JULY 2001 VOL. 11, #43 SPHINCTER OF ODDI MANOMETRY Evelyn Hilderman, RN, CGRN, Staff Nurse, Calgary Regional Hospital Authority, Peter Lougheed site, Calgary, Alberta, Canada

ANATOMY & PHYSIOLOGY OF In the fasting stage, there is tonic many names, including biliary dyski‑ THE SPHINCTER OF ODDI contraction of the sphincter of Oddi. nesia, biliary spasm, papillary stenosis The sphincter of Oddi is a bundle This maintains a basal tone that helps and postcholecystectomy syndrome. of circular and longitudinal smooth to divert bile into the gallbladder. The Sphincter of Oddi dysfunction can muscle fibers, 4‑6mm in length. It sur‑ phasic contractions keep the sphincter be broken up into two pathological rounds the ampulla of Vater, the distal segment empty. The sphincter of Oddi entities: papillary stenosis and sphincter common bile duct and pancreatic duct. is not an absolute barrier, so even dur‑ of Oddi dyskinesia. It consists of the biliary sphincter and ing fasting there is a small quantity of Sphincter of Oddi stenosis is a the pancreatic sphincter. Muscle fibers bile that enters the duodenum. structural narrowing of the sphincter, from these structures merge at the pa‑ Changes in sphincter of Oddi tonic continued on page 2 … pilla to form the common sphincter. activity are under neurohormonal con‑ The sphincter of Oddi has a trol. It has been assumed that the vagus variable basal or resting pressure nerve stimulates contractions of the INSIDE THIS ISSUE: which appears to be the predominant sphincter of Oddi . It has been estab‑ Sphincter of Oddi Manometry. . . . 1 mechanism in regulating the outflow lished that cholinergic agents stimulate of pancreaticobiliary secretion into contractions of the sphincter and anti‑ What’s New in G .I .?...... 5 the duodenum. Superimposed on the cholinergic agents inhibit them. Reports...... 6 basal pressure are high pressure pha‑ The predominant hormonal agent sic contractions that appear to aid in affecting sphincter of Oddi motility Synopsis CSGNA National the prevention of duodenum‑to‑duct is Cholecystokinin. Cholecystokinin Executive Meeting ...... 9 is released in response to fat in the reflux. These phasic contractions are CSGNA Chapter Executive List. . . 10. generally propagated towards the duodenum. It causes contraction of duodenum (antegrade), but retrograde the gallbladder and relaxation of the Position Statement: Responsibility and simultaneous contractions can also sphincter of Oddi. of the Registered Nurse. . . . . 11. occur. Position Statement: Reuse of Alterations in sphincter of Oddi ba‑ SPHINCTER OF ODDI Single-Use Medical Devices. . . . 13 sal pressure and phasic activity regulate DYSFUNCTION the entry of bile into the duodenum. Sphincter of Oddi dysfunction re‑ CSGNA – Use of Reusable After a meal, there is a requirement of fers to a benign, noncalculous obstruc‑ Medical Devices...... 14. bile in the duodenum for fat absorp‑ tion to flow of bile or pancreatic juice Position Statement: tion. The gallbladder muscle contracts through the sphincter of Oddi. It may Infection Control...... 16. and the Sphincter of Oddi relaxes so be manifested clinically by recurrent that the required amount of bile can pancreaticobiliary pain or pancreatitis. Mini Quiz ...... 20 flow easily to the duodenum. Through the years, it has been given Word Search ...... 21 Scholarship Awards 2001. . . . . 23.

You can never plan the future by the past. Page Two The Guiding Light, July 2001 continued from page 1 secondary to fibrosis, either from rent pancreatitis in which no cause for Indications for Sphincter of Oddi pancreatitis or from injury during the pancreatitis is apparent. Manometry passage of a common bile duct stone After initial evaluation, patients Patients who are classified as Type with resulting mucosal hyperplasia, are commonly categorized according 1 most likely have sphincter of Oddi or to other nonspecific inflammatory to the Hogan‑Geenan classification stenosis. The use of manometry is not conditions. system. This system was developed to an essential diagnostic study prior to Sphincter of Oddi dyskinesia is be‑ classify patients with suspected sphinc‑ treatment. lieved to be a motor abnormality which ter of Oddi dysfunction and to help Patients who are classified as Type causes a hypertonic sphincter. guide the appropriate utilization of 2 may have either sphincter of Oddi Because it is often impossible to sphincter of Oddi Manometry. stenosis or dyskinesia. Manometry is distinguish patients with sphincter highly recommended to diagnose and of Oddi stenosis from those with Hogan‑Geenan classification system direct therapy in these patients. sphincter of Oddi dyskinesia, the term The Hogan‑Geenan classification Patients who are classified as sphincter of Oddi dysfunction has been system categorizes patients into three Type 3 usually have pain arising from used to incorporate both groups of groups (types 1, 2 and 3). functional bowel disease. Only a small patients. Type 1 are patients with biliary‑type proportion have sphincter of Oddi dys‑ pain, abnormal liver enzymes (elevated function. Manometry is mandatory to Clinical Presentation AP and AST) documented on two or confirm sphincter of Oddi dysfunction Sphincter of Oddi dysfunction more occasions, a dilated common bile in these patients. It is performed when relates to either the biliary or the pan‑ duct greater than 12mm in diameter the biliary‑type pain persists despite creatic portions of the sphincter. There and delayed drainage of contrast be‑ investigation and treatment for func‑ are two main clinical presentations that yond 45 minutes in ERCP. tional gastrointestinal disease. relate to the portion of the sphincter Type 2 are patients with bil‑ that malfunctions. iary‑type pain but have only one or Sphincter of Oddi Manometric The more common problem is bil‑ two of the above findings. Values iary sphincter of Oddi dysfunction. It Type 3 are patients with biliary‑type Normal manometric values is most prevalent in young and middle pain but no other abnormalities. Baseline (resting) sphincter of aged females who usually present five Oddi pressure of 15-25mm Hg to seven years after having undergone It is thought that sphincter of Ductal pressures of 10mm Hg cholecystectomy for cholelithiasis. Oddi dysfunction is present in all type above duodenal pressure Acute attacks can be associated with 1 patients representing true papillary Phasic pressure waves of 50- severe pain, as in patients with true stenosis. Approximately 50%‑60% of 200mm Hg with a frequency of 3-5/ biliary colic. The pain is situated in type 2 patients and fewer than 10% of minute, duration of 2.8‑5.8 seconds the epigastrium or right upper quad‑ type 3 patients have sphincter of Oddi and 12‑100% antegrade (toward the rant, often radiates into the back, and dysfunction based on manometry. duodenum), 0‑50% retrograde (away may be associated with nausea and Many experts feel that the pain in type from the duodenum) or simultaneous vomiting. The pain generally occurs 3 patients arises from irritable bowel in propagation direction in episodes lasting up to several hours syndrome. Decrease in sphincter pressure in or until relieved by analgesics. These response to CCK pain episodes may occur at intervals SPHINCTER OF ODDI of weeks or months. Some patients Abnormal manometric values also describe discomfort in the upper MANOMETRY Elevated basal sphincter of Oddi abdomen that is more frequent and Sphincter of Oddi manometry is a pressure of greater than 40mm HG may occur every day. The attacks of diagnostic procedure performed dur‑ Increased ductal pressures pain can occur after fatty meals and ing an ERCP which measures pressures Increased amplitude of phasic con‑ are often nocturnal. Patients may within the sphincter of Oddi, common tractions of greater than 200‑300mm complain of sensitivity to codeine and bile duct, pancreatic duct and the Hg other opiates. duodenum. Increased frequency of phasic con‑ Patients with dysfunction of the Sphincter of Oddi manometry is tractions of greater than 10/minute pancreatic portion of the sphincter the only available method to measure Predominance of retrograde prop‑ present with typical pancreatic pain sphincter of Oddi motor activity di‑ agating waves of over 50% (epigastric or left upper quadrant ra‑ rectly. It is considered to be the gold Paradoxical increase in sphincter diating to the back). They have often standard for evaluating patients with pressure in response to CCK been diagnosed with idiopathic recur‑ sphincter dysfunction. The Guiding Light, July 2001 Page Three

ETIOLOGY OF SPHINCTER OF The only abnormal manometric An informed consent is very im‑ ODDI DYSFUNCTION value that has so far been proven to portant. The physician explains the The cause of sphincter of Oddi clinically predict improvement follow‑ procedure and the risks involved and dysfunction and the pain mechanisms ing endoscopic sphincterotomy is an verifies that the patient fully ‑ under involved are uncertain. elevated basal pressure of greater than stands them. It has been postulated that there 40mm Hg. It is explained to the patient that may be defect of neural connections Other values that are being studied their co‑operation is crucial in obtain‑ that coordinate the interaction be‑ as possible indications of sphincter of ing accurate results. tween the duodenum, biliary tract and Oddi dysfunction include excessive ret‑ All drugs that relax (anti­ sphincter of Oddi. rograde propagation of phasic waves, cholinergics, nitrates, calcium channel It may also occur as part of a gigantic phasic wave amplitudes, blockers and glucagon) or stimulate generalized motor disorder of the high frequency of phasic waves and a (narcotics or cholinergic agents) the gastrointestinal tract. paradoxical response to CCK. So far sphincter should be avoided for at least It may occur in conjection with none of these are being widely used 8‑12 hours prior to manometry and other diseases such as systemic scle‑ clinically. during the procedure. rosis, diabetes mellitus or chronic idi‑ Diazemuls and Demerol are given opathic intestinal pseudo‑obstruction EQUIPMENT for conscious sedation. The benzo­ diazepines have been shown to have no that are recognized to cause intestinal A triple lumen manometry catheter affect on sphincter pressure. Demerol, dysmotility. is used. This catheter has two perfusion at a dose of < I mg/kg does not affect It may be drug induced. The lumens and one aspiration/wireguide the basal sphincter pressure (although biliary tract is extremely sensitive to lumen. The distal end of the catheter it does increase the phasic wave fre‑ opiates. has ten 1mm markings. Two red mark‑ quency). If glucagon must be used to It is postulated that sphincter of ings indicate the recording ports and achieve cannulation, an 8 to 10 minute Oddi dysfunction causes pain by im‑ the remaining eight are black. The waiting period is required to restore peding the flow of bile and pancreatic two side lumens (recording ports) are the sphincter to its basal condition. juice resulting in ductal hypertension. 2mm apart. A zero duodenal baseline is ob‑ Alternatively, ischemia arising from The catheter is attached to a pneu‑ tained before cannulation of the spastic contractions and hypersensitiv‑ mohydraulic capillary perfusion system papilla. ity of the papilla have been proposed. and to two separate, external pressure The papilla is cannulated with transducers. The transducers are con‑ a triple lumen manometry catheter, nected to a computer which generates TREATMENT OF SPHINCTER OF which is passed through the sphincter a continuous graph of sphincter of ODDI DYSFUNCTION of Oddi into either the common bile Oddi pressure (mm Hg) versus time Endoscopic sphincterotomy has duct or the pancreatic duct. In sonic (seconds). been shown to be an effective treat‑ instances, the duct is cannulated with An infusion pump uses compressed ment for patients with Type 1 sphincter either a cannula or papillotome and an nitrogen gas to continuously perfuse of Oddi dysfunction. exchange for the manometry catheter the catheter with sterile distilled water. In patients with Type 2 sphincter is done over an .018 guidewire. As sphincter contractions occlude the of Oddi dysfunction or idiopathic Baseline ductal pressures are re‑ side recording ports on the catheter, recurrent pancreatitis, endoscopic corded. The catheter is then withdrawn the flow of the water is stopped. The sphincterotomy is only effective in at 1mm intervals while continuous resulting change in water pressure is those with elevated basal pressures of pressure measurements are being translated by the transducers into an greater than 40mm Hg. taken. This has been termed the station electrical signal that is amplified and The effectiveness of endoscopic pull‑through technique. Usually 2 pull recorded onto the computer screen. sphincterotomy in Type 3 patients is throughs are done. presently unclear. Ideally both the bile and pancreatic Drug therapy with nitrates and PROCEDURE ducts should be studied. Continuous calcium channel blockers which relax Since this procedure is performed aspiration of intraductal juice is done the sphincter of Oddi may benefit in conjunction with an ERCP the same during manometry of the pancreatic some patients with sphincter of Oddi considerations apply. duct using the aspiration/guidewire dysfunction. However the vasodilating Patients are advised that post pro‑ lumen of the manometry catheter. side effects of these drugs often limit cedure they will be admitted overnight their therapeutic use. to the hospital for observation. Page Four The Guiding Light, July 2001

