5. Patient Assessment
INTRODUCTION
PRE-ENDOSCOPY PATIENT OVERVIEW
CLINICAL INFORMATION
APPROPRIATE PROCEDURE?
RECOMMENDATION
CHAPTER REFERENCES
n = number of cases where information was provided

 

PRE-ENDOSCOPY PATIENT OVERVIEW

This study is not a review of a sample of all patients undergoing therapeutic endoscopy;
it is a study of inpatients who died within 30 days of a therapeutic endoscopy which reflects
a very small percentage of patients undergoing this procedure. Most of these inpatients, 91% (1,619/1,774), had been admitted as an emergency and in 44 cases the admission method was unknown.

One part of the endoscopy questionnaire required clinicians to provide an assessment of
the patient’s risk of death within 30 days of the proposed procedure. In the majority of cases where information was provided (74%, 1,303/1,753), death was either a definite risk (60%, 1,056/1,753) or expected (14%, 247/1,753). These values are reflected in the patient’s ASA status (Table 7).

Key point
Most patients, 85%, were deemed to have an ASA status of 3 or poorer.

Table 7. Pre-endoscopy condition
ASA Status
None
Small
Definate
Expected
Sub-total
Not answered
Total
1 2
10
12
4
28
1
29
2 61
47
97
15
220
2
222
3 157
50
355
46
608
11
619
4 72
20
464
97
653
8
661
5 9
0
91
77
177
1
178
Sub-total 301
127
1,019
239
1,686
23
1,709
Not answered 15
7
37
8
67
42
109
Total (%) 316 (18)
134 (8)
1,056 (60)
247 (14)
1,753
65
1,818

Case Study  
A very elderly patient was admitted following a severe stroke. After five weeks in hospital oral feeding was judged to be inadequate. Although their condition was very poor, assessed as ASA 5, a PEG was inserted. The patient deteriorated after the procedure
and a decision was made to give only palliative care. The patient died two weeks after the PEG insertion.

In this case the endoscopist should have recognised that the severity of the patient’s condition should have precluded this procedure. The opinion of the advisors was that there was no benefit to the patient’s care, even in the two-week period before death. Issues relating to PEG insertion are discussed in more detail in a separate chapter later in
this report.

Key point
Two or more co-existing medical conditions were present in 76% of patients.

Information was collected on the patients’ concurrent medical conditions.

Table 8. Co-existing medical conditions (answers may be multiple)
Co-existing medical condition
Total
n = 1,755
Respiratory
COPD
274
Acute chest infection
456
Asthma
65
Cardiac
Ischaemic heart disease/previous MI/angina
473
MI within three months of the endoscopy
44
Valvular heart disease
69
Neurological
CCF (at present or in the past)
253
CVA/TIAs
548
Dementia
197
Acute confusion state
127
Psychiatric disease
61
Parkinson’s disease
58
Hepatic/pancreatic
411
Alimentary
218
Renal failure
Acute
179
Chronic
122
Endocrine
Non-insulin dependent diabetes mellitus
167
Insulin dependent diabetes mellitus
51
Hypothyroidism
53
Musculoskeletal
181
Haematological
Bleeding disorder
73
Immunosupression
25
Sepsis
164
Other
534
Total
4,803
None 79
Not answered
63

Co-existing medical conditions were present in all except 79 patients (Table 8), with two or more conditions in 76% (1,341/1,755), and greater than 4 in 14% (249/1,755) (Table 9). It is interesting to note that cerebrovascular disease was the commonest co-existent condition, and this is likely to reflect the age distribution of the patients in this study.

Table 9. Count of co-existing medical conditions by procedure
Procedure
0
1
2
3
4
5
6
7
8
9
10
12
Sub-total
Not answered
Total
PEG 13
99
201
157
116
67
34
10
1
1
1
1
701
18
719
ERCP 27
56
47
39
28
16
7
7
0
0
0
0
227
10
237
Upper GI 37
174
223
146
102
56
22
10
7
1
1
0
779
30
809
Lower GI 2
6
14
8
11
4
1
1
1
0
0
0
48
5
53
Total
(%)		 79
(5)
335
(19)
485
(28)
350
(20)
257
(15)
143
(8)
64
(4)
28
(2)
9
(<1)
2
(<1)
2
(<1)
1
(<1)
1,755
63
1,818


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