- Email: [email protected]
461 Water Exchange CAP Assisted Colonoscopy (WECAC) Facilitates Completion of High Quality, Cost Effective Colonoscopy With Enhanced Access
AGA Abstracts
were at pre-treatment, weekly during treatment, and at post-treatment. Follow up assessments were made at 6 months after treatment. Results Post-treatment attrition rates were low (6%) and all randomized patients were included in intent-to-treat analyses based on maximum likelihood mixed models. Analyses showed significantly larger pre- to post-treatment change on the primary outcome GSRS-IBS and all secondary outcomes (see Figure 1 and Table 1) for the treatment group compared to the control group (see Table 1). Conclusions InternetCBT based exposure exercises for adolescents with IBS can effectively improve gastrointestinal symptoms and quality of life. This is the first study that evaluates internet-CBT for adolescents with IBS. Table 1. Estimated pre- and post-treatment means for treatment and waiting list groups.
symptoms on the CSI compared to the ES group (p< .05). Log-linear regressions showed that CBT and CBT-R groups differed significantly from the ES group in reducing health care visits for abdominal pain(p<.05) and the CBT-R group also showed a significant reduction in missed school days for abdominal pain over the ES group (p<.05). Conclusion: A very brief telephone intervention delivered to parents alone reduced reported symptoms, as well as both health care utilization and children's disability, as measured by missed school days, in children with abdominal pain of functional origin. This low cost intervention should be considered as a useful addition to the clinical treatment of these children.
460 Seasonal Variation in Functional Abdominal Pain Is Associated With Changes in Anxiety Katie Pollard, Christina Campbell, Megan M. Squires, Olafur S. Palsson, Miranda A. van Tilburg BACKGROUND: Many pediatric patients with Functional abdominal pain (FAP) report amelioration of symptoms during the summer months. Although stress has been suggested to explain seasonal variation, many possible other factors change during the summer that can affect FAP symptoms including sleep and diet. AIM: The aim of this pilot study was to examine if seasonal variation in stress, anxiety, sleep, diet, or physical activity are associated with seasonal variation in FAP symptoms. METHODS: Parents of children with physician diagnosis of FAP (ages 5-17 years old) attending traditional calendar school were asked to complete a battery of questionnaires once in the spring (February-May) and once in the summer (July-August). Questionnaires included Gastrointestinal Symptom subscale of the Child Somatization Inventory, Anxiety subscale of the Revised Child Anxiety and Depression Scale, Adolescent Sleep-Wake Scale, current stress level (low, averge, high), estimated average number of hours of physical activity, and the estimated number of servings of fruits, vegetables, caffeinated beverages, and dairy products consumed on a typical day. RESULTS: Out of 34 children with FAP (Age Mean+SD = 10.0±3.0, 61.8% female), 22 (64.7%) showed an improvement of >1 point in gastrointestinal symptom scores, with the remaining 12 reporting no change or increase in symptoms. Repeated measures ANCOVA was run to examine differences between the two groups in seasonal change. No seasonal effect was found for physical activity or consumption of fruits, vegetables, dairy, or caffeine. Stress diminished from winter/spring to summer (p=0.003) in both groups equally (p=0.85). Similarly, sleep was improved (p=0.02) in summer compared to winter/spring in both groups equally (p=0.16). A seasonal effect was found for anxiety (p=0.01) and this change was larger (see Figure) in the group with improved gastrointestinal symptoms (p=.02). CONCLUSIONS: Our findings suggest that amelioration of FAP symptoms during the summer is associated with amelioration of anxiety. It is not clear if a reduction in anxiety is the cause or effect of a reduction in FAP symptoms. Changes in other variables, such as stress, diet, sleep and exercise were not found to be associated with changes in pain. Longitudinal studies with larger samples are needed to determine causal relationships. This type of research is important in revealing future targets in the prevention and management of FAP.
(A) = Adolescent rated. (P) = Parent rated. GSRS-IBS = Gastrointestinal symptom rating scale for IBS. PedsQL QoL = PedsQL Quality of Life Scale. PedsQL Gastro = PedsQL Gastrointestinal symptoms scale. A significant interaction effect means that the treatment group reported a larger change (B) from pre- and post-treatment than the waiting list group.
459
Seasonal change in anxiety in those whose pain improved versus those whose pain did not improve during the summer.
