Office-based endoscopy: office-based endoscopy provides a good example of how to establish office-ba
This article aims to serve as a template for practitioners seekingto formally establish an office-based surgery and use an office-basedendoscopy service (OBE) as an example. We have drawn fromGastroenterological Society guidelines and our local experience. (1,2)Scope of practice
* Gastrointestinal endoscopy--upper GI, small bowel, sigmoidoscopy,
colonoscopy, including biopsy, ablation, dilatation
* Bronchoscopy
* ENT--rigid and fibre-optic endoscopy, laryngeal surgery (3,4)
* Urology--flexible cystoscopy, ultrasound-directed prostate biopsy
* Gynaecology--hysteroscopy, endometrial biopsy (ablation,
laparoscopy).
Reimbursement
In the current era of managed care there are formidable shifting
relationships that we must deal with. The OBE offers greater comfort and
satisfaction at a lower cost than traditional treatment facilities. Is
it ethical for surgeons or gastroenterologists to own the facility in
which they work, to self-refer and to charge for the use of the
facility? Yes, but there are safety, quality-of-care and ethical
constraints.
The current fee structure has lagged far behind endoscopy practice
costs. Activities by legislative bodies and managed care organisations
continue to stress the economic viability of the office environment. The
initial investment in OBE can be daunting.
One effort currently underway is to 'rebase' practice
costs and facility fees to reflect the actual costs of providing
services (so-called so-called national health reference price list
(NHRPL)) rather than on historic charges. An alternative proposal is to
use the fees developed for hospitals and apply these to OBS and OBE as a
classification system for grouping procedures for facility payment
(assignments purportedly would be based on clinical characteristics and
resource utilisation). Grouping and reimbursement levels are current
issues being discussed by the National Health Insurance (NHI) task
teams.
Along legislative lines, there are also impediments of outdatedlegislation, talks of Certificate of Need (CON) restrictions and thetrend towards accreditation of facilities. Accreditation is a naturalevolution as payers, managed care organisations and regulators placeincreasing emphasis on quality, safety and patient satisfaction. It willalso become increasingly important, if not essential, for obtainingfacility reimbursement.Functional plan and architectural issues
Size and volume
It is important to have a clear understanding of the expected
volume of procedures and the number of doctors sharing the facility.
Endoscopy
Separate space for cleaning equipment between procedures and a
separate recovery area will avoid delays in room turnover. If many
patients are 'first visits' on the day of their procedure,
consultation space and time must be factored in. Endoscopic case mix can
also influence volume.
Location
Locating in an existing professional building on your primary
hospital 'campus' has several advantages over a totally
free-standing facility. Patient trust may be higher when entering a
professional hospital complex. In the event of a complication, response
time is rapid. And since no hospital wants to lose your endoscopy
business, the hospital can see some rental return. Corporate and
hospital governance issues place additional pressure to ensure safety
compliance.
There are also strong arguments for a free-standing, geographically
separate facility: neutral turf, both politically and geographically,
might be best.
Construction basics and work flow
Plumbing, air conditioning, sound proofing, ventilation and
electricity are beyond the gambit of this article, but some basics are
as follows:
* Construction costs for endoscopic space tend to be 2-3 times as
expensive as standard office space. Several nuts- and-bolts issues will
be dictated by local building codes and licensing requirements. Make
sure you are aware of regulations.
* Adequate sound-proofing between endoscopy rooms, patient recovery
area and waiting rooms is essential. The sounds related to endoscopy can
be disturbing to patients waiting to undergo procedures, as well as
those recovering.
* Temperature regulation is desirable. Waiting rooms have fully
clothed people; pre-operation areas have nervous, undressed people;
endoscopy rooms have sedated people and others hard at work with
heat-generating equipment.
* The endoscopy rooms and endoscopy cleaning areas must bewell-ventilated.* The most desirable patient flow pattern is a simple,
one-directional movement. Consider the movement flow in the procedure
room--the number of people, where they stand, endoscope and monitors,
beds and trolleys, supplies, cleaning facility.
