoscopy Operational Policy appropriate to their discipline; NMC, GMC All staff must be up to date with their full mandatory training. 4.1 Accountable Executive Medical Director 4.2 Head of Department Professional Lead for Surgical Services Issue Date: Jan 2018 Page 29 of 55 Review Date: Jan 2021

30 4.3 Other staff (role title) (please complete as required) Key Endoscopy Staff in Brecon War Memorial Hospital (PTHB) (GRS domain leadership & organization 1.1, 1.2, 1.9, 1.10, Patient environment & equipment 9.6, 9.7, Teamwork 14.2) Clinical Consultant Surgeon from Cwm Taf HB Consultant Surgeon GP Endoscopist Consultant Gastroenterologist Consultant Gastroenterologist Consultant Nurse Clinical lead Bowel cancer screening Lead GRS clinical Lead Management Band 8A (WTE 0.2) Band 7 (WTE 1) Nursing/ ODP/ HCSW/ ODA Band 7 (WTE 1.64) Band 6 (WTE 0.8) Band 7 (WTE 0.6) Band 5 (WTE 8.16) Band 3 (WTE 1) Band 2 (WTE 4.14) Professional Lead for Surgical Services on SLA Endoscopy / Theatre Co-ordinator Day Ward Manager Lead Nurse Endoscopy SSP Clerical WTE 1 Patient Services Manager WTE 0.03 Bowel Screening Wales Administrator WTE 0.8 Data and Audit Support Officer Patient services schedulers WTE 1 Admin / Receptionist 4.4 Key staff responsibilities (GRS domain leadership & organization 1.4, 1.7, Patient environment & equipment 9.7, Patient involvement 13.2, Teamwork 14.4, 14.6, 14.7, 14.8, 14.14, Workforce delivery 15.2, 15.3, 15.4, 15.5, 15.6, 15.7, 15.8, 15.9, 15.10, 15.11) Endoscopy manager responsibilities are to ensure that: Endoscopy is carried out in a safe environment with adequate staffing. Endoscopy staff have specialised education and training required. Encourage and collate team feedback & disseminate and act on recommendations. Issue Date: Jan 2018 Page 30 of 55 Review Date: Jan 2021

31 Staff work to most recent evidence based guidelines and policies. Managing feedback from patients Recruitment and retention of staff There is training needs analysis with plan. Provide induction for new staff. To recognize and reward achievements of the team There is an annual review of skill-mix within the team with action plan and workforce plans. Procurement and management of equipment All risks are actioned. Endoscopist responsibilities are to ensure that: The process of consent is followed. Sedation is administered appropriately. A safe and high quality endoscopy is performed. The patient is monitored throughout the procedure. Endoscopy results are communicated clearly. Endoscopy nurse responsibilities are to ensure that: Patients have a realistic explanation and expectation of the procedure. Team brief and de-brief is completed. Patient care is provided by a qualified member of staff. Changes in the patient condition are relayed to the endoscopist. Assistance to the endoscopist is provided. Any samples are correctly labelled and sent to the appropriate lab. Patients have clear understanding of prost procedure instructions. Decontamination personnel responsibilities are to ensure that: Endoscopes are correctly decontaminated, stored and transported. All procedures are in line with infection control policies. There are safe practices of work i.e. PPE Endoscopes are maintained and monitored. All irregularities are reported to the Endoscopy manager. 5. Access 5.1 Brecon War Memorial Hospital Endoscopy Schedule (GRS domain Teamwork 14.5) Monday AM Monday PM Tuesday AM Consultant Nurse (weekly) Tuesday PM Ad hoc Wednesday AM Consultant Surgeon (weekly) Wednesday PM Consultant Nurse (weekly) Thursday AM Consultant Gastroenterologist (fortnightly) Thursday PM Consultant Surgeon (Monthly) / Cystoscopy (Monthly) Friday AM GP endoscopist (weekly) Friday PM Saturday AM Consultant Surgeon BSW (monthly) Issue Date: Jan 2018 Page 31 of 55 Review Date: Jan 2021

