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Minimum Registered Nurse Staffing for Patient Care in the Gastrointestinal Endoscopy Unit

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Disclaimer

The Society of Gastroenterology Nurses and Associates, Inc. (SGNA) assumes no responsibility for the practices or recommendations of any member or other practitioner or for the policies and procedures of any practice setting. Information contained in this position statement is based on current published data and current practice at the time of publication. Nurses and associates function within the limitations of licensure, state nurse practice act, and/or institutional policy. SGNA does not endorse or recommend any commercial products, processes, or services. A commercial product, process, or service is recognized as being consumed by or used on patients.

Definitions

For the purpose of this document, the Society of Gastroenterology Nurses and Associates, Inc. has adopted the following definitions: 

Anesthesia provider refers to a practitioner who is qualified to administer anesthesia, including a qualified anesthesiologist, a medical doctor (MD) or doctor of osteopathy (DO) other than an anesthesiologist, or a certified registered nurse anesthetist (CRNA) supervised by the operating practitioner or anesthesiologist (Centers for Medicare and Medicaid Services [CMS], 2011a, 2011b). 

Appropriate nurse staffing is defined as “a match of registered nurse expertise with the needs of the recipient of nursing care services in the context of the practice setting and situation” (American Nurses Association, 2012). 

Registered nurse (RN) refers to a registered professional nurse trained and experienced in:

  • Gastroenterology nursing
  • Endoscopic procedures
  • Administration and maintenance of sedation and analgesia by the order and supervision of a physician (ASGE/SGNA, 2004)

Staffing refers to the RN staffing pattern in the gastroenterology setting.

Patient care in gastroenterology setting refers to the pre-procedure, intra-procedure, and post-procedure care of the patient undergoing gastrointestinal endoscopy, regardless of the location or setting.

Background

Staff numbers and skill mix in endoscopy are influenced by the significant risks of invasive procedures, healthcare industry changes, technical advances, increasing patient complexity, and changes in sedation practices. Patient safety, quality of care, and cost effectiveness must all be considered when making staffing decisions (ANA, 2012). Although cost effectiveness is an important consideration when making staffing decisions, patient safety must take priority. Numerous studies demonstrate the importance of adequate RN staffing to decrease complications and improve patient safety and well-being (ANA, 2012; Aiken, et al., 2012; McHugh, Berez, & Small, 2013; Needleman, et al., 2011).

The Society of Gastroenterology Nurses and Associates, Inc. recognizes that appropriate nurse staffing is essential to providing safe and cost effective healthcare. All healthcare settings (ambulatory, hospital, and office-based) must provide the same standard of care (ANA, 2012) and must comply with state, federal, and accreditation regulations.

All endoscopy settings must have a gastroenterology RN present during the pre-procedure phase of care, the procedure, and the post-procedure phase of care. The RN is responsible for assessing patients, determining nursing diagnoses, identifying expected outcomes, and planning, implementing, and evaluating the nursing care of patients (ANA, 2012; SGNA, 2012). The RN promotes patient safety, advocates for the patient, communicates clearly, and bases interventions on knowledge and wisdom grounded in education and experience.

The RN assists the patient to achieve a level of wellness equal to or better than before the procedure and maintains accountability for all nursing activities that are delegated to competent assistive personnel. Core nursing activities that by licensure may not be delegated include assessment, nursing diagnosis, outcome identification, planning, and evaluation (ANA, 2012; AORN, 2014).

 Minimum safe RN staffing decisions should be based on (ANA, 2012):

  ·         Patient age, functional ability, and comorbidities
·         Patient language and cultural diversity
·         Number, variety, and complexity of procedures
·         RN education, knowledge, experience, and abilities
·         Staff skill mix
·         Knowledge gained from experience with previous staffing patterns and skill mix
·         Physical layout of the environment

RNs must have active involvement in staffing decisions in the gastroenterology setting. Staffing guidelines should be clear, well developed, and include nurse sensitive outcomes relevant to the setting and population served (ANA, 2012).

Staffing decisions must also consider overtime and on-call hours. Working overtime can lead to dangerous levels of fatigue that affect cognitive ability, judgment, and performance and can ultimately negatively impact patient safety (Warren, & Tart, 2008; Bae, et al., 2013). According to the ANA (2012), “Policies on length of shifts, management of meal and rest periods, and overtime should be in place to ensure the health and stamina of nurses and prevent fatigue-related errors.”

Position

The Society of Gastroenterology Nurses and Associates, Inc. recommends that healthcare facilities: 

1.      Follow appropriate nurse staffing levels and skill mix to meet state, federal, and accreditation regulations. The economic situation of the healthcare facility should not serve as the primary basis for determining services offered. 

2.      Consider staff education, experience, and competency when determining staffing patterns for the gastroenterology setting. 

3.      Establish RN staffing patterns in the gastroenterology setting based on patient characteristics, procedure volumes and complexity, RN abilities, and historical operational trends that reinforce quality patient outcomes. 

4.      Develop a staffing plan to ensure that emergency on-call staff have adequate meal and rest periods to avoid fatigue-related errors.

 
Minimum staffing requirements

To ensure quality, safety, and accountability, SGNA supports the position that wherever a gastrointestinal endoscopy procedure is performed, the minimum RN staffing pattern is as follows:

1.   One RN during the pre-procedure phase of care to perform baseline patient assessment and implement a plan of care based on individual patient needs prior to the procedure.

2.   One RN during the procedure to provide ongoing assessment, communicate effectively with the patient and healthcare team (SGNA, 2012), supervise unlicensed assistive personnel, and ensure quality and continuity of care. 