COMPLICATIONS REFERENCES Patients who have an endoscopic 1. Champion, Malcolm C. and Orr, William AIR CANADA sphincterotomy for sphincter of Oddi C.; editors Evolving Concepts in Gastrointes- We have appointed Air Canada tinal Motility, Blackwell Science Ltd 1996: as the official airline for the dysfunction have complication rates 316‑320 two to three times higher than patients Edmonton Odyssey, CSGNA 2. Chuttani, Ram and Carr‑Locke, David L.; who have had an endoscopic sphinc‑ Pathophysiology of the Sphincter of Oddi, Surgi‑ 17th Annual Conference in terotomy for ductal stones. cal Clinics of North America, Vol 73, No 6 Edmonton on September 28- Pancreatitis is the most common December 1993 30, 2001. Simply contact Air complication occurring in up to 10- 3. Lehman, Glen A. and Sherman, Stuart; Canada’s North America toll free ­25% of patients. Sphincter of Oddi Dysfunction, In: Yamada number at 1-800-361-7585 or T, Alpers DH, Laine L, Owyang C, Powell local number 514-393-9494 or DW, editors. Textbook of Gastroenterology Travel Agent and take advantage 3rd Ed. Philadelphia: Lippincott, Williams & ACKNOWLEDGEMENT of Special Discounted Airfares. The author thanks Dr. Gary R. Wilkins, 1999: 2343‑2354 4. Toouli, James and Craig, Alexander; Sphinc- Our convention number is May for his valuable assistance and CV150765. By ensuring that the guidance. ter of Oddi function and dysfunction, Can J Gastroenterology, Vol 14, No 5, May 2000 convention number appears on 5. Society of Gastroenterology Nurses and Associ- your ticket, you will be supporting ates, Procedure Manual, Williams & Wilkins, our organization. 3rd edition 1994: 173‑176 6. Gastroenterology Nursing, A Core Cur- We thank you. riculum, Mosby Inc., 2nd Edition 1998: 253‑254 FOR INFORMATION ON UPCOMING EVENTS VISIT OUR WEBSITE www.csgna.com The Guiding Light, July 2001 Page Five

What’s New In G.I.? Submitted by: Patsy Gosse, L.P.N. and Joan Rumsey, R.N. In June of 2000 a new technologi‑ pathology of the small bowel. Cur‑ Detroit News (Aug. 31, 2000), “Video pill cal advance was introduced. A camera rent technology only permits direct captures human body’s insides”, http:// detnews.com/2000/technology/008/31/ in a capsule, the newest breakthrough visualization of approximately the first a09-113473.htm in endoscopy, was about to hit the 1/3 of the small bowel. The pill is es‑ Korea Times, Sept. 9, 2000, Retrieved from market. Finally there is an easy way pecially designed to examine the small hankooki.com ‑ May 2, 2001, “Israelis to visualize the small bowel. Scientists intestine. The capsule could replace ready to test video pill”, wysiwyg://50/ with an Israeli based company called enteroscopy which can be quite time http://hk.co.kr/kt_plaza/200009/20000 Given lmaging have developed a de‑ consuming and uncomfortable for the 9091453384A1199.htm vice which consists of a camera, light patient. The patient is attached to an New York Times (May 30, 2000), National source, radio transmitter and batteries. endoscope for hours at a time with Science/Health, “Camera in a pill views digestive tract”, http://www.lib.rpi. All are sealed within a capsule slightly current enteroscopic techniques. This edu/dept/News Comm/Renns_news/ more than 2.5 cm long and less than capsule is not meant to replace cur‑ NYTsiegel.html 1.25 cm in width. When swallowed the rent endoscopic practice for examin‑ The Online Future Magazine (Oct, 16, capsule can view the digestive tract and ing the esophagus, stomach, proximal 2000), “Swallowable Capsule Pinpoints transmit pictures along the way. The duodenum and colon. It cannot do Digestive Disorders”, http://www.infinity camera takes several images per second biopsies, cauterizations or other pro‑ point.com/ Articles/ New/971710882, which are picked up by flexible anten‑ cedures that an endoscope can. The Retrieved May 1, 2001 nae and a receiver that is the size of a capsule cannot be stopped or steered Science News - Aug. 31, 2000, Retrieved from Cosmiverse on-line, May 2, 2001, personal stereo. The images are stored to collect close up details of the small “Testing to Begin of New Video Pill”, in memory chips and then downloaded intestine’s ailments. For now, use of http://www.cosmiverse.com/science to a computer for viewing. The receiver this device is contraindicated on those 083104.html is attached to an ambulatory belt which with suspected bowel obstruction, pa‑ USA Today - Tech Reviews - Aug. 30, 2000, allows the users to go about their daily tients who have had major abdominal “Video pill to be tested on humans”, activities during the G.I. exam. The surgery, pregnant women and patients wysiwyg://45http://www.USAtoday. battery in the camera lasts about six with pacemakers or diabetes. com/life/cyber/tech/review/crh462.htm, Retrieved May 1, 2001 hours. This allows enough time for This capsule will be able to achieve Virtual Medical Worlds - June 9, 2000, “Swal‑ the capsule to make its way through painless endoscopic imaging of the lowable Camera - Capsule to Visualize Gas‑ the small intestine. The capsule is pro‑ entire small bowel. The system is trointestinal Tract from Patient’s Interior”, pelled along by peristalsis and is able designed as an adjunctive tool in the http://www.hoise.com/vmw/oo/articles/ to transmit video images from pylorus diagnosis of diseases of the small intes‑ vmw/LV-VM-08-00-25.html, Retrieved to cocum, reaching the first part of the tine. For the future, the view is looking April 25, 2001 large intestine in less than two hours. good for the small bowel. The pill is naturally excreted. Data presented and published to BIBLIOGRAPHY ORIENTATION date includes results from animal test‑ Retrieved from Ananova on May 2, 2001, ing and ten human volunteers. Given “Video Pill to be Tested on Patients”, PACKAGE lmaging started clinical testing of the http://www.arianova.com/news/story/ To order: capsule in September 2000. Clinical sm_50116.htm/ Mail cheque made out to trials were also started in New York, Associated Press, Aug. 30, 2000, Retrieved CSGNA for $20.00 to: headed by Blair Lewis, M.D., Associ‑ from Wired News Web on April 25, 2001, Marlene Scrivens ate Clinical Professor at Mount Sinai “Video Pill Probes Intestines”, wysi‑ GI Unit Pasqua Hospital wyg://116/http://www./yc...news/busi‑ School of Medicine. The trials will ness/0,1367,38515,00.html Regina, Sask. evaluate the capsule on patients with Retrieved from Billingsgazette.com (Aug. S4T lA5 suspected bowel disorders. Trial results 31, 2000), “Tiny ‘pill’ camera takes gut Phone 306 766 2441 will be submitted to the U.S. Food pictures, http://www.billingsgazette.com/ Fax 306 766 2513 and Drug Administration. Similar tri‑ health/2000083/hlpill.html E mail: als have taken place in the U.K. and Canadian Healthcare Technology, “Wireless [email protected] capsule endoscopy tested as diagnostic tool Israel. Note: Receipt will be issued by Physicians will determine if the for bowel disorders”, Retrieved April 27, 2001 the treasurer. wireless capsule technology can detect Page Six The Guiding Light, July 2001

President’s Report Ontario Minister of Health. Any questions or concerns regard‑ CERTIFICATION: The CSGNA Website has been ing YOUR money please contact me or GREAT NEWS!!!! SPECIAL‑ updated and expanded to provide more any member of the Executive. TY DESIGNATION IS FINALLY information to our visitors. Updates on Sincerely, HERE!!!! Certification will be posted as the exam Edna Lang Gastroenterology Nursing has development progresses. National Treasurer, CSGNA been designated by the CNA Advi‑ Lorie Mcgeough and I attended the SGNA Conference in Tampa. sory Committee on Certification as a Dear Colleagues “SPECIALTY FOR THE PURPOSE Unfortunately, due to FOG in this It’s time again to renew your an‑ OF CNA CERTIFICATION”. This Beautiful Province, my flights were nual membership for the 2001-2002 completes Phase I. cancelled for three days and I missed year. Our renewal date will continue Congratulations to Cheryl the Business Meetings. The Confer‑ to be the month of June. Member‑ MacKinnon, our Project Coordinator ence was excellent and provided a great ship continues to fluctuate, depending and Michele Paquette, our Certifica‑ opportunity to network with many on where our National Conference is tion Chair, for a job well done. nursing colleagues. being held. With our National Con‑ PHASE 2, EXAM DEVELOP‑ EDMONTON CONFERENCE: ference in Alberta this year, the new MENT: Exam development requires The Edmonton Chapter of CSGNA is memberships & renewals are up in special consideration given the small very busy preparing for the 2001 CS‑ Alberta, British Columbia & Saskatch‑ number of nurses working in the Spe‑ GNA Annual Conference. Please make ewan. Please encourage your friends cialty. CNA and the CSGNA met in every effort to attend. It promises to be and colleagues to become members March to discuss the potential options an Educational and Enjoyable Event. I and maintain their membership, not available and the timeframe for the hope to see many of you there. only when the conference is coming to development of a certification exam. Have a Safe and Happy Summer. their area, but to help out with their Several options were discussed and Lorraine Miller Hamlyn local Chapters. As we all are aware of will be further explored over the next President, CSGNA the reorganizing in our health care several months. Our TARGET date system today, the benefits of being a remains 2002. Dear Colleagues member are: on going networking with BOARD OF DIRECTORS: The Please note the Financial Audit for colleagues from across the country, Board has been busy over the past sev‑ the year 2000 in our annual report. All keeping abreast of current research eral months reviewing all the CSGNA financial statements were submitted and technology, position statements Position Statements and Guidelines for to our current Auditor from Pricewa‑ and guidelines, scholarships, CSGNA Practice as well as developing new Posi‑ terhouseCoopers & LLP Chartered website and our goal of certification. tion Statements on “Single Use Items” Accountants. Please fill out membership application and “Reuse of Reusables”. As we strive toward Certification, forms when you renew and send any Our first Gastroenterology Nurses the majority of our funds are kept in changes of name or address to the ad‑ Day was celebrated on May 11th and Term Deposits to earn as much inter‑ dress below. from all reports was a very great suc‑ est as possible. These Term Deposits During a recent executive meeting, cess. We will use feedback from our are guaranteed with no risk to our a motion was passed that all past presi‑ members to plan our celebrations for funds. We keep a minimum in both our dents would be given a lifetime mem‑ 2002. operational and education accounts bership. To maintain your membership On behalf of all the members of to maximize our return. The Term please fill out the membership form & CSGNA, I sent the Proclamation and Deposits flow back to the appropriate return it to the membership chair each information on Colorectal Cancer account as required. year to keep your information current. Screening and the need for Canadian The funds in our Operational ac‑ If I have missed anyone please inform Citizens to have access to a Screening count are from our membership dues, me when you renew. Program, to All Provincial Ministers of national conference registration, ex‑ Please direct your membership Health, the Federal Minister of Health, hibitor booths, and support from our application to: the Prime Minister, Leader of the Op‑ generous sponsors. Edna Lang position, the Federal Health Critic, all The funds in our educational ac‑ CSGNA Treasurer/Membership Provincial Nursing Associations, the count are from the 25% profit each Chair CMA, CAG, and the Cancer Society. chapter submits post Educational 27 Nicholson Dr., Lakeside NS To date, I am pleased to report, Days, and Scholarships donated by B3T 1B3 I have received replies from the Sas‑ our sponsors. katchewan Minister of Health and the Sincerely, Edna Lang The Guiding Light, July 2001 Page Seven