32 This timetable is correct as per November 2016 and gives an overview which is an approximation given flexibility of some operators and back filling. Every attempt is made to back fill lists by the administrative staff & the endoscopy & theatre co-ordinator who flag up vacant slots to all endoscopists as soon as they are aware of them. Backfilling is performed by all endoscopists. Backfill is discussed monthly in the EUAG. If there are empty sessions and the waiting times are low, spare capacity can be offered to neighbouring LHB s if required. Each list has 10 units in the am and 8 in the pm. Morning list procedures should start at 09:00 and run until (3.5 hours) Afternoon lists procedures should start at 14:00 and run until (3.5 hours). Endoscopists should arrive at least 10 minutes before the start times wherever possible. To minimise downtime between each patient, all appropriate patients should have IV cannulas placed by the nurse who is admitting them and all areas of the unit are latex free to avoid the delayed starts for patients with latex allergy. The WHO checklist is incorporated into our endoscopy pathway and is used before every procedure as per the requirement of JAG in Wales. There is a brief at the beginning of the list and debrief at end of the list. 5.2 An outline of the administrative processes within the endoscopy service Referrals vetting and validation (GRS domain Appropriateness 5.2, 5.3, 5.6, 5.8, Respect and dignity 7.4) All referrals will be added to the pooled medical / surgical endoscopy waiting list after vetting by an endoscopist and logged on Myrddin. Those who for valid clinical reasons need to be on specified operators lists will be listed. Referrals will only be accepted when accompanied by relevant clinical information & having been vetted indicating clinical priority of the procedure and authorisation to issue bowel prep where appropriate (see bowel prep authorisation form appendix 9). Referrals that do not meet these criteria will be returned to the referring clinician Referrals to be added to the pooled endoscopy waiting list daily. The clinical referral date (CRD) should be the date of the outpatient clinic generating the referral or the date a direct access referral was made. Surveillance referrals will be validated clerically and clinically 2 months prior to the due date and before action is taken to appoint. Issue Date: Jan 2018 Page 32 of 55 Review Date: Jan 2021

33 Routine referrals will be filed and reviewed weekly to monitor time to component breach. Requests to expedite should be made in writing. The request & original referral will be given to a clinician who will make the decision to amend from routine to urgent if appropriate. If ANY endoscopy request is down graded after vetting, particularly of USC referrals, then a letter MUST be sent to the referring doctor informing them of this decision and outlining the reasons why. All inpatient referrals to be triaged by a consultant before listing. Waiting lists will be reviewed weekly & validated to ensure that the booking process has been implemented appropriately. Booking (GRS domain Access and booking 10.1, 10.2, 10.3, 10.4, 10.5, 10.6, 10.7, 10.8, 10.10, 10.11, 10.13, Productivity & planning 11.4, 11.8) All referrals prioritised as Urgent / USC will be actioned on the day of receipt into the coordinators office. A letter will be sent to all patients inviting them to ring within 72 hours to arrange an appointment. Then when the patient replies and the date is booked appropriate procedure information will be sent. All patients are pre-assessed using the PTHB endoscopy pre-assessment form (see appendix 5) this includes enquiring re the patient language needs, previous medical history and current medication. A date and time will be agreed with every effort made to accommodate patient preference and any endoscopist s instructions to target to a particular list, but most patients are pooled onto the next available list. All patients are sent information relevant to their procedure, and if necessary in their first language if this is not English. If an appropriate offer is rejected by the patient, this should be recorded as a refusal. Any contraindications identified in the clerical assessment will be referred to the nursing / ODP team who will contact the patient before admission to offer appropriate advice. Routine cases will be filtered in to the booking process according to the component breach date. Issue Date: Jan 2018 Page 33 of 55 Review Date: Jan 2021