Parent-Only Intervention Reduces Symptoms and Disability in Abdominal Pain Patients Rona L. Levy, Miranda A. van Tilburg, Shelby Langer, Joan Romano, Lloyd A. Mancl, Shara I. Feld
461 Water Exchange CAP Assisted Colonoscopy (WECAC) Facilitates Completion of High Quality, Cost Effective Colonoscopy With Enhanced Access Felix W. Leung
Background and Purpose: Abdominal pain is the most common recurrent pain complaint of childhood. Medical evaluations rarely yield evidence of an organic disease etiology, resulting in a diagnosis of functional abdominal pain. It is associated with considerable disruption of normal activity, including school attendance, and emotional distress in both children and parents. It also has a significant impact on health-care costs, accounting for more than 50 % of visits to pediatric gastroenterology practices. Previous research by our group and others has shown that the ways parents think about and respond to their child's pain are associated with the severity and impact of abdominal pain in children. Thus, the purpose of the present study was to investigate whether an intervention targeting parental cognitions and responses would reduce the level of symptoms and disability in children with abdominal pain of functional origin. Additionally, we sought to determine if this intervention could be effectively delivered remotely to parents via the telephone. Methods: Parents of 312 children ages 7-12 years old with a physician diagnosis of abdominal pain of functional origin, verified by Rome III criteria, were randomly assigned to one of three conditions: 1) in person CBT for 3 sessions; 2) telephone delivered, remote CBT (CBT-R) for 3 sessions and 3) a telephone delivered attention placebo condition (Education Support/ ES). Children and parents completed the Child Symptom Inventory (CSI) to obtain GI symptom before and immediately following treatment, as well as 3 and 6 months post treatment. Parents also completed health care and school attendance questionnaires at the same time points. Results: Participating parents were 96% female, 84.6% Caucasian, and their mean age was 40.3 years. Treatment groups were compared on reduction in symptoms from baseline through six month follow-up with linear mixed models adjusting for mean changes from baseline. Parents in the CBT-R treatment reported significantly reduced child
AGA Abstracts
Introduction: The advent of bundled payment (CHG 2013;11:454) and looming CMS cuts (AGA News 11/2015) threaten revenue streams , providing incentives to lower overhead (e.g. nursing) costs, and need for refinement of novel management approaches. On demand sedation (ODS) is acceptable in US community practice (GIE 2009;69:567). At VA facilities nursing shortage and no show dramatize the efficacy of scheduled unsedated colonoscopy (SUC) in reducing nursing requirement and inefficiency of no show due to no escort (GIE 2011;73:103, JIG 2014;4:91). Water-aided methods are endorsed for use with ODS (CGH 2015;13:1981); water exchange (WE) is the least painful (CGH 2015;13:1972). The addition of cap assisted colonoscopy (CAC) further decreases insertion pain in unsedated patients (JIG;2015:16) and increases adenoma yield (GIE 2013;77:944). Objective: In a proof-ofprinciple, performance improvement project, ODS was offered to all scheduled for sedation; and SUC, to those with no escort. The hypothesis that WECAC facilitates completion of high quality unsedated colonoscopy without pain in these patients is tested. Method: In 16 months, all patients examined (no trainees) were offered the ODS option by FWL (except those accepting SUC due to no escort). The primary outcome was insertion pain: proportion of unsedated patients with no pain (score=0) and mean maximum pain score for each group. All who requested sedation were examined with air insufflation (AI) without cap; the rest, with WECAC. Results: Table 1 shows that of 150 offered ODS, 48 declined, 102 accepted; 8 were excluded for poor bowel preparation. 22 required sedation; 72 completed without sedation, 36 (50%) had no pain. In the SUC group (N=32), 2 had poor bowel prep; 57%
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of the remaining 30 completing unsedated colonoscopy had no pain. Patients completing unsedated colonoscopy had significantly lower mean maximum pain score. Despite ADR (35%) exceeding performance standard of 25%, the sedated group examined by AI without cap showed the lowest yield of adenomas by all measures (ADR, APC and APPC)1; those examined with WECAC had significantly higher APC and APPC. Table 2 shows that compared with reports of ODS, the current cohort had the highest proportion (50% & 57%) completing unsedated colonoscopy with no pain with ODS & SUC option, respectively. Conclusion: The results indicate WECAC facilitates completion of high quality (high adenoma yield regardless of measure) unsedated colonoscopy without pain, with lower mean maximum pain score for both ODS and SUC options. The latter enhances access by obviating no show due to no escort. Recovery nursing time can be avoided by successful completion of unsedated colonoscopy. Augmented by WECAC, both ODS and SUC options achieve greater value (high quality at lower cost) and are suitable for managing threats to revenue streams (e.g. bundled payment and CMS cuts).