When an anesthesia provider is administering the sedation, the RN will remain to provide continuity of care and assist the healthcare team. 

RNs administering procedural sedation must not have other responsibilities that would compromise their ability to adequately monitor the patient before, during, and after the procedure (ANA, 2008). 

Refer to SGNA’s Statement on the Use of Sedation and Analgesia in the Gastrointestinal Endoscopy Setting (2013) for additional information. 

3.   One RN during the post-procedure phase of care to ensure continuity of all aspects of care dictated by the patient’s phase of recovery, active disease processes, changes in health stability brought on by the procedure performed, and plan for handoff, discharge, or transfer to the appropriate level of care.

Special considerations

Additional personnel may be needed in some or all phases of procedure-related care in order to provide an efficient, cost-effective, and safe patient experience. The level of additional personnel is dictated by: 

·         Technical aspects and complexity of particular procedures (e.g., ERCP, PEG/PEJ, EUS, large polyp removal)

·         Acuity of the expected patient population

·         Types of anesthesia or level of sedation

·         Volume of patients to be cared for during the specified time frame

·         Pediatric patients due to the unpredictable response of this population to sedative and analgesic medications, unpredictable movements and risk     for falls or injury, and need for intense emotional support and consistency of care (Hockenberry & Wilson, 2011; James, Nelson, & Ashwill, 2013)

·         Institutional policy

The RN’s role is outlined in SGNA’s Role Delineation of the Registered Nurse in a Staff Position in Gastroenterology (2012).

Ongoing research and legislation

SGNA supports ongoing research to determine appropriate RN staffing patterns in order to sustain high quality patient outcomes.

SGNA supports state and federal legislation requiring the collection and reporting of nursing quality indicators to monitor the effects of staffing (ANA, 2005).

References

Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2012). The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Journal of Nursing Administration, 42(10), S10–S16.

American Nurses Association. (2005). Utilization guide for the ANA principles for nurse staffing. Silver Spring, MD: Author.

American Nurses Association. (2008). Procedural sedation consensus statement [position statement]. Silver Spring, MD: Author.

American Nurses Association. (2012). ANA’s principles for nurse staffing (2nd ed.). Silver Spring, MD: Author.

Association of periOperative Registered Nurses. (2014). Safe staffing and on-call practices [position statement]. Denver, CO: Author.
ASGE/SGNA. (2004). Role of GI registered nurses in the management of patients undergoing sedated procedures [joint position statement]. Chicago, IL: Authors.

Bae, S. H., Trinkoff, A., Jing, H., & Brewer, C. (2013). Factors associated with hospital staff nurses working on-call hours: A pilot study. Workplace Health & Safety, 61(5), 203–211.

Centers for Medicare and Medicaid Services. (2011a). Revised hospital anesthesia services interpretive guidelines-state operations manual (SOM) appendix A [Memorandum to State Survey Agency Directors]. Retrieved from http://www.cms.gov/Medicare/Provider -Enrollment -and- Certification/SurveyCertificationGenInfo/downloads// SCLetter11_10.pdf 

Centers for Medicare and Medicaid Services. (2011b). Revised hospital anesthesia services interpretive guidelines-state operations manual (SOM) appendix A [Memorandum to State Survey Agency Directors]. Retrieved from http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads// SCLetter10_09.pdf 

Hockenberry, M. J., & Wilson, D. (2011). Wong’s nursing care of infants and children (9th ed.). St. Louis, MO: Elsevier.

James, S. R., Nelson, K. A., & Ashwill, J. W. (2013). Nursing care of children: Principles and practice (4th ed.). St. Louis, MO: Elsevier.

McHugh, M. D., Berez, J., & Small, D. S. (2013). Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Affairs, 32(10), 1740–1747.

Needleman, J., Buerhaus, P., Pankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. The New England Journal of Medicine, 364(11), 1037–1045. 

Society of Gastroenterology Nurses and Associates, Inc. (2012). Role delineation of the registered nurse in a staff position in gastroenterology [position statement]. Chicago, IL: Author.

Society of Gastroenterology Nurses and Associates, Inc. (2013). Statement on the use of sedation and analgesia in the gastrointestinal endoscopy setting [position statement]. Chicago, IL: Author.

Warren, A., & Tart, R. C. (2008). Fatigue and charting errors: The benefit of a reduced call schedule. AORN Journal, 88(1), 88–90, 92–95.

Recommended Reading

Calderwood, A. H., Chapman, F. J., Cohen, J., Cohen, L. B., Collins, J., Day, L. W., & Early, D. S. (2014). Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointestinal Endoscopy, 79(3), 363–372.

 

Centers for Medicare and Medicaid Services. (2015). State Operations Manual—Appendix L: Ambulatory surgical centers. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/ASCs.html

Centers for Medicare and Medicaid Services. (2011). Ambulatory Surgical Centers (ASC)—Conditions for coverage: Same day services (CMS-3217). Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/ASC.html


Contributors

SGNA Practice Committee 2015-2016

Ann Herrin, BSN RN CGRN—Chair

Midolie Loyola, MSN RN CGRN—Co-chair

Susan Bocian, MSN BSN RN

Angela Diskey, MSN RN CGRN

Cynthia M. Friis, MEd BSN RN-BC

LeaRae Herron-Rice, MSM BSN RN CGRN

Michelle R. Juan, MSN RN CGRN

Marilee Schmelzer, PhD RN

Susan Selking, BSN RN CGRN

Contributor: Beja Mlinarich, BSN RN CAPA

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