Author:

Chehkuan Tai

Acknowledgements:

Muditha Samarasinghe, Clinical Endoscopist 

Regina Raymond, Lead Clinical Nurse Endoscopist 

Chehkuan Tai, Consultant Gastroenterologist 

Eleanor Brothwood, Gastroenterology Service Manager 

Karim Abouahmed, Operations Manager for Medicine and Urgent Care

What were the challenges to your service and why did you need to change?

Despite running 50 lists per week, we struggle to meet our demand. As 2WW diagnostics was the priority, we have a big surveillance and routine diagnostic waiting list. In September 2023, we had 600 gastroscopies pending.

Our gastric ulcer (GU) rescope audit in 2022 demonstrated only 30% of patients received their repeat gastroscopies within 12 weeks with some waiting for over 70 weeks. 

How did you overcome the challenges?

We developed a transnasal endoscopy(TNE) service as a strategy to increase capacity. TNE cause less haemodynamic and is generally better tolerated. Sedation is not required, further minimising risk to the patient and allowing for a service to be delivered in the outpatient setting.

We are part of the same trust as Royal Free Hospital (RFH) which already has a successful outpatients-based TNE service. They run a one stop 2WW clinic where patients are seen by a clinical endoscopist (CE) and sent for further diagnostics including a TNE on the same day if appropriate. The 12 month service audit demonstrated that TNE in outpatients is safe and efficient. 420 patients were booked into clinic where 400 patients underwent TNE on the same day. In the 20 who did not receive TNE, 8 did not attend the appointment, 5 requested sedation and 7 did not adequately fast. There were no complications. 6 had failed intubation through the nose but had successful per oral intubation in clinic. All histopathological samples provided adequate sampling. In terms of patient satisfaction, 65% previously had a conventional gastroscopy and 96% reported that unsedated TNE would be their preferred option for future gastroscopies. That service served as proof of concept and provided us with a model for our service.

We have a successful nurse-run straight-to-test (STT) 2WW UGI service and CAS triage for routines which provided us with the stream to triage patients appropriately to TNE in outpatients.

One of the concerns about doing TNE in outpatients is with regards to quality of airflow in the outpatient setting, especially in the post covid era. Infection control assessed the outpatient space and confirmed that the outpatient rooms in which we deliver TNE have adequate airflow without need for additional filters.  

When we engaged the local ENT team to develop an SOP for management of  uncontrolled epistaxis, they was enthusiastic in collaborating to share the equipment as they found the TNE scopes superior for access and biopsies in high dysphagia. We put in a joint application for the equipment. At present, ENT and gastroenterology share access and ongoing maintenance cost. 

While we would like to deliver TNE 3 times per week, we are limited by outpatient clinic space. 2 clinic rooms are required as one would be to complete the procedure and the other to consent and administer the topical decongestant and anaesthetic to the nose. 

The nursing provision for the TNE service is less than a standard OGD list with the need for only 1 trained nurse and another HCA. During our pilot, we ran our TNE lists on days where there are fallowed lists as we did not have substantive nursing support to run an additional list. Our endoscopists convert another clinical activity on an adhoc basis to run these lists. 

What were the outcomes?

We began our pilot in October 2023 and delivered 9 lists between October to December 2023.  

The service has been delivered by a CE and a consultant who are both accredited in gastroscopy. Both had completed 20 independent TNE cases at the point in which they ran their own TNE service lists. 

We started with 4 cases per clinic whilst we trained our nursing team and gradually went up to 8. In total, we have had a total of 46 patients go through this service. We had 2 unsuccessful cases (4.3%) where both could not tolerate TNE without sedation. 6 were converted to successful oral intubation. We anticipate this number to decrease with increased experience of endoscopists. We have not had any complications. 

We have cleared the GU recheck waiting list and are currently doing prospective requests from the routine and 2WW pathways. 

While our numbers have been small thus far, our pilot demonstrates the feasibility of running TNE in outpatients. 

What were the learning points and how can this influence other teams?

This service has demonstrated how valuable it has been to engage with stakeholders. 

While we could theoretically run TNE on all 5 days on our own, we are limited by the availability of outpatient space and our collaboration with ENT has been helpful for us to reduce ongoing costs. Furthermore, we currently do not have adequate resource to run regular lists. 

This service has led to upskilling of endoscopists and nurses and admin team. Our endoscopy bookings team do not manage these “clinics”. While our requesters follow the check-list on the request form to ensure there is no contra-indication, we have a second layer of checks where our gastroenterology navigators gives the patient a welfare call to ensure they are aware of the appointment date, instructions for fasting and also provide explanation of the procedure when needed. 

At the start of the pilot, we faced a lot of scepticism from both clinicians and nursing staff. With time, the positive results of our service has led to a change in mindset. 

The clinical coding for these TNE cases is different to that of a standard gastroscopy despite the same tariff. We have had to educate our endoscopists to ensure that patients are adequately coded on the report and on EPR. This service will lead to net cost savings to the trust as we get the same remuneration as a standard gastroscopy but with reduced costs to running this service as we do not require as many nurses and do not use sedation. 

By doing TNE in the outpatient setting, we could increase endoscopy capacity. We are currently working on the business case for the resources to run a regular additional TNE list and at that time, we will increase net capacity.