Society: ASGE

Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO₂ tubing, O₂ connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.

Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.

<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Brian Hanson

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