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Acknowledgements

Copyright © 2012. Society of Gastroenterology Nurses and Associates, Inc. (SGNA). The original position statement was adopted by the SGNA Board of
Directors in 1995 and revised in 1998 and 1999. The original guideline was adopted in 1996 and revised in 1999 and 2002. The two documents were combined in 2005 and revised in 2008. Revised 2012.

This document was prepared and written by the SGNA Practice Committee. It is published as a service to SGNA members.

 

Contributors

SGNA Practice Committee 2011 – 12
Michelle E. Day MSN BSN RN CGRN Chair
Michelle Juan MSN ACNS-BC RN CGRN Co Chair
Kathy Buffington BSN RN CGRN
Rhonda L. Casey RN BS MHA CGRN
Cynthia M. Friis MEd BSN RN-BC
Ann Herrin, BSN RN CGRN
Colleen Kelley Keith MSN RN CGRN
Judy Lindsay MA BSN RN CGRN
Marilee Schmelzer PhD RN
Barbara Zuccala MSN RN CGRN

 

Reprints are available for purchase from SGNA Headquarters. To order, contact:
Department of Membership Services
Society of Gastroenterology Nurses and Associates, Inc.
330 North Wabash
Chicago, IL 60611-4267
Tel: (800) 245-SGNA or (312) 321-5165
Fax: (312) 673-6694
Online: www.SGNA.org
Email: SGNA@smithbucklin.com

 

Disclaimer

The Society of Gastroenterology Nurses and Associates, Inc. presents this guideline for use in developing institutional policies, procedures, and/or protocols. Information contained in this guideline is based on published data and current practice.
 

The Society of Gastroenterology Nurses and Associates, Inc. assumes no responsibility for the practices or recommendations of any member or other practitioner, or for the policies and practices of any practice setting. Nurses and associates function within the limits of state licensure, state nurse practice act, and/or institutional policy.

 

Preface

Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer death in both men and women in the United States (American Cancer Society [ACS], 2011). Early detection and removal of adenomatous polyps can prevent most colorectal cancers (American Society for Gastrointestinal Endoscopy [ASGE], 2006; Levin et al 2008). Research and practice publications illustrate the safety, accuracy, and support for the performance of routine screening flexible sigmoidoscopy by registered nurses (ASGE, 2009; Ho, Jacobs, Sandha, Noorani, & Skidmore, 2006; Levin et al., 2005; Maruthachalam, Stoker, Nicholson, & Horgan, 2006; Redwood et al 2010)

Colonoscopy is the most sensitive screening test for the detection of colorectal cancer or adenomatous polyps (ACS, 2011; Kahi & Rex, 2005; Levin et al., 2005). While colonoscopy is the preferred screening modality, alternatives include FOBT yearly and Flexible Sigmoidoscopy every 5 years (ASGE, 2006).

The Society of Gastroenterology Nurses and Associates, Inc. (SGNA) supports the position that registered nurses educated and experienced in gastroenterology nursing and trained in techniques of flexible sigmoidoscopy may assume this responsibility for the purpose of colorectal cancer screening of average risk individuals.

This guideline exists to define the qualifications and competencies necessary for successful performance of screening flexible sigmoidoscopy according to the standards set forth by SGNA.

In addition to following these guidelines for staff qualifications, SGNA also recommends that each practice setting maintain and implement a quality
monitoring plan (ASGE, 2009, Levin et al., 2005).

 

Definition of Terms

For the purpose of this document, SGNA has adopted the following definitions:

Flexible sigmoidoscopy refers to the examination of the mucosal lining of the rectum and sigmoid colon and may include examination of a portion of the descending colon (American Medical Association [AMA], 2002).

Average risk refers to the level of risk for colorectal cancer among asymptomatic persons age 50 or older with no other prior family or personal history of adenomatous polyps, colorectal cancers, or other secreting organ cancers (ACS, 2011; ASGE, 2006; Kahi & Rex, 2005).

High risk refers to the level of risk for colorectal cancer among persons with a history of adenomatous polyps, colorectal cancer or inflammatory bowel disease, close relative(s) who have had colorectal cancer or an adenomatous polyp, or a family history of familial adenomatous polyposis or hereditary non-polyposis colorectal cancer (ACS, 2011; ASGE, 2006; Kahi & Rex, 2005) . Colonoscopy is the only recommended screening method for individuals in these high risk groups (ACS, 2011).

