**5.2 Minimum staffing requirements**

Staffing requirements for the performance of GI endoscopy should be based on what is needed to ensure safe and proficient performance of the individual procedure. Currently, staffing may vary as determined by local practice requirements, patient characteristics, and the type of endoscopic procedure being performed. While the physician is performing endoscopic procedure, the endoscopy suite staff will concentrate on patient monitoring, documentation and technical assistance. The level of education and training of the staff can vary, including qualified nurses with training in endoscopy and qualified nurses trainable on the job.

Because objective evidence pertaining to the relationship between endoscopy unit staffing levels and patient outcomes is lacking, it is difficult to make concrete recommendations to the developing countries where there is an acute shortage of medical staff including trained endoscopists and support staff.

#### **5.3 Staff training**

The World Gastroenterology Organization (WGO), a Federation of 110 National Societies and 4 regional associations of gastroenterology representing over 50,000 individual members worldwide focuses on the improvement of standards in gastroenterology training and education on a global scale. It has been christened the "global guardian of digestive

Challenges of Gastrointestinal Endoscopy in Resource-Poor Countries 9

delicate structure endoscopes cannot be autoclaved. Therefore processing is achieved by mechanical cleaning, followed by high level disinfection (HLD), rinsing and drying. Stringent guidelines are in place in most developed societies for the reprocessing of endoscopes (ASGE 2003 and the Gastgroenterological Society of Australia 2003). If these guidelines are followed, virtually no cases of infection transmission are encountered

The ability to reprocess equipment efficiently and safely is one of the most important functions of an endoscopy facility. An area dedicated to the cleaning and disinfection of endoscopic equipment must be available and should contain at least two (2) large sinks plus a tank/container of disinfecting solution or an automatic flexible endoscope reprocessing

Reprocessing should commence immediately following use of an endoscope to prevent the drying of secretions within the channels. The cleaning and disinfection of endoscopes should only be performed by staff that have been fully trained and certified to do so. Inexperienced staff may not be aware of the specific design of the instrument and may cause

Automated endoscope reprocessors have become available in developed countries. These automated brushless systems are an important step in raising the standard of care for flexible endoscope reprocessing (ASGE 2008, Society of Gastroenterology Nurses and Associates, SGNA 2008). This innovation also allows facilities to utilize valuable staff resources in other patient-related activities and reduce occupational health problems

The situation in resource-poor countries is totally different. In the first place, there are no local guidelines for equipment reprocessing. Something as basic as potable water supply is a big challenge in many hospitals in resource-poor countries and that is bound to affect the cleaning of equipment. The acute shortage of trained endoscopy staff further worsens the picture. Supply of substandard disinfecting solution is a frequent occurrence in developing countries. Therefore, it is likely that infection transmission in endoscopy facilities may be

Very often the recommended period of immersion of endoscopes in the disinfecting solution may be unwittingly shortened between procedures to reduce the waiting time of patients especially where there is only one endoscope that has to be reused on many patients the

Automated endoscope reprocessors are not yet available in most resource-poor countries. No centre in Nigeria has this equipment and I doubt if any is planning to acquire it soon. It may be more expedient for them to intensify adherence to the traditional methods of

The provision of sedation and analgesia has been an important component of performing endoscopic procedure on the gastrointestinal tract. The different procedures can create pain and discomfort and are associated with anxiety for the patient. It is for this reason that

For routine diagnostic endoscopic procedures sedation is almost always used in North America and Australia. However in Europe, Asia and some African countries, the sedation

substantial. Unfortunately, there are no data on the magnitude of this challenge.

same day. This again has negative consequences for infection control.

thorough manual washing, rinsing and drying.

sedation has become an essential component of endoscopy.

**7. Sedation** 

(Ciancio et al 2005, McDonald et al 1976, Hanson et al 1990).

severe damage or inadequately clean and disinfect the equipment.

machine.

associated with reprocessing.

health". In 2007 it published a document about the basic standards of a gastroenterology training program (WGO 2007). In drawing up the standards of training the WGO took into consideration the existing training programs in various countries. It is noteworthy that Egypt and Sudan were the only African countries that provided information about their existing training programs to the WGO Committee. The other countries in Africa, including Nigeria did not respond to the enquiry.

The WGO has training centres in the developing countries but these are very few and countries in the catchment areas of the centres have not taken adequate advantage of the institutions to develop their local digestive endoscopists. Prospective trainees usually find it difficult to secure funding from their countries.