* Patients often arrive for endoscopy anxious and confused. If
possible, send careful instructions, and have signs posted in the
immediate vicinity. There must be wheelchair, stretcher and bed access.
* The reception area must have adequate room for patients'
families. As a general rule, 1-2 people accompany each endoscopy
patient. Use individual chairs instead of couches; people do not like to
sit with strangers in stressful situations. A toilet facility should
also be available.
* The pre-op (prep) area should be private. IVs are started and
patients are undressed. Nursing and doctor interviews are performed
here. Bathrooms should be easily accessible.
* Consider the use of television or music in the reception and prep
area.
* Procedure rooms have high electrical needs and the building must
have power back-up in both procedure and recovery rooms. Dimmers are
excellent, as well as spotlights over areas of paper work and biopsy
handling. Telescopic lights or headlamps are useful.
* The endoscope cleaning area should be near the procedure room,
and should be spacious and well-ventilated. The standard of practice is
moving to automatic endoscope reprocessors, but they are expensive and
require lots of space and hot water.
* The recovery area requires more planning than one might think.
There must be adequate space for recovery beds. Time in recovery can be
considerable and could create a 'log jam'. Until patients are
fully recovered and exit this unit, there is no way to bring new
patients through the system. A standard scenario may be as follows:
patient goes from procedure to recovery room on a stretcher; once alert
he/she sits up and gets dressed, then proceeds to a recliner before
reaching full ambulatory status. This frees up the stretcher area and
allows observation of nearly ambulatory patients prior to discharge.
* Have a transfer agreement with a hospital to handle emergency
admissions.
* Strongly consider training and accreditation in advanced life
support for doctors and staff.
* Do not compromise on quality of staff or endoscopic equipment
simply for economic reasons. You must be at least as comfortable working
in your OBE as you are at the hospital. The quality of care and quality
improvement process should address all areas, including access,
reception, procedures, storage, waste disposal, pathology, transfer
policy, housekeeping, administration, clinical records, billing as well
as continuing professional development (CPD).
* A note about the doctor's office: it is a great advantage to
have the office area adjacent
Endoscopy to the procedure room. The doctor can then easily go from
seeing patients to performing procedures. Checklis t for office-based
endoscopy set-up (office set-up)
(Note: these are illustrative and form the basis of local
accreditation processes that are under development.)
Regulations
* All office-based endoscopy practices must adhere to local and
state laws and regulations, including occupational health and safety and
infection control.
* Endoscopes must be cleaned to a high level of disinfection.
Reprocessing of endoscopes and other contaminated equipment should be
done in a room separate from where endoscopic procedures are performed.
* There must be adequate ventilation.
* Regular staff orientation and refresher training on policy and
procedures are important.
* There must be an appropriate plan for disposal of human waste,
blood and other potentially infectious materials.
* Compliance must be monitored.
Good clinical practice
Any office endoscopy setting where a patient receives intravenous
conscious sedation must comply with guidelines, accreditation and laws.
Indications/appropriateness
* Office-based procedures are to exclude: stent placement,
endoscopic retro-grade cholangiopancreatography (ERCP), removal of a
foreign body, therapeutic haemostatic control of acute bleeding,
procedures deemed emergencies, procedures carrying a considerable risk
of bleeding or major complication.
* Patients with an American Society of Anesthesiologists (ASA)
score of IV are not eligible to undergo office endoscopy.
* Patients with an ASA score of III are further assessed for their
appropriateness. Physical environment
* There should be appropriate patient facilities which include
disabled access.
* A private patient changing area is needed, as well as a storage
locker or equivalent for patient belongings.
* The bathroom should not be in a common area.
* A waiting area for accompanying family or others should be
provided.
* Acceptable patient privacy should be maintained at all times
throughout the pre-procedure, procedure and recovery care.
* All patient records and materials must be filed in a safe and
confidential area.
Exam room criteria
The endoscopy room should be at least 10 [m.sup.2]. One should be
able to reduce illumination from ambient light, to fit a rolling
stretcher through all doorways, and move freely on both sides of the
patient. The doctor should have an unimpeded view of all monitoring
equipment, and there should be sufficient storage for supplies and
equipment, adequate ventilation, auditory and visual privacy, and a
mechanism to summon additional assistance to the room.
