Performance of Flexible Sigmoidoscopy by Registered Nurses for the Purpose of Colorectal Cancer Screening

Disclaimer

The Society of Gastroenterology Nurses and Associates, Inc. present this guideline for use in developing institutional policies, procedures, and/or protocols. Information contained in this guideline is based on published data and current practice. The Society of Gastroenterology Nurses and Associates, Inc. assumes no responsibility for the practices or recommendations of any member or other practitioner, or for the policies and procedures of any practice setting. The registered nurse functions within the limitations of licensure, state nurse practice act, and institutional policy.

Acknowledgments

First edition 1996, Revised 2003.

This document was prepared and written by the Society of Gastroenterology Nurses and Associates, Inc. Practice Committee and adopted by the Society of Gastroenterology Nurses and Associates, Inc. Board of Directors 1999. Published as a service to members by the Society of Gastroenterology Nurses and Associates, Inc.

Copyright © 2003, Society of Gastroenterology Nurses and Associates, Inc. Additional reprints are available for purchase from the Society of Gastroenterology Nurses and Associates, Inc. (SGNA). To order, please write or call SGNA.

Society of Gastroenterology Nurses and Associates, Inc.
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Performance of Flexible Sigmoidoscopy by Registered Nurses for the Purpose of Colorectal Cancer Screening

Preface

The delivery of health care in the field of gastroenterology and endoscopy is expanding, thus modifying the traditional role of the registered nurse. Colorectal cancer is a leading cause of cancer death in the United States. It is believed that early detection and removal of adenomatous polyps can prevent most colorectal cancers. Current research and practice publications illustrate the safety, accuracy and support for the performance of routine screening flexible sigmoidoscopy by registered nurses.

The Society of Gastroenterology Nurses and Associates, Inc. (SGNA) supports the position that registered nurses educated and experienced in gastroenterology nursing and trained in techniques of flexible sigmoidoscopy may assume this responsibility for the purpose of colorectal cancer screening.

Definition of Terms

For the purpose of this document, SGNA has adopted the following definitions:

Flexible sigmoidoscopy refers to the examination of the mucosal lining of the rectum, sigmoid colon and may include examination of a portion of the descending colon (AMA, 2002).

Average risk for colorectal cancer includes persons age 50 or older but asymptomatic and with no other prior family or personal history of adenomatous polyps, colorectal cancers, or other secreting organ cancers (Lieberman, 2002).

High risk for colorectal cancer includes persons with a history of adenomatous polyps, colorectal cancer or inflammatory bowel disease, close relative(s) who have had colorectal cancer or an adenomatous polyp, or a family history of familial adenomatous polyposis or hereditary non-polyposis colorectal cancer (American Cancer Society, 2002).

General Principles

The competent performance of flexible sigmoidoscopy requires both cognitive and technical skills. Knowledge of the anatomy, physiology, and pathology of the colon and abdomen and indications/contraindications to the procedure are essential. SGNA believes that nurse endoscopists can best document their expertise in the field through board certification, and therefore recommends that registered nurses performing endoscopy hold current certification from the Certifying Board of Gastroenterology Nurses and Associates (CBGNA). Experience and good hand-eye coordination are also required to perform a safe and thorough examination.

Medical supervision is determined by institutional policy. SGNA recommends that a minimum of 30 flexible sigmoidoscopies be performed under the supervision of a skilled physician endoscopist before a registered nurse performs this procedure independently (ASGE, 1998; ASGE, 2002; Cash, 1998; Schoenfield, 1999; Sprout, 2000).

A quality-monitoring plan should be in place for each practice setting.

Indications for the Performance of Screening Flexible Sigmoidoscopy by the Registered Nurse

The American Cancer Society (2002) recommends sigmoidoscopy every 3 to 5 years after the age of 50. Screening flexible sigmoidoscopy by registered nurses is appropriate for adults defined as average risk.

Contraindications for the Performance of Screening Flexible Sigmoidoscopy by the Registered Nurse

• An indication for colonoscopy
• Inflammatory bowel disease (IBD)
• Recent cardiac or pulmonary event
• Acute illness
• Symptoms of colorectal disease
• Previous colorectal cancer diagnosis (Gruber, 1996; Gruber, 1999; Smith, 1999; Wallace, 1999)

Competencies

Phase I (Eisemon, 2001)

Cognitive Skills for the Registered Nurse Performing Flexible Sigmoidoscopy

• Describes the indications/contraindications for screening flexible sigmoidoscopy, including the definition of average and high-risk.
• Distinguishes normal versus abnormal anatomy, physiology, and pathophysiology of the abdomen, anus, rectum, sigmoid and descending colon.
• Identifies options for patient bowel preparation
• Obtains informed consent and discusses risks, benefits, and alternatives to flexible sigmoidoscopy
• Provides patient education, which includes



• Purpose of procedure
  
• Positioning and relaxation methods
  
• Sensations the patient is likely to experience
  



• Identifies indications for antibiotic prophylaxis based on current recommendations
• Demonstrates knowledge of and ensures compliance with SGNA guidelines for cleaning, disinfecting, and storing flexible sigmoidoscope and accessories
• Identifies and initiates nursing interventions for adverse reactions, such as



• Pain
• Perforation
• Bleeding
• Infection
• Vasovagal response- Abdominal distention