#### **5.4 Minimum training standards**

The WGO proposes a minimum number of each procedure that must be completed by the trainees in the training centres. The body differentiates between level 1 and level 2 endoscopists with a remark that level 1 might be sufficient for some developing countries. A level 1 endoscopist is expected to be proficient in esophagogastroduodenoscopy, treatment of non-variceal bleeding, treatment of variceal bleeding, esophageal dilatation, flexible sigmoidoscopy, colonoscopy, polypectomy, placement of percutaneous endoscopic gastrostomy, liver biopsy, abdominal puncture and foreign body removal. It is a sad truth that most endoscopy centres in developing countries such as Nigeria do not carry out any form of therapeutic endoscopy. It therefore follows that trainees in these centres will not acquire the competences required of a level 1 endoscopist. Training of endoscopists takes place in the teaching hospitals that are grossly ill-equiped to perform the function. There are 2 postgraduate medical colleges in Nigeria: The West African College of Physicians or Surgeons and the National Postgraduate Medical College of Nigeria. These colleges supervise the training of residents and eventually certify them after passing the requisite examinations. The current practice does not ensure adequate exposure for the trainees who hardly complete the minimum number of procedures before they present themselves for examination. Furthermore, the method of evaluation is such that one can pass without having completed the prescribed procedures. Sometimes incessant industrial actions make it practically impossible for trainees to complete the procedures during the training period. The evaluation has no practical endoscopy component. In the developed countries, methods used in the evaluation of trainee competence vary from place to place and may include observation during procedure, formal assessment of clinical skills, using a patient-based examination, formal in-practice examination, use of log books, annual assessments, final assessment and feedback from trainees. These evaluation methods are largely absent in the developing countries. Where they exist, the regulations are often not applied strictly for economic, social and political reasons. The regulatory authorities are sometimes faced with a situation where they have to decide between closing a health facility because it lacks basic equipment and staff; and allowing it to continue to function at a substandard level because of political interests.

#### **6. Infection control**

Over the course of endoscopic examination, the external surface and internal channels of flexible endoscopes and accessory equipment are exposed to body fluids and contaminants. Disinfection of these reusable instruments poses special problems. Given their relatively delicate structure endoscopes cannot be autoclaved. Therefore processing is achieved by mechanical cleaning, followed by high level disinfection (HLD), rinsing and drying. Stringent guidelines are in place in most developed societies for the reprocessing of endoscopes (ASGE 2003 and the Gastgroenterological Society of Australia 2003). If these guidelines are followed, virtually no cases of infection transmission are encountered (Ciancio et al 2005, McDonald et al 1976, Hanson et al 1990).

The ability to reprocess equipment efficiently and safely is one of the most important functions of an endoscopy facility. An area dedicated to the cleaning and disinfection of endoscopic equipment must be available and should contain at least two (2) large sinks plus a tank/container of disinfecting solution or an automatic flexible endoscope reprocessing machine.

Reprocessing should commence immediately following use of an endoscope to prevent the drying of secretions within the channels. The cleaning and disinfection of endoscopes should only be performed by staff that have been fully trained and certified to do so. Inexperienced staff may not be aware of the specific design of the instrument and may cause severe damage or inadequately clean and disinfect the equipment.

Automated endoscope reprocessors have become available in developed countries. These automated brushless systems are an important step in raising the standard of care for flexible endoscope reprocessing (ASGE 2008, Society of Gastroenterology Nurses and Associates, SGNA 2008). This innovation also allows facilities to utilize valuable staff resources in other patient-related activities and reduce occupational health problems associated with reprocessing.

The situation in resource-poor countries is totally different. In the first place, there are no local guidelines for equipment reprocessing. Something as basic as potable water supply is a big challenge in many hospitals in resource-poor countries and that is bound to affect the cleaning of equipment. The acute shortage of trained endoscopy staff further worsens the picture. Supply of substandard disinfecting solution is a frequent occurrence in developing countries. Therefore, it is likely that infection transmission in endoscopy facilities may be substantial. Unfortunately, there are no data on the magnitude of this challenge.

Very often the recommended period of immersion of endoscopes in the disinfecting solution may be unwittingly shortened between procedures to reduce the waiting time of patients especially where there is only one endoscope that has to be reused on many patients the same day. This again has negative consequences for infection control.

Automated endoscope reprocessors are not yet available in most resource-poor countries. No centre in Nigeria has this equipment and I doubt if any is planning to acquire it soon. It may be more expedient for them to intensify adherence to the traditional methods of thorough manual washing, rinsing and drying.