The following equipment must be in the room, functioning and
readily available: oxygen, endoscopes, suction, electronic monitors of
pulse, BP, oxygen saturation and ECG. There should be a written policy
for equipment checks and maintenance and a log to monitor compliance.
Emergency supplies, equipment and procedures
* The following equipment should be functioning and readily
available with properly trained staff: oxygen, suction, airway,
laryngoscope, Ambu bag, defibrillator, electrocautery, power backup.
* The defibrillator must be checked at the start of each work day,
and other equipment checked according to manufacturers'
recommendations.
* Safety provisions must be in place to evacuate a patient.
* All medications and devices must be stored in a secure and
environmentally controlled location.
* Relevant provisions of the Controlled Substances Regulations must
be adhered to. Controlled substances must be stored in a double-locked
cabinet and counted and signed for daily. Pharmaceutical agents must be
monitored for date of expiration and a log must be kept.
Procedure information and documentation
* Patients are given face-to-face preprocedure instructions.
* Informed consent must be taken by the doctor prior to the
procedure and documented in the patient's medical record.
* There must be written discharge instructions.
* A medical record system must be kept and there must be a
procedure for reporting results to the patient and referring doctor.
Administration of conscious sedation (sedation and analgesia)
* All patients should have a documented anaesthesia risk
assessment.
* Conscious sedation should be administered in accordance with
accepted policy.
* Intravenous access must be maintained until the patient has fully
recovered.
* Reversal agents must be readily available.
* Once sedation has begun at least one certified doctor or nurse
trained to monitor and assess the patient's well-being should be
physically present in close proximity to the patient at all times.
* A trained assistant should be present in the room throughout the
endoscopic procedure. If the procedure is particularly complex, so that
the assistant's attention may become diverted from monitoring, a
second assistant may be necessary.
* Pre-sedation and post-procedure stabilisation must include
baseline heart rate, blood pressure, respiratory rate and oxygen
saturation, and ECG for high-risk patients.
* A registered nurse must be present in the recovery area at all
times.
* Patients must be continuously monitored in the recovery area and
should be discharged only after they have been assessed and all criteria
have been met.
* Written discharge criteria are established to include: evaluation
of responsiveness, vital signs, ability to tolerate fluids and swallow.
Patients who have undergone conscious sedation must be accompanied by an
adult upon discharge.
Documentation
Initial findings are documented in the patient chart on the day of
the procedure. Subsequently, a signed report of the procedure should be
completed. The report must include: date of procedure(s), procedure(s),
extent of examination, duration, findings, tissue sampling, therapeutic
intervention, procedure-related and sedation-related complications,
limitations, copies of photographs or digital images.
Training and office management
* Doctor and staff must be properly trained and certified.
* To achieve quality assurance, regular peer review of the
appropriateness of procedures performed and their outcomes should be
done.
* A log or database of all procedures and outcomes should be kept.
Recognised procedure-related and sedation-related complications must be
tabulated and regularly reviewed.
* A written office policy and procedure manual must be maintained
and updated.
* Staff should receive orientation and continuous training in all
policies and procedures.
References
(1.) American Society for Gastrointestinal Endoscopy (ASGE).
http://www.asge. org; Establishment of Gastrointestinal Endoscopy Areas.
http://www.asge.org/ PublicationsProductsindex.aspx?id=352#esta
blishment.
(2.) American Gastroenterological Association (AGA).
www.gastro.org.
(3.) Koufman JA. Introduction to office-based surgery in
laryngology. Curr Opin Otolaryngol Head Neck Surg 2007; 15(6): 383-386.
(4.) Woo P. Office-based laryngeal procedures. Otolaryngol Clin N
Am 2006; 39(1): 111-133.
In a nutshell
* Many endoscopic procedures are suitable for the office.
* There are challenging reimbursement issues.
* Calculate expected volume of procedures and number of doctors
sharing.
* Plan work flow, access (including disabled) and trolleys and
beds.
* The doctor should be able to easily move between seeing patients
and doing procedures.
