Amy Ou

Development and initial validation of an endoscopic part-task training box

BACKGROUND AND STUDY AIMS There is currently no objective and validated methodology available to assess the progress of endoscopy trainees or to determine when technical competence has been achieved. The aims of the current study were to develop an endoscopic part-task simulator and to assess scoring system validity. METHODS Fundamental endoscopic skills were determined via kinematic analysis, literature review, and expert interviews. Simulator prototypes and scoring systems were developed to reflect these skills. Validity evidence for content, internal structure, and response process was evaluated. RESULTS The final training box consisted of five modules (knob control, torque, retroflexion, polypectomy, and navigation and loop reduction). A total of 5 minutes were permitted per module with extra points for early completion. Content validity index (CVI)-realism was 0.88, CVI-relevance was 1.00, and CVI-representativeness was 0.88, giving a composite CVI of 0.92. Overall, 82 % of participants considered the simulator to be capable of differentiating between ability levels, and 93 % thought the simulator should be used to assess ability prior to performing procedures in patients. Inter-item assessment revealed correlations from 0.67 to 0.93, suggesting that tasks were sufficiently correlated to assess the same underlying construct, with each task remaining independent. Each module represented 16.0 % - 26.1 % of the total score, suggesting that no module contributed disproportionately to the composite score. Average box scores were 272.6 and 284.4 (P = 0.94) when performed sequentially, and average score for all participants with proctor 1 was 297.6 and 308.1 with proctor 2 (P = 0.94), suggesting reproducibility and minimal error associated with test administration. CONCLUSION A part-task training box and scoring system were developed to assess fundamental endoscopic skills, and validity evidence regarding content, internal structure, and response process was demonstrated.

How We Cleaned It Up: A Simple Method That Improved Our Practice’s Bowel Prep

Colonoscopy is the only screening test that allows for direct visualization of the entire colon and removal of polyps. Poor bowel preparation limits the diagnostic accuracy of colonoscopy, lowering rates of cecal intubation and adenoma detection ( 1–3 ). Th us, adequate bowel cleansing serves to avoid the risk associated with repeat colonoscopies. Split-dose bowel preparation with polyethylene glycol (PEG) has emerged as the preferred regimen for purgative dosing ( 4 ). Medical and socioeconomic factors contribute to the risk of poor preparation, including history of diabetes, cirrhosis, dementia, colonic resection, and spinal cord injury ( 5 ). Medicaid status, interpreter requirement, and being unmarried are some of the social factors linked with poor bowel preparation ( 6,7 ). Furthermore, a complex relationship between these socioeconomic factors, poor health literacy, and low patient participation in health care may decrease the likelihood of adequate preparation ( 6–8 ). Previous studies that examine the eff ect of educational material on the quality of bowel preparation have not focused on populations with high-risk socioeconomic barriers to health care. Bellevue Hospital Center is a New York City public hospital that serves a high proportion of uninsured, underinsured, Medicaid patients and non-English speakers. Data collected on patients presenting to our suite show that ~46% have limited English profi ciency, 29% are uninsured, and 32% have Medicaid. Th e primary languages spoken in our hospital other than English include Spanish and Chinese Mandarin. Review of our data showed that nearly 35% of our patients who undergo colonoscopy have an inadequate bowel preparation requiring repeat procedures. Improving bowel preparation in this setting is a challenge; however, we utilized elements of the Plan Do Study Act (PDSA) cycle to characterize the eff ect of split-dose preparation and the use of a multi-language educational booklet on bowel cleanliness in our high-risk patient population. Th e PDSA cycle is a structure for testing changes to improve quality. Th e steps involve planning a test or observation (Plan), testing it out (Do), analyzing the data (Study), and making changes based on lessons learned (Act). We used a modifi ed version of an educational booklet that was originally developed by Spiegel et al. ( 9 ) at UCLA. Th is quality improvement project tested the implementation of a split-dose preparation and multi-language educational booklet on outpatients from January to December 2014. Th e study population included all outpatients undergoing colonoscopy, including procedures aborted because of inadequate preparation. Inpatients, unknown prep quality, and procedures aborted for reasons not related to the preparation were excluded from the analysis. Data were retrospectively and prospectively collected in monthly “snapshots” and included indication, extent reached, and preparation quality. An adequate preparation was defi ned as a Boston Bowel Preparation Score (BBPS) score of ≥6 with minimum of 2 in each segment or an Aronchick score of “good” or “excellent.” χ 2 testing was performed to evaluate for diff erences in preparation quality before and aft er cycles 1 and 2. Logistic regression analysis was performed with the stats package in R (v3.2.0, Bell Laboratories, Murray Hill, NJ), using prep dosing (single vs. split) and booklet use as independent categorical variables on the outcome variable of prep adequacy. Cycle 1: In January 2014, split-dose bowel preparation with 4 l of PEG and bisacodyl (20 mg) was initiated. Th e standard multilingual nurse teaching instructions were revised to include descriptions of the split-dose preparation. Within the endoscopy suite, the BBPS was implemented to quantify bowel preparation across all procedures to minimize bias. Prior to implementation of the BBPS score, our endoscopy staff quantifi ed bowel preparations using the Aronchick scale. Faculty and trainees were given a brief lecture on the BBPS scoring system prior to initiation of the intervention. Cycle 2: Aft er reviewing results from cycle 1, in August 2014, a multi-language educational booklet utilizing a visual aid was implemented ( Figure 1 ). Th e booklets were professionally translated to Spanish and Chinese, as these languages are the two most commonly spoken languages in our hospital other than English. Booklets were then distributed to the clinics, and the nursing staff was instructed to distribute the booklets during the standard teaching provided to the patients. Th e nurses reviewed the booklet with the use of a certifi ed medical translator for patients who did not speak English, Spanish, or Chinese. Feedback from the nursing staff demonstrated a positive impact of the visual aids for this subset of patients. How We Cleaned It Up: A Simple Method That Improved Our Practice’s Bowel Prep