Reply to Thoufeeq

Dr Thoufeeq raises some important issues with respect to our paper on nurse endoscopists performing colonoscopy [1]. As it is gastroenterologists who train and supervise nurse endoscopists, it is indeed important that they support nurse endoscopy practice. Gastroenterologists are, in general, positive toward the important, albeit restricted role of nurse endoscopists [2] [3]. Potential benefits are recognized but concerns are expressed, including the need for adequate training and quality assurance, as well as patient experience and the potential interference in training of gastroenterology fellows. Dealing with these concerns is a prerequisite for institutions considering the introduction of nurse endoscopists.

We fully agree that nurse endoscopists should be able to administer and control sedation. In The Netherlands, however, a physician’s order is needed to perform colonoscopy with or without conscious sedation. In our study, patients scheduled for colonoscopy were preprocedurally assessed and informed by a physician. After informed consent had been obtained, the physician ordered the endoscopy with or without conscious sedation. All enrolled nurse endoscopists were trained to premedicate and sedate according to the standards set in the Dutch guidelines for non-anesthesiologist administered sedation [4]. Immediately prior to the procedure, the nurse endoscopist conducted a brief re-assessment to identify any recent changes in patient history, American Society of Anesthesiologists (ASA) risk score, medication use, and consent for the endoscopy and sedation. In cases where the preprocedural assessment was confirmed and the use of sedation and or analgesia was considered appropriate, nurse endoscopists were allowed to administer, titrate, and control the sedative/analgesic medications, under the indirect supervision of a gastroenterologist. In one participating hospital, however, local prescription rules stated that the supervising gastroenterologist administered these medications.

We agree that nurse endoscopists required frequent assistance from supervising gastroenterologists. However, these practitioners were quite inexperienced, with a median of only 500 colonoscopies performed at baseline. Failure to reach the cecum and interpretation of endoscopy findings were the main reasons for requiring assistance. It is to be expected that the need for assistance will decrease as experience grows, as has been shown for nurse performed gastro- and sigmoidoscopy [5]. In addition, the requirement for assistance depends largely on the defined limits of practice and responsibilities, both for nurse endoscopists and their supervisors.

• References

• 1 van Putten PG, Ter Borg F, Adang RP et al. Nurse endoscopists perform colonoscopies according to the international standard and with high patient satisfaction. Endoscopy 2012; 44: 1127-1132
• 2 Pathmakanthan S, Murray I, Smith K et al. Nurse endoscopists in United Kingdom health care: a survey of prevalence, skills and attitudes. J Adv Nurs 2001; 36: 705-710
• 3 van Putten PG, van Leerdam ME, Kuipers EJ. The views of gastroenterologists about the role of nurse endoscopists, especially in colorectal cancer screening. Aliment Pharmacol Ther 2009; 29: 892-897
• 4 Dutch guidelines for non-anesthesiologists on sedation and/or analgesia at remote locations. 2009 Available from: http://www.anesthesiologie.nl/uploads/284/1340/Def_RL_PSA_Volwassenen_en_IC_2012.pdf
• 5 Williams J, Russell I, Durai D et al. What are the clinical outcome and cost-effectiveness of endoscopy undertaken by nurses when compared with doctors? A Multi-Institution Nurse Endoscopy Trial (MINuET). Health Technol Assess 2006; 10 iii-iv, ix-x, 1-195