P Dunckley

An analysis of the learning curve to achieve competency at colonoscopy using the JETS database

Objective The number of colonoscopies required to reach competency is not well established. The primary aim of this study was to determine the number of colonoscopies trainees need to perform to attain competency, defined by a caecal intubation rate (CIR) ≥90%. As competency depends on completion, we also investigated trainee factors that were associated with colonoscopy completion. Design The Joint Advisory Group on GI Endoscopy in the UK has developed a trainee e-portfolio from which colonoscopy data were retrieved. Inclusion criteria were all trainees who had performed a total of ≥20 colonoscopies and had performed ≤50 colonoscopies prior to submission of data to the e-portfolio. The primary outcome measure was colonoscopy completion. The number of colonoscopies required to achieve CIR ≥90% was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine factors which determine colonoscopy completion, a mixed effect logistic regression model was developed which allowed for nesting of patients within trainees and nesting of patients within hospitals, with various patient, trainee and training factors entered as fixed effects. Results 297 trainees undertook 36 730 colonoscopies. By moving average analysis, the cohort of trainees reached a CIR of 90% at 233 procedures. By LC-Cusum analysis, 41% of trainees were competent after 200 procedures. Of the trainee factors, the number of colonoscopies, intensity of training and previous flexible sigmoidoscopy experience were significant factors associated with colonoscopy completion. Conclusions This is the largest study to date investigating the number of procedures required to achieve competency in colonoscopy. The current training certification benchmark in the UK of 200 procedures does not appear to be an inappropriate minimum requirement. The LC-Cusum chart provides real time feedback on individual learning curves for trainees. The association of training intensity and flexible sigmoidoscopy experience with colonoscopy completion could be exploited in training programmes.

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. Pearsons 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.

Development and roll out of the JETS e-portfolio: a web based electronic portfolio for endoscopists

The JAG Endoscopy Training System (JETS) e-portfolio was designed to provide an electronic log of endoscopic experience, improve the effectiveness of training, streamline the JAG certification process and support the quality assurance of trainers, units and regional training programmes. It was piloted in 2008 with an 82.6% uptake in trainees offered the system. The system was released in the UK in September 2009. Steady adoption across the UK demonstrates the service finds it a valuable tool. In time it will be the only vehicle through which a trainee can achieve certification through JAG to practise independently.

The learning curve to achieve satisfactory completion rates in upper GI endoscopy: an analysis of a national training database

Objective The aim of this study was to determine the number of OGDs (oesophago-gastro-duodenoscopies) trainees need to perform to acquire competency in terms of successful unassisted completion to the second part of the duodenum 95% of the time. Design OGD data were retrieved from the trainee e-portfolio developed by the Joint Advisory Group on GI Endoscopy (JAG) in the UK. All trainees were included unless they were known to have a baseline experience of >20 procedures or had submitted data for <20 procedures. The primary outcome measure was OGD completion, defined as passage of the endoscope to the second part of the duodenum without physical assistance. The number of OGDs required to achieve a 95% completion rate was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine which factors were independently associated with OGD completion, a mixed effects logistic regression model was constructed with OGD completion as the outcome variable. Results Data were analysed for 1255 trainees over 288 centres, representing 243 555 OGDs. By moving average method, trainees attained a 95% completion rate at 187 procedures. By LC-Cusum analysis, after 200 procedures, >90% trainees had attained a 95% completion rate. Total number of OGDs performed, trainee age and experience in lower GI endoscopy were factors independently associated with OGD completion. Conclusions There are limited published data on the OGD learning curve. This is the largest study to date analysing the learning curve for competency acquisition. The JAG competency requirement for 200 procedures appears appropriate.

