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Benchmark data for quality assessment of colonoscopy
Abstracts Submitted to ASGE 2OO1 *'126 UNREGULATED GASTROINTESTINAL ENDOSCOPY CREDENTIALLING PRACTICES: A NATIONAL SURVEY. Angelo G. Coppola, Jr., Jean-Pierre Raufman, Virender K. Sharma, Univ of Arkansas, Little Rock, AR Endoscopic competence correlates with the number of procedures performed. ASGE guidelines indicate minimum numbers of procedures to assess competence. However, these may not be followed by everyone and data on credentialling practices are lacking. Aim: To evaluate credentialling practices by endoscopy centers. Methods: An anonymous survey was mailed to centers in the US. Results: Completed surveys (479 respondents) were received from 46 states (except AK, N-V,RI, NM), PR and DC. Respondents were physician endoscopy directors (24%), nurse managers/RN (57%), and others (19%). Most centers (62%) bad more than 5 endoscopists. 27%, 40% and 33% served communities of < 50,000, 50,000500,000 and > 500,000 persons, respectively. Of responding centers, gastroenterologists performed the majority of procedures (Table). More than half of centers require no minimum number of procedures and only 10% meet ASGE criteria for initial endoscopic credentialling. Over 2/3 have no minimum number and only 2% require > 25 cases/yr to maintain credentials. Three-quarters reported periodic review of procedures; < 5% review them more often than every 6 mos. 92% have mechanisms for reporting complications: 4%-verbal reports; 56%-adverse event forms; 38%-both; 2%another method. Only 20% had denied privileges [poor endoscopic skills (80%), no references (27%), poor communication skills (7%), excess complications (6%), and other reasons (7%)]. Of these, 52% faced litigation for denial of privileges. Conclusions: Various specialists, some with possibly suboptimal training, perform GI endoscopy. Most centers have no standards for determining endoscopic competence. Only 10% adhere to ASGE guidelines. Although most centers review procedures and complications, few use these data to renew or deny credentials. To guarantee high-quality endoscopic practice, more stringent, universal credentialling standards are required. Overalldistributionof proceduresperformedby differentspecialists Specialty
EGD
Colon
FS
ERCP
Gastroenterology Surgery FPIIM RNPIPA
54.7% 30.2% 13.1% 2.0%
53.8% 32.7% 13.0% 1.5%
40.2% 25.3% 32,0% 2.5%
91.2% 7.6% 0.6% 0.6%
*'127 BENCHMARK DATA F O R QUALITY ASSESSMENT OF COLONOSCOPY. John F. Johanson, U of Ill Cell of Medicine at Rockford, Rockford, IL; GI Practice Management Group Background. The ASGE recently released guidelines specifying indicators to be used to assess the quality of colonoseopy. Currently, no data are available for individual practitioners to use for comparison with their own practices. This study examined the outcomes of outpatient colonoseopy performed on a large group of patients from geographically diverse practices to provide initial benchmark data. Methods. All patients undergoing colonoscopy at 8 outpatient endoscopy centers from December 1997 to May 1998 were included in the study. Upon completion of the colonoscopy, the procedure indication, type and amount of sedation, final distance reached including reason if incomplete, specific findings, and therapeutic procedure(s) performed were recorded. Patients were contacted 24-48 hours after their procedure and a satisfaction survey was completed. Procedure complications were tracked and recorded. Results: 6,825 eolonoscopies were performed during the study period; 47% among females and 53% in males. Ages ranged between 10 and 96 years. Indications for colonoscopy were appropriate for 6615 procedures (96.9%) based on ASGE guidelines. The most frequent indication cited was screening and surveillance of
colonic neoplasia (34.5%). Among these patients, polyps were identified in 60%. The overall success rate in reaching the cecum was 92.6%. This number likely underestimates the true success rate, as patients with malignant obstruction or cecal resection were not excluded. Only 31 of the 6825 patients suffered a complication (0.45%). The majority of these were postpolypectomy bleeds (23) corresponding to an incidence of 0.33% which is well below published levels of 0.8-2.2%. Only two perforations occurred corresponding to an incidence of 0.03%, likewise well below previously reported levels. 5801 patients (85%) were successfully contacted after their procedure and completed a satisfaction survey. Overall satisfaction was rated as excellent by 72.2% and very good by another 23.1%. Conclusions: These data provide an initial attempt to identify national benchmarks for quality assessment of eolonoscopy. As ASGE quality indicators become more widely implemented, it is anticipated that more refined benchmark data will become available for comparison on both national and regional levels. The ultimate goal of these benchmarks, however, is to enable practitioners to compare the outcomes of their own endoscopic practices with widely accepted standards, ultimately improving the quality of care for each patient.
