Barriers to an Ergonomic Endo Suite

hands holding globes that have functionality and ergonomics on them

Originally posted on May 11, 2022

Increased awareness of the risk for endoscopy-related injuries, renewed efforts to design ergonomically healthier scopes, and implementation of engineering and administrative controls all are needed to reduce injuries seen in endoscopists treating adults and children.

Pediatric gastroenterologists face the same risk for endoscopy-related injuries as has been identified among adult gastroenterologists, but few pediatric gastroenterologists learn about ergonomics, according to survey data (Gastrointest Endosc 2020;91[6s]:AB500).

More than half of the 146 pediatric gastroenterologists and fellows surveyed (55.6%) reported experiencing musculoskeletal injuries, and more than half of those reporting injuries (62.5%) attributed some or all of their injuries to endoscopy. Overall, 36.5% of faculty and 30.0% of trainees reported experiencing a musculoskeletal injury attributable to endoscopy. In addition, 8% of pediatric endoscopists had taken time off from performing endoscopy due to an endoscopy-related injury, 32% had found it necessary to adjust their practice, and 24% received treatment for an injury.

These findings are similar to those of other surveys and studies conducted among adult gastroenterologists, who also frequently report musculoskeletal injuries and disorders. A survey of more than 1,600 American College of Gastroenterology physician members found that 75% of respondents reported endoscopy-related injuries, most commonly in the thumb (63.3%), neck (59%), hand/finger (56.5%), low back (52.6%), shoulder (47%) and wrist (45%) (Am J Gastroenterol 2021;116[3]:530-538).

“Performing endoscopy places unique strains on the body, which are known risk factors for workplace injuries,” said co-investigator Catherine Walsh, MD, PhD, during a session on ergonomics and endoscopy at the 2021 virtual meeting of the North American Society for Pediatric Gastroenterology, Hepatology & Nutrition.

“These include forces on the forearms, wrists and thumbs when torquing or inserting the insertion tube and adjusting the dials, standing for prolonged periods of time, and repetitive motions and awkward positioning,” noted Dr. Walsh, a clinician scientist and an associate professor in the Division of Gastroenterology, Hepatology and Nutrition at the Hospital for Sick Children at the University of Toronto.

The adult literature has highlighted a number of risk factors for endoscopy-related injury including higher procedural volumes, Dr. Walsh said. “Specifically, if you are performing more than 20 cases per week or 16 hours per week, or if you’re performing many endoscopies over time, you tend to accumulate injury. We did not find that correlation in our survey, but this may be because pediatric gastroenterologists generally perform fewer endoscopies than our adult colleagues. The adult studies have also identified prior injury as a risk factor for subsequent injury, which speaks to the importance of preventive care and identifying issues before they become problematic.”

Lack of Awareness

Although these are known risk factors, many endoscopists don’t learn about them or how to avoid injury. The survey of pediatric gastroenterologists revealed that few learn about ergonomics. Only 20.9% of those surveyed reported receiving formal ergonomics training, while 41.2% reported informal “at the bedside” training related to injury prevention strategies.

“Now that we know the scope of the problem, it’s important to know how we can use principles of ergonomics to guide us in preventing injury,” Dr. Walsh said. The National Institute for Occupational Safety and Health (NIOSH) has developed a commonly used hierarchy of controls for preventing occupational injuries ( Ranging from most to least effective, the hierarchy includes:

  • elimination of the risk by physically removing the hazard;
  • substitution (replacing the hazard);
  • engineering controls (isolating people from the hazard);
  • administrative controls (changing the way people work); and
  • personal protective equipment.

Efforts to Modify Scope Design

“Since we cannot eliminate the scope altogether, the next best solution would be to substitute a new piece of equipment or a modified design,” Dr. Walsh said.

