Over the past 20 years great strides have been
made in the diagnosis and treatment of gastrointestinal (GI)
disorders/diseases. Nurses who have worked in endoscopy have seen
numerous changes in the technology used in the GI procedures performed.
This new technology requires extensive, on going training of nurses.
This training allows them to feel comfortable and proficient when
assisting physicians in endoscopic procedures. In the past, little
training and/or education was available to GI nurses. Nurses learned by
modeling behavior observed in more experienced nurses. Nurses were
expected to be knowledgeable, competent and aggressive in technological
advances. At times, nurses were expected to assist in these procedures
without any previous didactic or clinical education. The nurses could
not demonstrate adequacy of knowledge, skill and/or competency prior to
performing this procedure, and expressed frustration regarding this lack
of education.
The New Jersey Board of Nursing states that
"the act of performing a procedure is not in your scope of practice
if you do not possess the knowledge and clinical competency to perform
safely."1
As a self-trained nurse in a very complicated GI
procedure, I know first-hand how frustrating a lack of education and
training can be. I am self trained in endoscopic retrograde
cholangiopancreatography (ERCP) -- the most challenging and riskiest
procedure that is performed in GI. ERCP uses a combination of endoscopic
and radiologic techniques to visualize the biliary and pancreatic ducts.2
Since the introduction of ERCP, there have been
great improvements in the technique, equipment, and clinical use of
biliary endoscopy.3 (Kochman, 2005). These improvements come
with new challenges for the GI nurse. Various techniques and accessories
are needed to perform this procedure and it is imperative that the nurse
be knowledgeable, competent and proficient in all aspects of ERCP.
Understanding the conceptual aspects of the devices used during this
procedure, and being skillful in handling this equipment leads to a
positive outcome for all involved. During an ERCP, the physician relies
on the nurse’s clinical knowledge, and patients are directly affected
by their skill and knowledge.
There are different models of endoscopes used in
ERCP, each having different inner channel sizes. The inner channel
allows the passage of accessories used during the procedure. Most
endo/GI units stock more than one model and physicians are not always
aware of scope specifications. The physician relies on the nurse to know
which accessories will fit into the channels of the different scopes.
Having this clinical knowledge can reduce the stress level of all
involved in the procedure and improve the patient’s outcome.
In order to increase confidence and decrease
stress, it is essential that the nurse be knowledgeable about the
indications, contraindications, and complications of the procedure.
As recently as 10 years ago, there was little
didactic or hands-on education available to nurses assisting with ERCP.
Unfortunately, in some hospitals today, there still is a minimal amount
of education for this challenging procedure. Nurses newly hired to work
in endoscopy/GI know very little about the biliary system. In order for
GI nurses to understand the anatomy of the GI tract, the reason for the
procedure and the sequences of the procedure, they need to be thoroughly
educated, and they must prove their competency on an on-going basis.
The first time I observed an ERCP, it was very
confusing. The nurse and physician talked about cannulating, an ampulla,
a sphincter, and injecting dye. Since I had limited knowledge about the
biliary system, I had no idea what they were doing or what they were
talking about. At that time (1990), ERCPs took three to four hours to
perform. After such a long procedure, the nurses and physician were
exhausted and stressed, and could not be bothered to explain to me what
was done in the procedure. I made it my mission to learn everything I
could, by reading, talking to physicians, experienced nurses and product
vendors, and attended numerous seminars on this subject. Since most
nurses were in the same situation as I was, I realized there was a great
need for education on ERCP. I started to organize seminars with hands-on
workshops for the nurses. Since numerous pieces of equipment and
accessories are used in ERCP and proficiency is key to a successful
procedure, the hands-on segment was a very important addition to the
seminars.
For the past four years, I have been presenting
at regional and national conferences for endo/ GI nurses on the subject
of ERCP. I also train the nurses in my unit for this procedure and have
developed competencies that must be completed prior to the nurse being
approved to assist in procedures.
The constant advances in technology in ERCP make
the procedure more challenging than ever, and ongoing training,
education and practice is critical. The new ERCP techniques can be very
intimidating even to experienced nurses and many are nervous about
assisting in this very stressful procedure. Many physicians performing
ERCPs are also anxious and sometimes insecure. They frequently blame the
assisting nurse for anything that goes wrong -- causing additional
stress for the nurse.