Insertion methods: AI, air insufflation; CD, carbon dioxide; WECAC, water exchange cap assisted colonoscopy; WI, water immersion; ODS, on demand sedation; SUC, scheduled unsedated colonoscopy.
Economic Impact of Computer Assisted Propofol Sedation Johannes Koch, Deborah Tombs, Otto S. Lin, Richard A. Kozarek, Michael Gluck, Michael C. Larsen, Andrew S. Ross Propofol sedation for routine outpatient endoscopic procedures has many advantages, yet has generally required ancillary staff that would contribute to escalating costs. Our institution has utilized lean management tools for 15 years to optimize staffing and procedure flow. In order to perform propofol sedation without additional staff, we implemented computer assisted propofol sedation in the fall of 2014 in our hospital based outpatient endoscopy unit which operates 1-5 rooms per day. Herein we assess the impact on staffing and costs since implementation of computer assisted propofol sedation. Methods At baseline, the recovery room was staffed with one recovery RN per utilized procedure room. Adjustments to recovery staff were made to accommodate changes observed with use of propofol. We compared total RN overtime hours for the 9 months (Jan-Sept 2014) before propofol sedation to the 9 months (Jan-Sept 2015) after all providers had been trained to use computer assisted propofol sedation. We assessed the impact on costs by comparing April 2014 to April 2015. We calculated costs using average RN expense of $40/hour, GI tech $20/hour and RN overtime hours at $60/hr. Results Given the shorter recovery time realized with computer assisted propofol sedation, recovery room staffing was adjusted over time to only one RN (independent of utilized rooms) and one GI tech. Additional admit and procedure RN/GI techs were not needed. The total overtime hours from Jan-Sept 2014 were 623.95 compared to 425 for the same time period in 2015 - a 31.8% reduction. Table 1 Despite ongoing efforts at cost reduction across our institution, similar reductions in staff and overtime where not achieved at our outpatient ambulatory surgical centers that used standard procedural sedation (midazolam and fentanyl). Conclusion With the implementation of computer assisted propofol sedation for routine endoscopic procedures we adjusted recovery room staffing without additional personnel for admit and procedures. Recovery staff overtime hours decreased more than 30%. We achieved savings greater than $14,000 per month while increasing procedure volume. Table 1 Monthly Recovery Room Staff Before (2014) vs After (2015) Implementation of Computer Assisted Propofol Sedation
^ (69.5*8*$40) + (68.5 * $60) ~ (22 * 8 * $40) + (30 * $60) + (22 * 8 * $20)
463 Systematic Review and Meta Analysis of the Effectiveness of Capnography Monitoring for Detecting Severe Oxygen Desaturation During Endoscopic Procedural Sedation Rhodri Saunders, Michel M. Struys, Richard Pollock, Michael L. Mestek, Jenifer R. Lightdale
Data are number and % total or mean (SD). Insertion methods: AI, air insufflation; WECAC, water exchange cap assisted colonoscopy; hr, hour; NR, not reported; ODS, on demand sedation; SD, standard deviation; SUC, scheduled unsedated colonoscopy, based on no escort; 1ADR, adenoma detection rate; 1APC, adenoma per colonoscopy; 1APPC, adenoma per positive colonoscopy. 20.0005; 30.0060, vs declined; 4immediately before start of intraprocedure sedation; 50.0001, vs both unsedated; 6p=0.0281; 7p=0.0028; 8p=0.0361; 9p= 0.0010; 10p=0.0001; 11p=0.0001, vs declined; t test. Table 2: Patients completing unsedated colonoscopy with no pain
