Author: Sabrina Cox, Clinical and Pre-assessment Endoscopy Nurse, Royal Gwent Hospital, Grange University Hospital

Key words 

Pre-assessment, endoscopy, nursing, documentation, pathway

Abbreviations

• BSG – British Society of Gastroenterology
• GI – Gastrointestinal
• GRS - Global Rating Scale
• JETS - JAG Endoscopy Training System
• DNA - Did Not Attend 

Learning points

1. A standardized pre-assessment process minimises procedural risks and enhances patient outcomes
2. Effective communication during pre-assessment reduces patient anxiety and ensures adherence to preparation guidelines.
3. Endoscopy pre-assessment practitioners are vital for patient safety.

What is pre-assessment in endoscopy?

The pre-assessment process plays a crucial role in gathering accurate information about patients ahead of their endoscopy. For the majority of patients, this assessment will take place before their scheduled appointment, either through a questionnaire, a pre-procedure phone call, or during an outpatient visit. Some patients, such as in-patients, may have pre-assessments carried out by an outreach nurse, while those undergoing bowel cancer screening may receive a pre-assessment via a telephone appointment with a Specialist Screening Practitioner (SSP) [1, 2].

The primary goal of patient pre-assessment is to provide a thorough risk assessment to help balance the potential risks and benefits of the endoscopic procedure. It ensures that the patient's suitability for the procedure is evaluated, factoring in aspects like consent, the management of comorbidities, risk assessment, bowel preparation, and sedation [3].

Effective pre-assessment is not only key to determining whether the patient is fit and suitable for the procedure but also helps ensure they are fully prepared for the endoscopy. This process is essential for ensuring patient safety and the smooth running of endoscopy services [5].

Without pre-assessment in endoscopy

Without pre-assessing patients prior to their endoscopic procedure, this creates several challenges that can affect the smooth running of the endoscopy service. One of the major issues is poorly prepared patients. Without proper pre-assessment, patients may not fully understand the requirements for preparation, such as fasting, bowel preparation, or medication adjustments. This can lead to inadequate preparation, which may compromise the quality of the procedure or even require rescheduling [3, 9].

In addition, the absence of pre-assessment service in endoscopy units increases the likelihood of cancellations and "Did Not Attend" (DNA) appointments. When patients are not properly informed or prepared, they may be more likely to miss their appointment or cancel at the last minute, resulting in inefficiencies and wasted time. This can lead to the need for rescheduling and result in a backlog, which further strains resources and causes delays throughout the patient's journey [3].

Furthermore, the lack of pre-assessment can also contribute to scheduling errors. Without prior assessment, patients might arrive at the procedure without the necessary consent, or an incorrect procedure might be scheduled based on incomplete or inaccurate information. This can lead to last-minute changes, errors in procedure planning, and delays in starting the endoscopic sessions. These issues not only impact the operational flow of the endoscopy unit but also cause significant stress for both patients and healthcare providers [3].

For patients and their families, the lack of proper preparation and communication creates heightened anxiety and fear, as they are uncertain about what to expect from the procedure. This anxiety can negatively affect their overall experience, making the procedure more stressful than it needs to be. When patients do not understand the risks, benefits, or the procedural details, it can also reduce their satisfaction and trust in the healthcare system [3, 10].

Moreover, many endoscopy teams have encountered situations where inpatient procedures were cancelled at the last minute, or patients arrived unprepared, with incomplete consent forms, or with inappropriate procedures scheduled due to a lack of proper assessment [6]. These situations disrupt the flow of the endoscopy unit, causing additional delays, cancellations, and operational inefficiencies.

The challenges have been further compounded by the COVID-19 pandemic, which has placed additional pressures on endoscopy services. The backlog of procedures has grown significantly, and without pre-assessment, teams are struggling to manage the increasing volume of referrals [7]. The pressure to keep up with this demand, while maintaining patient safety and efficiency, becomes even more difficult without the structured support that pre-assessment offers. As a result, endoscopy units face mounting delays, cancellations, and patient dissatisfaction.

Benefits of pre-assessing patients in endoscopy

It has been found that pre-assessment in endoscopy improved scheduling efficiency, optimized resource use, and proved to be cost-effective by reducing cancellations and shortening inpatient stays. The process also provided better patient education, alleviated anxiety, and enhanced procedure tolerance, decreasing the need for sedation. It has been recommended implementing pre-assessment for all endoscopy lists to improve service capacity and organizational efficiency [6].