* Do not compromise on quality of staff or endoscopic equipment.
* Adequate sound proofing, ventilation and temperature regulation
are important.
* The endoscope cleaning area should be separate and
well-ventilated.
* The recovery area requires careful planning.
* There should be a transfer agreement with a hospital to handle
emergency admissions.
* Accreditation of the facility is advisable.
* Training and accreditation in advanced life support for doctors
and staff is necessary.
* There should be a checklist for an office-based endoscopy set-up.
STEPHEN GROBLER, MB ChB, MMed (Chir) (Cert Gastroenterol)
Specialist Surgeon and Gastroenterologist, Universitas Netcare
Private Hospital and Part-time Consultant Surgeon, Department of
Surgery, Universitas Hospital, Bloemfontein Stephen Grobler undertook
his undergraduate and postgraduate surgical training in Bloemfontein. He
did his subspeciality training in Surgical Gastroenterology in
Bloemfontein as well as the University of Birmingham, UK and Cleveland
Clinic in Fort Lauderdale, USA. He serves as councillor on management
bodies for surgeons (Association of Surgeons of South Africa (ASSA) and
Surgicom), laparoscopic surgeons (South African Society of Endoscopic
Surgeons (SASES)), gastroenterology (the South African Gastroenterology
Society (SAGES) and he is an honorary member of the Association of
Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI). Current
interests are gastroenterology, colorectal conditions, laparoscopic
surgery, health informatics, practice guidelines, reimbursement and
coding.
ANDRE (JA) POTGIETER, MB ChB, MMed (Chir), FCS (SA)
Vascular/General Surgeon in private practice, Table View, Cape Town
Andre completed his undergraduate and general surgical training at
Tygerberg Hospital and Stellenbosch University. He has specialised
interests in gastrointestinal, vascular, endovascular, trauma and
laparoscopic surgery. He is President of the South African Society of
Endoscopic Surgeons (SASES) and an honorary member of the Association of
Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI). He is a
sought-after teacher in the ATLS, intensive care and laparoscopic
bariatric surgery programmes. His particular interests are development
of guidelines for laparoscopic surgery and the advancement of
laparo-endoscopic surgery in South Africa.
Corresponding author: sgrobler@global.co.za
* Gastrointestinal endoscopy--upper GI, small bowel, sigmoidoscopy,
colonoscopy, including biopsy, ablation, dilatation
* Bronchoscopy
* ENT--rigid and fibre-optic endoscopy, laryngeal surgery (3,4)
* Urology--flexible cystoscopy, ultrasound-directed prostate biopsy
* Gynaecology--hysteroscopy, endometrial biopsy (ablation,
laparoscopy).
Reimbursement
In the current era of managed care there are formidable shifting
relationships that we must deal with. The OBE offers greater comfort and
satisfaction at a lower cost than traditional treatment facilities. Is
it ethical for surgeons or gastroenterologists to own the facility in
which they work, to self-refer and to charge for the use of the
facility? Yes, but there are safety, quality-of-care and ethical
constraints.
The current fee structure has lagged far behind endoscopy practice
costs. Activities by legislative bodies and managed care organisations
continue to stress the economic viability of the office environment. The
initial investment in OBE can be daunting.
One effort currently underway is to 'rebase' practice
costs and facility fees to reflect the actual costs of providing
services (so-called so-called national health reference price list
(NHRPL)) rather than on historic charges. An alternative proposal is to
use the fees developed for hospitals and apply these to OBS and OBE as a
classification system for grouping procedures for facility payment
(assignments purportedly would be based on clinical characteristics and
resource utilisation). Grouping and reimbursement levels are current
issues being discussed by the National Health Insurance (NHI) task
teams.
Along legislative lines, there are also impediments of outdatedlegislation, talks of Certificate of Need (CON) restrictions and thetrend towards accreditation of facilities. Accreditation is a naturalevolution as payers, managed care organisations and regulators placeincreasing emphasis on quality, safety and patient satisfaction. It willalso become increasingly important, if not essential, for obtainingfacility reimbursement.Functional plan and architectural issues
Size and volume
It is important to have a clear understanding of the expected
volume of procedures and the number of doctors sharing the facility.