Despite randomized, controlled trials (RCTs) demonstrating clinical effectiveness of capnography for detecting arterial oxygen (SpO2) desaturation during procedural sedation for gastrointestinal (GI) procedures, clear evidence that its use can minimize clinically significant hypoxemia remains elusive. To date, RCTs have examined mild desaturation as a proxy for more severe adverse events, which occur far less frequently and would require significantly larger sample sizes. AIM: To quantify the impact of capnography on severe SpO2 desaturation during sedated GI procedures, we performed a systematic review and meta analysis of RCTs which compared pulse oximetry monitoring and visual assessment (standard of care, SOC) to SOC plus capnography. METHODS: Literature searches in PubMed, Cochrane Library and EMBASE, with no language restriction, identified RCTs published in or after 1995 in patients receiving sedation for outpatient procedures. Screening of 861 hits was performed independently by two authors. 19 hits remained for full text review, of which seven (5 articles, 2 abstracts) were included for analysis. Data were extracted on the population at risk, number of events, sedation protocol used, and study quality. Endpoints included desaturation and assisted ventilation, as well as apnea, hypotension, bradycardia, and mortality. All endpoints were categorized to ensure clinical comparability, with mild desaturation defined as a SpO2 85-94%, and severe desaturation <85%. The protocol allowed for analysis of other endpoints reported by ‡3 studies. Evidence synthesis used a random effects model to account for clinical effectiveness in the real world of endoscopy suites. Results are the pooled mean intervention effect (odds ratio [OR] for capnography relative to SOC). RESULTS: Across all 7 GI studies, 1,344 patients were randomized to SOC and 1,338 patients to SOC plus capnography. 3 protocols specified use of supplemental O2 at baseline. 4 studies reported mild desaturation to be significantly reduced with capnography monitoring: the mean (95% confidence interval) OR was 0.60 (0.45, 0.79). Severe desaturations were also significantly reduced: OR 0.45 (0.31, 0.63). Although there was no significant impact of capnography on the occurrence of assisted ventilation (OR: 1.02 [0.71, 1.48]), it did occur less frequently with capnography monitoring across studies. Insufficient data were available to assess other endpoints. The treatment effects of capnography were generally robust to removal of data only published in abstract form (n=2) and from pediatric populations (n= 1). CONCLUSION: Results suggest clear, consistent evidence that adding capnography to SOC reduces the likelihood of respiratory compromise in the form of clinically significant
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AGA Abstracts
AGA Abstracts
462
were at pre-treatment, weekly during treatment, and at post-treatment. Follow up assessments were made at 6 months after treatment. Results Post-treatment attrition rates were low (6%) and all randomized patients were included in intent-to-treat analyses based on maximum likelihood mixed models. Analyses showed significantly larger pre- to post-treatment change on the primary outcome GSRS-IBS and all secondary outcomes (see Figure 1 and Table 1) for the treatment group compared to the control group (see Table 1). Conclusions InternetCBT based exposure exercises for adolescents with IBS can effectively improve gastrointestinal symptoms and quality of life. This is the first study that evaluates internet-CBT for adolescents with IBS. Table 1. Estimated pre- and post-treatment means for treatment and waiting list groups.
symptoms on the CSI compared to the ES group (p< .05). Log-linear regressions showed that CBT and CBT-R groups differed significantly from the ES group in reducing health care visits for abdominal pain(p<.05) and the CBT-R group also showed a significant reduction in missed school days for abdominal pain over the ES group (p<.05). Conclusion: A very brief telephone intervention delivered to parents alone reduced reported symptoms, as well as both health care utilization and children's disability, as measured by missed school days, in children with abdominal pain of functional origin. This low cost intervention should be considered as a useful addition to the clinical treatment of these children.