I would like to welcome the fol‑ Annual Report for Take care and best wishes for the lowing new members: President‑Elect upcoming year. Catherine Armour Cobble Hill, BC I would like to take this opportu‑ Lorie McGeough Suzanne Stothers Vancouver, BC nity to thank the Bylaws Committee Lorna Murphy North Vancouver, BC members (Lorraine, Elaine, Judy, Donna Taker Yellowknife, NT Ottawa Chapter Report Evelyn Mc., Sandy) for their input and CSGNA Peggy Bienvieu Edmonton, AB work on the revision of the CSGNA The Ottawa Chapter is busy plan‑ Eileen Bryksa Lethbridge, AB Bylaws. At this time it is essential for ning a fall education event. Several Irene Irvine Calgary, AB each member to take the opportu‑ suggestions have been put forward and Colleen McNeil Calgary, AB nity to read through the Bylaws and are being looked at. We are also work‑ Rachel Pascoe Calgary, AB familiarize themselves with each one. ing on our poster for Edmonton and Beverly Waldorf St. Albert, AB Please exercise your right to vote on encourage others to do so. I would like Pamela Blakely St. Albert, AB the revisions and submit your vote to take this opportunity to thank you Shirley Tuinenga Redmeadows, AB before the end of July. The majority for your support during my four year Eva Berga Calgary, AB of revisions are simple and easy reads. tenure as Director of Canada Centre. It Monique Bouchet-Bert Calgary, AB We welcome any input from members was a very educational and fun experi‑ Vicki Braidberg Calgary, AB on the content of each bylaw. ence. I met many wonderful people Crystal Edgar Chestermere, AB Direction of the CSGNA is of along the way. I also learned alot not Karin Friedenberger Calgary, AB the utmost importance. Setting goals, only about GI, but about CSGNA Doris (DJ) Hacking Medicine Hat, AB working towards them and successfully and what hard working and dedicated Joan Heatherington Calgary, AB achieving them has been a focus for individuals come forward to serve on Pauline Gillis Calgary, AB several years. I am proud to be part the executive . Have a nice summer. Yvonne Ibbotson Medicine Hat, AB of a volunteer group that works as See you in Edmonton. Chris Larson Calgary, AB diligently as they do. It is commend‑ Jemma Lynch Calgary, AB able the amount of time and effort Yours in CSGNA, Linda Makar Calgary, AB that is put forward from a vast way of Nancy Campbell Donna Martin Medicine Hat, AB nurses across this country. During my Director of Canada Centre Sheryl Myden Calgary, AB participatory time I have witnessed the Corrine O’Brien Calgary, AB use and recognition of the CSGNA as CANADA CENTRE REPORT Helen Paget Calgary, AB a national and international respected The Golden Horseshoe Chapter Doreen Portas St. Albert, AB group. As members we should be is planning an education session for Nancy Steinkey Medicine Hat, AB proud of our achievements. I would the fall. Details will be available on Marg Stewart Medicine Hat, AB like to thank all of the executive mem‑ the web site later. The current Chap‑ Gwen Wall Calgary, AB bers from the past and present for ter President Cindy James is looking Kathy Whitman Lethbridge, AB their commitment. I would also like to for members who are interested in Jeanine Bernard Winnipeg, MB thank their families, for without their becoming part of the Golden Horse‑ Julia Beckstead Mallorytown, ON support none of this would have been shoe Chapter Executive. This is a great Louis Konstant Don Mills, ON possible. opportunity to learn and network with Iris Corrigan Toronto, ON Joining the CSGNA Executive members across the country. If you are Margaret Fisher Stayner, ON continues to be a wonderful learning interested, please speak with Cindy Rosemary Johnson Aurora, ON and growing experience. The develop‑ James. I am sure she will be delighted Tracy Kent Hillis Harrowsmith, ON ment of new expertise and new friend‑ to hear from you. Shahnaz Gborbani North York, ON ships will always remain invaluable. It The Southwestern Ontario Chap- Lorinda Melicor Scarborough, ON is important to have new Executive ter had an education session on March Jenefer Pardy Barrie, ON members in order to maintain and 22, 2001 on Gastroesophageal Reflux Linda Page Fleshertan, ON retain new and improved ways of do‑ Management presented by Dr. Peer. It Lisetta Seddon Toronto, ON ing things. We are only too happy to was a very informative evening. Thanks Kimberly Todd Markham, ON discuss any Executive position any to Abbott for sponsoring the evening. Berenice Vorne Acton, ON member may be considering undertak‑ The London and Area Chapter Phil Kenny Mississauga, ON ing. Please come forward, join us .... had an education session on April 17, Cathy Bidwell Burlington, ON you will not be disappointed. 2001 on Endoscopic Ultrasound pre‑ Kristine Bruce Acton, ON We are looking forward to the sented by Dr David Lloyd. Thanks to Sandra Killingbeck Acton, ON Edmonton Conference and once again Abbott Laboratories for sponsoring Ginette MacLeod Timmins, ON being together. the evening. Lorraine Majcen Scarborough, ON Page Eight The Guiding Light, July 2001

The Greater Toronto Chapter travelling in South America. While winner received a lovely gift basket. had an education session on May 2, there, she visited with Luisa Fanes in The G.I. Units treated their staff to a 2001 on “Burn, Inject, Loop, Clip – Curitiba, Brasil. Luisa was one of the wonderful Greek luncheon. The day Tools of the Trade in Managing GI nurses who received the Gastro ’99 was well received by all. Bleeding” presented by Dr. L. Cohen. nursing scholarship. After attending Currently meetings are on going Thanks to Byk Canada for sponsoring Gastro ’99, she spent 9 days in Kelowna to organize this fall’s G.I. Days for the evening. with Linda as her preceptor. Luisa gave Nurses. They are into the final planning Hoping to see many of you in Linda a tour of her hospital and G.I. stages and hope once again for a large Edmonton. Unit and took her and her husband to attendance. many lovely places in Curitiba. Yours in the CSGNA, Respectfully submitted by A chapter meeting was held on Sandy Saioud Evelyn Hilderman Monday, May 14. After business was Director, Canada West discussed, they spent time practicing CANADA WEST REPORT with the rotatable clipfixing device. VANCOUVER ISLAND For their treat for G.I. Nurses Day, Dear CSGNA colleagues, Chapter president Irene Ohly re‑ they each shared photos and stories of This my first year on the executive ports that monthly inservices are being their winter trips while sipping South as your Newsletter editor. held at both hospital sites. American wines and nibbling goodies. I wish to thank Lorie Mcgeough Chapter members attended a They were able to hear about Hawaii, for the outstanding work she has done presentation “Metal Stents in the G.I. Aruba, Australia and South America. with the Newsletter over the many Tract” given by Dr. Richard Kozarek, Several members are interested in years she was our editor. Her effort has Chief of Gastroenterology, Virginia attending the national conference in made it easier for me to relieve her of Mason Medical Centre and Clinical Edmonton. They are checking with her duties, so she could pursue other Professor of Medicine, University of their manager and doctors to see how interests. Washington, Seattle, Washington. many can be away at once. An educa‑ I see the Newsletter as a great Both G.I. Units in Victoria cele‑ tional workshop is planned for next means of communication, and a me‑ brated G.I. Nurses day with coffee and spring. dium for sharing ideas with our GI col‑ cake which was decorated with “Happy leagues across the country. I encourage first annual GI Nurses Day”­. SASKATCHEWAN and value your input for us to make it Four members of the chapter are The Saskatchewan chapter bids a just that. planning to attend the national confer‑ fond farewell to their past president, I thank those of you who have ence in Edmonton. Elaine Fehr, who has left G.I. nurs‑ submitted articles, and I look forward ing to pursue a career in Ambulatory to your comments, and or ideas that VANCOUVER REGIONAL Care. would enhance our present format. Gail Whitley reports that there They welcome Shirley Malach as As you know our present sponsor has not been much activity since their their new chapter president. Shirley is to the Newsletter is Carsen. I thank educational workshop in November. a 20 plus year veteran of G.I. nursing them for their continued support to A chapter meeting and educational and is currently employed in the En‑ our group. session is planned for the 3rd or 4th doscopy Unit at the Regina General I am pleased to be a part of this week in June. Hospital. dedicated group of GI nurses who The chapter is planning another To celebrate G.I. Nurses Day, in‑ presently make up this executive, and educational workshop this late fall. formation booths were set up outside I thank them for their assistance and They hope to raise funds to assist mem‑ the cafeteria in their two major hospi‑ support to make my passage into this bers in attending the 2002 national tals, with the view of promoting our or‑ position easier. conference in Newfoundland. ganization to fellow health care worker, I look forward to hearing from as well as the general public. Viewers you. OKANAGAN to the booths received give‑aways in Your editor, Linda Frandsen is back from South the form of a bran muffin recipe as well Kay Rhodes America and has resumed her role as as a piece of cake. There was a quiz chapter president. She had a great time with common G.I. conditions and the MINI QUIZ Answers

Team spirit evolves over time. 1. c 2. c 3. d 4. b The Guiding Light, July 2001 Page Nine

SYNOPSIS CSGNA NATIONAL EXECUTIVE MEETING March 16 ‑ 18, 2001, Toronto

Activity Reports: Newsletter Organization: CSGNA/Edmon‑ Business Arising: Certification: deadlines are June 15, October 15, ton Chapter. This is also posted on CNA reviewed and approved the and February 15. Our website now our website. CSGNA certification proposal. The had three sections for education. Na‑ A motion was passed for the first CBGNA are not willing at this time tional, Regional, and Local. Infection free ticket from Air Canada promo‑ to enter into an agreement to sell any control bibliography was updated and tion for our conference will go to the portion of their exam. Societal Status presented to all. Position statement planning committee. Any subsequent sent to Lawyer for final approval. was revised and will be published in tickets will be given to the National Conference evaluation, overall good the Guiding Light. It will be available Executive for future meeting and feedback. at the conference. conferences. Strategic Plan: May 11, 2001 is Committee report: Vacancies Director pins were given to the Proclaimed National Gastroenterol‑ for Executive positions in September Executives so that they can be worn ogy Nurses Day. Conference planning are Directors Canada east, centre and at the Annual Conference. document is being compiled, as a guide west. Changes to the Bylaws included for future conference. Mentoring All members attending Edmonton numbers, consistent titles, language Chapter Executives. For Edmonton conference are encouraged to use Air used, and new Committees were all Chapter Executive meeting preparing Canada, so the organization will be addressed. Members will receive these and presenting “cocoon to butterfly.” eligible for complimentary hospitality changes for voting. Teleconference June 11, 8 p.m. est. class tickets. Vendor Relations Committee was Respectfully submitted, The following information will be formed, consists of Treasurer, Direc‑ Elaine Binger required: tors one east and one west. Finance Name: Annual Conference 2001. Committee was formed, consists of Travel date: September 28‑30, 2001 Treasurer, Directors one east and one Event City: Edmonton. Personal‑ west ized Event #CV150675

Your executive hard at work. Your 2001 executive after a weekend of great accomplishments. Page Ten The Guiding Light, July 2001