*'128 REUSABLE BIOPSY FORCEPS: IS "ADEQUATE" CLEANSING ADEQUATE? Timothy P. Kinney, Fouad M. Attia, Richard A. Kozarek, Aiexandra Rusu, Virginia Mason Medical Ctr, Seattle, WA Background: In two recently published studies, 1, 2 reusable forceps were purported to be both contaminated and nonfunctional after 20 uses. As these studies have significant implications for endoscopic practice, we prospectively studied reusable forceps for specimen adequacy and ability to sterilize. Methods: Three new reusable biopsy forceps (FB-24U-1, Olympus America, Inc., New Hyde Park, NY) were prospectively studied. Based upon the above-mentioned publications, forceps were retired a l ~ r 20 uses, or prior to that number if mechanical failure occurred. Reprocessing followed the SGNA protocol and included manual cleaning, enzymatic soak, rinse, biopsy cup lubrication, and steam autoclave. At the end of the study, each forceps was dismantled with a sterile wire cutter and 2-4-inch-long pieces were cut (biopsy tip, mid-shaft, and near handle). These 9 forceps sections were separately cultured and examined under light microscopy. At time of forceps use, data collected included biopsy site, procedure, mechanical problems, and specimen size. Results: No bx forceps developed mechanical malfunction/problem during the clinical study of 60 pts. Procedures included EGD 29, colonoscopy 28, flex sig 2, and ileoscopy 1, and biopsy sites were large bowel 28, stomach 17, esophagus 11, and small bowel 4. Mean specimen size was 2.1 ± 0.2 mm (1-3.8) and all specimens were reported as adequate for pathological interpretation. None of the biopsy sections studied were found to have patient debris at the cups, hinges, needle, or shaft component. Neither aerobic nor anaerobic cultures demonstrated bacterial growth. Conclusions: 1) In contrast to previously published studies, reusable biopsy forceps proved adequate for tissue acquisition for a minimum of 20 cases. 2) Reusable biopsy forceps proved safe provided standard sterilization procedures were followed. 1. Rizzo J, Bernstein D, Gress F. A performance, safety and cost comparison of reusable and disposable endoscopic biopsy forceps: a prospective, randomized trial. Gastrointest Endose 2000;51:257.61.2. Yang R, Ng S, Nichol M, Laine L . A cost and performance evaluation of disposable and reusable biopsy forceps in GI endoscopy. Gastrointest Endose 2000;51:266-70.
*Invited to participate in the Poster Session o f the ASGE meeting. **Selected for Topic Forum. ***Selected for presentation at the ASGE Plenary Session.
