In my work with hospitals in the Midwest, it’s often part of my daily work life to assist with the introduction of new procedures and protocols. In some ways, this is the most exciting thing I do professionally.

Reflecting on this aspect of my career, I realized I may have knowledge to share, through the lens of a specific procedure as case study. My work to help establish ESD (endoscopic submucosal dissection) procedure protocols has illuminated a few points that can likely be applied across other procedures and specialty areas.

The New Procedure Context

ESD procedures entail removal of lesions that have not reached the muscle. Winning Centers for Medicare and Medicaid (CMS) coverage in October 2021,[i] ESD procedures continue to face slow uptake despite the procedural benefits they provide to patients. ESD holds promise for patients suffering from some of the toughest cases colo-rectal cancer, where ESD provides a much-needed quality of life benefit via avoidance of the colostomy bag.

The in-between nature of these procedures –somewhere between endoscopy and surgery -- means that there can sometimes be uncertainty regarding who is “in charge” of the case: will the surgery or GI team take the case? Can the ownership be shared and if so how can that be navigated? Can the nursing team assist with coordination between these teams? Ultimately, what is best for the patient?

These conditions are likely not unique to ESD but are shared across many new procedures coming into practice in healthcare. Nurses are essential to bringing new procedures like ESD to the fore. What follows are some observations I’ve made about the nursing staff’s role in helping to usher a new procedure into practice.

Nurses often can bring the human-interest perspective that may elude a physician in the midst of technical focus

Recently, I was at work on a case in which the doctor needed to make the decision of whether to remove a diseased portion of colon or refer the patient for ESD. There he was in the midst of a life-changing decision for the patient, but likely finding himself focused on the more technical ramifications.

“Would the margins be good enough with ESD?” he was asking himself about a procedure that is still new on the scene. Would the patient outcome be good enough to justify the longer time needed for an  ESD procedure, understanding that a longer procedure time comes with associated risks with every additional minute of OR time added, from anesthesia to bleeding to pathogen risks?[ii] ESD is gaining more and more real-world evidence of its value, but here was an older patient of 85 years. The physician had to ask himself if it made more sense to stick with the tried and true. Wasn’t the colostomy bag concern something that would be more relevant to a younger patient?

“What do you think this patient does with her daily life?” I asked him. He was deep into the decision-making process and asked what I meant by the question. “Well, I’m from these parts and the 85-year-old ladies I know have church and the local restaurant to go to with their families and that’s what makes their week a happy one.” He nodded, waiting for the upshot. “And if this 85-year-old lady is worried that she didn’t change the colostomy bag right, if she’s worried even a little bit that she might be smelly, she will not go out anymore. And so there goes the couple of things she has in life to make her happy. So, I think you should try to help her avoid the bag.”

He ultimately agreed, and the ESD procedure went well for this patient. And she is going about her normal life today.

Certain nurses – support specialists or travel nurses, for example – bring special awareness of the healthcare landscape

Nurses may have better knowledge than the physicians of the regional offerings and may be able to advise based on that perspective.

Despite the fact that reimbursement is now possible for ESD, the uptake is slow even though patients want procedures that will allow them quality of life advantages such as avoiding a colostomy bag and despite the fact that more physicians are being trained in ESD techniques.. I have noticed that one potential reason for slow uptake could be that there isn’t enough awareness of which physicians are offering new procedures.

For example, during a recent case in a rural Tennessee hospital, I asked a physician where he was sending ESD patients. He thought that if he chose ESD for this patient, who was elderly and wouldn’t weather travel well, that it would mean a referral to a surgeon hundreds of miles away in Georgia. No, I was able to inform him, today there is a surgeon at the University of Tennessee who can perform the procedure.

A subtle approach can help bring big changes to healthcare

Nurses should be knowledgeable about new techniques and procedures and indeed they usually are. This is a boon for healthcare and for innovative improvements in care reaching patients along a more expedient timeline. Physicians are no longer resistant to advice from non-physician professionals in the trenches – at least not as compared to the early years of my long career. They welcome the input and creative brainstorming that a range of specialists and team members bring them, especially the younger physicians who have come through their training with an enhanced understanding of the importance of working as a team. Still, physicians have worked long hours at great personal sacrifice, and their individual contribution cannot be taken for granted.

I try to approach new ideas with humility and awareness of the personal connectedness physicians have with their careers. I’ve noticed that the approach matters, particularly in cases where you’re suggesting that they refer away from their specialty area to another one that they haven’t mastered yet. It’s important to “soft sell” your reminders of alternate paths (like ESD) that they might consider. You might present your idea as a question, saying, “What’s that new thing they’re doing? Have you heard about it – I think it’s called ESD? Didn’t I hear that they offer it at such-and-such a hospital? I’ve heard that’s much better for patient quality of life.”

Critical mass takes time to build up. Facilities pay attention to what other regional players are doing and what kinds of results they’re seeing. For years to come, most ESD procedures will feel like a novelty, not a track record. But with critical mass, more patients will be able to benefit from ESD. And nurses will have been there every step of the way.

Dawn Denney is a Clinical Endotherapy Specialist for Olympus, serving the Midwest Region.

[i] Effective Oct. 1, 2021, there is a new HCPCS code C9779, endoscopic submucosal dissection (ESD), including endoscopy or colonoscopy, mucosal closure, when performed. Source: Centers for Medicare and Medicaid Services: "October 2021 Update of the Hospital Outpatient Prospective Payment System" Sept. 16, 2021. https://www.cms.gov/files/document/R10997CP.pdf#page=21

[ii] https://www.journalofsurgicalresearch.com/article/S0022-4804(18)30187-2/pdf