That’s a strategy that some experts in endoscopy ergonomics have been pressing for with little success. “The thing that needs to be changed is that this is a really archaic design that requires our thumbs and hands to manipulate dials and insertion tubes,” said Amandeep Shergill, MD, an associate professor of clinical medicine in the Division of Gastroenterology at the University of California, San Francisco (UCSF) and a co-founder of the UCSF/University of California, Berkeley Center for Ergonomic Endoscopy. “It was not developed with the majority of users in mind, particularly as more women are represented in the field. On average, we do not have as much hand and thumb strength as men do, so we are at an inherent disadvantage. This is an engineering problem, and the endoscope companies need to be interested to solve it.”

Klaus Mergener, MD, PhD, the immediate past president of the American Society for Gastrointestinal Endoscopy (ASGE), credited the leading endoscope manufacturers with devoting significant time and attention to development of more ergonomically friendly scopes, but said such adaptations are challenging. “There are a lot of things that could be changed ergonomically, but what is most important to the majority of doctors? That’s a question we don’t have a perfect answer to,” noted Dr. Mergener, an affiliate professor of medicine at the University of Washington School of Medicine, in Seattle. “I might tell you that for me the handle size is important to vary, another doctor might say the wheel, a third doctor might say the weight, and yet another the way the buttons are placed on the handle. I know that all the companies have a list of things they would like to work on, including different handle sizes as well as the issue of the weight of the endoscope in long procedures, like complicated colonoscopies.”

For nearly a decade, Pentax Medical has been studying the ergonomics problem, said Hrishikesh Deo, PhD, the company’s vice president of Strategy and Business Development. “We have devoted significant resources toward developing innovative solutions toward ergonomic scopes, involving many physicians in the innovation process.” Their team went to a variety of endoscopy practices, including academic medical centers where more interventional procedures are conducted and ambulatory surgery centers with a higher volume of screening procedures, and recorded physician movement as well as a variety of physician demographic factors, including experience, age, sex and hand size, and scoping styles.

“We got excellent feedback and put a lot of resources into developing novel ergonomic designs.,” Dr. Deo said. “We built ‘looks-like feels-like’ prototypes and took those back to physicians and got feedback, and one concept really stood out as ergonomically superior. This concept received favorable reviews from all the endoscopists who evaluated the prototype, with comments like, ‘This is great. I want it in my scope right now.’”

So, the Pentax Medical team built a working prototype of the ergonomic endoscope and took it back to endoscopists to complete a procedure in a dummy colon. “The same cohort of endoscopists who loved the ‘looks-like feels-like’ prototype required significant effort to complete the procedure,” Dr. Deo said.

“Endoscopy is an extremely challenging and nonintuitive procedure,” he said. “It takes a lot of training and time to become proficient, and any significant deviation from the current scope paradigm will require a similar learning curve. It’s like if you were suddenly asked to switch from writing with your right hand to writing with your left. There would be a significant drop in productivity, and potentially in procedure quality, for a sustained period of time to consistently learn a new scope like this.”

Manufacturers haven’t given up on ergonomically improved scope designs, Dr. Deo said. “The industry continues to devote a lot of effort into this. Every new scope model incorporates incremental ergonomics improvements, and in parallel we continue to work on new scope paradigms that are ergonomically superior and easy to adopt for endoscopists.”

Engineering and Administrative Controls Can Help

In the meantime, Pentax Medical has developed an adjunct solution, an ergonomic scope stand that takes the weight off physicians’ hands during procedures while maintaining the current scope paradigm, according to Dr. Deo. He said this stand should be on the market soon.

Dr. Mergener also suggested that one solution might be low-cost adaptive devices that are suited to individual physicians. “As a small example, Olympus does have an adapter for one of the endoscope ‘steering wheels,’ to make it easier to reach for people with smaller hands,” he said.

Until more ergonomically healthy scope designs are available, the next most effective solutions in the hierarchy are engineering controls, such as scope supports and adjustable tables, beds, and monitors. “A key principle of ergonomics is the fifth to 95th percentile rule, which states that your systems should accommodate heights from the fifth percentile female to the 95th percentile male,” Dr. Walsh said. “If you do this, you will make your working environment safe for 90% of the population.”

