Presentation by Dr. Marybeth Spanarkel: Endo Staff Under Pressure: Understanding Colonoscopy-Related Ergonomic Hazards

In March of 2024, at the AORN Global Surgical Conference & Expo, Dr. Marybeth Spanarkel presented on the topic of ergonomic hazards in colonoscopy today.

Presentation length: approximately 19 minutes

Transcribed Presentation

Dr. Marybeth Spanarkel:

Good morning, everyone, and thank you for coming at such an early hour. My name is Dr. Marybeth Spanarkel, and today I'll be talking about the Endo Staff Under Pressure: Understanding Colonoscopy Related
Ergonomic Hazards.

Well, I'm a gastroenterologist. I graduated from Duke University in 79. I had lots of training at the University of Pennsylvania, at the NIH and at Johns Hopkins.

And I took a clinical position at the Duke Regional Hospital for over 25 years. I have done thousands and thousands of colonoscopies. I'm here today to focus on four issues.

Let's discuss number one, the importance of colonoscopy. Number two, the manual pressure and repositioning. Three, the hazards for endoscopy, staff and patients. And four, potential solutions to these problems.

Well, as you know, colonoscopy is here to stay. It is the gold standard for colon cancer screening. It is the only combined diagnostic and therapeutic treatment tool in our armamentarium, because at the time of doing it, if you see a problem or you see a polyp, you can also therapeutically remove it.

And it has been demonstrated over the last two decades to be highly effective in reducing the incidence of colorectal cancer. These three graphs represent changes in the incidence of colorectal cancer between 1998 and 2019. In three separate age groups, 50 to 64, 65 and older, and the 20 to 49 age group. 

The two graphs on the left  demonstrate the effectiveness of screening colonoscopy, which since 1998, has been recommended to all adults age 50 and older.

The alarming thing, however, is the graph on the right, which shows increasing rates of colorectal cancer in adults younger than 50 and increasing by a rate of 1 to 2% per year.

And we don't know why. But in response to this, the recommended age of screening has now, as you know, been lowered to 45. And there's even some talk about lowering it to 40. 

Well, what does that mean to all of us? It means more colonoscopies and a greater burden on our physicians and staff. 

Well, what makes colonoscopy so difficult? The answer is looping. What is looping? The colon is not a straight shot. It's not a put the scope in and it goes around in an upside down U. It is a mobile floppy organ that has twists and turns all the way to reaching the cecum, which is your main goal. 

As a result, when you push the scope, the tip often does not go forward. Why? Because the scope is pushing into a loop. And the force applied is enlarging the loop, but not advancing the tip. 

And as you can see occurring in this video, as the scope is moving forward from pressure applied at the anus, the loop is enlarging rather than the tip advancing. 

So as a result, in many colonoscopies estimated to be at least 50% and upwards to 80 or 90%, you need some form of external pressure to prevent this loop from forming.

So when the doctor is pushing on the scope, the hand is applying external pressure to splint that loop, prevent it from forming, and then the tip will advance. 

Well, how is this external pressure done in the endoscopy suite? The nurses and techs are doing it. In 50 to 80% of colonoscopies either the tech or the nurse is applying pressure for 1 to 15 minutes, depending on the difficulty of the case.

And as you can see, and I'm sure many of you identify with these pictures, as you can see, this is often a challenging physical task. From the perspective of an ergonomist, this is a nightmare.

Now, ergonomic risk is defined by force, duration and repetition. Safety guidelines indicate that the upper limit of force for a push task that you are doing on a sustained basis is about 30 pounds for 5 minutes or less per day.

Now, consider what's likely going on in your unit. Studies indicate that with manual pressure, the push forces can reach up to 100 pounds. And our techs and nurses are doing that for up to 5  minutes or so per case. 

With multiple cases per day. So the net result is an ergonomic risk that is 3 to 8 times greater than what is considered safe by guidelines. 

Based on the Liberty Mutual Snook Tables, holding pressure for 4 minutes, let's say on a 250 pound patient, is the mathematical equivalent of pushing that same patient, 250 pounds, for half a mile. Gives you a sense of how much pressure that you are applying.

So is it any wonder that there are high rates of musculoskeletal disorders in our endoscopy staff? 

A recent SGNA study was performed asking 200 endoscopy nurses and techs about manual pressure. Of the 110 in the group that said that applying pressure was one of their primary responsibilities, 85% said that they had experienced significant pain or injury that they attributed specifically to the task of manual pressure. 

And other studies have shown that up to 28% of our staff may miss work. 48%, which is one in every two, is requiring pain medications. And the worst statistic, 14% will require surgery. 

In the same study, they also identified patient risks. One in four respondents of the same SGNA study had observed patient complications as a result of manual pressure. 

In most cases, these complications were minor, such as abdominal bruising, abdominal tenderness, but occasionally a rare or serious complications, such as a splint laceration or tear. And recent report of a mesenteric hematoma due to the pushing and a tear, intra abdominally. 

