The inspiration for the development of the nasogastroscopy service at our Trust started in October 2016 at the National Nurse Endoscopist Group annual meeting in Birmingham. During the conference, there was a presentation on nasogastroscopy by nurse endoscopist Anna Benton from Portsmouth NHS Trust. Her presentation outlined the benefits of the technique, how she had trained to complete the procedure and the benefits of the technique for patients. Part of her presentation included a live demonstration of a nasogastroscopy test on a volunteer (Dan, one of the company representatives), who kindly volunteered to starve on the day.
My background in endoscopy has mainly been in upper gastrointestinal (GI) work. I trained as a nurse endoscopist before the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) (https://www.thejag.org.uk) was established in the 1990s. My work followed my husband to the South West, and I have been working for Taunton and Somerset NHS Foundation Trust since 2015.
Like many nurse endoscopists and nurses generally who work in endoscopy, I have always been conscious of the challenges regarding the discomfort and gagging some people endure during a conventional oral gastroscopy test. As I watched Anna's demonstration, I immediately saw the benefits of using the technique. Dan was sitting upright in a chair, he was able to talk comfortably and laugh, and there was no gagging. Along with many others in the audience, I knew immediately that nasogastroscopy was a game changer in upper GI endoscopic work. I left the conference feeling motivated to find a way to bring it to our Trust.
Context and service development
The challenges facing the NHS nationally in terms of funding and the logistics of running a range of diverse services are not in question.
Endoscopy services are in constant demand and many units have growing waiting lists, partly in response to an increasing and ageing population. But it is not only changing demographics that are influencing demand. Public health screening projects and the introduction of diagnostic tests in primary care, such as the faecal immunochemical test (FIT), are also placing greater demand on diagnostic services.
In 2016, like many other endoscopy units, our unit at Musgrove Park Hospital was looking for ways to accommodate growing demand. Given the tight budgets, I thought we were unlikely to get funding, but unless we tried we would never know. Initially, I approached my then manager, Amanda Knight, and our endoscopy service lead, consultant gastroenterologist Emma Greig, about nasogastroscopy and its potential to add diagnostic capacity locally in Somerset.
To explain the local context in our Trust, we have two endoscopy units based between Musgrove Park Hospital and Bridgwater Community Hospital. Most of our complex care and therapeutic work occurs in Musgrove Park. However, general diagnostic work and the bowel cancer screening programmes were based at Bridgwater Community Hospital. This unit was primarily designed for diagnostic and screening services. The bowel screening lists ran for 3 days a week, potentially leaving 2 days to slot in a nasogastroscopy service, which looked like a feasible way to increase our capacity and so was worth pursuing.
Listening and evolution
Both Amanda and Emma had listened and responded to my idea by exploring its feasibility and seeing how we could make it work. We were all involved with writing a business plan for the project and worked our way through the trust process over a period of 9 months.
From the outset, we were never sure if the proposal would be approved, and Amanda and Emma were involved in most of the conversations with the executives. We had to provide data regarding the potential provision of the service, staffing and cost of purchasing equipment, which at times was challenging. In hindsight, the business case process is rigorous for good reason, but I always felt that the executives were approachable and supportive in our bid. The business case was accepted in August 2017, after which tendering began to ensure the equipment we needed was purchased by the end of the financial year (March 2018).
Training and service logistics
During the time of the business case review in 2017, Emma and I worked out a training plan that we considered to be the most appropriate way to start learning about the technique and nasal intubation. At Musgrove Park, we had one neonatal scope that could be utilised for nasogastroscopy. So, regardless of whether we got the business case approved, we considered that it was still a technique that was worth learning.
Following the experience and guidance—again from Anna from Portsmouth NHS Trust—we contacted our ear nose and throat colleagues to attend a few of their fast-track referral clinics, in which the majority of patients had nasoendoscopy as part of the initial assessment. We were able to observe these clinics for a few weeks and build our confidence with anatomy and nasal intubation, and preparation of nostrils for tests. There was much to learn from the whole team—nurses and doctors—who also shared their guidance on epistaxis management, which features in our aftercare patient leaflets.
Alongside our local training, and with the support of the company that had won the tender, we both attended the 5th European Transnasal Endoscopy Training Workshop at the Royal Free Hospital in London. This workshop has more recently been endorsed by the British Society of Gastroenterology (BSG) and is a helpful course to attend: it provides a general introduction to the technique and how to set up a transnasal service.
We were also able to visit a primary care-led treatment centre in Edinburgh, via NHS Lothian, The Leith Community Treatment Centre, to see an established nasogastroscopy service in action in a community setting. The service ran in a primary care treatment centre, by a team of clinicians from the Edinburgh Royal Infirmary. This service is now based in the Edinburgh Royal Infirmary. The visit to Leith gave us great insight into the patient experience, enabling us to observe the patient from admission, nasal preparation by the admitting nurse and consent through to the procedure and aftercare. The team were generous with their time, sharing practice, patient information and nasal preparation guidance, all of which helped us in developing our service.
Training for the endoscopy team
The training for nurses and technicians in the unit was structured around the patient journey. Guidelines were written on the nasal preparation procedure and, with the help of a resuscitation manikin, I prepared a training video for all admitting staff. I wrote all the patient information leaflets and aftercare leaflets, which were then reviewed and approved by our trust patient information panel. I also produced a training video for the management of epistaxis and the insertion of nasal tampons in the event of severe nasal trauma and nosebleeds, a risk during and after the procedure.
In the final stages before we started the lists, we ran training lists at Musgrove Park, which were attended by our ear nose and throat consultants, and also respiratory team doctors, who also intubate via the nose.
We ran these training lists by inviting selected patients with covering letters to explain to the public why we were developing the service. The entire team got behind the project and contributed to making the service happen. The nasogastroscopy service was finally launched at Bridgwater Community Hospital in July 2018 and continues to run to date.
BJN Awards
Around October 2018, I happened to notice the publicity for this annual event and decided to check the website for entry qualifications for the BJN Awards. Even though the service had only been running for 4 months, I was proud of what we had achieved as a team and the patients, so I decided to enter. Again, I thought, we probably didn't stand a chance, but unless you try you never know. I wanted to shout about a service that was working well.
The application process involved answering questions about your service or work. Although it was too early for us to have much demonstrable data, I knew we were offering improved access for many patients, such as wheelchair users, patients with Parkinson's who had severe head drop and tremor, and maxillofacial patients who cannot physically open their mouths for a conventional test. These patients were able to successfully have the test via the nasoendoscopy approach. Our service improved access and tolerance for many patients.
I did not expect to hear from the BJN Awards and was thrilled when an email arrived explaining that we had been shortlisted and inviting us to the ceremony. This was attended by our consultant gastroenterologist Emma and myself. When we found out that we were the runners up in the gastrointestinal/IBD nurse of the year 2019 category, it gave the team and our Trust such a boost. Since getting the award, we have received congratulations from across the country and winning the award has sparked interest and inquiries from other units, which are keen to set up similar services in the UK.
I would encourage anyone to enter the BJN Awards and celebrate nursing.