CANADIAN SOCIETY OF GASTROENTEROLOGY NURSES AND ASSOCIATES CHAPTER EXECUTIVE LIST

Vancouver Regional Chapter Manitoba Chapter London Area Chapter President: Gail Whitley President: Sylvia Dolynchuk President: Cheryl Parsons 5520 Lackner Cres. 1503 ‑ 55 Nassau St. N. 401 Sunnyside Cres. Richmond, BC V7E 6A3 Winnipeg, MB R3L 2G8 London, ON N5X 3N4 (604) 875‑4155 (H) (204) 237‑2249 (519) 646‑6000 Ext. 4355 (604) 875‑5391 (W) Secretary: Roberta Thompson Secretary: Lynette Elliott (604) 875‑ 5031 (Fax) Treasurer: Donna Dunsford Treasurer: Laura Mason Secretary: Judy Deslippe Treasurer: Nala Murray Ottawa Chapter Newfoundland Chapter President: Michelle Paquett President: Ellen Coady Okanagan Chapter 2719 Wylderwood St. 19 Forde Dr. President: Linda Frandsen St. Gloucester, ON K1T 2S1 St John’s, NFLD A1A 4Y1 3320 Jackson Court (613) 733‑1552 (H) (709) 737‑6431 Kelowna, BC V1W 2T6 (613) 737‑8384 (B) Secretary: June Peckham (250) 862‑4427 (Fax) Secretary: Denise Theriault Treasurer: Mabel Chaytor (604) 864‑4000 ext. 4427 Treasurer: Monique Travers Secretary: Arlene Schroeder New Brunswick and PEI Chapter Treasurer: Debb Levine Golden Horseshoe Chapter President: Fran Duguay President: Cindy James P.O. Box 973 Calgary Chapter 220 Taylor Rd. Bathurst, NB E2A 4H8 President: Debbie Taggart Ancaster, ON L9G 1P1 (506) 546-4907 (H) #102 ‑1800 26th Ave. SW (905) 648‑8771 (H) (506) 545-2408 (B) Calgary, AB T2T 1E1 (905) 521‑2100 Ext. 5350 (B) Secretary/Treasurer Mary Eva Smearer (403) 209‑0217 (H) Secretary: Jennifer Belbeck (403) 291‑8922 (W) Treasurer: Sharon Thomas Nova Scotia Chapter (403) 291‑1599 (F) President: Elizabeth Hendsbee Secretary: Christine Kunesky South Western Ontario Chapter 284 Ross Rd. Treasurer: Doreen Reid President: Diane Gray Westphal, NS B2Z 1H2 265 Jos Janisse (902) 473‑6541 Edmonton Chapter Windsor, ON N8Y 3A5 Secretary: Donna Cook President: Judy Langner (519) 948‑5422 (H) Treasurer: Theresa McKinon 129 Greenoch Crescent (519) 254‑1661 Ext 2019 (B) Edmonton, AB T6L 1W6 Secretary: Pam Hebert Greater Toronto Chapter (780) 450‑7323 (W) Treasurer: Joan Staddon President: Gail Stewart (780) 450‑7208 (F) 41 Richbourne Ct. (780) 463‑1934 (H) Vancouver Island Chapter Toronto, ON M1T 1T5 Secretary: Doris Strudwick President: Irene Ohly Secretary: Elaine Burgis Treasurer: Patti Ofner 642 Caimdale Rd. Treasurer: Brenda Latch (250) 727‑4234 Saskatchewan Chapter Secretary: Pat Savage President: Elaine Fehr Treasurer: Nelda Turner 195 Edenwold Cres. Regina, SK S4R 8A6 (306) 766‑2441 Secretary: Shannon Cote What you do today is important because you are exchanging Treasurer: Dianne Ryan a day of your life for time … Let it be something good. The Guiding Light, July 2001 Page Eleven

POSITION STATEMENT RESPONSIBILITIES OF THE REGISTERED NURSE RELATED TO CONSCIOUS SEDATION

Conscious sedation provides a intervene in the event of complica‑ Use of narcotics, benzoidiazepines minimally reduced level of conscious‑ tions. Whether or not the Registered or other analgesic of “social” ness in which the patient retains the Nurse is responsible for assessing and drugs. ability to independently and continu‑ monitoring the sedative/analgesic, 2. Inform the patient of restrictions ously maintain an airway and respond the Registered Nurse is responsible for related to driving or using equip‑ to physical stimulation and verbal assessing and monitoring the patient ment requiring clear judgements command. throughout the procedure and post or quick physical responses. It is The primary role of the Registered procedure phase of the patient’s care. advised not to drive for 24 hours Nurse during Endoscopy procedure is A second Registered Nurse may post sedation. the maintenance of patient safety. Con‑ be required to assist during proce‑ 3. Advise patients against ingesting scious sedation is commonly used during dures involving complex technical alcohol for 24 hours post seda‑ diagnostic and therapeutic endoscopic demands or in the procedures that are tion. procedures. The safe administration complicated due to the severity of the 4. Assure patient has made appro‑ and maintenance of conscious sedation patient’s illness. priate discharge transportation is one of the most important responsi‑ Automatic monitoring devices will arrangements. bilities of the Registered Nurse in the enhance the ability of the Registered 5. Document findings and inform Endoscopy setting. Care of the patient Nurse to accurately assess the patient physician of significant findings. undergoing a diagnostic or therapeutic but are no substitute for the watchful, endoscopic procedure continues to be educated assessment by the Registered INTRA PROCEDURE: more critical in nature, more complex Nurse. The R.N. will … in technology and more comprehensive The Registered Nurse is account‑ 1. Document medications received on scope. Nursing care of the patient able for the responsibilities he/she by the patient. has changed to include a continuous accepts. The Registered Nurse func‑ 2. Provide and document minimal comprehensive nursing assessment, tions within the limitation of the in‑ monitoring of all patients includ‑ administration and maintenance of stitutional policies and the provincial ing: BP, pulse, respirations, level continuous sedation in the presence of governing bodies. of consciousness, temperature and a physician, administration of reversal dryness of skin and pain tolerance agent, utilization of equipment during GUIDELINES FOR THE CARE at the initiation, during and at the the endoscopic procedures, and com‑ completion of the procedure. As prehensive documentation. OF PATIENTS RECEIVING indicated by the patient response, The Canadian Society of Gastro‑ CONSCIOUS SEDATION assessment may be more frequent. NOTE: enterology and Associates supports the 3. Monitor O2 saturation and heart position that registered nurses trained THIS STANDARD SHOULD rate as determined by continuous and experienced in Gastroenterology BE CONSIDERED IN COMBI- pulse oximetry. Document sig‑ NATION WITH THE PROCE- nursing and endoscopy may be given nificant changes in 2O saturation, the responsibility of administration DURE SPECIFIC PRACTICAL heart rate, and interventions taken and maintenance of conscious sedation GUIDELINES and patient responses. in the presence of and the order of a 4. Ensure the immediate availabil‑ physician. In addition, the Registered PRE PROCEDURE: ity of Emergency Equipment, eg. Nurse may be given the responsibil‑ The R.N. will … Oxygen, oral airway, ambu bag, ity for the administration of reversal 1. Complete the nursing history and medication to reverse the effects of agents prescribed by the physician. assessment form, particularly not‑ narcotics and benzodiazepines. The Registered Nurse had education ing prior response to: and experience in Endoscopy, knowl‑ IV Sedation (Valium, Demerol, edge of medications used and skills to Fentanyl, Versed, etc.) Page Twelve The Guiding Light, July 2001

POST PROCEDURE: REFERENCE LIST McCloy, R., Fleisher, D. (1993). Sedation and The R.N. will … American Society of Post Anaesthetic Care monitoring for gastrointestinal endoscopy. 1. Assess BP, heart rate, respira‑ Nurses (1991). Position Statement on the role UK Colloquim Internation, Ltd. tory depth and effort and level of the Registered Nurse in the management of Marley, R.A., Moline, B.M. (1996). Discharge the patient receiving conscious sedation. from the Ambulatory Setting. Journal of Post of consciousness on admission to Bailey, R. (1996). Consensus in Endoscopy. Anaesthesia Nursing. 11 (1) 39‑49. Recovery Area, after 15 minutes Canadian Journal of Gastroenterology. July Meeker, M.H., & Rothtrock, J.C. (1999) and at discharge. Post procedure 10 (4) 237‑242. Alexanders Care of the Patient in Surgery oximetry may be performed until Bell, G., McCloy, R., Charlton, J. Campbell, (11th edition) Toronto: Mosby Yearbook, the patient’s respiratory status is D., Dent, N., Gear, M., Logan, R., Swan, 208‑209 & 1194. stable or returned to pre‑proce‑ C. (1991) Recommendations for stand‑ Odom, J., (1997). Conscious Sedation in the dure state. ards of sedation and patient monitoring Ambulatory setting. Critical Care Nursing 2. Assess and document unexpected during Gastrointestinal Endoscopy. GUT Clinics of North America. 9 (3) 361‑368. 7(32)823‑827. events and post procedure compli‑ Tupper, D., (1999). Presentation and Discus‑ Kidwell, J. (1991). Nursing care of the patient sion regarding Decision to Discharge post cations related to sedation. receiving conscious sedation during gas‑ Procedure at QE11 Health Sciences Centre. 3. Assist and accompany patient to trointestinal procedures. Gastroenterology November 17,1999. Douglas Tupper, LLB the bathroom, assess presence of Nursing 13(,3) 134‑139. of Palmer, Paterson, Hunt, Murphy. Halifax, orthostatic hypotention. McCloy, R., Fleisher, D. (1993). Sedation and Nova Scotia. 4. Assess gait prior to discharge. monitoring for gastrointestinal endoscopy. QE11 Health Sciences Centre, Perioperative 5. Remove IV access (if present) prior UK Colloquim Internation, Ltd. Nursing Policy (1998). Discharge of Patient: to discharge, assess site and docu‑ Society of Gastroenterology Nurses and Associ‑ Same Day Surgery Unit (SDSU). Halifax, Nova Scotia. ment. ates Inc. (1991). Position Statement: Respon‑ sibilities of the Gastroentereology Registered Dunsworth, B.A., Hoffman, L.A., Messinger, 6. Reinforce pre procedure teach‑ Nurse related to Conscious Sedation. J.A., O’Donnell, J.M. (1999). Getting Con‑ ing regarding driving, equipment Somerson, S., Husted, C., Sicilia, M. (1995). scious Sedation Right. American Journal of operation and making decisions Insights into Conscious Sedation. American Nursing 99 (12) 44‑50. requiring judgement. The teaching journal of Nursing. June. 26 ‑ 32 Jagim, M. (2000) Conscious Sedation. Journal provided should be in written form Wansbrough, G. (1996). Quality Assurance of Emergency Nursing. 23 (3). 251‑259. and a copy given to the patient Medication Administration Standards. The prior to discharge. College of Nursing of Ontario College Com‑ NOTE: munque. November 21 (5) 4‑31.­ Patients requiring ongoing pulse Bailey, R., (Chairman) (1996). Consensus in Endoscopy. Canadian Journal of Gastroen‑ oximetry or those experiencing terology. July 10 (4). altered levels of consciousness Bell, G., McCloy, R., Charlton, J., Campbell, related to sedation will not be D., Dent, N., Gear, M., Logan, R., Swan, C. left unattended in the recovery (1991). Recommendations for standards of se‑ area. dation and patient monitoring during Gastroin‑ The Registered Nurse functions testinal Endoscopy. GUT 7 (32) 823‑827 within the limitations of the Kidwell, J., (1991). Nursing care of the patient provincial licensing body and receiving conscious sedation during gas‑ trointestinal procedures. Gastroenterology institutional policies. Nursing 13(3) 134‑139.