Let me also share with you at this point a personal experience. My father passed away from colon cancer. I'm one of six kids. We all were advised to have a screening colonoscopy. And all those studies were normal gratefully. But as a GI doctor, I selected a superb colonoscopist to do my procedure, of course. 

My colonoscopy was reportedly difficult. I apparently had a very redundant, torturous colon, and it required not one but two assistants to apply pressure to my abdomen and counter pressure and repositioning. I got a normal report gratefully. 

However, the next day my abdomen was incredibly bruised and the worst part I probably had a small either mesenteric tear or a micro perforation because I had considerable pelvic pain, particularly with walking for 1 to 2 days. 

The point being, if it could happen to me, it can happen to anyone. And in my experience, personally, and as a physician at the unit, these complications are going under reported. So let's summarize. 

Colonoscopy is very important and very effective. Two out of every three colonoscopies need some form of external pressure to splint the loops and get to the cecum. Yet the way we are doing it is hurting our staff and our patients. 

So there's got to be a better way. Can we stop doing manual pressure? Can we apply the pressure more safely? Orthese int can we find an alternative? 

Well, let's talk about stop doing manual pressure. Can we do this? There have been multiple attempts to solve the problem of how to get to the cecum. Variable stiffness scopes, magnetic imaging, scope guide, water immersion exchange colonoscopy. But none of these techniques is addressing the core problem of getting to the cecum, which is looping. 

The only solution consistently and effectively dealing with looping has been manual pressure. Can we apply manual pressure more safely? There have been numerous attempts to apply manual pressure more safely, as you can see in these pictures, and again, identify with these pictures simply due to the forces, duration and frequency that manual pressure is required, these interventions, they don't work to prevent looping and get to the cecum.

Can we apply manual pressure more safely? We can't standardize for each one of you the force pressure and duration that is required. 

So can we find an alternative? Well, an alternative does exist in the form of an external compression device that was specifically designed for colonoscopy. It is a one-time patient use and is applied to the lower abdomen before the procedure. It includes a primary aid band which applies consistent pressure across the lower abdomen to compress and make it concave. 

The device also has two secondary straps that can apply location specific pressure and can be adjusted during the case. As you see in this video, the secondary straps are initially adjusted to target the sigmoid colon and then are subsequently adjusted to target the transverse colon. 

And these are the two most common areas for looping. So does the colonoscopy compression device work? Well, let's look at the data. 

There have been several clinical studies that have shown the following...up to 90% reduction in the need for manual pressure and 85% reduction in staff-reported musculoskeletal pain. These studies also showed numerous clinical benefits that you would expect if you're reducing and eliminating looping...faster insertion times, less sedation required for the patient and increased polyp detection, which is the goal of why you're doing the colonoscopy. 

So let's again review our options. Can we stop doing manual pressure without an alternative? No, this isn't an option. Some form of external pressure is required to complete the majority of colonoscopies. Can we apply this more safely? Not really. 

There's no real way to perform this task manually without significant ergonomic risk. Can we find an alternative? Well, yes. 

A colonoscopy compression device is the only solution available to apply non manual external pressure to limit the looping. It effectively splints the colon, it keeps the pressure consistent, and it helps the physician reach the cecum safely and efficiently without pain and strain on our staff and patients. 

Now the question always comes up about cost. Cost is always a consideration, but it's probably, particularly in this instance, more important to consider the costs of inaction. Consider the following statistics. The average cost of one injury to the staff member exceeds $100,000. Up to 12% of our nurses are leaving the nursing profession annually. 

And of the top four reasons, musculoskeletal disorders and injuries are in those top four reasons, the direct cost to replace one nurse is over $64,000. 

And this does not include the brain drain that occurs when an experienced nurse leaves the unit and someone totally new has to be brought in and trained. 

Now, while these numbers are staggering, I recognize that it can still be challenging to build buy in around a new solution and sell it to the administration. 

ColoWrap recognizes this and has developed a new tool. This tool is called ColoWrap 360, which now quantifies the existing risk within your unit and predictably with AI determines which patients may need the device. If you can identify the one in three patients likely to be most problematic, you can use the ColoWrap with precision and achieve a very high return on investment. This can help overcome cost concerns while keeping you safe. The way we're doing colonoscopy is unsustainable. 

To close, let me again share another personal story. At the age of 59, after doing 25 years of twisting, turning, pulling, torquing, reducing loops, pressure on the sigmoid, pressure on the transverse, one minor slip and fall, one minor injury. And I lost power in my right arm. 

Despite physical therapy and surgery, I never again regained full power in my right arm. And in one split second I went from doing 10 to 12 colonoscopies per day to zero. I never scoped again. I lost my practice. I was forced to early retire. 

And all of this came at a tremendous personal, professional and financial price. And it is for this reason that I am such a passionate advocate for ergonomic reform in the endoscopy suite.