Endoscopy
Separate space for cleaning equipment between procedures and a
separate recovery area will avoid delays in room turnover. If many
patients are 'first visits' on the day of their procedure,
consultation space and time must be factored in. Endoscopic case mix can
also influence volume.
Location
Locating in an existing professional building on your primary
hospital 'campus' has several advantages over a totally
free-standing facility. Patient trust may be higher when entering a
professional hospital complex. In the event of a complication, response
time is rapid. And since no hospital wants to lose your endoscopy
business, the hospital can see some rental return. Corporate and
hospital governance issues place additional pressure to ensure safety
compliance.
There are also strong arguments for a free-standing, geographically
separate facility: neutral turf, both politically and geographically,
might be best.
Construction basics and work flow
Plumbing, air conditioning, sound proofing, ventilation and
electricity are beyond the gambit of this article, but some basics are
as follows:
* Construction costs for endoscopic space tend to be 2-3 times as
expensive as standard office space. Several nuts- and-bolts issues will
be dictated by local building codes and licensing requirements. Make
sure you are aware of regulations.
* Adequate sound-proofing between endoscopy rooms, patient recovery
area and waiting rooms is essential. The sounds related to endoscopy can
be disturbing to patients waiting to undergo procedures, as well as
those recovering.
* Temperature regulation is desirable. Waiting rooms have fully
clothed people; pre-operation areas have nervous, undressed people;
endoscopy rooms have sedated people and others hard at work with
heat-generating equipment.
* The endoscopy rooms and endoscopy cleaning areas must bewell-ventilated.* The most desirable patient flow pattern is a simple,
one-directional movement. Consider the movement flow in the procedure
room--the number of people, where they stand, endoscope and monitors,
beds and trolleys, supplies, cleaning facility.
* Patients often arrive for endoscopy anxious and confused. If
possible, send careful instructions, and have signs posted in the
immediate vicinity. There must be wheelchair, stretcher and bed access.
* The reception area must have adequate room for patients'
families. As a general rule, 1-2 people accompany each endoscopy
patient. Use individual chairs instead of couches; people do not like to
sit with strangers in stressful situations. A toilet facility should
also be available.
* The pre-op (prep) area should be private. IVs are started and
patients are undressed. Nursing and doctor interviews are performed
here. Bathrooms should be easily accessible.
* Consider the use of television or music in the reception and prep
area.
* Procedure rooms have high electrical needs and the building must
have power back-up in both procedure and recovery rooms. Dimmers are
excellent, as well as spotlights over areas of paper work and biopsy
handling. Telescopic lights or headlamps are useful.
* The endoscope cleaning area should be near the procedure room,
and should be spacious and well-ventilated. The standard of practice is
moving to automatic endoscope reprocessors, but they are expensive and
require lots of space and hot water.
* The recovery area requires more planning than one might think.
There must be adequate space for recovery beds. Time in recovery can be
considerable and could create a 'log jam'. Until patients are
fully recovered and exit this unit, there is no way to bring new
patients through the system. A standard scenario may be as follows:
patient goes from procedure to recovery room on a stretcher; once alert
he/she sits up and gets dressed, then proceeds to a recliner before
reaching full ambulatory status. This frees up the stretcher area and
allows observation of nearly ambulatory patients prior to discharge.
* Have a transfer agreement with a hospital to handle emergency
admissions.
* Strongly consider training and accreditation in advanced life
support for doctors and staff.
* Do not compromise on quality of staff or endoscopic equipment
simply for economic reasons. You must be at least as comfortable working
in your OBE as you are at the hospital. The quality of care and quality
improvement process should address all areas, including access,
reception, procedures, storage, waste disposal, pathology, transfer
policy, housekeeping, administration, clinical records, billing as well
as continuing professional development (CPD).
* A note about the doctor's office: it is a great advantage to
have the office area adjacent
Endoscopy to the procedure room. The doctor can then easily go from
seeing patients to performing procedures. Checklis t for office-based
endoscopy set-up (office set-up)
(Note: these are illustrative and form the basis of local
accreditation processes that are under development.)
