1. Huber, Deb A. MSN, ARNP, CGRN

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Do you ever feel you have been called in to do an "emergent case" because it was more convenient, not because it was a true emergency? In reviewing the Society of Gastroenterology Nurses and Associates (SGNA) online Discussion Forum, I noted requests for "guidelines" to decide what should be classified as an emergency. Depending on where you work, an emergency may involve a patient, a physician, and a nurse taking call for the unit. In other areas or units, there may be a team that deals with emergent cases, which could involve nurses, technicians, anesthesiologists, and the like. Taking care of these cases during regular hours of operation would, of course, save significant costs to the facility and minimize the additional stress and inconvenience to those who work call shifts.


If you work in a setting used by multiple physicians or groups, you often find that after you have returned home from doing a case with one physician, another may call you back in. If you are an institutional employee, you probably work regular shifts during the week and then can be called in frequently during the evenings, nights, and weekends. This experience, however, leads to fatigue, stress, poor decision making, and (often) turnover in units.


In my earlier years of endoscopy experience, I worked in a hospital-based endoscopy unit. The nurses rotated call for 1 week at a time (they no longer do this). I was a full-time employee, so I was scheduled Monday through Saturday, with 1 day off during the week as well as Sunday. If, however, there was an emergent case toward the end of my day off, I still was supposed to come in as the "on call" nurse. It was not uncommon to get called in at least a couple evenings during the week as well as on Sunday. A truly bad day was one in which I had worked all day, had come in for a case in the evening (usually a minimum of 2 hr because I had to set up, do the case, and clean up), had gotten called back in for another case at night, and then had to work a full shift the next day. We did not have sufficient extra staff to be able to say "stay home and someone else will take care of your shift."


It is one thing to work these hours if you feel you are really needed (i.e., to deal with gastrointestinal [GI] bleeds). However, when you are called in to assist with patients who could have been treated electively at another time, it is extremely frustrating.


Many people are trying to develop guidelines to define "emergency." That is a tough call. When formulating guidelines, it often is better to work with objective data that are measurable than to work with subjective data that are not. Many times as a nurse practitioner I have been asked to see someone for a GI bleed. This very broad phrase may incorporate anything from a hemoccult-positive stool to frank blood.


One of the most common reasons to be called in for an emergency is active GI bleeding (i.e., melena, frank blood, hematemesis). I do not think anyone would dispute the need for immediate attention in these cases. Another frequent reason is the need to remove a foreign body (e.g., food impaction, swallowed foreign objects, rectal or colonic foreign body impaction). Colonic decompression, another good reason, was listed in the Discussion Forum. In the case of endoscopic retrograde cholangiopancreatography (ERCP), acute duct obstruction is a good reason for an emergent procedure.


Another online justification reported for an emergent procedure, however, was decreased hemoglobin and hematocrit (H and H). I see people every day in the office with decreasing H and H. Should the clinician try to define what size decrease in count has occurred or to establish a certain time during which the decrease occurred before it is considered emergent? Otherwise, just the experience of a decreased H and H seems pretty broad.


Ultimately, if a physician declares a patient's situation as an emergency, can the endoscopy director say it is not? Who has the highest level of education and is considered most knowledgeable about the patient's disease state? I believe it is the "practitioner." The practitioner is the one who has the greatest responsibility with regard to the patient and the greatest liability, not the endoscopy director.


Do we all recognize that there are abuses of this approach? I think we all are aware of inappropriate situations in which this occurs. I also think we must look at the dynamics of what makes this happen and what we can potentially do to change the "inappropriate" situations. Ultimately, time, patients, and money are driving forces. But which of these three variables is seen as the most important?


Historically, hospital endoscopy units were established for both inpatients and outpatients. Ideally, procedures were scheduled during the day when more staff were available. When problems arose during other times, they were managed on an "as needed" basis. Currently, we are seeing increasing numbers of freestanding endoscopy or outpatient surgery centers and physicians offices that perform procedures. These locations usually are scheduled and staffed for work during regular hours. They do not staff for evenings, nights, or weekends. As a result, when problems arise after hours, patients are referred to the hospital or other units with more flexible schedules.


Many practitioners try to make the best use of their time and schedules. Most schedule patients and procedures well in advance. If an emergency arises, it is not easy to rearrange a physician's schedule to address the emergency, nor does making a regular patient wait result in a happy patient. If a patient has taken time off work for a scheduled procedure or is prepared with a colon prep, he or she does not take rescheduling lightly, even in the case of an emergency. Also, a practitioner running to multiple sites on any given day frequently tries to complete work at one site before moving to another without thought or concern for what impact this has on the other facility (and patients).


Where can you go for help? Realistically, you may be limited in what you can do unless you have support at the administrative level and from medical staff. What are the options and who is going to make these decisions? If you have a practitioner who frequently does late procedures that seem more routine than emergent, who can track this trend? Even if a trend is found and addressed, who will handle the problem and how will it be addressed? Is it possible to have a medical director or other physicians review "emergency cases" to see whether they truly are emergencies or whether the procedures could have been scheduled routinely instead? If staff are frequently being called in and extra costs are being incurred to the unit, will the administration step in to curtail this activity because it is not cost effective? I am sure the unit does not want to turn away cases or have them go somewhere else, but can schedules or shifts be added or adjusted to help with these demands?


So what do you do? This is a tough situation without a good answer. Working with the endoscopy staff, practitioners, and administration will hopefully give an improved outcome. But accepting the process as it exists without identifying a tremendous need for change will not help anyone. Reworking the "on call" process for endoscopy deserves a good look, with nursing participating in the solution.