Comfort scores in colonoscopy performance

Introduction The principle indicator for assessing competence in colonoscopy is caecal intubation rate (CIR). Comfort is a key auditable outcome for colonoscopy but there are no standards for patient comfort during colonoscopy and no reports of comfort scores in relation to other quality indicators. The aim of this study is to analyze the role of different factors in determining an individuals performance in colonoscopy and to explore the significance of patient comfort scores in colonoscopist performance. Methods All colonoscopies performed in our endoscopy centres are recorded in customised reporting systems (SQLscope and Unisoft), which log all key performance indicators. Data was extracted between 2007 and 2010. The following variables were measured: CIR, nurse-reported comfort levels (NRCL) on a 5-point scale (1 = no discomfort, 2 = minimal discomfort, 3 = mild discomfort, 4 = moderate discomfort, 5 = severe discomfort), polyp detection rate (PDR) (hyperplastic and adenomatous), patients experience (PE) of the procedure (better than expected, as expected, worse than expected) and use of sedation. Significant discomfort was defined as a NRCL of 4 or 5 or a PE of worse than expected. Results A total of 12561 colonoscopies were recorded with NRCL and PE. NRCL of 4 or 5 was measured in 1181 cases (9.4%). The average number of procedures performed per endoscopist per year was 146 (range 11–483). Figure 1 shows the relation between CIR and NRCL (4–5). There was a significant negative correlation (R = −0.57 ; p < 0.005). A positive correlation was found between PDR and CIR (R = 0.57; p < 0.005). The amount of midazolam given during the procedure was negatively correlated with CIR (R = −0.39; p = 0.055). Finally, fewer than one in 20 patients rated their experience worse than expected and a worse than expected PE of colonoscopy showed a negative correlation with CIR (R = -0.54; p < 0.01). Table 1 shows the outcome of the different variables per year (2007 and 2010 are only partial years). CIR, PDR and NRCL have collectively improved year on year. Figure 1 OC-088 Relation between CIR and NRCL 4-5 Table 1 OC-088 Performance per year Year Number of colonoscopies CIR (%) NCRL 4–5 (%) PDR (%) PE worse than expected (%) 2007 1328 90.7 12.7 20.5 4.7 2008 3966 92.2 10.5 28.4 5.5 2009 4235 93.1 7.9 27.3 4.2 2010 3032 94.5 8.6 30 4.3 Conclusion This study shows that endoscopists with a high CIR perform colonoscopies with less patient discomfort than those with lower CIRs, use less midazolam and see and remove more polyps. Thus achieving a high CIR and high PDR does not need to be associated with more pain and more sedation. Comfort scores should be included in the assessment of overall performance in colonoscopy to provide a fuller picture of performance.

The impact of the introduction of formalised polypectomy assessment on training in the UK

Objective The aim was to describe the impact on polypectomy experience by the mandatory introduction of the Directly Observed Polypectomy Skills tool (DOPyS) and electronic portfolio as part of the formal colonoscopy certification process. Design Applications for colonoscopy certification in the UK in the year prior to the introduction of DOPyS were analysed retrospectively and compared with data collected prospectively for those in the following year. Setting UK National Health Service. Patients None. Interventions None. Main outcome measures The outcomes studied included whether evidence of exposure to polypectomy, endoscopic mucosal resection (EMR) and colonoscopy changed over the 2-year period. The nature of the polyps removed by trainees was also studied. Results Thirty two per cent of candidates in the first year had evidence of any observed polypectomy with 7% of candidates referring to training in EMR. The median number of formative colonoscopy assessments was 3 (range 0–16). All of these candidates in the second year had evidence of polypectomy assessment, with a median number of DOPyS of 7 (range 3–27). Eighty nine per cent of applicants had evidence of assessed EMR. The median number of formative colonoscopy assessments in this cohort was 32 (range 9–199). There was a significant increase in the number of logged polypectomy assessments (p<0.001), experience of EMR (p<0.001) and formative colonoscopy assessments (p<0.001). There was no significant difference in the total number of colonoscopy procedures performed. Conclusions Structured polypectomy assessment improves trainees’ documented exposure to therapeutic endoscopy as well as providing formal evidence of skills acquisition. As polypectomy plays an increasing role globally in colorectal cancer prevention, the DOPyS provides an effective means of assessing and certifying polypectomy.

OC-001 The Impact of the Introduction of Formalised Polypectomy Assessment on Training in the United Kingdom