Keen or what?! The Guiding Light, July 2001 Page Thirteen

POSITION STATEMENT REUSE OF SINGLE‑USE MEDICAL DEVICES

In the absence of clear regula‑ for single‑use. Based on the result of Michele, T., Cronin, W., Graham, N., Dwyer, tory guidelines for reuse of single‑use these required tests, the manufacturers D., Spiespope, D., Harrington, S., Chaisson, R., Bishai, N. “Transmission of Mycobacte‑ medical devices, based on current have defined recommended usage on rium tuberculosis by a fiberoptic broncho‑ scientifically-­based literature, and tak‑ package labels. The topic of reuse raises scope” JAMA 1997: 1093‑1095. ing into consideration concerns for concerns about the ability to clean Muscarella, L., “High‑level disinfection or steri‑ patient safety and ethical practice, The single‑use critical devices, how well a lization of endoscopes” Infection Control Canadian Society of Gastroenterology device holds up after sterilization, and and Hospital Epidemiology. March 1996; Nurses and Associates, support the how many times a device can be reused 17: 183‑187. position that critical medical devices while maintaining patient safety and Olympus Evis 100 & 130 Cleaning and Disin‑ labeled for single­-use should NOT mechanical effectiveness. Many de‑ fection Video 1997. be reused. vices, whether labeled as single‑use or Olympus Evis 140 Reprocessing Video 1998. reusable, appear identical on visual in‑ Rutala, W.A., “APIC Guideline for selection spection. However, manufacturers may and use of Disinfectants.” American Journal REUSE OF SINGLE‑USE of Infection Control, vol. 18, no.2 (April for a number of reasons change the 1990), 99‑117. MEDICAL DEVICES material used in production. Changes Rutala, N., “FDA Labeling Requirements for Definitions: in materials may not be obvious on Reuse refers to the cleaning, pack‑ Disinfection of Endoscopes: A Counterpoint” visual inspection, but unless the device Infection Control and Hospital Epidemiology aging and sterilization of a single‑use is labeled reuse, the new materials may 1995. 1995; 16(4) 231‑235. medical device used on a patient for not be able to withstand the heat of Society of Gastroenterology Nurses and Assist‑ the intended purpose of using it on chemicals required for sterilization. ants. Recommended Guidelines for Infection another patient. Control (2nd Ed.) Rochester, NY: 1992. Critical devices are those which Disclaimer: SANG Endoscopic Cleaning Video 1997. break the mucus membrane, coming The Canadian Society of Gastroen‑ Vesley, D., Norlien, K., Nelson, B., OH, B., into contact with sterile tissue or the terology Nurses and Associates assumes Streifel, A. “Significant factors in the disinfec‑ vascular system. tion and sterilization of flexible endoscopes” no responsibility for the practices or American Journal of Infection Control. 1992: recommendations of any member or 291‑299. Advanced Sterilization Products Background: other practitioner, or for the policies (1999) Cidex opa solution material safety This statement is intended to or procedures of any practice setting. data sheet 015, revision. address the controversy surrounding Nurses and associates function within SGNA Guidelines for the use of High Level the issue of the reuse of critical medi‑ the limitations of licensure, delegated Disinfectants and Sterilants for Reprocess‑ cal devices packaged and labeled for medical acts, and/or institutional ing of Flexible Gastrointestinal Endoscopies Feb 2000. single‑use. Cost containment concerns policy. have led some healthcare facilities to SGNA Standards of Infection Control in consider reuse of single‑use critical Reprocessing of Flexible Gastrointestinal Bibliography Endoscopies Feb 2000. medical devices. Manufacturers are Society of Gastroenterology Nurses and As‑ Decontamination of Reusable Medical Devices required to conduct very stringent test‑ sociates, Inc. (1998). Position Statement on CSA International 2314:8‑00 March 2000. ing for reusable products. They must Reuse of Single‑Use Medical Devices. Advanced Sterilization Products (1999) Cidex Martin, A.M., Reichelder, M., “APIC GUIDE‑ meet FDA criteria to validate that a OPA Solution Material Safety Data Sheet LINES FOR INFECTION CONTROL device can be cleaned and, if necessary, (015) revision C. resterilized in order for it to be labeled PRACTICE: APIC guideline for infection prevention and control in flexible endos‑ “reusable”. These same stringent tests copy”, AJIC AM J Infect Control 1994; are not required for items intended 22:19‑38.

One man with courage makes a majority. Page Fourteen The Guiding Light, July 2001

CSGNA USE OF REUSABLE MEDICAL DEVICES RECOMMENDED GUIDELINES IN ENDOSCOPY SETTINGS

PREFACE TERMINOLOGY PURPOSE These guidelines were developed Reuse – The process by which a reus‑ To develop a guide to assist en‑ by the Canadian Society of Gastro‑ able device that has come into doscopy nurses to make informed enterology Nurses and Associates in contact with a patient is cleaned, decision on the use of reusable medical 2001. decontaminated, reconditioned/ devices. refurbished, and disinfected or DISCLAIMER sterilized prior to subsequent use RECOMMENDATIONS FOR on the same or another patient. These guidelines are based on Reprocessing – The process by which a REUSE current understanding and practice pack, which is opened but unused, All reusable medical devices must be in the field of gastroenterology. Each is repackaged and sterilized. placed into three categories: institution is responsible for establish‑ Resterilization – The further pro­cess­ 1. Critical ing policies and procedures for that ing of a product (which was sterile 2. Semi‑Critical particular endoscopy setting. and unopened) due to a passing 3. Non‑Critical The Canadian Society of Gastroen‑ expiry date or for its inclusion into The process for reuse, resterilizing terology Nurses and Associates assumes larger pack. and reprocessing is determined by no responsibility for the practices and Non‑critical Device – Any device that the category in which the medical recommendations of any member, comes in contact with intact skin device is classified. other practitioner and for the policies e.g. blood pressure cuff. and practices of any endoscopy unit. Semi‑critical Device – Any device Reprocessing of reusable endoscopic which comes in contact with mu‑ devices include the following steps: INTRODUCTION cus membrane. e.g. endoscope. • Transport to the reprocessing Attention must be given to the re‑ Critical Device – Any device which area use of medical devices. Contaminated comes in contact with sterile areas • Soaking and unsafe medical devices pose a po‑ of the body or the vascular system. • Brush cleaning tential source for cross‑contamination, e.g. biopsy forceps and sphinc­ • Rinsing infection and injury to patients and terotomes • Ultrasonic cleaning personnel. Strict guidelines are needed • Inspection • Drying to standardize the process of reusing BACKGROUND medical devices. The guidelines are • Lubrication The reuse of critical and semi‑criti‑ intended to assist institutions and • Packaging cal devices has become a common prac‑ endoscopy units in the development • Sterilization according to Manu‑ tice in many institutions. The reuse of of their specific needs. Providing the facturers Recommendation medical devices is a practice undertaken best possible care is the ultimate mis‑ • Transport back to the endoscopy primarily for economic reasons as a sion of each healthcare institution suite means to maximize the effective usage and the professionals who staff it. • Inspection of a particular nondisposable device. An integral component of delivering • Prepare for use It is estimated that 41% of Canadian quality care is instrumentation. Most (Refer to CSGNA Infection Control: hospitals reuse medical devices of some Endoscopy procedures are performed Recommended Guidelines in Endoscopy kind. Only the devices labeled reusable on an outpatient basis. The volume of Setting) can be reused. procedures scheduled each day is often Due to this concern the CSGNA high. Whether that schedule can be Reusable Device Reprocessing and decided to establish some guidelines met and each patient given high quality Validation of Performance and recommendation for reuse of reus‑ care is dependent on device reliability • Requires thorough policy and able medical devices. and safety. procedure program • Requires assignment of responsibil‑ ity to highly qualified individuals The Guiding Light, July 2001 Page Fifteen

• Must ensure integrity of the de‑ sterilization. Gas is excellent in When infections occur or injuries vice sterilizing provided the equip‑ take place due to an instrument ment is free from all blood selected and maintained by the Issues to Consider to Meet Perform- and other organic materials. institution, there is a potential for ance Standards The item should be dry be‑ significant legal liability. Instru‑ • Strict adherence to the Manufactur‑ cause the presence of saline or ments that are continually reproc‑ er’s Instructions for Reprocessing water may form a poisonous essed can increase that risk. • Clinically Proven Device chemical in the presence of Disposal of the instrument after • Inspect Upon Opening Package gas. With the elimination of its useful life must be performed • Necessity to Perform Multi‑Step chlorofluorocarbons (CFCS), according to institutional and Cleaning Process and High Level which are required for most governmental regulations. Disinfection/Sterilization Proc‑ gas sterilizers, institutions are Liability may be avoided or re‑ ess switching to other technolo‑ duced if a reasonable standard of • Ensure Adequate Backup Inven‑ gies. Check manufacturer’s care can be demonstrated, includ‑ tory label for reprocessing. ing the adherence to established • Establish Protocol for Reprocess‑ C) High Level Disinfection: hospital guidelines on reuse. ing High level disinfection may 5. Ethical Issues • Establish Protocol for Inspection be appropriate for semi‑critical Must the patient be informed and Repair devices, but the effect on func‑ that the instruments/devices be‑ • Establish Training and Retraining tionality must be assessed. ing used for their procedure is a Protocols for Staff D) Risk to personnel: Personnel reusable device? Is this part of an • Establish Institutional Policy/ performing the reprocessing informed consent? Usually, specific Standards to determine maximum of the item are at risk if being consent is not obtained from the number of use for the device exposed to body fluids and/ patient. The risk of the procedure or cleaning, disinfection or in general is described to the pa‑ Preventing patient infection means sterilization products. Person‑ tient in the same manner whether that the device must be free of contam‑ nel must follow the Health and it is a new or reusable device. ination. Preventing injury means that Safety guidelines for their in‑ the device must function according to stitution. (See Recommenda‑ It has been suggested that internal specifications without degradation of tions in the CSGNA Infection procedures must be developed, ap‑ parts that might become dangerous to Control Guidelines). proved by the Board of Directors, and the patient or staff. Perhaps the most 2. Medical Device Integrity that hospital policy must become pub‑ significant risk of injury from product It is necessary to assess what ef‑ lic policy. The debate revolves around degradation is the fraying of electrical fect the high level disinfection or the social responsibility of stakeholders sheaths due to reprocessing plus nor‑ sterilization process will have on to society and to individuals. mal wear and tear during procedures. the integrity and functionality of This is difficult to monitor even with the device. The number of reuses SUMMARY close inspection. The potential of in‑ should be based on manufacturer There is a high volume of endo‑ jury to both the patient and staff may guidelines. scopic procedures performed in many be significant. 3. Cost‑effectiveness institutions. For both the patient’s Institutions should consider the safety and the financial health of the following; cost of labour, supplies ISSUES IN REUSE institution, it is important that these and machine use, storage, quality 1. Risk of infection procedures be performed reliably, assurance programs, overhead, A) Thorough cleaning: Thor‑ safely and efficiently. possible additional liability insur‑ ough cleaning is the most Most of the devices used in en‑ ance and possible increase in price integral part of reprocessing. doscopic procedures are classified as of an item if fewer are used. There Concern is expressed regard‑ critical or semi‑critical. The threat of are also protocol development ing mechanical parts being potentially life threatening malfunc‑ costs and educational costs to difficult to clean, and that po‑ tion can lead to patient/staff injury consider. rous material, such as plastic, or needless prolongation of the pro‑ 4. Legal Issues may absorb contaminants and cedure. The manufacturer’s labeled infor‑ chemicals. Reusable devices provide assured mation on care and usage of reus‑ B) Sterilization: Most manu‑ first‑use performance. After that, a se‑ able products must be adhered to. facturers recommend steam ries of steps must be performed to en‑ Page Sixteen The Guiding Light, July 2001

sure that they are properly reprocessed BIBLIOGRAPHY Favaro, M.S. and Bond, W., “Sterilization, and provide acceptable performance SGNA Position Statement – Reuse of single‑use Disinfection, and Antisepsis in the Hospi‑ Critical Medical Devices. tal.” Manual of Clinical Microbiology (5th during subsequent procedures. Ed.). Washington, DC: American Society for Health Care Corporation of St. John’s – Reuse It is important that each institution Microbiology, 1990. of single‑use Items. be fully aware of the issues involved Considerations: Endoscopic Device Selection Medical Devices Canada – Industry Position in device selection. Institutions that – Performance, Safety and Cost – Making Paper – The Reuse of Medical Devices. choose to reuse devices need to vali‑ Informed Decisions – Microvasive Education date the sterility and integrity of the International Association of Healthcare Central Center, Boston Scientific Corporation. Service Material Management – Position Recommended Guidelines for Infection Control reprocessed devices, and have in place Statement Paper on The Reuse of Medical in Gastrointestinal Endoscopy Setting. SGNA detailed protocols to include mecha‑ Devices. Inc., SGNA Monograph Services. 1995. nisms for ongoing evaluation and Canadian Healthcare Association – The Reuse Reichert M., Choice to Reuse Disposables quality assurance monitoring. of Single‑Use Medical Devices: Guidelines Requires Factual Assessment. OR Manager. for Healthcare Facilities. 1996; 12,6:8‑9. Michelle Alfa, “The Effectiveness of Hospital Decontamination of Reusable Medical Devices, Sterilization”, Infection Control Hospital 2314:8‑00 Mach 2000. Epidemic., 1996 ECRI Special Report: Reuse of Medical Devices. Making Informed Decisions 1996