In most hospitals, ERCPs are not performed as
frequently as other GI procedures, so nurses can easily lose their
skills due to limited exposure. In order for the nurse to remain
proficient, they are encouraged to practice, practice, practice. My
motto is, "The procedures that are performed the least must be
practiced the most."
Helpful Tips
Before observing an ERCP, a review of the
anatomy and physiology of the biliary system is a must. This knowledge
will provide an understanding about where the physician and nurses are
working in the body and exactly what is being done. Understanding the
theory behind the nursing actions separates the nurse from technicians.
Asking questions is the best way to learn. Ask the physician why ERCP is
indicated on this particular patient and what therapeutic steps will be
taken during this procedure. Knowing the physician’s possible plan of
action ahead of time allows the nurse to prepare the necessary equipment
and review anything he/she is unsure of prior to the procedure. For
example, if the nurse is aware that placement of a stent is indicated
and is unsure of how to set up and deploy a stent , this would give
her/him the necessary time to review stent placement with the physician
or another experienced nurse. Being prepared will alleviate much of your
stress.
Prior to an ERCP, review the patient’s chart.
Be aware of the history, medical conditions and lab values that could
complicate or delay the procedure.
Although there is an array of equipment
necessary to perform ERCP, an attempt to limit certain accessories
(i.e., guidewires) to one or two vendors can decrease confusion.
Numerous accessories are used during this
procedure, and the nurse is responsible to know the purpose of each
piece of equipment, how it is used and where it is located in the
procedure room. Be familiar with all of your scopes: have knowledge of
the scopes’ inner channel sizes and which accessories they will
accommodate. When the physician asks for an accessory, he/she wants it
NOW! During the procedure, time is of the essence. Wasting time fumbling
for equipment could cause the physician to lose his/her position in the
common bile duct (CBD). If position is lost, recannulation can be very
difficult. Recannulating the papilla not only lengthens the procedure
time, putting the patient at a higher risk of anesthesia related
complications , but repeated attempts to cannulate causes edema of the
papilla, which increases the patient’s risk of pancreatitis.
Pancreatitis is the most common major complication of ERCP , occurring
in five percent to seven percent of patients.4
Mock ERCP has proven to be very helpful in
educating and reinforcing existing knowledge. For these mock ERCPs, all
the equipment needed for a procedure is set up. Nurses work as if they
were really assisting, while the physician’s role is played by a
nurse. Since there is no physician or patient present, it is a less
stressful environment and more learning can occur. The feedback from the
nursing staff on mock ERCPs has been very positive.
Vendors are very willing to give practice
equipment to the unit so that whenever the nurses have the opportunity,
they can practice and work with the equipment, which assists them in
maintaining competency.
Team communication is very important when
assisting in ERCP. The nurse should have confidence that her team
partner will know where all equipment is located and be able to prepare
it for use when needed. During an ERCP is not the time to learn where
equipment is located -– time and efficiency are of the utmost
importance.
Since ERCP is not performed as frequently as
other GI procedures, skill and proficiency can easily be lost. This can
be avoided if a core team of nurses is trained to do ERCP. If the core
team is kept small, chances are they will do ERCPs frequently and
maintain their skills with repetition and practice.
Numerous accessories, devices, and medications
are needed for ERCP. Keeping laminated lists (on the ERCP traveling cart
or in the procedure room) that can be referred to when setting up for a
procedure can prevent forgetting important equipment. The use of a flow
chart that shows all the necessary steps in setting up for an ERCP can
also be helpful. Increasing confidence and reducing the fear of ERCP
will lead to successful procedures.
With constant advances in technology, nurses
must take an active role in educating themselves. Seize every
opportunity to keep up with this technology in order to best serve our
patients. Taking advantage of educational courses and vendor programs
will help maintain skills and proficiency. Our goal as competent nurses
is to deliver quality patient care. "Proficiency is the key to a
positive outcome."
References
1. New Jersey Board of Nursing. (1999).Fact
Sheet: Decision Making Model for Determining Scope of Nursing Practice.
Retrieved October 13, 2005, from www.state.nj.us/lps/ca/nursing/algo1.htm