• Documents per institutional policy, including findings and outcomes, actions and interventions, patient response, and patient education.
• Communicates outcomes or recommendations for follow-up care to the patient’s primary healthcare provider
• Communicates findings and recommendations to the patient as appropriate
• Assumes responsibilities related to abnormal findings



• Notifies supervising physician
• Documents per institutional policy
• After consultation with the supervising physician, refers patients requiring further work-up to the appropriate provider (primary care provider, gastroenterologist, or surgeon) for diagnostic/therapeutic studies including follow-up of biopsy findings

Phase II (Eisemon, 2001)

Technical Skills for the Registered Nurse Performing Flexible Sigmoidoscopy

• Demonstrates the proper techniques of flexible sigmoidoscopy, including patient positioning and digital rectal examination
• Demonstrates correct functioning of equipment and manipulation of the endoscope including insertion, insufflation, advancement, and withdrawal techniques
• Completes examination in an average of 10 minutes and achieves an adequate depth of insertion with minimal patient discomfort
• Obtains biopsy specimen according to institutional policy

Phase III (Eisemon, 2001)

Continued Competency and Quality Monitoring for the Registered Nurse

• Maintains quality and competency in performing digital rectal exam and flexible sigmoidoscopy
• Documents continuing education and competency at least annually

References

American Cancer Society, Inc. (2002). Cancer facts and figures. Atlanta, GA: Author.

American Cancer Society, Inc. (2002). What are the risk factors for colon and rectum cancer? [online] http://www.cancer.org.

American Medical Association (AMA). (2002). Current Procedural Terminology: CPT 2002. Chicago: AMA Press.

American Society for Gastrointestinal Endoscopy. (1998). Endoscopy by non-physicians. Guidelines for clinical applications (ASGE publication No. 1035). Manchester, MA: Author.

American Society for Gastrointestinal Endoscopy. (2002). Methods of granting privileges to perform gastrointestinal endoscopy. Gastrointestinal Endoscopy, 55, 780-783.

Cash, B., Schoenfeld, P., & Ransohoff, D. F. (1998). Licensure, utilization and training of paramedical personnel to perform flexible sigmoidoscopy. Gastrointestinal Endoscopy, 49, 163-169.

Eisemon, N, Stucky-Marshall, L, and Talamonti, M. (2001). Screening for colorectal cancer: developing a preventive healthcare program utilizing nurse endoscopists. Gastroenterology Nursing, 24(1):12-19.

Gruber, M. (1996). Performance of flexible sigmoidoscopy by clinical nurse specialist. Gastroenterology Nursing, 19, 105-108.

Gruber, M., Watson, C., Spaulding, M., & Mahl, T. (1999). Implementation of a process action team to improve colorectal cancer screening and treatment. Veterans’ Health System Journal, 2(2), 37-43.

Leiberman, D (2000). Colon cancer screening: role of endoscopy. [Clinical Update]. [online] http://www.asge.org

Schoenfeld, P. (1999). Flexible sigmoidoscopy by paramedical personnel. Journal of Clinical Gastroenterology, 28, 110-116.

Smith, P. (1999). The role of the gastroenterology nurse in colorectal cancer screening. Gastroenterology Nursing, 22, 217-220.

Sprout, J. (2000). Nurse endoscopist training: the next step. Gastrointestinal Nursing, 23(3), 111-115.

Wallace, M., Kemp, J., Meyer, F., et al. (1999). Screening for colorectal cancer with flexible sigmoidoscopy by nonphysician endoscopists. American Journal of Medicine, 107: 214-218.

Additional Source Materials

Johnson, B. A. (1999). Flexible sigmoidoscopy: Screening for colorectal cancer. American Family Physician, 59, 313-324.

Read, T., & Kodner, I. (1999). Colorectal cancer: Risk factors and recommendations for early detection. American Family Physician, 59, 3083-3092.

Schoenfeld, P., Cash, B., Kita, J., et al. (1999). Effectiveness and patient satisfaction with screening flexible sigmoidoscopy performed by registered nurses. Gastrointestinal Endoscopy, 49 (2), 158-161.

Schoenfeld, P., Lipscomb, S., Crook, J.,et al. (1999). Accuracy of polyp detection during screening flexible sigmoidoscopy by nurse endoscopists and gastroenterologists. Gastroenterology 117, 312-318.

Society of Gastroenterology Nurses and Associates, Inc. (1998). Gastroenterology Nursing. A Core Curriculum (2nd Edition). St Louis: Mosby.

Society of Gastroenterology Nurses and Associates, Inc. (2000). Manual of Gastrointestinal Procedures (4th Edition). Chicago, IL: Author.

Winawer, S. J., Fletcher, R. H., Miller L., Godlee, et al. (1997). Colorectal cancer screening: Clinical guidelines and rationale. Gastroenterology, 112, 594-642.

Wright, K. (2000). The description of the gastroenterology nurse endoscopist role in the United States. Gastroenterology Nursing, 23(2): 78-82.

Practice committee members 2002-2003

Marilee Ball,MHA,RN,CGRN - Committee chair

Susan L. Bohlander,BSN,RN,CGRN

Deb Huber,MSN,RN,CGRN,ARNP

Debbie L. Miller,AND,RN

Lisa D. Miller,LPN,CGN

Nancy B. Miller,RN,CGRN

Sharon C.Reid,ADN,RN,CGRN

Cindy A.Taylor,MSA,BSN,RN,CGRN

Patricia M. Maher,RN,CGRN

Cynthia M. Friis,RN,BSN,MEd