Regulations
* All office-based endoscopy practices must adhere to local and
state laws and regulations, including occupational health and safety and
infection control.
* Endoscopes must be cleaned to a high level of disinfection.
Reprocessing of endoscopes and other contaminated equipment should be
done in a room separate from where endoscopic procedures are performed.
* There must be adequate ventilation.
* Regular staff orientation and refresher training on policy and
procedures are important.
* There must be an appropriate plan for disposal of human waste,
blood and other potentially infectious materials.
* Compliance must be monitored.
Good clinical practice
Any office endoscopy setting where a patient receives intravenous
conscious sedation must comply with guidelines, accreditation and laws.
Indications/appropriateness
* Office-based procedures are to exclude: stent placement,
endoscopic retro-grade cholangiopancreatography (ERCP), removal of a
foreign body, therapeutic haemostatic control of acute bleeding,
procedures deemed emergencies, procedures carrying a considerable risk
of bleeding or major complication.
* Patients with an American Society of Anesthesiologists (ASA)
score of IV are not eligible to undergo office endoscopy.
* Patients with an ASA score of III are further assessed for their
appropriateness. Physical environment
* There should be appropriate patient facilities which include
disabled access.
* A private patient changing area is needed, as well as a storage
locker or equivalent for patient belongings.
* The bathroom should not be in a common area.
* A waiting area for accompanying family or others should be
provided.
* Acceptable patient privacy should be maintained at all times
throughout the pre-procedure, procedure and recovery care.
* All patient records and materials must be filed in a safe and
confidential area.
Exam room criteria
The endoscopy room should be at least 10 [m.sup.2]. One should be
able to reduce illumination from ambient light, to fit a rolling
stretcher through all doorways, and move freely on both sides of the
patient. The doctor should have an unimpeded view of all monitoring
equipment, and there should be sufficient storage for supplies and
equipment, adequate ventilation, auditory and visual privacy, and a
mechanism to summon additional assistance to the room.
The following equipment must be in the room, functioning and
readily available: oxygen, endoscopes, suction, electronic monitors of
pulse, BP, oxygen saturation and ECG. There should be a written policy
for equipment checks and maintenance and a log to monitor compliance.
Emergency supplies, equipment and procedures
* The following equipment should be functioning and readily
available with properly trained staff: oxygen, suction, airway,
laryngoscope, Ambu bag, defibrillator, electrocautery, power backup.
* The defibrillator must be checked at the start of each work day,
and other equipment checked according to manufacturers'
recommendations.
* Safety provisions must be in place to evacuate a patient.
* All medications and devices must be stored in a secure and
environmentally controlled location.
* Relevant provisions of the Controlled Substances Regulations must
be adhered to. Controlled substances must be stored in a double-locked
cabinet and counted and signed for daily. Pharmaceutical agents must be
monitored for date of expiration and a log must be kept.
Procedure information and documentation
* Patients are given face-to-face preprocedure instructions.
* Informed consent must be taken by the doctor prior to the
procedure and documented in the patient's medical record.
* There must be written discharge instructions.
* A medical record system must be kept and there must be a
procedure for reporting results to the patient and referring doctor.
Administration of conscious sedation (sedation and analgesia)
* All patients should have a documented anaesthesia risk
assessment.
* Conscious sedation should be administered in accordance with
accepted policy.
* Intravenous access must be maintained until the patient has fully
recovered.
* Reversal agents must be readily available.
* Once sedation has begun at least one certified doctor or nurse
trained to monitor and assess the patient's well-being should be
physically present in close proximity to the patient at all times.
* A trained assistant should be present in the room throughout the
endoscopic procedure. If the procedure is particularly complex, so that
the assistant's attention may become diverted from monitoring, a
second assistant may be necessary.
* Pre-sedation and post-procedure stabilisation must include
baseline heart rate, blood pressure, respiratory rate and oxygen
saturation, and ECG for high-risk patients.
* A registered nurse must be present in the recovery area at all
times.
* Patients must be continuously monitored in the recovery area and
should be discharged only after they have been assessed and all criteria
have been met.
