Transnasal Endoscopy Improves Patient Outcomes and Productivity

In 2018 / 2019, endoscopy capacity was challenged with increased levels of demand impacting on targets and waiting times. With staffing availability and physical environment limitations impacting on potential expansion plans for the Endoscopy department, the Royal United Hospitals considered other options to increase activity and support waiting times and backlog recovery. One of the options explored was to have a dedicated Transnasal endoscopy service that could be run from an outpatient clinic room, hence bypassing the space issue, and supporting increased activity levels. In order to realise benefits for this plan, a trial was set up where 109 patients received their upper GI endoscopy via Transnasal endoscopy. Following a successful trial, business plans were developed to introduce this solution on a permanent basis.

Nuno Aguiar, Specialty Manager, Gastroenterology and Radiology, Royal United Hospitals Bath NHS Foundation Trust

The Royal United Hospitals Bath NHS Foundation Trust (RUH) provides acute treatment and care for a catchment population of around 500,000 people, employing over 4,800 staff.

Endoscopy procedures are critical for the diagnosis and treatment of gastrointestinal conditions, ranging from acute bleeding to cancers. The trust performed approximately 3,500 to 4,000 diagnostic upper GI endoscopy (Gastroscopy) procedures each year before the pandemic. Conventional transoral gastroscopy procedure (an endoscope inserted via the mouth) can be difficult for patients to tolerate and a substantial proportion of patients require some form of sedation. Sedated patients typically spend longer in post-procedure recovery and require a friend or family member to bring them to and take them home from the procedure as they are unable to drive. A small proportion of patients are even unable to tolerate the procedure with sedation and are sent on to have their gastroscopy under general anaesthetic.

With the demand for endoscopy services continually growing, RUH acknowledged that they needed to expand capacity. Expanding capacity in endoscopy presents challenges, with limitations on resources including staffing and infrastructure.

The aim of this Value Based Procurement pilot was to expand capacity in endoscopy by creating a nurse led, transnasal (through the nose) endoscopy service to:

• Support increased demand for diagnostic upper endoscopy
• Release capacity in recovery space
• Improve patient experience and tolerability
• Reduce the staffing resource requirement
• Reduce the overall cost per procedure.

Olympus Medical and RUH explored how Value Based Procurement could be applied to the introduction of a Transnasal endoscopy (TNE) service. Olympus worked with the trust’s clinical, operational and finance teams to pilot TNE outside of the Endoscopy department. Since patients do not need to be sedated for the TNE procedure, they do not require access to recovery. This reduces the total amount of time required for each procedure (in terms of hospital stay). In addition, TNE can be performed with one less member of staff in the procedure room as the “head end” nurse is not required.

During the TNE pilot, 109 patients had a TNE procedure as opposed to a conventional Transoral endoscopy (TOE). A process map was drawn up to define the gastroscopy pathway with and without the use of Transnasal endoscopy (TNE). The differences in the resource requirements between procedure were identified.

A difference in cost per procedure was forecasted by creating a model that translated the resource requirements into financial costs. Patient experience was observed to understand the impact of implementing TNE on patients.

Before

After

The TNE pilot delivered on the expected outcomes and was able to support evidence of benefits gained with this type of service. The positive impacts of this were seen in patient experience, clinical outcomes and demand/capacity management.

The key results from a patient perspective were highlighted as:

• Improved patient satisfaction. Patients reported that they were more satisfied with their experience overall, and they were particularly impressed with the shorter operating times and the reduced number of complications.
• Better tolerated procedure (reduced gagging and discomfort).
• Improved patient outcomes. There was a significant reduction in the number of complications. This means that patients are more likely to have a positive outcome from their procedure.
• Ability to attend appointments without a chaperone and subsequently drive home.
• A patient who would ordinarily have undergone a general anaesthetic was able to have a TNE procedure using only local anaesthetic.

In addition, the key results for the trust were:

• Reduction in the cost of treatment by approximately £30 per procedure.
• Reduction in operating time by an average of 10 minutes per procedure. This means that patients can be treated more quickly and efficiently, and it also frees up clinicians to treat more patients.
• Reduced staffing requirement to run the service.
• Conventional endoscopy rooms could be used to continue to treat patients whilst TNE lists were going on as recovery was not needed.

This VBP pilot project is a positive example of how VBP can be used to improve patient outcomes and reduce costs in the NHS. It is hoped that VBP approach will be adopted more widely across the NHS in the coming years.

Based on the experience at RUH Bath, TNE demonstrated a reduction of cost by £30.57 per suitable gastroscopy patient.

71% of the savings are related to staff and 29% to consumables and sedation costs.

During the 2018/19 financial year (pre-COVID), the trust performed approximately 3,655 diagnostic gastroscopy procedures (with or without biopsy). It is anticipated that approximately 85% of these patients would be suitable for a transnasal procedure. On this basis, the annual forecasted saving could be as high as £94,984. It was recognised that it could take time to reach high levels of TNE uptake so if only 60% uptake were to be achieved, the forecasted saving was £56,990.

It was also anticipated that TNE could enable the Endoscopy department to increase reimbursement revenue by enabling a capacity expansion, though this was not measured during the pilot project.

The TNE pilot project demonstrated that providers and suppliers can create beneficial partnerships to deliver savings and improved patient experience through the adoption of innovation. The trust was able to deliver benefits to patients, whilst reducing costs and staffing requirements.

TNE also has some clear advantages over standard transoral approaches in reducing the need for single use plastic devices such as cannulas, tubing, mouthguards, and syringes for sedation as well as the pharmaceuticals themselves. At present although the financial benefit/cost reduction of this has been quantified in this case study, data is lacking to enable a carbon benefit of the streamlined endoscopy procedure. * It is anticipated that TNE has reduced the carbon footprint of endoscopy, but more data and research is required to confirm this reduced impact.

Other sustainability co-benefits have been referenced such as patient wellbeing through improved patient experience, tolerability and satisfaction and the benefit to patients being discharged directly, able to drive home or use public transport without the need for a chaperone.

Solutions such as TNE offer opportunities for improving patient care and improving efficiency and support the NHS-wide restore and recovery programme. Adoption at scale across an Integrated Care System would maximise the benefits of this solution.

For further information relating to this pilot, please contact:

Please note:
This case study was conducted at Royal United Hospitals Bath NHS Foundation Trust with Olympus. There may be other comparable solutions within the market that are suitable in addressing the challenges highlighted in this report.

* “A high-quality evidence base of the actual carbon footprint of clinical activity and various elements of endoscopic procedures is presently lacking, more research needs to be done to generate this evidence, there is recognition that steps need to be taken now to protect our planet.” January 2023. British Medical Journals https://gut.bmj.com/content/72/1/12