460 Seasonal Variation in Functional Abdominal Pain Is Associated With Changes in Anxiety Katie Pollard, Christina Campbell, Megan M. Squires, Olafur S. Palsson, Miranda A. van Tilburg BACKGROUND: Many pediatric patients with Functional abdominal pain (FAP) report amelioration of symptoms during the summer months. Although stress has been suggested to explain seasonal variation, many possible other factors change during the summer that can affect FAP symptoms including sleep and diet. AIM: The aim of this pilot study was to examine if seasonal variation in stress, anxiety, sleep, diet, or physical activity are associated with seasonal variation in FAP symptoms. METHODS: Parents of children with physician diagnosis of FAP (ages 5-17 years old) attending traditional calendar school were asked to complete a battery of questionnaires once in the spring (February-May) and once in the summer (July-August). Questionnaires included Gastrointestinal Symptom subscale of the Child Somatization Inventory, Anxiety subscale of the Revised Child Anxiety and Depression Scale, Adolescent Sleep-Wake Scale, current stress level (low, averge, high), estimated average number of hours of physical activity, and the estimated number of servings of fruits, vegetables, caffeinated beverages, and dairy products consumed on a typical day. RESULTS: Out of 34 children with FAP (Age Mean+SD = 10.0±3.0, 61.8% female), 22 (64.7%) showed an improvement of >1 point in gastrointestinal symptom scores, with the remaining 12 reporting no change or increase in symptoms. Repeated measures ANCOVA was run to examine differences between the two groups in seasonal change. No seasonal effect was found for physical activity or consumption of fruits, vegetables, dairy, or caffeine. Stress diminished from winter/spring to summer (p=0.003) in both groups equally (p=0.85). Similarly, sleep was improved (p=0.02) in summer compared to winter/spring in both groups equally (p=0.16). A seasonal effect was found for anxiety (p=0.01) and this change was larger (see Figure) in the group with improved gastrointestinal symptoms (p=.02). CONCLUSIONS: Our findings suggest that amelioration of FAP symptoms during the summer is associated with amelioration of anxiety. It is not clear if a reduction in anxiety is the cause or effect of a reduction in FAP symptoms. Changes in other variables, such as stress, diet, sleep and exercise were not found to be associated with changes in pain. Longitudinal studies with larger samples are needed to determine causal relationships. This type of research is important in revealing future targets in the prevention and management of FAP.
(A) = Adolescent rated. (P) = Parent rated. GSRS-IBS = Gastrointestinal symptom rating scale for IBS. PedsQL QoL = PedsQL Quality of Life Scale. PedsQL Gastro = PedsQL Gastrointestinal symptoms scale. A significant interaction effect means that the treatment group reported a larger change (B) from pre- and post-treatment than the waiting list group.
459
Seasonal change in anxiety in those whose pain improved versus those whose pain did not improve during the summer.
Parent-Only Intervention Reduces Symptoms and Disability in Abdominal Pain Patients Rona L. Levy, Miranda A. van Tilburg, Shelby Langer, Joan Romano, Lloyd A. Mancl, Shara I. Feld
461 Water Exchange CAP Assisted Colonoscopy (WECAC) Facilitates Completion of High Quality, Cost Effective Colonoscopy With Enhanced Access Felix W. Leung
Background and Purpose: Abdominal pain is the most common recurrent pain complaint of childhood. Medical evaluations rarely yield evidence of an organic disease etiology, resulting in a diagnosis of functional abdominal pain. It is associated with considerable disruption of normal activity, including school attendance, and emotional distress in both children and parents. It also has a significant impact on health-care costs, accounting for more than 50 % of visits to pediatric gastroenterology practices. Previous research by our group and others has shown that the ways parents think about and respond to their child's pain are associated with the severity and impact of abdominal pain in children. Thus, the purpose of the present study was to investigate whether an intervention targeting parental cognitions and responses would reduce the level of symptoms and disability in children with abdominal pain of functional origin. Additionally, we sought to determine if this intervention could be effectively delivered remotely to parents via the telephone. Methods: Parents of 312 children ages 7-12 years old with a physician diagnosis of abdominal pain of functional origin, verified by Rome III criteria, were randomly assigned to one of three conditions: 1) in person CBT for 3 sessions; 2) telephone delivered, remote CBT (CBT-R) for 3 sessions and 3) a telephone delivered attention placebo condition (Education Support/ ES). Children and parents completed the Child Symptom Inventory (CSI) to obtain GI symptom before and immediately following treatment, as well as 3 and 6 months post treatment. Parents also completed health care and school attendance questionnaires at the same time points. Results: Participating parents were 96% female, 84.6% Caucasian, and their mean age was 40.3 years. Treatment groups were compared on reduction in symptoms from baseline through six month follow-up with linear mixed models adjusting for mean changes from baseline. Parents in the CBT-R treatment reported significantly reduced child