* Written discharge criteria are established to include: evaluation
of responsiveness, vital signs, ability to tolerate fluids and swallow.
Patients who have undergone conscious sedation must be accompanied by an
adult upon discharge.
Documentation
Initial findings are documented in the patient chart on the day of
the procedure. Subsequently, a signed report of the procedure should be
completed. The report must include: date of procedure(s), procedure(s),
extent of examination, duration, findings, tissue sampling, therapeutic
intervention, procedure-related and sedation-related complications,
limitations, copies of photographs or digital images.
Training and office management
* Doctor and staff must be properly trained and certified.
* To achieve quality assurance, regular peer review of the
appropriateness of procedures performed and their outcomes should be
done.
* A log or database of all procedures and outcomes should be kept.
Recognised procedure-related and sedation-related complications must be
tabulated and regularly reviewed.
* A written office policy and procedure manual must be maintained
and updated.
* Staff should receive orientation and continuous training in all
policies and procedures.
References
(1.) American Society for Gastrointestinal Endoscopy (ASGE).
http://www.asge. org; Establishment of Gastrointestinal Endoscopy Areas.
http://www.asge.org/ PublicationsProductsindex.aspx?id=352#esta
blishment.
(2.) American Gastroenterological Association (AGA).
www.gastro.org.
(3.) Koufman JA. Introduction to office-based surgery in
laryngology. Curr Opin Otolaryngol Head Neck Surg 2007; 15(6): 383-386.
(4.) Woo P. Office-based laryngeal procedures. Otolaryngol Clin N
Am 2006; 39(1): 111-133.
In a nutshell
* Many endoscopic procedures are suitable for the office.
* There are challenging reimbursement issues.
* Calculate expected volume of procedures and number of doctors
sharing.
* Plan work flow, access (including disabled) and trolleys and
beds.
* The doctor should be able to easily move between seeing patients
and doing procedures.
* Do not compromise on quality of staff or endoscopic equipment.
* Adequate sound proofing, ventilation and temperature regulation
are important.
* The endoscope cleaning area should be separate and
well-ventilated.
* The recovery area requires careful planning.
* There should be a transfer agreement with a hospital to handle
emergency admissions.
* Accreditation of the facility is advisable.
* Training and accreditation in advanced life support for doctors
and staff is necessary.
* There should be a checklist for an office-based endoscopy set-up.
STEPHEN GROBLER, MB ChB, MMed (Chir) (Cert Gastroenterol)
Specialist Surgeon and Gastroenterologist, Universitas Netcare
Private Hospital and Part-time Consultant Surgeon, Department of
Surgery, Universitas Hospital, Bloemfontein Stephen Grobler undertook
his undergraduate and postgraduate surgical training in Bloemfontein. He
did his subspeciality training in Surgical Gastroenterology in
Bloemfontein as well as the University of Birmingham, UK and Cleveland
Clinic in Fort Lauderdale, USA. He serves as councillor on management
bodies for surgeons (Association of Surgeons of South Africa (ASSA) and
Surgicom), laparoscopic surgeons (South African Society of Endoscopic
Surgeons (SASES)), gastroenterology (the South African Gastroenterology
Society (SAGES) and he is an honorary member of the Association of
Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI). Current
interests are gastroenterology, colorectal conditions, laparoscopic
surgery, health informatics, practice guidelines, reimbursement and
coding.
ANDRE (JA) POTGIETER, MB ChB, MMed (Chir), FCS (SA)
Vascular/General Surgeon in private practice, Table View, Cape Town
Andre completed his undergraduate and general surgical training at
Tygerberg Hospital and Stellenbosch University. He has specialised
interests in gastrointestinal, vascular, endovascular, trauma and
laparoscopic surgery. He is President of the South African Society of
Endoscopic Surgeons (SASES) and an honorary member of the Association of
Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI). He is a
sought-after teacher in the ATLS, intensive care and laparoscopic
bariatric surgery programmes. His particular interests are development
of guidelines for laparoscopic surgery and the advancement of
laparo-endoscopic surgery in South Africa.
Corresponding author: sgrobler@global.co.za
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