Impact of Operator Fatigue on Endoscopy Performance: Implications for Procedure Scheduling

Background With increasing volumes of endoscopic procedures, endoscopists’ workload has had to increase to meet this escalating demand. The aim of this study was to characterize the impact of endoscopist fatigue on quality of endoscopy performance by comparing outcomes based on chronological procedure order. Methods Consecutive endoscopic procedures were prospectively observed. Quality indicators of colonoscopy (cecal intubation rate, lesion detection, withdrawal time, insertion time) and esophagogastroduodenoscopy (EGD) duration were compared among procedures based on their chronological sequence. Results Colonoscopy completion rates declined with successive procedures; completion for 1st to 3rd procedures (90%) was significantly higher than for 4th and subsequent procedures (76%) (P = 0.03). Median insertion times lengthened; times for 1st to 4th procedures [8 min, interquartile range (IQR) 6–11 min] were shorter than for 5th and subsequent procedures (10 min, IQR 7–15 min) (P = 0.06). Lesion detection rates, withdrawal times, and EGD duration remained stable with procedure order. Conclusions Colonoscopy cecal intubation rates appear to decline with successive procedures. There also appears to be a trend for insertion times to lengthen. Reassuringly, other quality indicators of colonoscopy (lesion detection and withdrawal time) and EGD duration do not appear to be impacted by repetitive procedures.     

Patient comfort and quality in colonoscopy

AIM: To explore the relationship of patient comfort and experience to commonly used performance indicators for colonoscopy. METHODS: All colonoscopies performed in our four endoscopy centres are recorded in two reporting systems that log key performance indicators. From 2008 to 2011, all procedures performed by qualified endoscopists were evaluated; procedures performed by trainees were excluded. The following variables were measured: Caecal intubation rate (CIR), nurse-reported comfort levels (NRCL) on a scale from 1 to 5, polyp detection rate (PDR), patient experience of the procedure (worse than expected, as expected, better than expected), and use of sedation and analgesia. Pearson’ s correlation coefficient was used to identify relationships between performance indicators.RESULTS: A total of 17027 colonoscopies were performed by 23 independent endoscopists between 2008 and 2011. Caecal intubation rate varied from 79.0% to 97.8%, with 18 out of 23 endoscopists achieving a CIR of > 90%. The percentage of patients experiencing significant discomfort during their procedure (defined as NRCL of 4 or 5) ranged from 3.9% to 19.2% with an average of 7.7%. CIR was negatively correlated with NRCL-45 (r=-0.61, P < 0.005), and with poor patient experience (r=-0.54, P < 0.01). The average dose of midazolam (mean 1.9 mg, with a range of 1.1 to 3.5 mg) given by the endoscopist was negatively correlated with CIR (r=-0.59, P < 0.01). CIR was positively correlated with PDR (r=0.44, P < 0.05), and with the numbers of procedures performed by the endoscopists (r=0.64, P < 0.01). CONCLUSION: The best colonoscopists have a higher CIR, use less sedation, cause less discomfort and find more polyps. Measuring patient comfort is valuable in monitoring performance.     

The endoscopy Global Rating Scale – Canada: Development and implementation of a quality improvement tool

BACKGROUND:

Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality highlight the need for endoscopy facilities to review the quality of the service they offer.

OBJECTIVE:

To adapt the United Kingdom Global Rating Scale (UK-GRS) to develop a web-based and patient-centred tool to assess and improve the quality of endoscopy services provided.

METHODS:

Based on feedback from 22 sites across Canada that completed the UK endoscopy GRS, and integrating results of the Canadian consensus on safety and quality indicators in endoscopy and other Canadian consensus reports, a working group of endoscopists experienced with the GRS developed the GRS-Canada (GRS-C).