Pre-assessing patients requiring GI endoscopy also provides an opportunity to address factors that can influence the patient's overall experience. It allows time for patients to understand the procedure, and this understanding can be checked again when they attend for the procedure. An NHS Improvement document highlights that pre-assessment enhances patient understanding of the procedure, which has been linked to improved attendance rates. This information can be provided in various methods through written patient information leaflets, face-to-face or verbal discussions, or even through videos which have proven effective in addressing patient concerns and questions [14].

Pre-assessment also provides an opportunity to inform patients about their sedation options, allowing them to make an informed decision regarding the sedation regimen. Ideally, this information should be given in writing before the pre-assessment clinic, with a final sedation decision made during the assessment. If pre-assessment takes place immediately after the decision to refer for the test, such as in a clinic setting, sedation details can still be provided, with the final decision made at a later time. When decisions are made in advance, patients experience less anxiety at the time of the procedure, which can reduce its impact on their decision-making [11,13].

Another key benefit of pre-assessment is that it gives patients the chance to ask questions and receive answers. This offers patients the opportunity to ask questions and process the information before the procedure. In cases where consent is obtained in advance, the endoscopist should briefly confirm consent upon the patient's arrival at the unit [13].

Additionally, pre-assessment can help assess and address pre-procedure anxiety. Identifying patients with high anxiety levels before the procedure can help in deciding whether sedation is necessary to improve tolerance. Pre-assessment can also reduce the number of “did not attend” cases, as patients who undergo pre-assessment are more likely to attend their procedures [13, 14].

Research supports that pre-assessment significantly reduces same-day cancellations, improves procedural success, and enhances the overall patient experience [8]. Additionally, studies indicate that conducting pre-assessment 30 to 39 days before a colonoscopy leads to better bowel preparation, regardless of whether the patient has had a previous colonoscopy. This extra time allows patients to mentally prepare for the procedure and adjust their dietary intake for optimal bowel preparation [9].

What is involved in pre-assessment in endoscopy and the endoscopy pre-assessment practitioner role?

Endoscopy pre-assessment should be conducted by a well-trained practitioner who can explain the procedure, preparation, and follow-up in a setting that ensures patient privacy and facilitates open communication. Also, it provides an opportunity for a thorough discussion about the planned procedure, including its risks, benefits, and alternatives. Whether performed in person or via telephone, this process helps ease anxiety and ensures that all aspects of the patient’s health and preparation are addressed [11].

1. Comprehensive patient evaluation [10, 11]
   Reviewing the patient’s medical history, medications, and comorbidities to identify potential risks and comorbidities that could impact the procedure or sedation, such as: 

• Cardiovascular diseases (e.g., atrial fibrillation, hypertension), presence of cardiac devices
• Respiratory disorders (e.g., COPD, sleep apnoea)
• Bleeding risks associated with anticoagulants
• Kidney problems 
• Pregnancy
• Previous history of cerebrovascular disease/events
• Gastrointestinal conditions
• Hematological disorders
• Neurological conditions
• Allergies/sensitivities
• Infection risk
• Previous surgeries: implants, metal work, cataract surgery, upper or lower GI, any other organs

2. Determining sedation requirements
   The appropriate level of sedation—deep or conscious—is determined based on patient risk factors and medical history.        The need for an anaesthetic review should be identified when planning the endoscopic procedure. Both patient and procedural factors play a role in deciding who requires formal anaesthetic assessment. Deep sedation should be considered for procedures that are longer in duration or involve complex therapeutic interventions. The British Society of Gastroenterology (BSG) provides specific guidelines on sedation protocols and options [11].

3. Enhancing Patient education and Procedure preparation [3 ,10, 11]
   Ensuring patients follow preparation protocols, such as bowel cleansing, to maximize procedural success and to receive clear, timely information on:

• Fasting requirements
• Medication adjustments i.e. diabetic regimen, anticoagulants
• Bowel preparation
• Procedure expectations to reduce anxiety and improve compliance

4. Addressing additional patient needs [3 ,10, 11]

• Accessibility and transport issues
• Mobility status and use of assistive devices
• Social factors (e.g., patients who live alone)
• Language barriers and need for interpreters
• Cognitive or neurological impairments
• providing reassurance and psychological support 

