The Origin of ULENA  (Upper-Lower Endoscopic Nurse Assistants)

 by: Dr. Robert McIntyre, MD

 The Surgery Center of Southern Oregon opened in May of 1997.  Shortly thereafter, Dr. John Walker contacted me to help solve a problem he was having in his endoscopic procedures done in the center.  Since I was the medical director of the center, an anesthesiologist, and present every day, we had the opportunity to work on this problem together.

"...the nurses achieved a perfect record..."

At that time, Dr. Walker was administering intra-procedure sedations in the usual manner, using IV Demerol and IV Versed, but he found that there were some patients for whom this was less than satisfactory.  They were identified as patients who required huge doses of medicine and were still not appropriately sedated for the procedure.  Most of these patients were agitated, had prior drug use, or had a past experience of painful procedures.

Dr. Walker and I decided that these patients might best be studies with IV Diprivan use.  The reasons were the following:

•  ease of administration

•  familiarity with the product and its effects
• availability of an anesthesiologist on site (this caveat no longer felt necessary May, 1999)
• 100% patient satisfaction
• 100% appropriate sedation for the endoscopic procedure

We began using Diprivan for the anticipated problem patients, and have had excellent results.  Patient acceptance was superb and we obtained optimum sedation for the procedure.  However, as the popularity increased, the availability and cost of an anesthesiologist became an obstacle.

"maintain... maximum patient satisfaction."

We then entertained the idea of nurse administration of the drug under the supervision of a gastroenterologist.  We set out to select the personnel who would perform this sedation according to very strict criteria.  We determined that the nurses should have recovery room experience, airway management skills, and be current with ACLS certification.  Having identified these nurses in our facility, we initiated a training period which consisted of two weeks of observation of anesthesia induction by staff anesthesiologists in the OR, using Diprivan.

A video of conscious sedation guidelines and Diprivan administration suggestions was viewed, and subsequently an exam was given to the nurses to test the overall knowledge of the pharmacokinetics and properties of the drug in all sorts of patient types.

The next step was to have the nursing personnel observe the anesthesiologist sedating patients in the Endo Suite. The final stage was to have the nurses do the procedure themselves (with an anesthesiologist observing them).  The protocol has worked so well that all the nurses who have mastered this discipline have achieved a perfect record of no complications over 500 procedures.  The gastroenterologists have all rapidly accepted their competence and all use them for their procedures.  These MDs have accepted the role of supervising the nurses and communicate with them to maintain a safe, efficient atmosphere with maximum patient satisfaction.

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