RESULTS:

The GRS-C mirrors the two dimensions (clinical quality and quality of the patient experience) and 12 patient-centred items of the UK-GRS, but was modified to apply to Canadian health care infrastructure, language and current practice. Each item is assessed by a yes/no response to eight to 12 statements that are divided into levels graded D (basic) through A (advanced). A core team consisting of a booking clerk, charge nurse and the physician responsible for the unit is recommended to complete the GRS-C twice yearly.

CONCLUSION:

The GRS-C is intended to improve endoscopic services in Canada by providing endoscopy units with a straightforward process to review the quality of the service they provide.     

A literature review of quality in lower gastrointestinal endoscopy from the patient perspective

BACKGROUND:

Given the limited state of health care resources, increased demand for colorectal cancer (CRC) screening raises concerns about the quality of endoscopy services. Little is known about quality in colonoscopy and endoscopy from the patient perspective.

OBJECTIVE:

To systematically review the literature on quality that is relevant to patients who require colonoscopy or endoscopy services.

METHODS:

A systematic PubMed search was performed on articles that were published between January 2000 and February 2011. Keywords included “colonoscopy” or “sigmoidoscopy” or “endoscopy” AND “quality”; “colonoscopy” or “sigmoidoscopy” or “endoscopy” AND “patient satisfaction” or “willingness to return”. The included articles were qualitative and quantitative English language studies regarding aspects of colonoscopy and/or endoscopy services that were evaluated by patients in which data were collected within one year of the colonoscopy/endoscopy procedure.

RESULTS:

In total, 28 quantitative studies were identified, of which eight (28.6%) met the inclusion criteria (four cross-sectional, three prospective cohort and one single-blinded controlled study). Aspects of quality included comfort, management of pain and anxiety, endoscopy unit staff manner, skills and specialty, procedure and results discussion with the doctor, physical environment, wait times for the appointment and procedure, and discharge. Qualitative studies eliciting the patient perspective on what constituted quality in colonoscopy/endoscopy were not found.

CONCLUSIONS:

Factors related to comfort, staff, communication and the service environment were evaluated from the patient perspective using closed-ended questions that were designed by clinicians and researchers. Future research using qualitative methodology to elicit the patient perspective on quality in colonoscopy and/or endoscopy services is needed.     

Assessments and skills improvement for endoscopists

Different countries employ a range of assessment methods to monitor trainees from novice to independent practice. The optimal method to monitor and assess individuals' training in endoscopy has not been formally determined. The UK has developed a competency based assessment training and certification (credentialing) programme.The tools developed to provide endoscopy work based assessments (DOPS) have been validated and are used for trainees and independent endoscopists, providing formative feedback for targeted training. Summative assessments are used for trainee certification and independent colonoscopists wishing to provide part of the National Bowel Cancer Screening Programme.The UK was able to develop both clinical standards and an endoscopy training and certification process applied to all individuals and monitored by a single professional body. The supporting IT system enabled a structured and robust quality assurance process to be applied to all individuals and endoscopy units.Assessment of practising endoscopists relies on the development and measurement of surrogate measures, which represent key performance indicators for those individuals. These surrogates for performance are still evolving although they are now well established for colonoscopy practice. Monitoring of independent practice is dependent on clinical audit of these key performance indicators. Feedback of data to individuals helps benchmarking and identification of those with sub-optimal performance. Independent endoscopists now recognize the benefit of on-going training to help both skills development and to address sub-optimal performance.This chapter describes how the UK developed a web-based integrated training and certification system.     

Endoscopy in Canada: Proceedings of the National Roundtable: Toronto,Ontario, February 7, 2014

This 2014 roundtable discussion, hosted by the Canadian Association of General Surgeons, brought together general surgeons and gastroenterologists with expertise in endoscopy from across Canada to discuss the state of endoscopy in Canada. The focus of the roundtable was the evaluation of the competence of general surgeons at endoscopy, reviewing quality assurance parameters for high-quality endoscopy, measuring and assessing surgical resident preparedness for endoscopy practice, evaluating credentialing programs for the endosuite and predicting the future of endoscopic services in Canada. The roundtable noted several important observations. There exist inadequacies in both resident training and the assessment of competency in endoscopy. From these observations, several collaborative recommendations were then stated. These included the need for a formal and standardized system of both accreditation and training endoscopists.     