Indications for the performance of Screening Flexible Sigmoidoscopy performed by a GI registered nurse
Screening flexible sigmoidoscopy by GI registered nurses is appropriate for adults defined as average risk (ASGE, 2009)
 
Contraindications for the performance of Screening Flexible Sigmoidoscopy by the registered nurse
Individuals should be interviewed and screened carefully prior to the procedure to see if they demonstrate the following contraindications for the performance of screening flexible sigmoidoscopy (ASGE, 2006):
  1. Symptoms of colorectal disease
  2. Inflammatory bowel disease (IBD)
  3. Previous colorectal cancer diagnosis
  4. Hereditary syndromes (Familial Adenomatous Polyposis [FAP] or Hereditary Non Polyposis Colorectal Cancer [HNPCC])
  5. Acute illness, comorbidities, or severe systemic disease

General GI RN Qualifications

The competent performance of flexible sigmoidoscopy requires both cognitive and technical skills (ASGE, 2009; Levin et al, 2005). Knowledge of the anatomy, physiology, and pathology of the colon and abdomen and indications/contraindications to the procedure are essential. Experience and good hand-eye coordination are also required to perform a safe and thorough examination (ASGE, 2009; Levin et al., 2005).

SGNA believes that nurse endoscopists can best document their expertise in the field through board certification and therefore recommends that GI registered nurses performing endoscopy hold current certification from the American Board of Certification for Gastroenterology Nurses (ABCGN)(Eisemon & Cline, 2006).

Medical supervision is determined by institutional policy. SGNA recommends that a minimum of 50 flexible sigmoidoscopies be performed under the supervision of a skilled physician endoscopist before a GI registered nurse performs this procedure independently (Eisemon et al., 2001; Levin et al., 2005). GI registered nurses performing Flexible Sigmoidoscopy should practice within the limits of state licensure as well as institutional policy (ASGE, 2009).

Specific GI RN Competencies

In addition to the general qualifications, the following specific competencies are required of GI registered nurses who perform flexible sigmoidoscopy in any practice setting:

A. Phase I - Cognitive Skills (ASGE, 2009; Eisemon et al., 2001; Levin et al., 2005)

  1. Describe the indications/contraindications for screening flexible sigmoidoscopy, including the definition of average and high-risk.
  2. Distinguish normal versus abnormal anatomy, physiology, and pathophysiology of the abdomen, anus, rectum, sigmoid and descending colon.
  3. Identify options for patient bowel preparation.
  4.  Discuss risks, benefits, and alternatives to flexible sigmoidoscopy with patient in order to obtain informed consent.
  5. Provide patient education, which includes
    1. the purpose of procedure,
    2. positioning and relaxation methods, and
    3. sensations the patient is likely to experience.
  6. Identify indications for antibiotic prophylaxis based on current recommendations.
  7. Demonstrate knowledge of and ensure compliance with SGNA guidelines for cleaning, disinfecting, and storing flexible sigmoidoscope and accessories.
  8. Identify and initiate nursing interventions for adverse reactions, such as pain, perforation, bleeding, infection, vasovagal response and abdominal distention.
  9. Document per institutional policy, including informed consent, universal protocol, bowel prep quality, actions and interventions, patient response, findings and outcomes, and patient education.
  10. Communicate outcomes or recommendations for follow-up care to the supervising physician and patient’s primary healthcare provider.
  11. Communicate findings and recommendations to the patient as appropriate.
  12. Assume responsibilities related to abnormal findings including:
    1. Notify supervising physician.
    2. Document per institutional policy.
    3. After consultation with the supervising physician, refer patients requiring further work-up to the appropriate provider (primary care provider, gastroenterologist, or surgeon) for diagnostic/therapeutic studies, including follow-up of biopsy findings.

B. Phase II - Technical Skills (ASGE, 2009; Eisemon et al, 2001; Levin et al, 2005)
Demonstrate the proper techniques of flexible sigmoidoscopy including:

  1. patient positioning,
  2. digital rectal examination,
  3. use of equipment,
  4. manipulation of the endoscope including insertion, insufflation, advancement, and withdrawal techniques,
  5. adequate depth of insertion with minimal patient discomfort (Levin et al, 2005),
  6. biopsy specimen collection as indicated and according to institutional policy.

C. Phase III - Continued Competency and Quality monitoring
Maintain competency in performing flexible sigmoidoscopy (Eisemon et al, 2001; ASGE, 2009; Levin et al, 2005) by:

  1. participating in quality monitoring as outlined by institutional policy,
  2. completing and documenting continuing education at least annually or as outlined by institutional policy,
  3. demonstrating and documenting competency at least annually or as outlined by institutional policy.

Summary

While colonoscopy is the most sensitive screening test for the detection of colorectal cancer or adenomatous polyps, flexible sigmoidoscopy is an acceptable alternative for patients of average risk. A specially trained GI registered nurse may perform flexible sigmoidoscopy. GI Registered Nurses performing flexible sigmoidoscopy must maintain qualifications and competencies and participate in continuous quality improvement.

 

References

American Cancer Society. (2011). Colorectal Cancer Facts & Figures 2011-2013. Alanta: American Cancer Society.

American Medical Association. (2002). Current procedural terminology. Chicago, IL: AMA Press.

