Preoperative Endoscopy Discharge Instructions

Endoscopy is a common procedure performed in the United States with approximately 51.5 million people undergoing the procedure per year (iData Research, 2018).  During an endoscopy, a gastroenterologist physician uses an endoscope, which is a slender tube with a camera at the end to visualize either the esophagus, stomach, or bowel.  An endoscopy can be performed as a screening and/or diagnostic procedure (Lee, Saltzman & Grover, 2018).  Endoscopy screenings are performed to diagnose a disease in an early stage or to slow the progression of the disease.  Diagnostic endoscopies are used to obtain specimens in order to determine a diagnosis that can range from an infection or inflammation to cancer.

A colonoscopy is a type of endoscopy procedure where the slender tube with a camera is inserted through the anus and advanced to visualize the large intestine and colon.  The most common symptoms that warrant a colonoscopy are stomach pain and chronic diarrhea or constipation.  An endoscopy screening for colon cancer is recommended to start at 45 years old and continue yearly until 75 years of age (U.S. Preventive Services Task Force [USPSTF], 2016).  Starting at the age of 76, before performing screenings, patients’ overall health is taken into consideration, including if they would be able to handle any treatment if any findings warranted treatment (USPSTF, 2016).  In the United States, colorectal cancer is the second-leading cause of cancer death (USPSTF, 2016).  In 2016, 134,000 people were diagnosed with colorectal cancer (USPSTF, 2016).  Most people are diagnosed with colorectal cancer between the ages of 65 years to 74 years with an average age at diagnosis of 73 years (USPSTF, 2016).

A colonoscopy is considered a screening with the following criteria: no family history of colon cancer or polyps, no personal history of polyps, and none of the following symptoms: abdominal cramping, blood in the stool, weight loss, or anemia (Barnes, 2013).  A colonoscopy is considered diagnostic with the following criteria: family history of colon cancer or polyps, personal history of colon cancer or polyps, previous colonoscopies with findings of polyps, colon cancer, or diverticulitis, or if patients present with symptoms of abdominal cramping, blood in the stool, weight loss, anemia or vomiting prior to the colonoscopy (Barnes, 2013).  Depending on family history of colon cancer or if polyps were present during their colonoscopy, the recommendation will be to have a colonoscopy every 5 years; otherwise, if everything was normal, the next screening will be in 10 years (USPSTF, 2016).

An esophagogastroduodenoscopy (EGD) is a procedure that is performed by advancing an endoscope through a bite guard in the mouth to examine the esophagus, stomach, and the duodenum, the first part of the small intestines.  Unlike a colonoscopy, there are no formal screening guidelines for an EGD.  An EGD is performed on patients with any of the following symptoms: chronic heartburn, upper abdominal pain, persistent nausea or vomiting, black stools, or difficulty swallowing.  EGD screening is performed on patients with chronic gastroesophageal reflux disease (GERD), have risk of Barrett’s esophagus, symptomatic anemia, cirrhosis of the liver, or portal hypertension (Park, Shaheen, Cohen, Pike, & Adler, 2015).  Otherwise, EGDs are considered diagnostic.  Diagnostic EGDs are performed to diagnose gastric ulcer, GERD, cancer, or difficulty swallowing.  Depending on the diagnosis, follow-up EGDs can be recommended anywhere from two weeks to every three or five years (P. Dryer, MD, personal communication, June 17, 2019).

According to internal records, T……… Hospital (THBBH) performs 2,608 endoscopies per year on average.  In the endoscopy department at THBBH, patients are scheduled for a colonoscopy, an esophagogastroduodenoscopy (EGD) procedure, or both.  These procedures are conducted by a gastroenterologist physician.  The personnel in the room to assist with the procedures include a nurse to circulate and document, one technician or another nurse to assist the physician, and personnel in the cleaning room to clean and disinfect the endoscopes after each procedure.

Adult patients who have had an endoscopy procedure at THBBH receive a survey by email, phone call, or postal mail after their procedure that asks questions about their experience throughout the entire perioperative process.  The survey that is sent to patients who had a procedure or surgery is known as the Outpatient and Ambulatory Surgery Consumer Assessment of Hospital Providers and System (OAS CAHPS).  The OAS CAHPS survey was developed by the Centers for Medicare and Medicaid Services (CMS) who follow the Agency for Healthcare research and Quality (AHRQ) guidelines (CAHPS, 2016).  Press Ganey oversees the OAS CAHPS survey by sending it to patients, gathering the data, and reporting the results to health care organizations, including THBBH (D. Mylod, personal communication, March 11, 2019).

The OAS CAHPS survey began development in 2012 and was implemented in January 2016 (Press Ganey, 2016).  Effective January 2018, the OAS CAHPS survey became a requirement for Medicare-certified facilities to receive reimbursement from Medicare and Medicaid (Press Ganey, 2016).  The OAS CAHPS survey asks a total of 37 questions that fall into one of five domains.  The five domains focus on patient satisfaction in the following areas: before procedure process, facility and staff, communication about procedure, recovery, and overall experience (Crockett, James, Morris, Schuster, Shipley, & Topjian, 2017).  There are several questions under the communication domain with one focusing on discharge instructions. Discharge instructions are rated by asking patients if they were given symptoms to watch for, medication instructions, home care instructions, and if they received written discharge instructions prior to leaving the facility (Crockett et al., 2017).

It is important that endoscopy patients are satisfied with the care they received and understand their discharge instructions.  Discharge instructions provide information the patient should follow once they leave the hospital.  Discharge instructions include what to watch for after the procedure, phone number for the physician in case there are any concerns, medication instructions, recommended activity level, and stipulations to call the physician’s office to make a follow-up appointment or for biopsy results.

Endoscopy patients are in the facility for a short period of time.  The patients arrive one hour prior to their procedure and on average are discharged thirty minutes after the procedure.  There is a lot of information that is given to patients in a limited amount of time.  Communication between the health care team and patient is important.  The health care team needs to be certain patients understand their discharge instructions.