Introduction Polypectomy is regarded as the most hazardous part of colonoscopy, accounting for the majority of procedure-associated morbidity and yet is a necessary skill for all colonoscopists. Training in polypectomy has, to date, been variable and poorly structured. Anecdotal evidence suggested poor exposure to polypectomy during training. A novel assessment tool, the Directly Observed Polypectomy Skills (DoPYS), was introduced nationally in the United Kingdom in October 2011 with the intention of both improving training and facilitating documentation of competency. Methods The aim was to assess the impact of the mandatory introduction of the DOPyS as part of the formal colonoscopy certification process. Applications for certification in the year prior to the introduction of DOPyS were analysed retrospectively and compared with data collected prospectively for those in the following year. Data were collected on the total lifetime number of colonoscopies performed, the number of assessments for both colonoscopy and polypectomy and whether applicants had any evidence of performing polypectomy before certification of competence in colonoscopy. Results There were 175 applicants for certification in the first year. The median number of procedures per candidate was 287. Thirty two per cent of candidates had evidence of any observed polypectomy with 7 per cent of candidates referring to training in endoscopic mucosal resection (EMR). The median number of formative colonoscopy assessments was 3 (range 0–16). In the year since DOPyS was introduced there were 150 applications for certification. The median number of procedures per candidate was 206. All of these candidates had evidence of polypectomy assessment with a median number of DOPyS of 7 (range 3–27). 89 per cent of applicants had evidence of assessed EMR. The median number of formative colonoscopy assessments in this cohort was 32 (range 9–199). There was a significant increase in the number of logged polypectomy assessments (p < 0.001), experience of EMR (p < 0.001) and formative colonoscopy assessments (p < 0.001). There was no significant difference in the total number of colonoscopy procedures performed. Conclusion These data – the largest in the literature to date – show that structured polypectomy assessment improves trainees’ documented exposure to therapeutic endoscopy as well as providing formal evidence of skills acquisition. As polypectomy plays an increasing role globally in colorectal cancer prevention, the DOPyS provides an effective means of assessing and certifying polypectomy in order to minimise the well-recognised risks associated with this technique. Disclosure of Interest None Declared.

OWE-003 Cold snare polypectomy is safe yet under-utilised: an analysis of 281,194 UK trainee polypectomies

Introduction Multiple techniques exist for the management of colorectal polyps. Recent ESGE guidelines1 have defined an evidence based guide to the optimal technique for removing different sizes of polyps. Previously this decision often depended on an individual operator’s experience and training. We sought to examine current polypectomy practice amongst United Kingdom endoscopy trainees with to these guidelines. Methods The ESGE polypectomy guideline1 suggests polyps<10 mm should be removed using cold snare polypectomy (CSP) or cold biopsy forceps (CBF) [≤3 mm only], 10–19 mm using endoscopic mucosal resection (EMR) or hot snare polypectomy (HSP) and ≥20 mm using EMR. The JETS database is a prospectively collected record of trainee colonoscopic procedures in the United Kingdom and its use during training is mandatory for accreditation. Data is entered by trainees on their own endoscopic procedures. Adverse events were classified as delayed bleeding or delayed perforation. We retrospectively analysed procedures entered into the JETS database from Jan 2008 to December 2017 for polypectomy technique and compared this to the 2017 ESGE guideline. Results 2 91 778 polypectomies were performed in 1 76 569 trainee-performed procedures by 3395 trainees over the study period. 10 584 polypectomies were missing data. 2 81 194 polypectomies were analysed. Of 2 50 783 polyps<10 mm in size removed, 29.5% were performed using CBF, 27.9% by CSP, 25.1% by HSP, 9.5% by HBF, and 8.0% by EMR. Of 26 605 polyps 10–19 mm in size, 55.3% were removed by HSP, 31.0% by EMR and 3.5% by CSP. 8.4% of lesions were biopsied and not removed. Of 3806 polyps≥20 mm in size, 39.4% were removed by EMR, 36.3% by HSP, 1.1% were removed by CSP and 21.9% of these lesions were biopsied and not removed. Overall, adherence to the ESGE guidance was observed in 1 54 948 polypectomies (55.1%). Nurse endoscopists were more adherent (61.7%), versus physicians (57.9%) versus surgeons (44.3%), p<0.001. Of 219 (0.1%) adverse events reported amongst all polypectomies, 50.8% were amongst HSP, 19.2% EMR, 16.9% CSP and 12.7% after HBF p<0.001. Of 20 delayed perforations (event rate 0.01%), 55% were due to EMR, 30% to HSP and 15% to HBF. No perforations resulted from CSP. Conclusions Cold snare polypectomy is under-utilised for diminutive polypectomy, despite its proven safety and efficacy; its use amongst trainees should be promoted in line with ESGE guidance. Trainees are likely to follow the example of their trainers and, as such, this study likely provides an insight into current polypectomy practice in the wider UK endoscopic community. Trainees in the United Kingdom predominantly remove diminutive polyps with extremely low rates of adverse events. Reference . Ferlitsch M, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): Endoscopy. 2017 Mar 1;49(3):270–97.