AGA Abstracts
Introduction: The advent of bundled payment (CHG 2013;11:454) and looming CMS cuts (AGA News 11/2015) threaten revenue streams , providing incentives to lower overhead (e.g. nursing) costs, and need for refinement of novel management approaches. On demand sedation (ODS) is acceptable in US community practice (GIE 2009;69:567). At VA facilities nursing shortage and no show dramatize the efficacy of scheduled unsedated colonoscopy (SUC) in reducing nursing requirement and inefficiency of no show due to no escort (GIE 2011;73:103, JIG 2014;4:91). Water-aided methods are endorsed for use with ODS (CGH 2015;13:1981); water exchange (WE) is the least painful (CGH 2015;13:1972). The addition of cap assisted colonoscopy (CAC) further decreases insertion pain in unsedated patients (JIG;2015:16) and increases adenoma yield (GIE 2013;77:944). Objective: In a proof-ofprinciple, performance improvement project, ODS was offered to all scheduled for sedation; and SUC, to those with no escort. The hypothesis that WECAC facilitates completion of high quality unsedated colonoscopy without pain in these patients is tested. Method: In 16 months, all patients examined (no trainees) were offered the ODS option by FWL (except those accepting SUC due to no escort). The primary outcome was insertion pain: proportion of unsedated patients with no pain (score=0) and mean maximum pain score for each group. All who requested sedation were examined with air insufflation (AI) without cap; the rest, with WECAC. Results: Table 1 shows that of 150 offered ODS, 48 declined, 102 accepted; 8 were excluded for poor bowel preparation. 22 required sedation; 72 completed without sedation, 36 (50%) had no pain. In the SUC group (N=32), 2 had poor bowel prep; 57%
S-100
of the remaining 30 completing unsedated colonoscopy had no pain. Patients completing unsedated colonoscopy had significantly lower mean maximum pain score. Despite ADR (35%) exceeding performance standard of 25%, the sedated group examined by AI without cap showed the lowest yield of adenomas by all measures (ADR, APC and APPC)1; those examined with WECAC had significantly higher APC and APPC. Table 2 shows that compared with reports of ODS, the current cohort had the highest proportion (50% & 57%) completing unsedated colonoscopy with no pain with ODS & SUC option, respectively. Conclusion: The results indicate WECAC facilitates completion of high quality (high adenoma yield regardless of measure) unsedated colonoscopy without pain, with lower mean maximum pain score for both ODS and SUC options. The latter enhances access by obviating no show due to no escort. Recovery nursing time can be avoided by successful completion of unsedated colonoscopy. Augmented by WECAC, both ODS and SUC options achieve greater value (high quality at lower cost) and are suitable for managing threats to revenue streams (e.g. bundled payment and CMS cuts).
Insertion methods: AI, air insufflation; CD, carbon dioxide; WECAC, water exchange cap assisted colonoscopy; WI, water immersion; ODS, on demand sedation; SUC, scheduled unsedated colonoscopy.
Economic Impact of Computer Assisted Propofol Sedation Johannes Koch, Deborah Tombs, Otto S. Lin, Richard A. Kozarek, Michael Gluck, Michael C. Larsen, Andrew S. Ross Propofol sedation for routine outpatient endoscopic procedures has many advantages, yet has generally required ancillary staff that would contribute to escalating costs. Our institution has utilized lean management tools for 15 years to optimize staffing and procedure flow. In order to perform propofol sedation without additional staff, we implemented computer assisted propofol sedation in the fall of 2014 in our hospital based outpatient endoscopy unit which operates 1-5 rooms per day. Herein we assess the impact on staffing and costs since implementation of computer assisted propofol sedation. Methods At baseline, the recovery room was staffed with one recovery RN per utilized procedure room. Adjustments to recovery staff were made to accommodate changes observed with use of propofol. We compared total RN overtime hours for the 9 months (Jan-Sept 2014) before propofol sedation to the 9 months (Jan-Sept 2015) after all providers had been trained to use computer assisted propofol sedation. We assessed the impact on costs by comparing April 2014 to April 2015. We calculated costs using average RN expense of $40/hour, GI