POSITION STATEMENT Infection Control: Recommended Guidelines in the Endoscopy Setting

Disclaimer are intended to assist institutions and Patient‑Ready Endoscope – An endo‑ These guidelines are based on endoscopy units in the development of scope rendered clean after being current understanding and practice policies for their specific needs. subjected to a validated cleaning in the field of gastroenterology. Each procedure subjected minimally to a institution is responsible for establish‑ Terminology high level disinfection process and rinsed so that it does not contain ing policies and procedures for that Clean – Visibly free from debris residual chemicals in amounts that particular endoscopy setting. Endoscope ‑ Flexible – Flexible fiberop‑ can be harmful to humans. The Canadian Society of Gastroen‑ tic or video endoscope used in the Alcohol – 70% isopropyl or ethyl al‑ terology Nurses and Associates assumes examination of the hollow viscera cohol no responsibility for the practices or (i.e. colonoscope, gastroscope, Air – Airflow provided by a pump or recommendations of any member or duodenoscope, sigmoidoscope, compressor. other practitioner or for the policies bronchoscope). Detergent – Low‑sudsing enzymatic and practices of any endoscopy unit. High‑Level Disinfectant – A liquid formulations recommended by the chemical germicide which is capa‑ manufacturer of the endoscope. ble of destroying all microbial life Introduction Water – Clean potable water or po‑ including high numbers of bacte‑ Attention must be given to the table water that has been filtered rial endospores but is used under implementation of infection control by passage through a .2um filter conditions where it achieves the standards. Contaminated endoscopes of otherwise treated by a method destruction of all vegetative bacte‑ and accessories are potential sources documented to improve the micro‑ ria, viruses and fungi but not nec‑ of infection for both patients and per‑ biological quality of the ­water. sonnel. Strict guidelines are needed to essarily all bacterial endospores. standardize the cleaning/disinfecting/ sterilization processes. These guidelines The Guiding Light, July 2001 Page Seventeen

Recommendations for • Meticulous hand washing should immersible parts of the endoscope be Safety of Personnel be done between patient contact, cleaned. Safety is of the utmost importance after glove removal and when en‑ Wipe the outer surface with enzy‑ and should be in the forefront of each tering or leaving the Endoscopy matic soaked gauze immediately after employee’s mind. Consistent practice area. If hands and other skin sur‑ removal of the endoscope from the must be maintained to prevent the faces are contaminated with blood patient. Using the air/ water channel spread of disease and to protect from or body fluids, wash immediately. valve, flush the air/ water channel with the dangers of the chemicals used in • Health care workers who have exu‑ water from the water bottle. Transport the cleaning and high level disinfection dative lesions or weeping derma‑ the scope to the cleaning area. of endoscopes. Universal precautions titis should refrain from all direct • If unable to initiate the manual must be practiced at all times. patient care and from handling cleaning process immediately, the • All personnel should be immu‑ patient care equipment until the endoscope may be flushed and nized against Hepatitis B. condition resolves. then soaked with enzymatic solu‑ • Health care workers who have tion. respiratory problems (i.e. asthma) Recommendations for • Leakage test the scope following the manufacturer’s instructions. should be assessed by Occupa‑ Endoscopes tional Health prior to working • Fully immerse the scope in a solu‑ Refer to the manufacturer’s in‑ tion with an enzymatic cleaner to with chemical germicides. structions for cleaning and disinfecting • Eye protection and moisture resist‑ prevent the drying of secretions. each particular endoscope: Scrupulous Brush all channels to remove the ant masks or face shields should cleaning and disinfection after each be worn to prevent contact with organic material and decrease the patient use must be completed to number of organisms present. splashes during the cleaning proce‑ prevent the spread of infection. Only dure and disinfection/sterilization Ensure that access to the air/ trained personnel will perform this water/ C0 channel is attained, as process. procedure. 2 • Moisture resistant gowns should these channels are very difficult to Inspection clean. be worn to prevent contamination At all stages of handling there of personnel due to splashes of • Ensure the outer surface of the should be inspection of the endo‑ scope is thoroughly cleaned. Use blood or other body fluids or in‑ scope for damage. jury due to chemical disinfectant/ of a soft bristle toothbrush to clean Leakage testing of the endoscope the lens end is acceptable. sterilant contact. The changing of should be done each time before gowns is recommended between • All channels must be brushed and the cleaning process starts. irrigated to remove particulate procedures. Ensure immersion cap is placed on • Protective apparel (gown and matter. A channel irrigator should all videoscopes. be used to facilitate complete mask) should be removed when If damage is detected or bub‑ leaving the procedure room and cleaning of all channels. bling occurs, ensure the pressure is • Rinse all the channels and the cleaning room. maintained through the leakage tester • Gloves should be worn for han‑ endoscope thoroughly with water and proceed to carry out a thorough following the cleaning process to dling and cleaning of dirty equip‑ external cleaning and cleaning of the ment as well as for any potential remove the residual of the enzy‑ internal channels. Follow your service matic agent. contact with blood or body fluids. provider’s instructions concerning Chemical resistant gloves (nitrile) • Remove all excess water from the disinfection of a damaged fiberscope. channels by injecting air via the are recommended when handling However, with proper maintenance disinfectant solutions. all channel irrigator to decrease of internal pressure, manual disinfec‑ the possibility of dilution of the • All needles and sharps are to be ap‑ tion of the scope in many cases can be propriately disposed of in puncture disinfectant solution. achieved. Send to the repair service • Clean all non‑immersible parts resistant containers at their point immediately. If the scope cannot be of use. Do not recap needles. with a hospital recommended cleaned prior to transport, ensure that surface disinfectant. • Fingernails should be kept short to it is clearly labeled ‘contaminated’. prevent the puncturing of gloves. • Non‑immersible endoscopes Cleaning should be replaced because they Jewelry should not be worn on Meticulous manual cleaning is the hands because it harbors mi‑ are very difficult to clean and dis‑ the most important step in the clean‑ infect. croorganisms and may puncture ing process. It is imperative that all gloves. channels, removable parts and all Page Eighteen The Guiding Light, July 2001

Sterilization and Disinfection predetermined time or duration of Documentation When deciding whether to steri‑ use. Results of disinfectant solution lize or disinfect the endoscope, it is • Ethylene Oxide (ETO) gas sterili‑ testing should be documented. Institu‑ important to refer to the following zation requires an extended time tional policy may require documenta‑ classifications; to complete the sterilizing and tion of disinfection cycles. 1. Critical devices are those that enter aeration process. This may not Culturing sterile tissue: the vascular system always be practical. Culturing requires very precise or body space (i.e. biopsy forceps, • The Peracetic Acid based auto‑ techniques done in close consultation polyp snares and surgical instru‑ mated system sterilizes immersible with an infection control department. ments). instruments and rinses them with Institutional policy may dictate when 2. Semi‑critical devices (i.e. laryn‑ sterile water. Contact of all exter‑ and how culturing of scopes should be goscopes, endoscopes) come into nal and internal surfaces with the carried out. contact with mucous membranes sterilant must occur. Check with Special Considerations or non‑intact skin during use and the manufacturer’s instructions re‑ Sterilization or high level disinfec‑ should at least receive high‑level garding the cleaning of the elevator tion should be used as directed by insti‑ disinfection (defined as the inac‑ channel of the duodenoscope. tutional policy. Diagnosed or suspected tivation of all micro‑organisms • Hydrogen Peroxide (H202) is infection, including Hepatitis B, VRE, with the exception of bacterial acceptable for endoscopic reproc‑ MRSA or HIV is not a contraindication endospores). essing although it can damage the for endoscopy. It is not recommended 3. Non‑critical devices (i.e. blood external surfaces of the insertion to have instruments dedicated for use pressure cuffs, bedpans) come into tube and corrodes copper, zinc and with infected patients. contact with intact skin. brass. Endoscopes that come into contact Rinsing Recommendations for with mucous membranes are clas‑ To remove all traces of the disin‑ sified as semi­-critical items. fectant, adequate rinsing must follow Accessories Endoscopes that enter sterile body the disinfection process. Any residual Non‑disposable accessories re‑ cavities are classified as critical chemical can cause toxic effects in a quire meticulous manual cleaning items. patient if it is transmitted during the and disinfection or sterilization after • High level disinfection of the en‑ next endoscopic procedure. each use according to manufacturer’s doscope internally and externally The use of sterile water for rinsing guidelines and as directed by institu‑ must be performed after scrupu‑ is recommended. If tap water is used, tional policy. lous mechanical cleaning has been follow with 70% alcohol rinse and dry Biopsy Forceps completed. All processes will be with compressed air. Meticulous manual cleaning with rendered ineffective if any organic Drying an enzymatic agent is required as soon material or moisture is present on Air drying by the use of forced air as possible after the procedure. or in the endoscope. should be done after disinfection and Ultrasonic cleaning is recom‑ • Chemical agents registered with before storage. mended to remove debris that hand Canada Health and Welfare, as Prior to storage, facilitate drying of cleaning cannot. sterilant/disinfectants are appropri‑ the endoscope by flushing all channels Biopsy forceps break the mucosal ate for high level disinfection. To with a 70% isopropyl alcohol followed barrier. Therefore they are classified ensure efficacy, the manufacturer’s by forced air. Dry the insertion tube as critical instruments and require instructions regarding use of disin‑ completely. Moist environments are sterilization. fectant must be adhered to. conducive to bacterial growth. The only method that will effec‑ • All internal and external surfaces Channel valves should remain out tively penetrate the metal coils of the and channels must be in contact of scopes at the time of storage to fa‑ spring‑like structure and any residual with the disinfecting agent for not cilitate the drying of channels. organic material is steam under pres‑ less than 20 minutes. Storage sure. Chemical sterilization does not • Disinfectant agents must be cho‑ Endoscopes should be stored hang‑ completely penetrate the coils and sen carefully and must be used ing vertically in a well‑ventilated area in therefore is not effective. according to the manufacturer’s a manner that prevents recontamina‑ Water Bottle instructions including monitoring tion or damage. They should not be According to manufacturer’s in‑ chemical concentrations. Effec‑ coiled and stored in their cases. structions, sterilize or high level disin‑ tive use‑life is more dependent on Wipe down the storage cupboard fect the water bottle and its connecting frequency of use rather than on a with disinfectant solution weekly. tubing at least daily. The Guiding Light, July 2001 Page Nineteen

