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Su1594 A Novel Training and Assessment Tool for the Endoscopic Management of Upper GI Bleeding (UGIB)
Abstracts
258) and 54% males (140/258). Patients admitted with NSTEMI were 196 (75%,), STEMI 45 (18%) and demand ischemia from GI bleeding 15 (5%). Seventy four percent (nZ190/258) underwent cardiac catheterization of whom 132 patients received either angioplasty alone (8%, nZ10/132), stent placement (71%, nZ94/132) or were referred for CABG (9%, nZ12/132). Fifty four percent (nZ138/258) were on dual antiplatelet medication and the rest on acetylsalicylic acid alone. Major indications were GI bleeding 98 (38%), anemia in 86 (34%) and for nutrition support in 30 (12%). The distribution of endoscopic procedures include, EGD 158 (61%), colonoscopy 13 (5%), EGD and colonoscopy in 45 (17%), flex sigmoidoscopy 10 (3.8%), PEG tube placement 30 (12%) and ERCP in 1 patient. The majority received conscious sedation (non-propofol) (nZ 194/ 258, 75%) administered by a GI nurse, 20 patients (7%) were on mechanical ventilator with sedation protocol, and 38 patients (15%) were sedated with propofol by anesthesia team. A total of 27 complications recorded (10%). Majority (24/27) were transient tachycardia or hypotension not requiring resuscitation. Two patients required intervention with small doses of phenylephrine for hypotension and another patient required fluid boluses and 2 units of pRBC during the procedure that was attributed to active bleeding from Mallory Weiss tear. There were no major complications such fatal or non-fatal MI/arrhythmias or cardiac arrest occurred in relation to endoscopic procedures. There was no procedure related bleeding complications recorded despite the frequent use of antiplatelet medications in this patient population. Conclusion: Gastrointestinal endoscopy within 72 hours of acute myocardial infarction can be performed if necessary with a low risk of severe complications.
of these aspects. The performance rating scale was based on the degree of independence demonstrated by the trainee in each aspect. These aspects of performance, definitions of standards and rating scales were then used to construct the UGIB DOPS (fig1). Phase 2: Pilot of the DOPS tool: We evaluated the feasibility, validity and educational impact of the new tool using 8 trainees paired with trainers for cases of UGIB using questionnaires and semi-structured interviews. Results: The trainee cohort displayed a range of experience: 2 were very experienced (managed 80+ bleeding cases) with 2 being relative novices (1-10 cases). All trainees commented on improved feedback using the DOPS (fig 2). 2 experienced trainees perceived less of an educational impact, however they stated no observation or feedback would have occurred in the absence of the new tool. Thematic analysis revealed recurring themes regarding improvement of feedback using defined assessment criteria: more specific, better structure and the creation of action plans. The educational value of the DOPS was universally acknowledged. Both trainers and trainees found the tool feasible, transparent and valid. All trainers strongly agreed the tool facilitated feedback structure and perceived the overall grade awarded reflected trainees current competence. Conclusion: This novel UGIB DOPS has demonstrated significant educational impact by leading to effective feedback on the trainee’s performance and results in an action plan for further training. The DOPS is feasible for routine use in the clinical setting. The tool is currently fit for purpose to improve training in UGIB management. A further study is planned to determine the reliability of the UGIB DOPS which is essential for the tool to be used summatively to ‘sign off’ endoscopists as competent in the independent management of UGIB.
Su1593 The Risk of Rebleeding After Endoscopic Hemostasis Differs According to the Use of Aspirin Medication At the Time of Initial Upper Gastrointestinal Bleeding MI Jin Hong, Sun-Young Lee*, Jeong Hwan Kim, in Kyung Sung, Hyung Seok Park, Chan Sup Shim, Choon Jo Jin Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea Background: Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify the risk factors for rebleeding after a successful endoscopic hemostasis according to the use of antithrombotics. Methods: UGIB patients who underwent successful endoscopic hemostasis between August 2005 and September 2012 were included. Rebleeding was diagnosed when the previously treated lesion bled again within 30 days of the initial episode. The risk of rebleeding was analyzed according to the underlying disease(s) and recent medication(s) of the patient, characteristics of the bleeding lesion, and variables related to the initial endoscopic hemostasis. Results: Of 614 UGIB patients who were controlled by endoscopic hemostasis, 138 patients (22.5%) were taking antithrombotics. Rebleeding occurred in 113 patients (18.4%). The risk of rebleeding was higher with aspirin medication (pZ0.009) and after a long endoscopic hemostasis (p!0.001). Of 33 patients with antithrombotics who showed rebleeding, 32 (97.0%) were taking aspirin and 32 (97.0%) revealed peptic ulcer bleeding. The preferences for the use epinephrine injection (p!0.001) and electrocauterization (p!0.001) were significantly different among GI endoscopists, but there was no significant difference in the rate of rebleeding (pZ0.303). Conclusions: The risk of rebleeding after endoscopic hemostasis for UGIB is higher in the patients with aspirin medication and after a long endoscopic hemostasis. The use of aspirin at the time of UGIB should be considered significantly in terms of rebleeding.
