By Allison Mascarenhas, Vizient Senior Category Manager
Janet Tamborini, Sg2 Consulting Director, Intelligence
Gastroenterologists spend a significant amount of time performing endoscopic procedures throughout their medical career — theoretically, as many as 100,000 procedures in a 35-year career span.
While gastroenterologists are saving lives with these vital endoscopy procedures, they need to be mindful of their own health and well-being, as poor body mechanics and improper ergonomics are negatively impacting their health, productivity and career longevity. Musculoskeletal injuries are prevalent among GI physicians: A variety of studies over the years have determined that 37% to 89% of gastroenterologists suffer from musculoskeletal (MSK) pain as a result of their practice.
A combination of factors contributes to this severe problem including the design of the flexible endoscopes, the repetitive, awkward motion when using the device and other external factors. While examining the detrimental influences, there are existing and future actions that can mitigate these endoscopic-related injuries. Vizient’s insights and recommendations are centered on colonoscopy due to the category’s current and projected procedural volumes and the dramatic manipulations applied to these procedures. However, it is not the only specialty with these concerns — there is equally compelling data within urology and other endoscopy categories.
A flexible colonoscope weighs less than 11 pounds, which falls within a safe one-handed handling range. However, the acceptable range by Occupational Safety and Health Administration standards decreases as duration dependent. In a 15- to 20-minute procedure, the device can be a source of fatigue even in static holding positions. Factoring in the one-size-fits-all design of the control head and angulation knobs, the problem is exacerbated for physicians who have smaller hands. Smaller hands are disadvantaged for a comfortable fit and manipulation of the controls with grip, reach and strength.
The repetitive motion and exaggerated body mechanics associated with unwieldy, long flexible scopes is a significant factor in physician pain and injury. While advancing the endoscope’s insertion tube through the anatomy, there is a high degree of repetitive force, torque and bend on the physician’s hips, back and shoulders. As they manipulate the controls on the scope there is additional flexion and extension of their fingers, hand, wrist, forearm, elbow and shoulder. According to The American Journal of Gastroenterology, the most common actions attributed to endoscopy-related musculoskeletal injuries were torquing (65%), supporting the scope in an awkward position (62%), standing for prolonged periods (60.3%), and adjusting the tip angulation (55.8%).
Certain patient characteristics are correlated with higher incidence muscle exertion and prolonged cases. Female patients and patients with a body mass index of 25 kg/m2 or lower are associated with longer procedural times and increased, measured muscle strain. It is suspected that lack of visceral fat, colonic tortuosity, altered anatomy from a hysterectomy or other anomalies can significantly affect insertion tube navigation during the procedure, adding to the degree of difficulty and duration. While these conditions cannot be controlled, it is important to acknowledge the potential added risk and add counteractive measures of intervention.
The source and location of injury will vary for physicians, as will the consequences, severity and combination of ailments. Common physical ailments include frozen shoulder, osteoarthritis and tendonitis. Reports of endoscopy-related injuries were most common in the thumb (63.3%), neck (59%), hand/finger (56.5%), lower back (52.6%), shoulder (47%) and wrist (45%). These injuries can result in short term or lifelong disability presenting as a disruption with missed work and lost productivity or a more devastating impact with an early departure from practice. To promote improved body mechanics and an ergonomic environment, Vizient recommends the following solutions:
- Training and timeout: Despite the prolific evidence and disheartening consequences of MSK disorders in the practice of endoscopy, there are encouraging simple immediate solutions and promising aid in the future. The first effort to combat ergonomic strain is awareness of potential injury at the onset of a physician’s career during residency. Training on ergonomic principles with lessons on physical conditioning and stretching exercises produces positive results with fewer reported injuries. Taking breaks or “micro breaks” allows rest and recovery of muscles, tendons and ligaments. Timeout pre-procedure with a checklist allows for a quick assessment of conditions and an opportunity to adjust to a healthier set-up and environment without compromise.
- Ergonomic device solutions: There are a variety of ergonomic products that can be introduced in procedural settings such as back braces and scope holders. Since the viewing monitor should be positioned in a direct line of sight and at eye level to avoid excessive head and neck twisting, it is important to ensure that the monitors are mounted on fully articulating arms. Likewise, the patient surface, stretcher, bed or surgical table should be height adjustable for optimal seated or standing position. If standing, use anti-fatigue mats or more appropriate footwear. Stools and chairs may seem like a commodity to some who select this “furniture” but never use it. However, consider it more like a tool and evaluate it with the right features promoting ergonomics.
Lead aprons are requisite attire in the presence of fluoroscopy. As a safety device, there is a struggle to find the balance between effectiveness and lightweight for comfort. It is noted that a 15-pound lead apron can place up to 300 pounds per square inch of pressure on the wearer’s intravertebral discs, and their frequent use has been shown to be associated with an increased incidence of back pain. Participating in the healthcare system’s ergonomic task force will allow for the discovery of solutions used in other departments, as will inviting committee members to tailor options for the endoscopy setting.
- Future scope design considerations: Scope manufacturers will continue to be part of the solution in circumventing ergonomic strain with enhancements for field of view, bend radius, tip angulation, adjustable flexibility and stiffness, navigation guidance, and other material and contouring technologies that reduce force and exertion. Variations on the traditional, upright scope control body with a more relaxed, natural pistol grip design are emerging. As studies and awareness of hand size and strength bring future design consideration for reusable scopes, the increasing introduction of lightweight, disposable endoscopes — including those for colonoscopy — will potentially spotlight the weight disparity and present an opportunity for continued ergonomic enhancements. That includes novel innovations such as steerable and robotic-assisted endoscopes that inch through the anatomy to prevent excessive force during insertion while enhancing visibility and contributing to ergonomic safety.
Musculoskeletal injuries in the GI endoscopy field can be addressed with awareness, training, physical intervention and ancillary products. It is a burden that can be shared and countered by physicians and device manufacturers who can reimagine the technology and design for more comfortable, effective use.
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About the authors
Allison Mascarenhas is a senior category manager on Vizient’s capital, imaging and asset management team. She has more than eight years of experience in medical supply chain operations, health insurance and managed care administration. Her educational background includes a Bachelor of Science in biological sciences from Louisiana State University, a Master of Public Health with a concentration in health policy and systems management from Louisiana State University Health Sciences Center, and a Master of Business Administration from the University of New Orleans.
Janet Tamborini is a consulting director, intelligence, on the Sg2 spend management team. She has more than 25 years in healthcare marketing with surgical product development, commercial marketing, strategic partnerships and clinical market insights. She supports the company’s thought leaders and supply chain leaders with actionable insights and deliverables that leverage its data, analytics and research. Tamborini has a Bachelor of Arts from Bowling Green State University and has been a long-standing member of the Association of Perioperative Registered Nurses.