Impact of endoscopy-based research on quality of life in healthy volunteers

AIM:To study the impact of an endoscopy-based long-term study on the quality of life in healthy volunteers(HV).METHODS:Ten HV were included into a long-term prospective endoscopy-based placebo-controlled trial with 15 endoscopic examinations per person in 5 different drug phases.Participants completed short form-36(SF-36) and visual analog scale-based questionnaires(VAS) for different abdominal symptoms at days 0,7 and 14 of each drug phase.Analyses wereperformed according to short-and long-term changes and...     

Acquiring and maintaining competency in gastrointestinal endoscopy

In recent years, an important transformation has taken place in the field of gastrointestinal endoscopy training. Two important movements have helped initiate this transformation: patient centered quality and competency based training.Patient centered quality in endoscopy became an important focus for colorectal cancer screening programs, as it was acknowledged that colonoscopy services played a central role in the outcomes of screening. This prompted the need to close the quality loop through the development of innovative endoscopist training and upskilling programs. As well, the importance of leadership skills and leadership training was highlighted as a key factor in effective quality improvement.Competency-based training depends on well-defined goals of training and on the regular documentation and review of the learner's progress. This is facilitated by objective assessment and performance enhancing feedback, enabled by measurement tools that can provide a quantitative or qualitative assessment and identify areas in need of further development. Simulators and scope imagers can aid the acquisition of technical skills, particularly in the novice phase.These important advances in our evolving concepts around endoscopy training have also raised many questions, highlighting important knowledge gaps which, we hope, will be addressed in coming years.     

Canadian Association of Gastroenterology consensus guidelines on safety and quality indicators in endoscopy

BACKGROUND:

Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality, highlight the need for clearly defined, evidence-based processes to support quality improvement in endoscopy.

OBJECTIVE:

To identify processes and indicators of quality and safety relevant to high-quality endoscopy service delivery.

METHODS:

A multidisciplinary group of 35 voting participants developed recommendation statements and performance indicators. Systematic literature searches generated 50 initial statements that were revised iteratively following a modified Delphi approach using a web-based evaluation and voting tool. Statement development and evidence evaluation followed the AGREE (Appraisal of Guidelines, REsearch and Evaluation) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) guidelines. At the consensus conference, participants voted anonymously on all statements using a 6-point scale. Subsequent web-based voting evaluated recommendations for specific, individual quality indicators, safety indicators and mandatory endoscopy reporting fields. Consensus was defined a priori as agreement by 80% of participants.

RESULTS:

Consensus was reached on 23 recommendation statements addressing the following: ethics (statement 1: agreement 100%), facility standards and policies (statements 2 to 9: 90% to 100%), quality assurance (statements 10 to 13: 94% to 100%), training, education, competency and privileges (statements 14 to 19: 97% to 100%), endoscopy reporting standards (statements 20 and 21: 97% to 100%) and patient perceptions (statements 22 and 23: 100%). Additionally, 18 quality indicators (agreement 83% to 100%), 20 safety indicators (agreement 77% to 100%) and 23 recommended endoscopy-reporting elements (agreement 91% to 100%) were identified.Statement 1. For a patient to give a physician informed consent to perform an elective endoscopic procedure, the patient must be advised, in a timely fashion, of all relevant information about the procedure, its risks, benefits and alternatives, if any, and be given an opportunity to ask questions that the physician must answer.Evidence grade: Low/very lowStrength of recommendation: Do it, 91%; possibly do it, 6%; possibly don’t do it, 3%Level of agreement with recommendation: Agree, 100% (agree strongly, 65%; agree moderately, 29%; agree slightly, 6%)Statement 2. Endoscopy facilities should meet or exceed defined operating standards, in all domains, consistent with accreditation under the appropriate national or regional standards.Evidence grade: Low/very lowStrength of recommendation: Do it, 91%; possibly do it, 6%; don’t do it, 3%Level of agreement with recommendation: Agree, 97% (agree strongly, 85%; agree moderately, 12%; disagree slightly, 3%)Statement 10. Endoscopy facilities should maintain a comprehensive quality improvement program incorporating formal, regular, scheduled review of performance reports.Evidence grade: Low/very lowStrength of recommendation: Do it, 85%; possibly do it, 9%; possibly don’t do it, 3%; don’t do it, 3%Level of agreement with recommendation: Agree, 94% (agree strongly, 76%; agree moderately, 12%; agree slightly, 6%; disagree slightly, 6%)Statement 14. Endoscopy facilities should provide high-quality education programs or opportunities for all staff.Evidence grade: Very lowStrength of recommendation: Do it, 86%; possibly do it, 14%Level of agreement with recommendation: Agree, 100% (agree strongly, 66%; agree moderately, 26%; agree slightly, 9%)Statement 19. Endoscopists’ privileges should be subject to formal, regular, scheduled review to ensure that renewal is based on documented competence to perform specified procedures consistent with appropriate current standards.Evidence grade: Low/very lowStrength of recommendation: Do it, 94%; possibly do it, 3%; possibly don’t do it, 3%Level of agreement with recommendation: Agree, 97% (agree strongly, 89%; agree moderately, 9%; disagree slightly, 3%)Statement 20. Endoscopic procedures should be reported in a standardized electronic format, including mandatory reporting fields, to provide full documentation of all necessary clinical and quality measures.Evidence grade: Low/very lowStrength of recommendation: Do it, 82%; possibly do it, 15%; don’t do it, 3%Level of agreement with recommendation: Agree, 97% (agree strongly, 76%; agree moderately, 15%; agree slightly, 6%; disagree strongly, 3%)Statement 21. Endoscopy facilities should implement policies to monitor and ensure the timeliness and completeness of procedure reporting.Evidence grade: Low/very lowStrength of recommendation: Do it, 100%Level of agreement with recommendation: Agree, 100% (agree strongly, 91%; agree moderately, 6%; agree slightly, 3%)Statement 22. Endoscopy facilities should ensure that the services they provide are patient-centred.Evidence grade: Moderate to very lowStrength of recommendation: Do it, 85%; possibly do it, 12%; don’t do it, 3%Level of agreement with recommendation: Agree, 100% (agree strongly, 71%; agree moderately, 26%; agree slightly, 3%)Statement 23. Endoscopy facilities should systematically and at least annually solicit patient feedback, report the results to the service and to the institution’s quality committee, and implement effective measures to address patients’ concerns.Evidence grade: Very lowStrength of recommendation: Do it, 94%; possibly do it, 6%Level of agreement with recommendation: Agree, 100% (agree strongly, 82%; agree moderately, 15%; agree slightly, 3%)

DISCUSSION:

The consensus process identified a clear need for high-quality clinical and outcomes research to support quality improvement in the delivery of endoscopy services.

CONCLUSIONS:

The guidelines support quality improvement in endoscopy by providing explicit recommendations on systematic monitoring, assessment and modification of endoscopy service delivery to yield benefits for all patients affected by the practice of gastrointestinal endoscopy.     

A prospective intervention study of colonoscopy reporting among patients screened or surveilled for colorectal neoplasia

BACKGROUND:

The impact of modifying electronic colonoscopy reporting software for improving adherence to guidelines regarding quality standards documentation remains poorly characterized.