34 Surveillance patients will be clinically validated 2 months before their due date & brought into the booking process in a timely manner (see appendix 3). Should a patient request that a procedure is deferred, the new planned date should be entered on PMS. Patients who have failed to respond after 7 days should receive a 2 nd letter advising them that contact should be made within 2 weeks to avoid removal from the waiting list. In the case of USC referrals, when it is possible to do so, every effort should be made to contact them by telephone during this 2 week period to confirm that the procedure is not required. If no contact is made the waiting list entry is removed & both the patient & referring doctor advised of the action taken. (See flow chart on page 36). Copies of direct access USC referrals are also returned to the clinician who signed the proforma who will decide if any further action should be taken. Patients who decline a procedure or who fail to respond to booking requests can be re-instated to the waiting list at their own request or at the request of the referring practitioner within a period of 3 months. 1 space per list should be reserved for urgent referrals who will be booked into the next appropriate slot following triage of the referral and pre-assessment. To enable lists to be booked consistently, procedures are allocated a point which corresponds to the complexity of the procedure and how long the procedure is anticipated to take : OGD 1 Flexible sigmoidoscopy 1 Colon 2 OGD & flexible sigmoidoscopy 2 OGD & colonoscopy 3 Colonoscopy & polypectomy 3 Colonoscopy & OGD & polypectomy 4 Surveillance procedures OGD & Barrett s oesophagus biopsies 2 Colonoscopy & segmental biopsies 2 Colonoscopy & polypectomy 3 Lists are booked to a maximum of 12 points. Every patient will be assessed by the Endoscopy receptionist to ensure that they are fit for procedure (see appendix 5) for telephone checklist used for each procedure) Unavailability Issue Date: Jan 2018 Page 34 of 55 Review Date: Jan 2021

35 All periods of unavailability, whether social or medical should be recorded with a covering message against the waiting list entry. Medical If the period of unavailability is expected to be less than 21 days record & continue on the pathway. If the patient remains unfit after 21 days, record & return for review to referring practitioner. If the patient is unable to determine when s/he will be able to proceed, remove from waiting list & advise that patient should be re-referred when fit for procedure. Social When a patient is unable to attend for a period of up to 2 weeks this should be recorded & no adjustment will be made to the pathway clock If the period of unavailability is between 2 & 8 weeks the clock will adjust accordingly. When the period of unavailability exceeds 8 weeks, the patient should be removed from the waiting list. The referring practitioner should be advised & asked to re-refer the patient at an appropriate time. Waiting times (GRS domain Productivity & planning 11.2, 11.3, 11.8, 11.9) Waiting times, demand and capacity and scheduling are reviewed weekly and discussed with service leads, reported monthly to the EUAG and used to plan services. There is an annual measurement of demand and capacity used to support service planning. There is active backfilling of lost lists. Issue Date: Jan 2018 Page 35 of 55 Review Date: Jan 2021

36 USC / Urgent Routine Surveillance Direct Booking Add to Waiting List Add to Waiting List Add to Waiting List Patient directed to endoscopy unit from clinic & is given procedure info to read before interview. In file according to CRD & monitor for 8 week component breach File according to due date Send appropriate procedure information with covering invitation to make an appointment Validate as Operational Policy (page 28) Face to face preassessment by admin staff in endoscopy unit Check weekly & send 2 nd letters to non-responders Date & time for procedure agreed with patient & bowel prep issued where appropriate Patient makes contact & agrees a date & time for TCI. Telephone check list by admin staff & identified medical issues referred to pre-assessment nursing team. If patient fails to make contact after 2 weeks, remove from waiting list. Patient & referring practitioner to be advised of action taken. Issue Date: Jan 2018 Page 36 of 55 Review Date: Jan 2021