For endoscopic irrigation, fill the Waste done. bottle with sterile water. Minimal handling of all medical Other considerations; Each ERCP procedure requires a waste should be encouraged. • A channel irrigator may miss a fresh sterile bottle with sterile water. The storage and disposal of waste blockage of one channel. Pseudomonas aeruginosa colonization should be handled according to institu‑ • When used to disinfect duodeno‑ of equipment has been associated with tional policy and provincial and federal scopes, ensure that the channel patient infection following ERCP. guidelines. for the elevator is cleaned and Other Accessories Processing Area disinfected as part of the process‑ Clean all non‑disposable acces‑ Patient care areas should be sepa‑ ing cycle or it may require manual sories (i.e. polyp snares, tripods and rate from cleaning/ disinfection processing. foreign body forceps) meticulously areas. • A forced air‑drying cycle or air‑dry‑ with an enzymatic agent followed by Clean and dirty areas should be ing should be completed by hand rinsing thoroughly with water. Use separate with proper plumbing and after the final rinse. the ultrasonic cleaner prior to steam drains. Adequate storage space should • If unsterile water is used in the final autoclave. be provided. rinse following the disinfection Consult the manufacturer if steam The use of covered containers and cycle all endoscope channels must sterilization is not applicable. proper ventilation to remove toxic be flushed with 70% alcohol and Critical accessories (i.e. sclerother‑ vapors is essential. dried with air. apy needles, electrocautery probes and Periodic air quality monitoring • Colonization of bacteria may be hot biopsy forceps) should be sterilized of glutaraldehyde levels should be caused by residual water remaining or discarded after each use. performed. in the water hoses and reservoirs. Medical Equipment This could lead to contamination Keep all non‑critical equipment Automated Washers/ during subsequent instrument (i.e. teaching heads, light sources, processing. cameras) visibly clean with soap and Disinfectants Endoscopy unit cleaning/disin‑ water or recommended institutional CLEANING DISINFECTION AND disinfectant. fecting process may be standardized If significantly soiled, use an inter‑ by the use of scope washer/ disinfect‑ STERILIZATION PROCEDURES mediate disinfectant after cleaning. ants. This equipment may be useful in circulating germicides, containing Endoscope Withdrawal vapors and decreasing exposure of → Recommendations for personnel to contaminated equipment Precleaning at bedside Environment and disinfectants. → General Cleaning Meticulous manual cleaning must Leakage testing For general wipe‑down of equip‑ precede the use of any automated sys‑ → ment such as procedure carts, stretch‑ tem as previously described. Manual cleaning Enzymatic Rinse Air

ers, sinks, etc. after each use, an EPA Clean all non‑immersible parts of → registered housekeeping product is the endoscope with hospital recom‑ → recommended. mended surface disinfectant. → Spills The following capabilities must be → → In keeping with Universal Precau‑ present in any washer/ disinfectant; High level Storing the tions: • Enzymatic and/ or disinfectant Disinfection endoscope → • Use gloves; blot spills of blood or should be circulated through all Air → body fluid with disposable tow‑ channels at equal pressure without → els. trapping air. Rinse & Air → • Wipe the area with clean, dispos‑ • Washing and disinfecting cycles →

able towels soaked in a freshly should be followed by thorough Sterilization → prepared household bleach (1:10) rinsing cycles followed by forced → dilution or an EPA registered tu‑ air to remove the used solution. Alcohol flush → berculocidal ‘hospital disinfectant’ • Disinfectant should not be diluted and allow to dry. with wash or rinse water. Forced air Disinfectant spills should be han‑ • Routine disinfection of the wash‑ dled by consulting the solution MSDS er/disinfectant according to the (Material Safety Data Sheet) WHMIS manufacturer’s recommendations Guidelines. and institutional policy must be Page Twenty The Guiding Light, July 2001

Bibliography Lutz, B. “Every Patients Right” ASTM Stand‑ “Virus transmission via Fiberoptic Endoscope: ardization News. 1995, August 32‑35 Mini Quiz: Recommended Disinfection”. Endoscopy Society of Gastroenterology Nurses and Assist‑ Review, March/April 1989, 63‑64 ants. Recommended Guidelines for Infection GI Nursing Core “Multi‑state Investigation of the Actual Dis‑ Control (2nd Ed.) Rochester, NY: 1992. Curriculum infection / Sterilization of Endoscopes in Martin, A.M. Reichelder, M “APIC GUIDE‑ Health Care Facilities,” The American Jour‑ LINES FOR INFECTION CONTROL nal of Medicine, March/April 1992 PRACTICE: APIC guidelines for infection 1. The outermost layer of the es‑ “Infection Control During Gastrointestinal En‑ prevention and control in flexible endos‑ ophagus is made up of: doscopy” Gastrointestinal Endoscopy, vol.34 copy” AJIC AM J INFECT Control 1994; a. Mucosa (suppl.3) (May/June 1988, 37s‑40s) 22:19‑38 b. Submucosa “Pseudomonas Infection Linked to Contami‑ “Transmission of Mycobacterium Tuberculosis c. Muscularis nated Endoscopes” Hospital Infection Con‑ by a fiberoptic Bronchoscope” JAMA 1996: trol, Vol. 14 no. 5 (May 1987), 69‑84 1093-1095 d. Serosa “Standard Practice for Cleaning and Disinfec‑ Muscarella, L., “High‑level disinfection or steri‑ tion of Flexible Fiberoptic and Video Endo‑ lization of endoscopes” Infection Control 2. Outpouchings of the esophageal scopes Used in the Examination Of Hollow and Hospital Epidemiology. March 1996; wall located immediately above 17: 183‑187. Viscera” ASTM 1994 the lower esophageal sphincter Agerton, T., Valway, S., Gore, B., Pozsik, C., Olympus Evis 100 & 130 Cleaning and Disin‑ Plikaytis, B., Woodley, C., Onorator, l., fection Video 1997. are known as: “Transmission of a Highly Drug‑Resistant Olympus Evis 140 Reprocessing Video 1998. a. Zenkers diverticulum Strain (SrainW.) of Mycobacterium tubercu‑ Rutala, W.A., “APIC Guideline for selection b. Traction diverticula losis.” JAMA 1997; Vol 278, 1073‑1077 and use of Disinfectants.” American Journal c. Epiphrenic diverticula Dwyer, D., Klien, G., et al. “Salmonella New‑ of Infection Control, vol. 18, no.2 (April d. Intramural diverticulosis port Infection Transmitted by Fiberoptic 1990), 99‑117. Colonscopy.” Gastrointestinal Endoscope, Rutala, N. “FDA Labeling Requirements for vol.33, no2, 84‑87 Disinfection of Endoscopes: A Counterpoint” 3. A saclike structure in the pancreas Favaro, M.S. and Bond, W.,” Sterilization, Infection Control And Hospital Epidemiol‑ that is filled with fluid, blood, and Disinfection and Antisepsis in the Hospi‑ ogy 1995. 1995;16(4) 231‑235. pancreatic enzymes is called a: tal” Manual Of Clinical Microbiology (5th SGNA Guidelines for the use of High Level a. Pancreatic rest E.) Washington, DC: American Society for Disinfectants and Sterilants for Reprocess‑ Microbiology, 1990. ing of Flexible Gastrointestinal Endoscopes b. Pancreas divisum Hendrick, E.: “Cleaning and Disinfection of Feb 2000. c. Annular pancreas Endoscopes”. Plant, Technology And Safety SGNA Standards of Infection Control in d. Pseudocyst Management Series, no3 (1989), 42‑46 Reprocessing of Flexible Gastrointestinal Hendrick,E. et al. “Gastrointestinal Endosco‑ Endoscopes Feb 2000. py‑Infection Transmission And Prevention” 4. The parietal cells secrete: Advanced Sterilization Products (1999) Cidex a. Mucus Asepsis, Vol.9, no3 (1987), 2‑10 OPA Solution Material Safety Data Sheet Jonas, G., Mahoney, A., Murray, J., and Ger‑ (015) revision C. b. Hydrochloric acid and intrin‑ tler, S. “Chemical Colitis Due to Endoscope SGNA Standards of Infection Control in sic factor Cleaning Solutions: A Mimic of Pseudomem‑ Reprocessing of Flexible Gastrointestinal c. Pepsinogens branous Colitis.” Gastroenterology vol.95 Endoscopes Feb 2000. (1988), 1403‑8. d. Gastrin Decontamination of Reusable Medical Devices CSA International 2314:8‑00 March 2000 See answers on page 8.

Change of Name Address/Name Name:______

New Address:______

City:______Province:______MOVING? Postal Code:______Phone:______LET US KNOW! Remember to send in your Fax:______E-Mail:______change of address! The Guiding Light, July 2001 Page Twenty One

WORD SEARCH ASPIRATE j P D U O D E N O S C O P E P CHART CIDEX U b v t h G I L G N I D I U G COLON DUODENOSCOPE G A S t R I N b t O x E D I C EDMONTON C G A S t R O S C O P y A v v ENZYMES ESOPHAGUS P O A R A D I O L O G I S t C GASTRIN GASTROSCOPY R D L L N A N O I t I S O P C GUIDING LIGHT t h Q j N N O t N O M D E A O LIVER NEWSLETTER t C j C b y t R E v I L M N N NURSING ONCOLOGY E A E t A R I P S A z x R C C PANCREAS L M f U A h E N S y M E S R O PEN POSITION S O t h S U G A h P O S E E L PYLORUS RADIOLOGIST W t C v P E N O I t C U S A O SPHINCTER STENT E S P y L O R U S t E N t S G STOMACH N R h D O N U R S I N G N b y SUCTION

GUIDELINES FOR SUBMISSION to C.S.G.N.A. DISCLAIMER “THE GUIDING LIGHT” The Canadian Society of Gastroenterology Nurses • white paper with dimensions of 81/2 x 11 inches and Associates is proud to present The Guiding Light • double space newsletter as an educational tool for use in develop‑ • typewritten ing/promoting your own ­policies and procedures • margin of 1 inch and protocols. • submission must be in the possession of the newslet‑ The Canadian Society of Gastroenterology Nurses ter editor 6 weeks prior to the next issue and Associates does not assume any responsibility for • keep a copy of submission for your record the practices or recommendations of any individual, or • All submissions to the newsletter “The Guiding for the practices and policies of any Gastroenterology Light” will not be returned. Unit or endoscopy unit. 2001: AN EDMONTON GI ODYSSEY

SEPTEMBER 28-30,2001 FANTASYLAND HOTEL WEST EDMONTON MALL Patti Ofner Judy Langer (780) 973-6343(H) (780)463-1934(H) (780)477-4431 (W) CONTACT: (780)450-7116(W) Fax:(780)491-5739 or (780)450-7323 Fax:(780)450-7208 SCHOLARSHIP AWARDS 2001 CAG Jennifer Belbeck, Stoney Creek, Ontario

CSGNA REGIONAL

CSGNA ANNUAL Dianne Gray, Windsor, Ontario Debra Ann St. Louis, Tecumseh, Ontario Rachel Thibeault-Walsh, Ottawa, Ontario Pamela Hebert, St. Clair Beach, Ontario Robert W. Smith, Midland, Ontario Monique Travers, Orleans, Ontario Patsy Gosse, Torbay, Newfoundland Mabel Chator, Conception Bay, Newfoundland

Judy, Marlene, Sandy and Lorie – Happy Bunch! Great listeners!

C/O EDUCATION CHAIR: MARLENE SCRIVENS, 2107 BONNEAU PLACE, REGINA, SASK. S4V 0L4

APPLICATION FORM FOR CSGNA REGIONAL SCHOLARSHIPS AWARD

The Regional Conference award of $400.00 is to be used for travel and accommodation to a Regional Conference in Canada. Six scholarships will be awarded yearly.

EXCEPTIONS:

1. Applicant cannot have received THIS award in the previous two years. 2. Current members of the Executive and Conference Planning Committee are not eligible for this award. 3. Scholarships are available only to active members.

PLEASE SUBMIT THE FOLLOWING WITH THIS APPLICATION:

1. A written summary of how this scholarship and attendance at the proposed meeting would benefit you in your work. 2. A current Curriculum Vitae. 3. Please specify your past involvement in the CSGNA: e.g., acted as speaker at a meeting, actively recruited new members for CSGNA, aided in the formation of a local Chapter, served on an Ad Hoc Committee, and any Newsletter articles submitted. Describe your current involvement with your Chapter: e.g., fundraising or planning Chapter conferences. 4. Outline projected financial needs to attend this meeting. 5. Geographical location and related travel expenses will be taken into consideration by the Education Committee when scoring applications.

