The goal of this study was to assess outcomes with respect to significant cardiopulmonary complications following endoscopy. Post-procedural cardiopulmonary complications were chosen as a marker for preprocedural preparedness. This study compares annual data before and after a systematic approach to preprocedural risk stratification and management was instituted at the Carilion Clinic, a large integrated health care system with a medical draw area of over 1 million patients serving a wide geographic area. Procedures were performed by gastroenterologist, surgeons and trainee physicians under the supervision of staff physicians at 8 endoscopy facilities. The management algorithms used for this study were developed by a multi-disciplinary task force that included gastroenterologist, anesthesiologists, Carilion Registration and Education for Surgery (CARES) nurses, appointment schedulers and information technology specialists. Study Hypothesis: A systematic approach to preprocedural risk stratification and management will not increase the rate of postprocedural cardiopulmonary events. Results: There were 14,358 cases performed between September 1, 2013 and August 31, 2014 which represents baseline annual data before the systemic approach to risk stratification and management was initiated (group 1). Of these cases, 53 had cardiopulmonary complications or a complication rate of 0.37%. There were 13,685 cases performed between September 1, 2015 and August 31, 2016, which represents annual data after the systemic approach was started (group 2). There were 41 cardiopulmonary complications, or a complication rate of 0.30%. There were no significant differences between these two groups with respect to cardiopulmonary complications with p value of 0.1571, thus confirming the study hypothesis. Group 1 patient had 53 cardiopulmonary complications with most of these seen with Esophagogastroduodenoscopy (EGD) 40, colonoscopy accounted for 9 and Endoscopic Retrograde Cholangiopancreatography (ERCP) 4. A similar pattern for cardiopulmonary complications was seen for group 2 patients with 30 of 41 patients having EGD, colonoscopy 9 and ERCP 2. Discussion: Our results confirm the hypothesis that a systematic approach to endoscopic preprocedural risk stratification and management will not increase postprocedural cardiopulmonary complications and in fact there was a trend toward improvement. Additionally, this systematic method reduced costs by eliminating preprocedural testing and CARES office nursing visits for ASA I and II patients undergoing colonoscopy and EGD. The pattern of cardiopulmonary complications suggests that EGD carries the greatest risk. The risk for ERCP is very low in our experience compared to historical data and may be related to our practice of intubated general anesthesia for all ERCP patients. We hope the methods developed by this task force and presented in this article will be useful to other institutions interested in developing a systematic approach to preprocedural preparedness.