37 5.2.3 Cancellations In the case of hospital cancellations, every effort should be made to agree an alternative date with the patient at the time of cancellation. When patients cancel an agreed appointment: An urgent case should be offered an alternative date at the time of cancellation. Routine patients will be advised that they will return to the waiting list and be contacted at the appropriate time. The referral will be filed under the adjusted waiting list date (OWLD). Cancellations up to the end of the day of admission are not treated as DNA s. Patients who cancel an agreed date for the second time will be told that only one further appointment will be offered. A third cancellation will result in removal from the waiting list & the referral will be returned to the referring practitioner. Every effort should be made to fill a cancelled slot to ensure that lists are used to capacity by contacting patients who are available at short notice, or by appointing an inpatient into the space DNA s (GRS domain Productivity and planning 11.5) All patients who fail to attend without notification will be removed from the waiting list. However, if a patient is known to have care & support needs seek advice from a line manager or from the Safeguarding Team. In all cases the referrer will be advised of the action taken. If the referral has been given a USC priority, the clinician who signed the proforma will receive a copy of all relevant paper work to determine whether an alternative course of action is appropriate. Cancellations and DNA s will be monitored monthly & reported in the EUAG accordingly. 5.3 Prospective clinical validation of planned (surveillance) procedures 1. At the beginning of each month the patient services team will identify the patients due for surveillance in 3 months from current date. 2. Clinical notes are obtained for the patient and notes and referral are given to the validating Consultant. 3. The patients are clinically validated according to agreed BSG guidance reflected in the upper and lower proforma agreed in the PTHB EUAG. (see appendix 6 & 7) Issue Date: Jan 2018 Page 37 of 55 Review Date: Jan 2021

38 4. Patient procedures outside of agreed protocol are discussed with the evidence to alter / cancel procedure with the Clinician responsible for the patient care. 5. Appropriate procedure patients are contacted and invited to ring to make an appointment on schedule for surveillance. 6. Appropriate procedure but different timescale needed. Patients are booked to clinic appointment to discuss. 7. No longer appropriate surveillance patients are invited to clinic to discuss the change in patient pathway and are removed from the waiting list. 5.8 Inpatients requiring endoscopy BWMH does not carry out in-patient endoscopy. There is no on-call bleed rota as BWMH is a community hospital. All urgent or complex cases are referred to the local DGH: Prince Charles Hospital. 6. Training & development (GRS domain leadership & organization 1.12, Professional development 16.1, 16.2, 16.3, 16.4, Professional development 16.7, 16.8, 16.9, 16.10, 16.11, 16.12, 16.13) All staff revalidate as required by their professional body. All staff have sufficient time allocated to meet their learning needs. All staff have training is a new piece of equipment or technique is employed. All staff have annual appraisals. Students are assigned a mentor and supervised during their placement within the department. 6.1 Nursing / ODP All new nurses are assigned a mentor during the induction period and until they are competent to perform their allocated tasks. ENDO 1 (foundation), 2 (advanced clinical assisting skills), 3 (leadership / management) courses to be attended as appropriate. All endoscopy nurses to complete the AWENcf (All Wales Endoscopy Nurse competency framework) AER / decontamination manufacturer training plus annual update. Degree level module in Enhanced practice for Endoscopy, Swansea University 6.2 Policy for monitoring endoscopic competence (GRS domain Professional development 16.13, 16.14) BWMH is not a training centre for endoscopy and has no registered trainees. Issue Date: Jan 2018 Page 38 of 55 Review Date: Jan 2021

39 6.3 Consultants/ Nurse Endoscopists (GRS domain Comfort 3.4, 3.5, Quality 4.5, 4.8, 4.9, Teamwork 14.3, Professional development 16.5, 16.6) Endoscopy trainers should have completed a training the trainers (TTT) or (preferably) a training the endoscopic trainers (TET) course. There is a matrix of endoscopic competence and accredited procedures to be undertaken displayed in the endoscopy room. Numbers of procedures, sedation levels, completion rates, comfort scores and patient acceptability (for colonoscopy) will be audited twice yearly as part of GRS comfort audit. Results will be fed back within 3 months of the audit by the lead clinician for GRS. If audit results fall outside the expected range (see below) a meeting will be arranged with the consultant and GRS lead to discuss possible reasons for outlying results. A review of the endoscopists previous 3-6 months procedures will be done. Attendance at endoscopy lists with colleagues (and access to scope guide where possible) will be encouraged. Attendance at a colonoscopy improver s course or observer at a colonoscopy training course should be arranged. A further audit of scores will be performed within 6 months. If scores remain unacceptable, results will be discussed with Endoscopy services manager and arrangements made for further endoscopy training. A further audit of scores will be performed within 3 months. If scores remain unacceptable, the endoscopist will be advised not to continue with endoscopy procedures and the list re-allocated or the individuals practice will be reviewed by the Trust Clinical Governance/ Risk committee. Criteria for independent colonoscopy practice (including BCS guidelines) Unadjusted caecal intubation rate of 90% Lifetime perforation rate less than 1 in 1000 Adenoma detection rates >20% Maximum sedation rates less than 5mg midazolam, 50mg pethidine or 100mcg fentanyl in patients under 70 years (50% less of above in patients over 70 years) Issue Date: Jan 2018 Page 39 of 55 Review Date: Jan 2021