APPLICATION FORM AND SUBMISSIONS MUST BE RECEIVED BY THE EDUCATION CHAIR AT THE ABOVE ADDRESS AT LEAST 8 WEEKS PRIOR TO THE EVENT.

NAME:______

CIRCLE ALL THAT APPLY: RN BSN BAN MSN OTHER______

HOME ADDRESS:______

CITY:______PROV:______

POSTAL CODE:______HOME TELEPHONE: ( )______

FAX: ( )______

NAME OF THE MEETING YOU WISH TO ATTEND:______

DATE OF THE MEETING:______

CITY WHERE PROPOSED MEETING WILL BE HELD:______

JOINED THE CSGNA IN _ ____ (year).

SIGNATURE______DATE______C/O EDUCATION CHAIR: MARLENE SCRIVENS, 2107 BONNEAU PLACE, REGINA, SASK. S4V 0L4

APPLICATION FORM FOR CSGNA ANNUAL SCHOLARSHIP AWARD

The Annual National Conference award of $700.00 is to be used for travel and accommodation to the Annual National Conference in Canada.

EXCEPTIONS:

1. Applicant cannot have received THIS award in the previous two years. 2. Current members of the Executive and Conference Planning Committee are not eligible for this award. 3. Scholarships are available only to active members.

PLEASE SUBMIT THE FOLLOWING WITH THIS APPLICATION:

1. A written summary of how this scholarship and attendance at the proposed meeting would benefit you in your work. 2. A current Curriculum Vitae. 3. Please specify your past involvement in the CSGNA: e.g., acted as speaker at a meeting, actively recruited new members for CSGNA, aided in the formation of a local Chapter, served on an Ad Hoc Committee, and any Newsletter articles submitted. Describe your current involvement with your Chapter: e.g., fundraising or planning Chapter conferences. 4. Outline projected financial needs to attend this meeting. 5. Geographical location and related travel expenses will be taken into consideration by the Education Committee when scoring applications. 6. Copy of CSGNA Membership Card.

APPLICATION FORM AND SUBMISSIONS MUST BE RECEIVED BY THE EDUCATION CHAIR AT THE ABOVE ADDRESS BY JUNE 1 OF THE CURRENT YEAR.

NAME:______

CIRCLE ALL THAT APPLY: RN BSN BAN MSN OTHER______

HOME ADDRESS:______

CITY:______PROV:______

POSTAL CODE:______HOME TELEPHONE: ( )______

FAX: ( )______E-MAIL:______

HOSPITAL/EMPLOYER:______

WORK ADDRESS:______

CITY:______PROV:______

POSTAL CODE:______JOINED THE CSGNA IN ______(year).

SIGNATURE______DATE______C/O EDUCATION CHAIR: MARLENE SCRIVENS, 2107 BONNEAU PLACE, REGINA, SASK. S4V 0L4 APPLICATION FORM FOR CAG NURSE SCHOLARSHIP PRIZES

The Canadian Association of Gastroenterologists (CAG) scholarship prizes are available to one research nurse and one endoscopy nurse in the amount of $500.00 each, to be used for travel to an appropriate endoscopic gastroenterology or research meeting. The CAG nurse scholarship prize is sponsored by an Educational Grant from the Canadian Association of Gastroenterology.

ELIGIBILITY:

1. You are and have been for two years or more, an active member of the CSGNA. 2. You actively support CSGNA goals and objectives.

PRIZE APPLYING FOR: (please circle one) RESEARCH NURSE ENDOSCOPY NURSE

PLEASE SUBMIT THE FOLLOWING WITH THIS APPLICATION:

1. A two page summary of how this scholarship and attendance at the proposed meeting would benefit you in your research / endo - clinical role in gastroenterology, and what self initiated research projects you are involved in. 2. A current Curriculum Vitae. 3. A letter of reference from your Unit Director. 4. Two letters of reference from CAG members. 5. Copy of CSGNA Membership Card.

APPLICATION FORMS AND SUBMISSIONS MUST BE RECEIVED BY THE EDUCATION CHAIR AT THE ABOVE ADDRESS BY FEBRUARY 15 OF THE CURRENT YEAR. THEY WILL BE FORWARDED TO THE SECRETARY OF THE CAG FOR SELECTION.

NAME:______

CIRCLE ALL THAT APPLY: RN BSN BAN MSN OTHER______

HOME ADDRESS:______

CITY:______PROV:______POSTAL CODE:______

HOME TELEPHONE: ( )______FAX: ( )______

HOSPITAL / EMPLOYER:______

WORK ADDRESS:______

CITY:______PROV:______POSTAL CODE:______

NAME OF DIRECTOR OF UNIT:______

NAME OF THE MEETING YOU WISH TO ATTEND:______

DATE OF THE MEETING:______CITY WHERE MEETING WILL BE HELD:______

JOINED THE CSGNA IN ______(year). E-MAIL:______

SIGNATURE______DATE______180 Waterford Br. Rd., St. John’s, Newfoundland A1E 1E2

20 SIGNEA MEMBERSHIP MEMBERSHIP APPLICATION SOCIETY OF INTERNATIONAL GASTROENTEROLOGICAL NURSES AND ENDOSCOPY ASSOCIATES

Individual Membership Individual Memberships for Gastroenterological Nurses and Endoscopy Associates are available for $10.00 annually ($US). Affiliate Membership Individuals interested in joining SIGNEA, such as physicians, other medical professionals, and non G.E. nurses, pay affiliate membership fees of $50 annually ($US). National G.E. Nursing Organization Membership Membership in SIGNEA is available to national nursing organizations. Membership inquiries may be sent to the SIGNEA Secretariat. National G.E. Nursing organization dues are dependent upon the number of national members in each organization. Membership applications should be accompanied by payment and the name of the organization’s official contact person. Corporate Membership SIGNEA welcomes corporate memberships by companies which supply G.E. products, drugs, general medical equipment and any service that would be utilized by G.E. nurses. Detailed corporate membership information may be obtained from: Pat Pethigal, Chair, fax: 206.223.6379, phone: 206.223.6965 or the SIGNEA Secretariat. WORKPLACE  Check Membership Level/Payment 1 year 2 year 3 year Endoscopy Unit/Hospital  Endoscopy Unit/Clinic  Inpatient/Outpatient Individual Membership $10  $20  $30 

POSITION Affiliate Membership $50  $100  $150   Administrative/Director  Consultant Nurse National G.E. Nursing up to 100 $50  $100  $150   Head Nurse Membership  Staff Nurse 101 - 400 $200  $400  $600   Supervisor/Coordinator  Technician (Patient Care) 401 - 1,000 $400  $800  $1,200   Clinical Specialist  Educator  Over 1,000 $750  $1,500  $2,250  Researcher  Technician (machine)  Nurse Practitioner Corporate Membership $1,000  $2,000  $3,000   Manufacturer Representative  Corporate nurse Consultant Please add an additional $15 for those checks that are drawn off Non-US banks. $ ______Total Pymnt.  Other______

# Years Education/Training First Name (Given Name) ______1 Year ______2 Year ______3 Year Last Name (Family Name) ______4 Year ______5 Year

Address for Mail City

State/Province Country Postal Code

Telephone Fax Email address

Employing Organization Title Send completed form to: Kimberly Svevo, SIGNEA 401 N. Michigan Ave., Suite 2200 Chicago, IL 60611 USA Phone: 312.644.6610 Fax: 312.321.6869 E-mail: [email protected]

27 Nicholson Dr., Lakeside, Nova Scotia B3T 1B3 MEMBERSHIP APPLICATION FORMULE D’APPLICATION (CHECK ONE) (COCHEZ UN) ACTIVE ACTIVE $40.00 40,00$ Open to nurses or other health care professionals engaged in full- or Ouvert aux infirmières et autres membres de la santé engagés à plein part-time gastroenterology and endoscopy procedure in supervisory, ou demi-temps en gastroentérologie ou procédure endoscopique teaching, research, clinical or administrative capacities. en temps que superviseurs, engeignants, recherches application clinique ou administrative. AFFILIATE $40.00 AFFILIÉE Open to physicians active in gastroenterology/endoscopy, or persons 40,00$ engaged in any activities relevant to gastroenterology/endoscopy Ouvert aux médecins, actifs en gastroentérologie endoscopique ou (includes commercial representatives on an individual basis). personnes engagés en activités en gastroentérologie/endoscopiques incluant représentants de compagnies sur une base individuelle. LIFETIME MEMBERSHIP MEMBRE Appointed by CSGNA Executive. À VIE Appointed by CSGNA Executive.

E-MAIL: Page Thirty Two The Guiding Light, July 2001

CSGNA 2000-2001 Executive

PRESIDENT______NEWSLETTER EDITOR______PRESIDENT ELECT______LORRAINE MILLER HAMLYN KAY RHODES LORIE McGEOUGH 180 Waterford Br. Rd. 72 Hiscock Blvd. G. I. Unit St. John’s Newfoundland Scarborough, Ontario Pasqua Hospital A1E 1E2 M1G 1T1 4101 Dewdney Avenue (709) 722-0294 (H) (416) 289-2328 (H) Regina, Saskatchewan (709) 778-6737 (W) (416) 480-4005 (W) S4T 1A5 E-MAIL: [email protected] FAX: (416) 480-6762 (306) 766-2441 (W) FAX: (709) 722-0294 E-MAIL: [email protected] (306) 766-2762 (W) E-MAIL: [email protected] FAX: (306) 766-2513 E-MAIL: [email protected]

SECRETARY______CANADA EAST DIRECTORS______ELAINE BINGER linda Feltham EVELYN McMULLEN 113 Spragg Circle 74 Penetanguishene Road 5532 Northridge Rd. Markham, Ontario St. John’s, Newfoundland Halifax, Nova Scotia L3P 7N4 A1A 4Z8 B3K 4B1 (905) 294-3378 (H) (709) 753-6756 (H) (902) 453-6151 (H) (905) 472-7036 (W) (709) 737-6431 (W) (902) 473-4006 (W) FAX: (905) 472-7086 FAX: (709) 737-3605 FAX: (902) 473-4406 E-MAIL: [email protected] E-MAIL: [email protected]

TREASURER/MEMBERSHIP______CANADA CENTRE DIRECTORS______EDNA LANG NANCY CAMPBELL SANDY SAIOUD 27 Nicholson Dr. Endoscopy Unit 113 Commonwealth Avenue Lakeside, Nova Scotia Montfort Hospital Scarborough, Ontario B3T 1B3 713 Montreal Road M1K 4K6 (902) 876-2521 (H) Ottawa, Ontario (416) 261-5664 (H) (902) 473-4006 (W) K1K 0T2 (416) 284-8131 Ext. 4037 (W) FAX: (902) 473-4406 (613) 746-4621 Ext. 2704 FAX: (416) 281-7141 E-MAIL: [email protected] FAX: (613) 748-4914 E-MAIL: [email protected] E-MAIL: [email protected]

EDUCATION CHAIR______CANADA WEST DIRECTORS______MARLENE SCRIVENS EVELYN HILDERMAN JUDY LANGNER G.I. Unit 109 Strathearn Garden S.W. 129 Greenoch Cres. Pasqua Hospital Calgary, Alberta Edmonton, Alberta 4101 Dewdney Avenue T3H 2R1 T6L 1W6 Regina, Saskatchewan (403) 246-8036 (H) (780) 463-1934 (H) S4T 1A5 (403) 291-8922 (W) (780) 450-7116 (W) (306) 766-2441 (W) FAX: (403) 291-1599 or (780) 450-7323 (W) (306) 789-3305 (H) E-MAIL: [email protected] FAX: (780) 450-7208 FAX: (306) 766-2513 E-MAIL: [email protected] e-mail: [email protected] Website: www.csgna.com