VOLUME 53, NO. 5, 2001
GASTROINTESTINAL ENDOSCOPY
AB55
EGD
Colon
FS
ERCP
Gastroenterology Surgery FPIIM RNPIPA
54.7% 30.2% 13.1% 2.0%
53.8% 32.7% 13.0% 1.5%
40.2% 25.3% 32,0% 2.5%
91.2% 7.6% 0.6% 0.6%
*'127 BENCHMARK DATA F O R QUALITY ASSESSMENT OF COLONOSCOPY. John F. Johanson, U of Ill Cell of Medicine at Rockford, Rockford, IL; GI Practice Management Group Background. The ASGE recently released guidelines specifying indicators to be used to assess the quality of colonoseopy. Currently, no data are available for individual practitioners to use for comparison with their own practices. This study examined the outcomes of outpatient colonoseopy performed on a large group of patients from geographically diverse practices to provide initial benchmark data. Methods. All patients undergoing colonoscopy at 8 outpatient endoscopy centers from December 1997 to May 1998 were included in the study. Upon completion of the colonoscopy, the procedure indication, type and amount of sedation, final distance reached including reason if incomplete, specific findings, and therapeutic procedure(s) performed were recorded. Patients were contacted 24-48 hours after their procedure and a satisfaction survey was completed. Procedure complications were tracked and recorded. Results: 6,825 eolonoscopies were performed during the study period; 47% among females and 53% in males. Ages ranged between 10 and 96 years. Indications for colonoscopy were appropriate for 6615 procedures (96.9%) based on ASGE guidelines. The most frequent indication cited was screening and surveillance of
colonic neoplasia (34.5%). Among these patients, polyps were identified in 60%. The overall success rate in reaching the cecum was 92.6%. This number likely underestimates the true success rate, as patients with malignant obstruction or cecal resection were not excluded. Only 31 of the 6825 patients suffered a complication (0.45%). The majority of these were postpolypectomy bleeds (23) corresponding to an incidence of 0.33% which is well below published levels of 0.8-2.2%. Only two perforations occurred corresponding to an incidence of 0.03%, likewise well below previously reported levels. 5801 patients (85%) were successfully contacted after their procedure and completed a satisfaction survey. Overall satisfaction was rated as excellent by 72.2% and very good by another 23.1%. Conclusions: These data provide an initial attempt to identify national benchmarks for quality assessment of eolonoscopy. As ASGE quality indicators become more widely implemented, it is anticipated that more refined benchmark data will become available for comparison on both national and regional levels. The ultimate goal of these benchmarks, however, is to enable practitioners to compare the outcomes of their own endoscopic practices with widely accepted standards, ultimately improving the quality of care for each patient.
*'128 REUSABLE BIOPSY FORCEPS: IS "ADEQUATE" CLEANSING ADEQUATE? Timothy P. Kinney, Fouad M. Attia, Richard A. Kozarek, Aiexandra Rusu, Virginia Mason Medical Ctr, Seattle, WA Background: In two recently published studies, 1, 2 reusable forceps were purported to be both contaminated and nonfunctional after 20 uses. As these studies have significant implications for endoscopic practice, we prospectively studied reusable forceps for specimen adequacy and ability to sterilize. Methods: Three new reusable biopsy forceps (FB-24U-1, Olympus America, Inc., New Hyde Park, NY) were prospectively studied. Based upon the above-mentioned publications, forceps were retired a l ~ r 20 uses, or prior to that number if mechanical failure occurred. Reprocessing followed the SGNA protocol and included manual cleaning, enzymatic soak, rinse, biopsy cup lubrication, and steam autoclave. At the end of the study, each forceps was dismantled with a sterile wire cutter and 2-4-inch-long pieces were cut (biopsy tip, mid-shaft, and near handle). These 9 forceps sections were separately cultured and examined under light microscopy. At time of forceps use, data collected included biopsy site, procedure, mechanical problems, and specimen size. Results: No bx forceps developed mechanical malfunction/problem during the clinical study of 60 pts. Procedures included EGD 29, colonoscopy 28, flex sig 2, and ileoscopy 1, and biopsy sites were large bowel 28, stomach 17, esophagus 11, and small bowel 4. Mean specimen size was 2.1 ± 0.2 mm (1-3.8) and all specimens were reported as adequate for pathological interpretation. None of the biopsy sections studied were found to have patient debris at the cups, hinges, needle, or shaft component. Neither aerobic nor anaerobic cultures demonstrated bacterial growth. Conclusions: 1) In contrast to previously published studies, reusable biopsy forceps proved adequate for tissue acquisition for a minimum of 20 cases. 2) Reusable biopsy forceps proved safe provided standard sterilization procedures were followed. 1. Rizzo J, Bernstein D, Gress F. A performance, safety and cost comparison of reusable and disposable endoscopic biopsy forceps: a prospective, randomized trial. Gastrointest Endose 2000;51:257.61.2. Yang R, Ng S, Nichol M, Laine L . A cost and performance evaluation of disposable and reusable biopsy forceps in GI endoscopy. Gastrointest Endose 2000;51:266-70.
*Invited to participate in the Poster Session o f the ASGE meeting. **Selected for Topic Forum. ***Selected for presentation at the ASGE Plenary Session.
VOLUME 53, NO. 5, 2001
GASTROINTESTINAL ENDOSCOPY
AB55