Colonoscopy discomfort affects patient satisfaction
Correlation between pre-op meds and results
[Editor’s note: Same-Day Surgery attended the 2002 annual meeting of the Federated Ambulatory Surgery Association (FASA). We covered one of the financial benchmarks sessions, and we’ve added details and suggestions on how to improve. This information is on our web site: www.same-daysurgery.com. Click on "archives," then click on "Coverage of FASA Financial Benchmarks Session" underneath the search box.]
In a diagnostic colonoscopy study conducted by the Institute for Quality Improvement (IQI), a subsidiary of the Accreditation Association for Ambulatory Health Care (AAAHC) in Wilmette, IL, 3% of the patients surveyed following their colonoscopies said they would not undergo another colonoscopy.
This statistic concerns providers because colonoscopy is an effective way to detect cancer, as well as remove polyps and lesions. More than one-third of these patients reported pain levels of 4 and 5 during the procedure. One represented no discomfort, and 5 represented severe discomfort. Of the patients reporting severe discomfort, 28% did not receive preoperative pain medication, as compared to 16% of patients reporting no discomfort or lower levels of discomfort.
"Ninety-five percent of our patients report little or no discomfort with the procedure," says Howard J. Goldberg, MD, medical director of Montgomery Endoscopy Center in Wheaton, MD. His program uses midazolam in conjunction with meperidine or fentanyl. Colonoscopy is an inherently uncomfortable procedure, and every patient tolerates pain differently, Goldberg says. "Patients are uncomfortable during the procedure, but with the use of midazolam, they don’t recall the discomfort," he points out.
Goldberg’s program has an average discharge time of 31.4 minutes. Discharge time is defined as from the time the patient is out of the operating or procedure room to the time the patient is ready for discharge from the recovery area. Goldberg attributes that benchmark to several reasons. "We don’t oversedate the patients, and we get them moving 10 minutes after the procedure is completed," he says.
Patients sit up, talk, and walk to the waiting room or doctor’s office, with a family member, as soon as possible, he adds. "We also have healthier, younger patients than a hospital-based endoscopy program would see, so they do recover more quickly," Goldberg admits.
The median pre-procedure time for all 33 survey respondents was almost 37 minutes. (For information on ordering the report, see "Sources and resource" at the end of this article.) The pre-procedure time is defined as the time the patient enters the facility to the time the patient is in the operating or procedure room. However, the staff at Redding (CA) Endoscopy Center reported an average pre-procedure time of fewer than 25 minutes. "We call our patients the day before their procedure to get medical history information as well as billing information," says Patty Benton, LVN, administrator of the endoscopy center. "Everything is filled in and ready for a quick review and signature when the patient arrives, so our check-in time is usually only five minutes." After checking in, the patient is directed to a changing room, then into the procedure room where a nurse re-checks the medical history, starts the intravenous line, and hooks up the patient to monitors, Benton says. "We run two rooms, and our staff work well together to keep the process moving smoothly," she says.
Because pre-procedure time is affected by how early or late patients arrive, Benton’s organization looked at how they instruct the patients. Many of the patients are traveling a great distance, so Benton’s staff tell them to be at the facility 30 minutes before the procedure. "This gives them time to get stuck at the train crossing or be delayed by bad weather without being late to the appointment," she explains. "It also does not have them arrive so early, they have to wait a lengthy time before going to the procedure room."
The overall median procedure time for survey respondents was 16.6 minutes, but Goldberg’s facility reported a procedure time of slightly longer than 10 minutes. "The fact that we are a dedicated endoscopy unit contributes to our efficiency," Goldberg points out. The number of polyps and other abnormalities identified, removed, or biopsied also can affect procedure time, he adds.
Goldberg’s and Benton’s facilities reported overall facility times of fewer than 100 minutes, which is lower than the 125.7-minute median facility time. The facility time is defined as the time the patient enters the facility up to the time the patient is ready for discharge from the recovery area.
All of the physicians are experienced gastroenterologists who are owners of this facility, Benton says. "They want to make the center run smoothly so they show up on time for all of their procedures," she explains. "If one of the surgeons does arrive late on a regular basis, I include it in reports to the physician-owners, and they handle it among themselves."
Sources and resource
For more information about use of the colonoscopy study results within same-day surgery programs, contact:
• Patty Benton, LVN, Administrator, Redding Endoscopy Center, 1825 Sonoma St., Redding, CA 96001. Telephone: (530) 246-7000.
• Howard J. Goldberg, MD, Medical Director, Montgomery Endoscopy Center, 12012 Veirs Mill Road, Wheaton, MD 20906. Telephone: (301) 942-3550.
The study, Diagnostic Colonoscopy, is $50 plus $10 for shipping. To order, contact: AAAHC Institute for Quality Improvement, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091-2992. Telephone: (847) 853-6060. Fax: (847) 853-9028. Web: www.aaahciqi.org.
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