Figure 1. DOPS for The Endoscopic Management of Upper GI Bleeding
Su1594 A Novel Training and Assessment Tool for the Endoscopic Management of Upper GI Bleeding (UGIB) Louise China*1,2, Gavin J. Johnson2,1 1 Medical School, University College London, London, United Kingdom; 2 Gastroenterology, University College London Hospital, London, United Kingdom Endoscopy training has moved away from pure number based training, and towards the summative assessment of competence in endoscopic skills. There is currently no structured, formal tool with which to assess and provide feedback for the specific generic and endoscopic skills required in effective management of UGIB. There is also pressure on hospitals in the UK to provide a 24/7 endoscopy service for UGIB, resulting in an urgent need to determine endoscopists competence. Aim: DOPS (Directly Observed Procedural Skills) are used as a tool to assess practical skills by providing a framework for an expert to observe, assess and provide feedback on a procedure. We developed a new DOPS tailored to the specific aspects of endoscopic management of UGIB. Methods: Phase 1: Design: UGIB ‘task deconstruction’ was undertaken by an expert group of endoscopists in a busy UK teaching hospital. Consensus was reached on the individual aspects of UGIB management, and then to define what was considered a satisfactory performance in each
AB226 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
Figure 2. Assessment of perceptions of change in feedback using the DOPS form compared to current standard practice.
www.giejournal.org
258) and 54% males (140/258). Patients admitted with NSTEMI were 196 (75%,), STEMI 45 (18%) and demand ischemia from GI bleeding 15 (5%). Seventy four percent (nZ190/258) underwent cardiac catheterization of whom 132 patients received either angioplasty alone (8%, nZ10/132), stent placement (71%, nZ94/132) or were referred for CABG (9%, nZ12/132). Fifty four percent (nZ138/258) were on dual antiplatelet medication and the rest on acetylsalicylic acid alone. Major indications were GI bleeding 98 (38%), anemia in 86 (34%) and for nutrition support in 30 (12%). The distribution of endoscopic procedures include, EGD 158 (61%), colonoscopy 13 (5%), EGD and colonoscopy in 45 (17%), flex sigmoidoscopy 10 (3.8%), PEG tube placement 30 (12%) and ERCP in 1 patient. The majority received conscious sedation (non-propofol) (nZ 194/ 258, 75%) administered by a GI nurse, 20 patients (7%) were on mechanical ventilator with sedation protocol, and 38 patients (15%) were sedated with propofol by anesthesia team. A total of 27 complications recorded (10%). Majority (24/27) were transient tachycardia or hypotension not requiring resuscitation. Two patients required intervention with small doses of phenylephrine for hypotension and another patient required fluid boluses and 2 units of pRBC during the procedure that was attributed to active bleeding from Mallory Weiss tear. There were no major complications such fatal or non-fatal MI/arrhythmias or cardiac arrest occurred in relation to endoscopic procedures. There was no procedure related bleeding complications recorded despite the frequent use of antiplatelet medications in this patient population. Conclusion: Gastrointestinal endoscopy within 72 hours of acute myocardial infarction can be performed if necessary with a low risk of severe complications.