40 Patient comfort scores It is difficult to set specific criteria for acceptable comfort scores during colonoscopy. At each audit patients will be asked to assess overall discomfort on a scale from 1-5 (five being most uncomfortable) AND whether the procedure was acceptable or unacceptable and whether they would have the procedure again. The GRS lead will review all audit results and give feedback on individual and overall results. If an individual has results divergent from the mean, a more detailed review of their colonoscopy outcomes for the previous months will be undertaken as above. Newly appointed endoscopists/ locum appointments Newly appointed or locum staff will be asked to provide evidence of endoscopic experience and JAG certification. They will be assessed by a member of staff at the beginning of their appointment before working independently and be included in audits. Any areas of concern will be managed as above. 7. Service /professional committees or groups (GRS domain Patient Involvement 13.11) 7.1 Endoscopy User and Audit Group There are regular monthly meetings of the PTHB Endoscopy User and Audit Group. These have set agenda items including reviews of audits, waiting lists, complaints, adverse events, policies & protocols, training and workforce issues. These are attended by clinical, nursing, managerial, administrative, training leads as well as a lay member (one of our patients). EUAG terms of reference are agreed and are available upon request. 30 day mortality, 8 day readmission and coded complication rates post endoscopy are available to the EUAG via the audit manager & discussed monthly at the EUAG. Where appropriate, individual clinicians are informed, adverse incident forms completed and cases / themes are raised to the Quality & Safety group. The unit completes and submits the GRS census every 6 months. The results are presented to all staff at the EUAG and in the staff departmental meetings. There is a patient representative who attends EUAG meetings and helps plan and evaluate services. 8. Audit schedule (GRS domain leadership & organization 1.5, 1.6, 1.8, 1.13, Safety 2.8, 2.9, Comfort 3.3, Quality 4.1, 4.2, 4.4, Appropriateness 5.9, Productivity & planning 11.1, 11.6, 11.7, Patient involvement 13.7, 13.8, 13.9, 13.10, Teamwork 14.9, 14.11, 14.12, 14.13) As part of our quality assurance, we routinely collect outcome data against the key quality indicators as per British Society for Gastroenterology standards (available in the unit). See below for the audit schedule: Issue Date: Jan 2018 Page 40 of 55 Review Date: Jan 2021

41 Audit Date Staff responsible Polyp detection, removal & retrieval, January Endoscopist tattoo of tumors Quality of the endoscopy report January Endoscopist Scope traceability February Staff nurse / ODP Vetting and validation March Endoscopist Sedation & use of reversals March Endoscopist Comfort levels April Staff Nurse / ODP Renal function prior to bowel prep April Endoscopist Patient satisfaction May Endoscopy Manager Completion rate June Endoscopist Quality of bowel prep June Staff Nurse / ODP Patient story July Staff Nurse / ODP Staff satisfaction August Endoscopy Manager Consent September Endoscopist Start / finish time & room turnaround September Staff nurse / ODP Comfort October Staff nurse / ODP Annual endoscopy incidents / 30 day November Endoscopy Lead mortality Endoscopy performance e.g. DNA, no. November Endoscopy Lead of procedures Annual planning & productivity report December Endoscopy Manager This information is reviewed in our Endoscopy User and Audit monthly meetings and also is collated and discussed at clinical governance meetings. To quality assure the service, a rolling audit program is in place this has been designed to correspond with the requirements of the Global rating scale (GRS). It includes patient and staff satisfaction audits, safety including 30 day deaths following endoscopy and 8 day readmission rates (monthly), as well as those that focus on decontamination, vetting and outcomes of endoscopy eg colonoscopy completion rates, comfort scores, sedation rates etc (as per BSG quality levels A C). All operators are included. These are presented and reviewed at the meetings with action points being determined. Where appropriate eg colonoscopy outcomes, data is sent to individual operators and when necessary action plans drawn up for suboptimal performance. Endoscopists are given feedback twice yearly on their performance as per procedure key performance indicators and monthly if there are 30 day mortality and 8 day unplanned admissions following endoscopy. An annual planning & productivity report with action plan is discussed in the EUAG. Policies and standard operating procedures are reviewed as per agreed and stated within the documents. Issue Date: Jan 2018 Page 41 of 55 Review Date: Jan 2021

