When Emergencies Arise in the GI Lab
…Who you gonna call?
David Hambrick, BSN, RN, CGRN
GI Nursing Director
Dallas, TX
Objectives

1) Describe potential GI patient specific emergent
situations

2) Describe adequate preparation and response
techniques for GI patient-specific emergent situations
2
What Admin & patients think GI staff look like
3
What we really feel like
4
Emergencies in #MyGILab?

It’s more common than one would think

Emergencies are not confined to just the procedure
room, often occur during off-unit procedures

Regardless of setting, emergencies can happen
throughout the peri-procedural continuum

Occur in hospital & ASC based units
What is a GI Endoscopy Emergency?

Definition depends on several factors…
 Overall patient presentation
 Significant co-morbidities
 Intra-procedural complications
 Presence of Specialists incl Anesthesia

Also depends on:
 Who you ask (Internist, GI, Surgeon)
 Time of Day, Day of week, Discharge status
 Availability of physician, their clinic/office time
and/or a 0700 open room tomorrow morning
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Our Definition of Patient Emergency

“An unexpected situation requiring an immediate
response in order to prevent or minimize undesirable
patient complication or outcome” D Hambrick, 2015
 Bleeding, Hypo/hyper tension
 Malignant hypertension (est 0.00001% GA cases)
 Equipment malfunction
 Worsening patient condition despite intervention

May also include:
 Facility related issues (power loss, fire, etc)
 Staffing availability
 Internal/external disaster scenario
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Disclaimer time


This presentation is to review unit preparation for
Emergencies, not clarification of the definition
Each facility’s Medical Staff/GI Lab Committee has to
set up expectations for:
 Response time for emergencies
 Patient conditions requiring emergency
intervention
 Who responds to emergency procedures
(anesthesia)
 Quality/Performance metrics associated with
utilization of on-call/after hours atff
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Most Common (Clinical) GI Emergencies

Acute Abdominal Pain

Gastrointestinal Hemorrhage

Biliary Tract Obstruction

Hepatic Failure (Variceal Bleed)
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The GI Lab is Everywhere

Ideally, emergent procedures are handled in the GI
Lab, M-F, 0700-1500, but…

Emergency Room

Intensive Care Unit

Operating Room

“The Floor”
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Leadership Responsibilities

Scope of practice review to determine potential
emergent procedures

Staff competencies and practices must be reviewed to
identify potential failure points

Coordination with ancillary Leadership and staff for
expectations of emergency response
 Anesthesia, Radiology, ICU, ED, Periop, Lab, Blood
Bank, etc
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Okay, so what does that mean to us?

All staff responding to GI emergencies must be
competent in the expected treatment modalities
 Different depending on practice settings
 ASC vs Community vs Academic

All staff performing a role in emergent GI procedures
must be trained to standard/competency with regular
re-validation or demonstration

All equipment required for scope of intervention must
be available & servicable 24/7
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The Safest Way to Do Anything…

Standardize the Process



All unscheduled/urgent/emergent procedures should be
handled the same way
Starting with notification of the GI Lab staff, have one
way to do it, regardless of day, time, procedure
Have a standardized report form, including






Pt ID (two identifiers, name DOB)
Pt location
Procedure to be performed
Location of procedure (ICU, ED, GI Lab, etc)
Expected time of procedure
Other services needed (Anesthesia, blood bank, pathology, etc)
Let’s Do It Right the First Time

Benefits of standardizing the process:





Eliminate problems with mis-communication, direct calls to staff
from physicians to nursing/tech staff
Education of physicians, Fellows, Nursing/Tech staff
conducted, documented, part of Orientation
Ensures equipment, devices, etc are present and available for
use
Ensures trained & competent staff present
Process should go through Governance process, accepted by
GI Lab Committee to ensure compliance
What Could Possibly Go Wrong?

Usual scenario:

It’s 0115 on Tuesday night, the GI Fellow calls the cell
phone of GI Tech/Nurse on call:

“We need to do an EGD, patient is in the ED waiting on an
ICU bed. GI bleed, need to do it ASAP, let the on call nurse &
anesthesia know, thanks <click>”
Recipe for Disaster…

The GI staff now has to figure out:

Name, location of patient, where the patient will be
when they arrive

What type of GI Bleed? Variceal? Foreign body
damage? Hematemesis? Gastric? Rectal bleed but r/o
upper GI cause? Post-surgical?

What equipment is needed?

Is anesthesia available? Have they been notified? Are
they necessary?
The Staff tries to figure it out…

So, they:
Call other on-call staff, give general patient info
 Go to hospital, grab everything based on personal
experience
 Spend 30 minutes tracking down where the patient is, find
out that Anesthesia wasn’t notified
 Go to patient location, start procedure, realize you don’t
have what is needed, case is delayed while running back to
the GI Lab to find it
Meanwhile:
 The patient care is delayed
 Physician is frustrated
 Everybody gets yelled at the next morning


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Replay using Standardized Process



The physician notifies the hospital operator to page the on-call
staff, creating a log entry to review in case of performance
variances
On-call staff responds to page, calls physician to get patient
and procedure information
Using standardized report format, receives all pertinent
information including:
 Pt ID (two identifiers, name & DOB)
 Pt location
 Procedure(s) to be performed & special equipment needed
 Location of procedure (ICU, ED, GI Lab, etc)
 Expected time of procedure
 Other services needed (Anesthesia, blood bank, pathology,
etc)
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Once the Team is on site…

All team members meet at the agreed upon procedure location

All requested or expected equipment is present

All ancillary staff is prepared per protocol

Staff demonstrates competency in equipment and device set-up
and use

Procedure is performed, optimal patient care is delivered

Nobody is yelled at the next morning
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How to Standardize the Process



Recognize the Need
Recognize the Need
Recognize the need
How do we do that?

Present objective data to GI Governance team to demonstrate
change is required to improve patient care, outcomes,
physician, patient, staff satisfaction

Identify shortcomings in staff education and procedural
competencies using:

Formal competency evaluations

Feedback from staff, physicians

Data elements from scheduling and procedure reporting
software
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Then what?

Develop standardized exectations for each role

Use task specific training plans based on identified
shortcomings for all roles

Use standardized Best Practice training & processes to
minimize staff performance variances

Using (unit experts, vendor clinical experts) train staff to
competency, documenting competency in employee files

Establish feedback mechanisms between staff, physicians and
leadership (GI Lab Committee) on improvement processes and
outcomes
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Let’s wrap it up

There’s one standard of performance to competency regardless
of time, location or duration or procedure

All team members are to be trained to competency and then
required to perform to that standard

Variances in the process are identified, trended, and corrective
action taken as required

Expecting untrained, incompetent staff to perform to standard is
harmful to patient outcomes as well as staff and team
development and cohesiveness
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Questions?