of these aspects. The performance rating scale was based on the degree of independence demonstrated by the trainee in each aspect. These aspects of performance, definitions of standards and rating scales were then used to construct the UGIB DOPS (fig1). Phase 2: Pilot of the DOPS tool: We evaluated the feasibility, validity and educational impact of the new tool using 8 trainees paired with trainers for cases of UGIB using questionnaires and semi-structured interviews. Results: The trainee cohort displayed a range of experience: 2 were very experienced (managed 80+ bleeding cases) with 2 being relative novices (1-10 cases). All trainees commented on improved feedback using the DOPS (fig 2). 2 experienced trainees perceived less of an educational impact, however they stated no observation or feedback would have occurred in the absence of the new tool. Thematic analysis revealed recurring themes regarding improvement of feedback using defined assessment criteria: more specific, better structure and the creation of action plans. The educational value of the DOPS was universally acknowledged. Both trainers and trainees found the tool feasible, transparent and valid. All trainers strongly agreed the tool facilitated feedback structure and perceived the overall grade awarded reflected trainees current competence. Conclusion: This novel UGIB DOPS has demonstrated significant educational impact by leading to effective feedback on the trainee’s performance and results in an action plan for further training. The DOPS is feasible for routine use in the clinical setting. The tool is currently fit for purpose to improve training in UGIB management. A further study is planned to determine the reliability of the UGIB DOPS which is essential for the tool to be used summatively to ‘sign off’ endoscopists as competent in the independent management of UGIB.
Su1593 The Risk of Rebleeding After Endoscopic Hemostasis Differs According to the Use of Aspirin Medication At the Time of Initial Upper Gastrointestinal Bleeding MI Jin Hong, Sun-Young Lee*, Jeong Hwan Kim, in Kyung Sung, Hyung Seok Park, Chan Sup Shim, Choon Jo Jin Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea Background: Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify the risk factors for rebleeding after a successful endoscopic hemostasis according to the use of antithrombotics. Methods: UGIB patients who underwent successful endoscopic hemostasis between August 2005 and September 2012 were included. Rebleeding was diagnosed when the previously treated lesion bled again within 30 days of the initial episode. The risk of rebleeding was analyzed according to the underlying disease(s) and recent medication(s) of the patient, characteristics of the bleeding lesion, and variables related to the initial endoscopic hemostasis. Results: Of 614 UGIB patients who were controlled by endoscopic hemostasis, 138 patients (22.5%) were taking antithrombotics. Rebleeding occurred in 113 patients (18.4%). The risk of rebleeding was higher with aspirin medication (pZ0.009) and after a long endoscopic hemostasis (p!0.001). Of 33 patients with antithrombotics who showed rebleeding, 32 (97.0%) were taking aspirin and 32 (97.0%) revealed peptic ulcer bleeding. The preferences for the use epinephrine injection (p!0.001) and electrocauterization (p!0.001) were significantly different among GI endoscopists, but there was no significant difference in the rate of rebleeding (pZ0.303). Conclusions: The risk of rebleeding after endoscopic hemostasis for UGIB is higher in the patients with aspirin medication and after a long endoscopic hemostasis. The use of aspirin at the time of UGIB should be considered significantly in terms of rebleeding.
Figure 1. DOPS for The Endoscopic Management of Upper GI Bleeding
Su1594 A Novel Training and Assessment Tool for the Endoscopic Management of Upper GI Bleeding (UGIB) Louise China*1,2, Gavin J. Johnson2,1 1 Medical School, University College London, London, United Kingdom; 2 Gastroenterology, University College London Hospital, London, United Kingdom Endoscopy training has moved away from pure number based training, and towards the summative assessment of competence in endoscopic skills. There is currently no structured, formal tool with which to assess and provide feedback for the specific generic and endoscopic skills required in effective management of UGIB. There is also pressure on hospitals in the UK to provide a 24/7 endoscopy service for UGIB, resulting in an urgent need to determine endoscopists competence. Aim: DOPS (Directly Observed Procedural Skills) are used as a tool to assess practical skills by providing a framework for an expert to observe, assess and provide feedback on a procedure. We developed a new DOPS tailored to the specific aspects of endoscopic management of UGIB. Methods: Phase 1: Design: UGIB ‘task deconstruction’ was undertaken by an expert group of endoscopists in a busy UK teaching hospital. Consensus was reached on the individual aspects of UGIB management, and then to define what was considered a satisfactory performance in each
AB226 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
Figure 2. Assessment of perceptions of change in feedback using the DOPS form compared to current standard practice.
www.giejournal.org