42 9. Service/Department Specific Policies, Procedures & other written control documents (GRS domain Respect and dignity 7.2) List of: Department / Service key documentation that staff must read / comply with (either list or reference to the service policy intranet page) Safeguarding Adults Safeguarding Children 9.1 Department/Service intranet page This is the internal or intranet page that you develop and where you may upload forms, leaflets and other supplementary information for your staff. I suggest you add the webpage link here In addition to this document, guidelines and policies are available in paper form in the unit and on the Endoscopy section of the PTHB intranet 9.2 Department/Service internet page This is the external page that you develop and where you may upload forms, leaflets and other supplementary information for patients/the public. Again I suggest you add the webpage link here. 10. Change control /review This document will be reviewed every three years or earlier should audit results or changes to legislation / practice within the PTHB indicate otherwise. 11. References / Bibliography / Professional Organisations / Support or Key Contacts Practical Gastrointestinal Endoscopy, 4th Edition, Cotton & Williams Practical Endoscopy, Shephard and Mason British Society of Gastroenterology Guidelines Issue Date: Jan 2018 Page 42 of 55 Review Date: Jan 2021

43 APPENDIX 1 Issue Date: Jan 2018 Page 43 of 55 Review Date: Jan 2021

44 APPENDIX 2 Issue Date: Jan 2018 Page 44 of 55 Review Date: Jan 2021

45 APPENDIX 3 APPENDIX 4 New BSG Guidelines (Eaden & Rutter, 2010) SCREENING COLONOSCOPY AT 10Y (preferably in remission, pan colonic dye spray) LOWER RISK Extensive colitis with NO ACTIVE inflammation OR left-sided colitis OR Crohn s colitis of <50% colon INTERMEDIATE RISK Extensive colitis with MILD ACTIVE inflammation OR post-inflammatory polyps OR FH CRC in FDR aged 50+ HIGHER RISK Extensive colitis with MODERATE/SEVERE ACTIVE OR stricture in past 5y OR dysplasia in past 5y OR PSC / transplant for PSC OR FH CRC in FDR aged <50 5Y 3Y 1Y BIOPSY PROTOCOL Pan colonic dye spray with targeted biopsy of abnormal areas. If poor views revert to taking 4 quadrant biopsies every 10cm) OTHER CONSIDERATIONS Patient preference, multiple post inflammatory polyps, age and comorbidity, accuracy and completeness of procedure. Issue Date: Jan 2018 Page 45 of 55 Review Date: Jan 2021

46 APPENDIX 5 Endoscopy pre-assessment checklist Patient ID label Planned procedure: Procedure date: Do you take blood thinning medication such as Warfarin, Clopidrogel, Dipyrdamole or others? Have you got a cardiac pacemaker or internal cardiac defibrillator? Are you diabetic? Do you have or have you ever had : Angina A heart attack or heart failure A stroke Lung problems such as asthma, pneumonia or emphysema High blood pressure Epilepsy Glucoma Blood disorders such as haemophilia or leukaemia Or any other on-going or serious illness we should be aware of? Are you allergic to latex? Have you ever had an adverse reaction to sedation? Do you have any liver problems such as hepatitis? Have you ever been notified by your GP or Public Health that you are at risk of having CJD (Creutzfeldt-Jakob disease)? Or had more than 80 units of blood? Yes No Do you have or have you ever suffered from a hospital acquired infection such as MRSA? Issue Date: Jan 2018 Page 46 of 55 Review Date: Jan 2021