What documentation requirements apply to endoscopy premises?

The Procedures Standard Advice to the Profession document contains information regarding what needs to be documented by a physician in relation to a certain patient and procedure. The Quality Assurance Standard also contains further requirements regarding what should be reviewed in the patient record when undertaking a record review as part of the quality assurance process.

In addition to what is set out in those two documents, physicians performing endoscopies need to ensure that they document which scope, including serial number, was used on which patient if not done automatically by the endoscope technology. The same information will need to be documented when reprocessing scopes.

What drugs and equipment does an endoscopy premises need to have onsite?

In addition to the drugs listed in the Drugs and Equipment Standard, endoscopy premises need to have the appropriate drugs and equipment immediately available to remove polyps and manage complications.

Examples of drugs and equipment that may be appropriate to remove polyps and manage complications include:

• thermal devices,
• vasoconstricting agents,
• clipping devices, and
• tattooing equipment.

Are there specific Infection Prevention and Control (IPAC) requirements for endoscopy premises?

All OHPs are required to comply with the requirements in Public Health Ontario’s Infection Prevention and Control for Clinical Office Practice document.

In addition to the requirements in this document, endoscopy premises need to ensure they:

• Use automatic endoscopic reprocessors (AERs) for all procedures.
• Have enough AER capacity to ensure that the necessary endoscopes are cleaned and ready for use before the next scheduled patient.
• Have an automatic irrigator available for every patient.

Public Health Ontario’s Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices In All Health Care Settings also provides helpful guidance for endoscopy premises to ensure that the critical elements and methods of decontamination, disinfection and sterilization are incorporated into health care facility procedures.

What other resources or guidelines do endoscopy premises and providers need to be aware of?

Cancer Care Ontario’s Gastroscopy Standards and Quality Indicators for Ontario is an important resource for endoscopy providers. Endoscopy providers need to be aware of the Standards set out in this document and comply with them, where relevant.