American Society for Gastrointestinal Endoscopy. ASGE (2006). ASGE guideline: colorectal cancer screening and surveillance. Gastrointestinal Endoscopy, 63 (4) 546-557. American Society for Gastrointestinal Endoscopy. ASGE (2009). Endoscopy by non-physicians. Gastrointestinal Endoscopy, 69(4),767-770.

Eisemon, N., Stucky-Marshall, L., & Talamonti, M. S. (2001). Screening for colorectal cancer: Developing a preventative healthcare program utilizing nurse endoscopists. Gastroenterology Nursing, 24(1), 12-19.

Eisemon,N ,& Cline, A (2006).The value of certification. Gastroenterology Nursing, 29(6), 428 -30

Ho, C., Jacobs, P., Sandha, G., Noorani, H. Z., & Skidmore, B. (2006). Non-physicians performing flexible sigmoidoscopy: Clinical efficacy and cost-effectiveness (Technology Report No. 60). Ottawa: Canadian Coordinating Office for Health Technology Assessment.

Kahi, C. J., & Rex, D. K. (2005). Screening and surveillance of colorectal cancer. Gastrointestinal Endoscopy Clinics of North America, 15(3), 533-547.

Levin, T. R., Farraye, F. A., Schoen, R. E., Hoff, G., Atkin, W., Bond, J. H., et al. (2005). Quality in the technical performance of screening flexible
sigmoidoscopy: Recommendations of an international multi-society task group. GUT, 54(6), 807-813.

Levin, B., Lieberman, D., McFarland, B, Smith, R., Brooks, D, Andrews, K., Dash, C, Giardiello, F., Glick, S, Levin, T., Pickhardt, P, Rex, D., Thorson, A, Winawer, S., for the American Cancer Society Colorectal Cancer Advisory Group, the US Multi-Society Task Force, and the American College of Radiology Colon Cancer Committee, (2008). Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008 : A joint guideline from the American Cancer Society , the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA: A Cancer Journal for Clinicians. 58: 130-160 doi: 10.3322/CA.2007.0018

Maruthachalam, K., Stoker, E., Nicholson, G., & Horgan, A. F. (2006). Nurse led flexible sigmoidoscopy in primary care- the first thousand patients.
Colorectal Disease, 8(7), 557-562.
 
Redwood, D., Joseph, D. A., Christensen, C., Provost, E., Peterson, V. L., Espey, D., & Sacco, F. (2009). Development of a flexible sigmoidoscopy training program for rural nurse practitioners and physician assistants to increase colorectal cancer screening among alaska native people. Journal of Health Care for the Poor and Underserved, 20(4), 1041
 
Shum, N. F., Lui, Y. L., Choi, H. K., Lau, S. C. and Ho, J. W. (2010), A
comprehensive training programme for nurse endoscopist performing flexible sigmoidoscopy in Hong Kong. Journal of Clinical ursing, 19: 1891–1896. doi: 10.1111/j.1365-2702.2009.03093.x

Recommended Reading

Eisen, G. M., Baron, T. H., Dominitz, J. A., Faigel, D. O., Goldstein, J. L., Johanson, J. F., et al. (2002). Methods of granting hospital privileges to perform gastrointestinal endoscopy. Gastrointestinal Endoscopy, 55(7), 780-783.

Gruber, M. (1996). Performance of flexible sigmoidoscopy by a clinical nurse specialist. Gastroenterology Nursing, 19(3), 105-108.

Schoenfeld, P., Piorkowski, M., Allaire, J., Ernst, R., & Holmes, L. (1999). Flexible sigmoidoscopy by nurses: State of the art 1999. Gastroenterology Nursing, 22(6), 254-261.

Smith, P. A. (1999). The role of the gastroenterology nurse in colorectal cancer screening. Gastroenterology Nursing, 22(5), 217-220.

Society of Gastroenterology Nurses and Associates, Inc. (2008). Gastroenterology nursing: A core curriculum (4th ed.). Chicago, IL: Author.

Society of Gastroenterology Nurses and Associates, Inc. (2009). Manual of gastrointestinal procedures (6th ed.). Chicago, IL: Author.

Sprout, J. (2000). Nurse endoscopist training: The next step. Gastroenterology Nursing, 23(3), 111-115.

Wallace, M. B., Kemp, J. A., Meyer, F., Horton, K., Reffel, A., Christiansen, C. L., et al. (1999). Screening for colorectal cancer with flexible sigmoidoscopy by nonphysician endoscopists. American Journal of Medicine, 107(3), 214-218.

Winawer, S., Fletcher, R., Rex, D., Bond, J., Burt, R., Ferrucci, J., et al. (2003). Colorectal cancer screening and surveillance: Clinical guidelines and
rationale-update on new evidence. Gastroenterology, 124(2), 544-560.

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