Ideally, the endoscopy suite will have adjustable monitors and beds that allow for this level of accommodation. “For the monitor, you want your eyes to be even with the top, which places the center of the image 15 to 25 degrees below the horizon, allowing you to have a neutral neck position and avoiding flexing of the neck and curving the cervical spine,” Dr. Walsh said. “To account for a variety of heights, the monitor should be adjustable from 93 cm to 162 cm.”

Optimal bed positioning is between elbow height and 10 cm below that, allowing for a working range of forearm motion. This can be achieved with beds that are adjustable from 85 to 120 cm, Dr. Walsh said. “An easy way to assess this is to stand in front of the bed and see if the surface lies between your elbows and wrists. This allows for the shoulders and the arms to be in a relaxed, neutral position. If the bed is too low, you tend to lean forward and put strain on your paraspinal muscles. If it’s too high, you’re forced to raise your arms and shoulders and put strain on your deltoids and trapezius muscles.”

Engineering controls like these should be a given in the endoscopy suite, but all too often they are not, Dr. Shergill said. “It’s surprising how hard it can be for people to advocate for things like these. I’ve been shocked by what I’ve seen in some centers, what endoscopists are fighting against and the environment they’re working in just to care for their patients.”

The next most effective method to mitigate risk on the NIOSH hierarchy is administrative controls, such as adjusting procedural scheduling. “Our templates are not typically designed with injury prevention in mind. They focus on efficiency and moving from one task to the next as quickly as possible,” Dr. Walsh said. “Daily schedules should allow for micro-breaks that can help to promote muscle recovery between procedures. Similarly, think about how the week is scheduled. Some centers have very focused, high-intensity endoscopy blocks which may not be optimal from an ergonomic perspective. Spacing out shifts as opposed to putting them on back-to-back days can be helpful.”

Training, Stances and Grips

Dr. Walsh also recommended that endoscopy centers establish policies related to ergonomic training. “In a recent trial, we demonstrated that learning about endoscopy through a lecture and a video of best ergonomic practices produced sustained improvements in ergonomic habits at least four to six weeks after the training was completed,” she said (Gastrointest Endosc 2020;92[5]:1070-1080.e3). Another study found that after a group of eight endoscopists received individual ergonomic consultations and instruction from a physical therapist, 63% of 22 identified pain sites were reduced in intensity or resolved (Gastrointest Endosc 2021;94[2]:248-259.e2). In 2021, Dr. Walsh helped to lead the development of the ASGE’s core curriculum for ergonomics in endoscopy (Gastrointest Endosc 2021;93[6]:1222-1227).

The final level in the hierarchy of controls—the least effective, but often the last line of defense and the most readily available—is personal protective equipment and other personal controls. “For endoscopy, this includes how you position yourself: Use an ‘athletic’ neutral stance with your shoulders back and feet hip width apart, your body square to the monitor screen, to prevent your pelvic girdle from twisting and bending back in an awkward position,” Dr. Walsh said. “Use a bow grip rather than a fist grip with your scope. Use cushioned mats to increase blood flow and prevent leg, foot and back injuries, and compression stockings to prevent venous pooling. For lead aprons, two-piece types are preferable to one-piece, so that not all the weight is on your shoulders. And finally, try to maintain good physical fitness and do stretches throughout the day.”

Dr. Shergill called for the major gastroenterology societies to join forces around reducing ergonomic risk in endoscopy. “They each have efforts that they are pursuing in ergonomics, but it may be that all of us need to come together and speak with one voice to draw attention to this issue and bring about change.”

—Gina Shaw

Dr. Deo reported that he is an employee of Pentax Medical. Dr. Mergener reported financial relationships with Ambu, Boston Scientific, Fujifilm, Kate Farms, Pentax and Sebela. He is a member of the Gastroenterology & Endoscopy News editorial board. Dr. Shergill reported financial relationships with Boston Scientific and Pentax. Dr. Walsh reported no relevant financial disclosures.

This article is from the May 2022 print issue.

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