High complete resection rate for pre-lift and cold biopsy of diminutive colorectal polyps

Background and study aims  The majority of polyps removed at colonoscopy are diminutive (≤ 5 mm) to small (< 10 mm) and there are few guidelines for the best way for these polyps to be removed. We aimed to assess the feasibility and effectiveness of cold biopsy forceps polypectomy with pre-lift (CBPP) for polyps ≤ 7 mm. Our aims were to assess completeness of histological resection of this technique, to identify factors contributing to this and assess secondary considerations such as timing, retrieval and complication rates. Patients and methods  We conducted a prospective cohort study on consecutive patients receiving a colonoscopy at Cheltenham General Hospital, as part of the National Bowel Cancer Screening Program (BCSP) in England. The study included only polyps that were judged as ≤ 7 mm by the colonoscopist. A small sub-mucosal pre-lift injection was administered prior to removal of the polyp using cold biopsy forceps. One or more biopsies were taken until the polyp was confidently assessed visually as being completely removed by the colonoscopist. The entire polypectomy site was then removed en bloc by endomucosal resection (EMR) with a margin of at least 1 to 2 mm around defect. This was sent for histopathological analysis to assess completeness of resection. Polypectomy timing, tissue retrieval, number of bites required for visual resection and complications were recorded at the time of the procedure. Results  Sixty-four patients were recruited and consented. Of them, 42 patients had a total of 60 polyps resected. Three patients had inflammatory polyps and were excluded from the study, leaving 57/60 polyps for final analysis. Seventeen were hyperplastic and 40 adenomatous polyps. Retrieval was complete for all 57 polyps and there were no complications both during or post- polypectomy. The complete resection rate (CRR) was 86 %. The technique was more effective in smaller polyps with 91.7 % of diminutive polyps (≤ 5 mm) completely excised. Conclusions  CBPP is a safe and highly effective technique for polyps < 5 mm with a high complete resection and retrieval rate. The time taken for the procedure is significantly greater than cold forceps alone, or cold snare as seen in other studies.

PTH-032 Assessing the merits of sedation practice on comfort scores during gastroscopy training procedures in the uk

Introduction Oesophagogastroduodenoscopy (OGD) is invaluable in the investigation and treatment of the upper gastrointestinal tract, but may cause patient anxiety and discomfort. Many patients elect to have no sedation. For the remainder, sedation practice varies with limited data regarding the merits or risks of differing sedation practice. The 2004 NCEPOD report “Scoping our practice”1 raised concerns about sedation practice in the UK. Sedation practice is safer now2, but there has been limited research into minimising patient discomfort. This study compared patient comfort scores using different combinations of sedation; midazolam alone, a combination of pharyngeal anaesthesia (PA) and midazolam, or a combination of PA, midazolam and opiates. Method Retrospective data from the Joint Advisory Group (JAG) Endoscopy Training System (JETS) database of patients having OGDs performed by trainees between September 2009 and March 2016 was analysed. Procedures carried out under general anaesthesia and in patients under 18 years of age were excluded. Procedural discomfort was scored using the Gloucester comfort scale and grouped into: significant discomfort (4 or 5) and non-significant discomfort (1, 2 or 3). A multivariate analysis was used to compare data. Data was reviewed to determine if sedation practice effected immediate complication rates. Results 826,593 OGDs were included in the study. 46.9% (387886) of procedures used PA alone, 23.4% (193014) PA and midazolam, 17.5% (144315) midazolam alone and 3.1% (26017) PA, midazolam and opiates. Average doses of midazolam used were 2.44 mg (PA and midazolam) compared with 2.68 mg (midazolam alone). Patients had less significant discomfort when midazolam was used in combination compared to midazolam alone; midazolam with PA (OR 0.69, 95% CI 0.67–0.72 p<0.01) and midazolam with PA and opiates (OR 0.60, 95% CI 0.55–0.65 p<0.01). There was no statistically significant difference in immediate complication rates when comparing with midazolam alone; PA and midazolam (OR 1.36, 95% CI 0.80–2.32 p=0.25) or PA, midazolam and opiates (OR 0.92, 95% CI 0.31–2.72 p 0.88) vs midazolam alone. Conclusion This study describes a variation in sedation practice for OGDs in the UK. The use of midazolam in combination therapy is correlated with better comfort scores with no increase in immediate complications. References . Scoping our practice. NCEPOD. London 2004, (http://www.ncepod.org.uk/2004report/) . Gavin DR, et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut2013;62(2):242–249 Disclosure of Interest None Declared