WASHINGTON — The increasing need for endoscopists may be partially met by training midlevel providers such as nurse-endoscopists, according to a gastroenterologist who has embarked on a training program and presented his early findings at the annual Digestive Disease Week.
Dr. Jan Koornstra, of the University Medical Center Groningen (the Netherlands), presented results of the first 100 colonoscopies performed by two nurses who completed the training. Their results were compared with those of a first-year gastroenterology fellow.
The two nurses were already part of the endoscopy team and volunteered for training. There were no special selection criteria or minimum standards for participation, Dr. Koornstra said.
Initially, the nurses were trained on a simulator. They were also given textbook instruction on the relevant theoretical background on colonoscopy. The nurses were also given Game Boy devices to help them improve hand-eye coordination at home. They then started performing two to three flexible sigmoidoscopies and colonoscopies per week.
Competence was assessed by measuring the unassisted cecal intubation rate and time. The nurses were given 30 minutes to reach the cecum. After each procedure, patients were interviewed about pain or discomfort; responses were rated on a 10-point visual analog scale. They were also asked to rate their overall satisfaction.
Dr. Koornstra and his colleagues evaluated the first 100 procedures for each nurse-endoscopist. They included only complete colonoscopies (that is, those in which the cecum could be reached) and diagnostic procedures. Therapeutic procedures and patients with previous large-bowel surgery were excluded.
The procedure results were split into four quarters. For the first 25 procedures, the cecal intubation rates were 70% for the nurses and 60% for the fellow. By the final 25 procedures, rates had improved to 96% for the nurses and 90% for the fellow.
For nurses, the mean intubation time was 14 minutes for the first 25 procedures, gradually decreasing to 12–13 minutes for the final quarter. Results were similar for the fellow, Dr. Koornstra said.
Pain decreased from a score of 3.1 on the 10-point scale to a score of 2 for the final quarter, and discomfort decreased from 1.7 to 0.2. There were virtually no differences on these measures between the nurses and the fellow, he said.
Patients were generally satisfied with the procedures. Abnormalities were identified in about half of the cases, all of which were correctly recognized by the nurses, Dr. Koornstra said.
“Although our data may be a bit premature, I believe our training program for nurse-performed colonoscopy is safe and effective,” at least regarding the nurses' acquisition of technical skills and competency, he said.