METHODS:

Consecutive colonoscopy reports of patients undergoing screening or surveillance for colorectal neoplasia were reviewed. Following a pre-intervention quality audit conducted in 2009, some modifications were made to the reporting software (Endoworks, Olympus Corporation, USA), including changes to field navigation, drop-down menus and visual cues, to optimize all compulsory items identified by existing guidelines in the report-generating template. Results from both audits were compared. Independent validation of 10% of all data was completed.

RESULTS:

In 250 patient reports (mean [± SD] age 61.7±10.2 years, 51.2% female, February to May 2011) of five endoscopists (mean 11.6±7.8 years in practice), procedural indication was always present, as was informed consent. Seventy-six per cent of patients had undergone previous colonoscopy, 41% provided a previous colonoscopy date, with details on past polyp removal in 42.9%. Most procedural indicators were recorded (examination date 100%, medications given 100%, difficulty level 96.4%, preparation quality 100%). All reports noted extent of visualization (cecal intubation in 97.6%, photo documentation in 96.8%). Total procedural time was recorded in 8.2% and withdrawal time in 44%. Polyps were reported in 112 patients (44.8%), with polyp size (5.01±4.42 mm) reported in 95.5%, morphology in 88.4% and anatomical location in all. The method of polyp removal was missing in 2.7% of reports. Significant improvements were noted in the documentation of withdrawal and total time, cecal landmarks, type of bowel preparation, completeness of removal, morphology and method of polyp removal, and photo documentation compared with the 2009 audit.

CONCLUSION:

These results illustrate the value of targeted modifications to an electronic colonoscopic reporting system in significantly enhancing the quality of reporting.     

Accrediting for screening-related colonoscopy services: What is required of the endoscopist and of the endoscopy service?

Colorectal cancer (CRC) screening is widely implemented to reduce CRC incidence and related mortality. The impact of screening as well as the balance between screening burden and benefits strongly depends on the quality of colonoscopy. Besides quality, safety of the endoscopic procedure and patient satisfaction are important outcome parameters for a screening program. Therefore the requirements for both CRC screening endoscopy services and endoscopists focus on technical aspects, patient safety, and patient experience. Stringent quality assurance by means of routine monitoring of quality indicators for the performance of endoscopists and endoscopy units is recommended. This allows setting minimum standards, targeted interventions, and enhancement of the overall quality of population screening. This reviews deals with guidelines and quality standards for colorectal cancer screening, with focus on both endoscopist and endoscopy services.     

基于深度学习的消化内镜检查辅助质量控制系统研究（含视频）

目的构建智能消化内镜质控系统并评估其在胃肠镜检查中的质量监控作用。方法基于医学数字成像与通信协议,获取武汉大学人民医院消化内镜中心2016年12月—2018年10月胃肠镜检查患者的电子医疗记录和图像,采用深度卷积神经网络和深度强化学习方法开发智能消化内镜质控系统。该系统运用回盲部识别模型、体内外图像识别模型以及胃的26个部位识别模型,监控达盲率、肠镜退镜时间、胃镜检查时间、胃镜检查覆盖部位数等质控指标。随机选取武汉大学人民医院消化内镜中心2019年3—11月83例胃镜检查和205例肠镜检查患者的图像,测试智能消化内镜质控系统质量控制功能的准确性。结果智能消化内镜质控系统由胃镜质量分析、肠镜质量分析组成,可随时自动生成包含各质控指标的内镜医师胃肠镜检查质控报告。该系统监控的达盲率、肠镜退镜时间、胃镜检查时间和胃镜检查覆盖部位数的准确率分别为92.5%（172/186）、91.7%（188/205）、100.0%（83/83）和89.3%（1 928/2 158）。结论智能消化内镜质控系统可实现胃肠镜检查的质量监控作用,以便内镜医师了解自身的工作情况,从而提升胃肠镜检查质量。     

Artificial intelligence technologies for the detection of colorectal lesions: The future is now

Several studies have shown a significant adenoma miss rate up to 35% during screening colonoscopy, especially in patients with diminutive adenomas. The use of artificial intelligence(AI) in colonoscopy has been gaining popularity by helping endoscopists in polyp detection, with the aim to increase their adenoma detection rate(ADR) and polyp detection rate(PDR) in order to reduce the incidence of interval cancers. The efficacy of deep convolutional neural network(DCNN)-based AI system for polyp detection has been trained and tested in ex vivo settings such as colonoscopy still images or videos. Recent trials have evaluated the real-time efficacy of DCNN-based systems showing promising results in term of improved ADR and PDR. In this review we reported data from the preliminary ex vivo experiences and summarized the results of the initial randomized controlled trials.     