5. Identifying High-Risk Patients and Procedures [5]
   Patients with an ASA (American Society of Anesthesiologists) score of 3 or higher are considered high-risk due to underlying health conditions. High-risk patients are assessed to determine the risks and benefits of the procedure. The consent process ensures the patient fully understands and agrees to the procedure. High-risk procedures include:

• Therapeutic oesophagogastroduodenoscopy (OGD)
• Percutaneous endoscopic gastrostomy (PEG)
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Endoscopic submucosal dissection (ESD)
• Endoscopic mucosal resection (EMR) 

6. Coordination of Care
   Collaboration with gastroenterologists, anaesthetists, nurses, and other specialists is important for a smooth and well-planned endoscopy process. Working together helps ensure patient safety and makes the procedure more efficient. Gastroenterologists assess whether the procedure is needed, while anaesthetists determine the right level of sedation based on the patient’s health. Nurses play a key role in explaining the procedure, obtaining consent, and making sure the patient is properly prepared. In some cases, input from other specialists, such as cardiologists, respiratory doctors or haematologists, may be needed for patients with existing health conditions. Proper coordination helps prevent delays, reduces last-minute cancellations, and ensures the patient is fully prepared for the procedure.

Standardised pre-assessment pathways

To streamline the pre-assessment process, standardized pathways are essential. Clear referral criteria ensure consistent guidelines are followed, particularly for high-risk patients, such as those with comorbidities or complex medical needs [3].

Using electronic pre-assessment tools helps collect patient data efficiently, reducing paperwork errors and improving the overall effectiveness of the process. An example of a digital pre-assessment tool is MyEndo, a patient-driven online platform for endoscopy pre-procedure assessments. This digital system empowers patients to engage in their own pre-assessment, enhancing their involvement and providing more accurate information [12].

While the necessity of pre-assessment is widely recognized, its real impact comes from evidence-based improvements in patient safety, procedural efficiency, and overall outcomes. Studies show that structured pre-assessment protocols can reduce endoscopy cancellations by up to 30%, prevent major complications, and improve patient satisfaction [8]. Without thorough pre-assessment, patients may experience increased procedure failures, prolonged hospital stays, and higher healthcare costs.

The Global Rating Scale (GRS), developed by the Joint Advisory Group (JAG), mandates that all endoscopy services implement structured documentation processes. This ensures that patient risk factors, medical history, and sedation plans are tracked and communicated effectively [3, 5].

How to become a pre-assessment practitioner

By ensuring these aspects are thoroughly addressed, pre-assessment practitioners play a crucial role in streamlining the endoscopy process, reducing procedural risks, and improving patient outcomes.  A well-planned and organized pre-assessment ensures that patients are both psychologically and physically prepared for their procedure, making them feel more informed and at ease [3] To specialize in endoscopy pre-assessment, practitioners need a combination of formal education, training, and experience. 

1. Educational Requirements

• Registered Nurse (RN) or Allied Healthcare Professional – Most candidates are Registered General Nurses (RGN), Operating Department Practitioners (ODPs)
• Professional Registration – Practitioners must be registered with the Nursing and Midwifery Council (NMC) or Health and Care Professions Council (HCPC).

2. Available Training & Certifications

• JETS Workforce ENDO1 Training Programme – A UK-based program designed to equip healthcare professionals with endoscopy-specific pre-assessment skills.

3. Experience Requirements

• 1-2 years in endoscopy or gastrointestinal nursing

In addition to formal training programs, nurses and healthcare professionals can also benefit from foundational pre-assessment courses which are designed to deepen understanding of pre-assessment practices, including medical history evaluation, patient preparation, and the identification of potential risks associated with procedures. 

Preoperative Assessment Courses - The Perioperative Association

Pre-assessment skills - Knowledge4nurses.com

Becoming a proficient pre-assessment practitioner involves a combination of formal education, ongoing training, and hands-on experience, all aimed at ensuring patient safety, optimizing procedure success, and improving patient outcomes.

Conclusion

Endoscopy pre-assessment is a critical process that ensures patient safety, optimizes procedure success, and enhances overall patient experience. A well-planned pre-assessment approach reduces cancellations, minimizes risks, and improves efficiency.

By implementing structured pre-assessment pathways, utilizing digital screening tools, and training skilled practitioners, endoscopy services can improve patient outcomes, reduce procedural delays, and enhance overall service efficiency.

Author Biography