Gastrointestinal (GI) endoscopy takes less time when an anesthesiologist oversees the sedation, researchers say.
“We have increased patient access to our GI unit by making these modifications,” said Adeel Faruki, MD, a senior instructor of anesthesiology and fellow in operations at the University of Colorado Anschutz Medical Campus in Aurora.
The finding was presented at the American Society of Anesthesiologists’ ADVANCE 2022, the Anesthesiology Business Event.
Sedation for endoscopy in the United States generally follows one of two models, Faruki told Medscape Medical News: nurse-administered sedation (NAS), or monitored anesthesia care (MAC). During NAS, a GI proceduralist monitors a registered nurse who sedates patients using medications such as fentanyl, midazolam, and diphenhydramine. This was the approach at the researchers’ GI unit until July 1, 2021.
After that date, the GI unit switched to the MAC model, in which an anesthesiologist supervises a certified registered nurse anesthesiologist or an anesthesiology assistant who administers propofol. Propofol is faster acting than the drug combination the GI unit previously used and causes deeper sedation. But it can also cause respiratory or cardiovascular depression or low blood pressure, Faruki said, so most institutions require an anesthesiologist to oversee its use.
NAS vs MAC: Seeking the Superior Model
To see which approach was faster, Faruki and colleagues recorded times for endoscopic procedures from August 1, 2021, to October 31, 2021, and compared them with the data they had logged in electronic medical records from January 1, 2021, to June 30, 2021. They excluded the month of July to allow for a transition period between the two approaches.
After comparing results from 4606 patients undergoing endoscopy with NAS to 1034 undergoing it with MAC, they observed that switching to the latter model reduced by 2 to 2.5 minutes the time from sedation start to scope-in.
Because recovery is faster with propofol, the patients also spent 7 minutes less in the post-anesthesia care unit for upper GI endoscopies and 2 minutes less for lower GI endoscopies. Patients also told the researchers they felt less groggy.
At the same time the unit was transitioning from NAS to MAC, they also began requiring patients to sign consent forms for both the anesthesia and GI procedures in the preoperative room rather than in the procedure room. That saved about 19 minutes.
Putting all these changes together, the researchers calculated that they increased the capacity of their GI unit by 25%.
“With a pandemic raging and capacity crises continuing, it becomes very relevant to the care we can provide patients,” Faruki said. “That’s something we’re actually really proud of.”
The university is now instituting similar procedures at its other ambulatory surgical centers, he added.
How Efficient Is Your Endoscopy Center?
“Other factors can also affect the efficiency of endoscopy,” said Joseph Vicari, MD, MBA, a partner at Rockford Gastroenterology Associates in Illinois, who was not involved in this study.
For example, the unit has to have enough endoscopes and enough techs to clean them so they’re always available, he told Medscape Medical News. There have to be enough nurses and other staff to turn the rooms over efficiently. There also have to be enough pre-op and post-op beds, so that no one is waiting for either one.
Vicari recommended that GI endoscopy centers compare their times to those of benchmarks provided by professional societies and in published papers.
Having sorted out these factors, the MAC and NAS approaches both have their pros and cons, said Vicari.
“I think it’s a good idea for units that are struggling with efficiency, especially hospital-based units, to consider new ways to upload patient information and maybe have a dedicated anesthesia team to improve efficiency,” he said. “Procedure time can be reduced because you generally have a much steadier state of sedation with MAC, and then the recovery is much faster with propofol. Your patients wake up faster.”
But Rockford Gastroenterology continues to use the NAS approach in at least 90% of its endoscopies, because it is already so efficient that it doesn’t believe that MAC would make a significant difference.
“Academic centers tend to be less efficient,” he said. “Units like ours, an ambulatory endoscopy center, are different.”
NAS is also less expensive, Vicari said. “We have leveraged our lower-cost ambulatory endoscopy center by providing fentanyl and Versed [midazolam], turning it into an advantage in developing bundled contracts. Payers can significantly reduce expenses.”
The involvement of an anesthesiologist could increase the cost, Faruki acknowledged, and he said the researchers are analyzing that question. But he added that anesthesiologists can also oversee four rooms at once.
Faruki and Vicari report no relevant financial relationships.
ADVANCE 2022: The Anesthesiology Business Event: Abstract A01. Presented January 28–30, 2022.
Laird Harrison writes about science, health, and culture. His work has appeared in magazines, newspapers, on public radio, and on websites. He is at work on a novel about alternate realities in physics. Harrison teaches writing at the Writers Grotto. Visit him at lairdharrison.com or follow him on Twitter: @LairdH.
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