A process improvement project at one endoscopy center has identified a consistent delay in inpatient procedural start times as a culprit for reduced patient throughput. The project, presented at 2023 Canadian Digestive Diseases Week 2023, looked at maximizing endoscopy unit efficiency over a period of 12 months by adding one completed procedure per day.
“It wasn’t that we needed more resources,” said lead researcher Mayur Brahmania, MD, MPH, a gastroenterologist/hepatologist and an assistant professor of medicine at the University of Western Ontario, in London, Ontario. “It was that we needed to better utilize the time we already had.”
Due to preexisting and COVID-19 pandemic–related supply and personnel constraints, an increased strain is being placed on inpatient endoscopic services at the hospital, with efficiency at only about 65%. While staffing and procedure types are similar for inpatients and outpatients, the researchers found a significant discrepancy between the two in efficiency.
Typically, eight to 10 endoscopies can be performed daily between 8 a.m. and 12 p.m. in the outpatient slot, or one endoscopy every 30 minutes. In the inpatient slot, however, an additional three to four endoscopies are scheduled during the same period. As a result, Dr. Brahmania said, a spillover effect has continuously occurred.
“If you end up spilling over these endoscopies every day, they accumulate on a Saturday or Sunday, so you’re spending more resources on weekend endoscopies,” he said. While outpatient procedures are uniform and follow a rigorous process, the inpatient process can vary due to system, provider and patient factors.
Dr. Brahmania and a team of researchers collected baseline data via direct observation and completion of a time series study over a period of two months by looking at the typical inpatient flow (abstract A93).
“We wanted to know where and if we could improve the inpatient flow to better serve our patients and improve system performance,” Dr. Brahmania said.
Through interviews with gastroenterologists, endoscopy nurses and managers, along with portering services, the team determined relevant delays.
“We looked at gaps in care and where redundancies could be eliminated,” Dr. Brahmania said. Simple solutions included earlier physician handover and earlier preparation of endoscopy lists and patient transfer to the endoscopy suite, the latter related to portering services. Improvements in these areas ultimately increased throughput.
“There are uncontrolled patient factors and hospital factors, but there are endoscopy unit factors that we can control and improve to better the process,” Dr. Brahmania said.
He said he believes other hospitals are struggling with an underuse or inefficient use of existing resources.
His team obtained a more optimized average procedural suite start time of 8:22 a.m., rather than 8:35 a.m., which resulted in “the completion of an additional procedure and increased the throughput of the endoscopy unit,” they wrote.
Shani Woolard Clay, MD, a gastroenterologist practicing at Emory Healthcare in Jonesboro, Ga., who was not involved with the study, said endoscopy services were limited at her hospital as well, as is the case in many large, busy hospitals. But she said the main issue was lack of staff.
“We have the [physical] space as well as the equipment. However, we do not have enough nurses/techs for each room,” Dr. Woolard Clay said. “As a result, we run [fewer] rooms than we should at any given time based on our patient load, and we are consistently doing procedures in the late evenings, during ‘on-call’ times.”
Vaishali Patel, MD, a gastroenterologist and an assistant professor of medicine at Emory University, in Atlanta, said early physician handover made a lot of sense, as well as a standardized inpatient procedure list and good team communication.
But she said every institution would likely have its own issues. “I think probably many institutions across the country struggle with efficiency for their inpatient endoscopy units,” she said.
Similar to Dr. Woolard Clay, she said Emory University Hospital was deeply affected by nursing shortages that led to bottlenecks at various stages in the endoscopy unit.
In her own experience, differences in procedural start times of two or three minutes had not made much of a difference. “When we looked at internal data at our institution, we found that a little delay of less than 10 minutes in our first-case start time doesn’t impact the overall efficiency.”
—Natalie Schachar
The sources reported no relevant financial disclosures.
This article is from the June 2023 print issue.