tech $20/hour and RN overtime hours at $60/hr. Results Given the shorter recovery time realized with computer assisted propofol sedation, recovery room staffing was adjusted over time to only one RN (independent of utilized rooms) and one GI tech. Additional admit and procedure RN/GI techs were not needed. The total overtime hours from Jan-Sept 2014 were 623.95 compared to 425 for the same time period in 2015 - a 31.8% reduction. Table 1 Despite ongoing efforts at cost reduction across our institution, similar reductions in staff and overtime where not achieved at our outpatient ambulatory surgical centers that used standard procedural sedation (midazolam and fentanyl). Conclusion With the implementation of computer assisted propofol sedation for routine endoscopic procedures we adjusted recovery room staffing without additional personnel for admit and procedures. Recovery staff overtime hours decreased more than 30%. We achieved savings greater than $14,000 per month while increasing procedure volume. Table 1 Monthly Recovery Room Staff Before (2014) vs After (2015) Implementation of Computer Assisted Propofol Sedation
^ (69.5*8*$40) + (68.5 * $60) ~ (22 * 8 * $40) + (30 * $60) + (22 * 8 * $20)
463 Systematic Review and Meta Analysis of the Effectiveness of Capnography Monitoring for Detecting Severe Oxygen Desaturation During Endoscopic Procedural Sedation Rhodri Saunders, Michel M. Struys, Richard Pollock, Michael L. Mestek, Jenifer R. Lightdale
Data are number and % total or mean (SD). Insertion methods: AI, air insufflation; WECAC, water exchange cap assisted colonoscopy; hr, hour; NR, not reported; ODS, on demand sedation; SD, standard deviation; SUC, scheduled unsedated colonoscopy, based on no escort; 1ADR, adenoma detection rate; 1APC, adenoma per colonoscopy; 1APPC, adenoma per positive colonoscopy. 20.0005; 30.0060, vs declined; 4immediately before start of intraprocedure sedation; 50.0001, vs both unsedated; 6p=0.0281; 7p=0.0028; 8p=0.0361; 9p= 0.0010; 10p=0.0001; 11p=0.0001, vs declined; t test. Table 2: Patients completing unsedated colonoscopy with no pain
Despite randomized, controlled trials (RCTs) demonstrating clinical effectiveness of capnography for detecting arterial oxygen (SpO2) desaturation during procedural sedation for gastrointestinal (GI) procedures, clear evidence that its use can minimize clinically significant hypoxemia remains elusive. To date, RCTs have examined mild desaturation as a proxy for more severe adverse events, which occur far less frequently and would require significantly larger sample sizes. AIM: To quantify the impact of capnography on severe SpO2 desaturation during sedated GI procedures, we performed a systematic review and meta analysis of RCTs which compared pulse oximetry monitoring and visual assessment (standard of care, SOC) to SOC plus capnography. METHODS: Literature searches in PubMed, Cochrane Library and EMBASE, with no language restriction, identified RCTs published in or after 1995 in patients receiving sedation for outpatient procedures. Screening of 861 hits was performed independently by two authors. 19 hits remained for full text review, of which seven (5 articles, 2 abstracts) were included for analysis. Data were extracted on the population at risk, number of events, sedation protocol used, and study quality. Endpoints included desaturation and assisted ventilation, as well as apnea, hypotension, bradycardia, and mortality. All endpoints were categorized to ensure clinical comparability, with mild desaturation defined as a SpO2 85-94%, and severe desaturation <85%. The protocol allowed for analysis of other endpoints reported by ‡3 studies. Evidence synthesis used a random effects model to account for clinical effectiveness in the real world of endoscopy suites. Results are the pooled mean intervention effect (odds ratio [OR] for capnography relative to SOC). RESULTS: Across all 7 GI studies, 1,344 patients were randomized to SOC and 1,338 patients to SOC plus capnography. 3 protocols specified use of supplemental O2 at baseline. 4 studies reported mild desaturation to be significantly reduced with capnography monitoring: the mean (95% confidence interval) OR was 0.60 (0.45, 0.79). Severe desaturations were also significantly reduced: OR 0.45 (0.31, 0.63). Although there was no significant impact of capnography on the occurrence of assisted ventilation (OR: 1.02 [0.71, 1.48]), it did occur less frequently with capnography monitoring across studies. Insufficient data were available to assess other endpoints. The treatment effects of capnography were generally robust to removal of data only published in abstract form (n=2) and from pediatric populations (n= 1). CONCLUSION: Results suggest clear, consistent evidence that adding capnography to SOC reduces the likelihood of respiratory compromise in the form of clinically significant
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AGA Abstracts
462