内镜医师眼中胃肠病学家在未来消化肿瘤学中的作用

消化肿瘤学的发展需要创建一个多学科的团队。专攻消化肿瘤学的胃肠病学专家(肿瘤-胃肠病学家)也应该包含在这样高质量的团队中。为实现这一目标,肿瘤-胃肠病学家需接受与消化道肿瘤内镜诊断和治疗所有相关方面的充分培训。本文涵盖所有需要用来保证最佳诊治的专业技术。     

Indicators of safety compromise in gastrointestinal endoscopy

INTRODUCTION:

The importance of quality indicators has become increasingly recognized in gastrointestinal endoscopy. Patient safety requires the identification and monitoring of occurrences associated with harm or the potential for harm. The identification of relevant indicators of safety compromise is, therefore, a critical element that is key to the effective implementation of endoscopy quality improvement programs.

OBJECTIVE:

To identify key indicators of safety compromise in gastrointestinal endoscopy.

METHODS:

The Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group was formed to address issues of quality in endoscopy. A subcommittee was formed to identify key safety indicators. A systematic literature review was undertaken, and articles pertinent to safety in endoscopy were identified and reviewed. All complications and measures used to document safety were recorded. From this, a preliminary list of 16 indicators was compiled and presented to the 35-person consensus group during a three-day meeting. A revised list of 20 items was subsequently put to the consensus group for vote for inclusion on the final list of safety indicators. Items were retained only if the consensus group highly agreed on their importance.

RESULTS:

A total of 19 indicators of safety compromise were retained and grouped into the three following categories: medication-related – the need for CPR, use of reversal agents, hypoxia, hypotension, hypertension, sedation doses in patients older than 70 years of age, allergic reactions and laryngospasm/bronchospasm; procedure-related early – perforation, immediate postpolypectomy bleeding, need for hospital admission or transfer to emergency department from the gastroenterology unit, instrument impaction, severe persistent abdominal pain requiring evaluation proven to not be perforation; and procedure-related delayed – death within 30 days of procedure, 14-day unplanned hospitalization, 14-day unplanned contact with a health provider, gastrointestinal bleeding within 14 days of procedure, infection or symptomatic metabolic complications.

CONCLUSIONS:

The 19 indicators of safety compromise in endoscopy, identified by a rigorous, evidence-based consensus process, provide clear outcomes to be recorded by all facilities as part of their continuing quality improvement programs.     

Controles de calidad de la colonoscopia como requisito de las campañas de cribado del cáncer colorrectal

The strategies used in population-based colorectal screening strategies culminate in colonoscopy and consequently the success of these programs largely depends on the quality of this diagnostic test. The main factors to consider when evaluating quality are scientific-technical quality, safety, patient satisfaction, and accessibility. Quality indicators allow variability among hospitals, endoscopy units and endoscopists to be determined and can identify those not achieving recommended standards. In Spain, the working group for colonoscopy quality of the Spanish Society of Gastroenterology and the Spanish Society of Gastrointestinal Endoscopy have recently drawn up a Clinical Practice Guideline that contains the available evidence on the quality of screening colonoscopy, as well as the basic requirements that must be met by endoscopy units and endoscopists carrying out this procedure. The implementation of training programs and screening colonoscopy quality controls are strongly recommended to guarantee the success of population-based colorectal cancer screening.