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8 Quality indicators as a critical part of pediatric endoscopy provision

Priya Narula and Mike Thomson

KEY POINTS

 Safe, efficient, technically‐competent endoscopy is only part of the story.

 A child and family‐friendly environment, good pre‐procedure preparation, accurate documentation and clear and concise communication between team members is essential.

 Appropriate after care and information with follow up complete an ideal endoscopic experience for a child and family.

Introduction

High‐quality pediatric endoscopy occurs when a child or adolescent receives an indicated procedure safely and efficiently in an appropriate environment, with relevant and adequate communication and documentation occurring before, during and after the procedure among the involved health professionals and the patient and family or carer, a correct diagnosis is made or excluded and appropriate therapy is provided as indicated. Quality in endoscopy is not just limited to technical expertise but includes other elements such as clinical quality, quality of patient experience, workforce providing this service, and training, which can influence the overall quality of endoscopy provision.

A quality indicator or measure or metric can be used to compare actual performance against a standard defined by ideal performance or benchmark and enable potential quality improvement [1]. Clinically relevant measures should correlate with clinically relevant endpoints, be evidence based with demonstrable gaps in performance and be amenable to both measurement and improvement [1]. Quality indicators in adult endoscopy are well established and involve measures of structure, process, and outcome [2] (www.thejag.org.uk). However, there is a limited evidence base for pediatric endoscopy quality indicators.

Quality indicators may be flexible as evidence and practice evolve. In the UK, identified quality and safety indicators have been used to underpin the respective items of the Pediatric Endoscopy Global Rating Scale (P‐GRS), a quality improvement tool launched in 2017 which, amongst other measures, assesses the extent to which the audit cycle has been applied to the quality and safety indicators (www.bspghan.org.uk; www.thejag.org.uk). Suggested pediatric procedural quality indicators include procedure completion rates such as cecal intubation and terminal ileal intubation rates, appropriate diagnostic biopsies based on best evidence, adequate bowel preparation for colonoscopies, and safety indicators that relate to complication rates. These are auditable outcomes for which there is some evidence base to help recommend a minimum standard, for example, ileal intubation rates in pediatric colonoscopy. As confirmation or exclusion of inflammatory bowel disease is one of the main reasons for pediatric colonoscopy, ileal intubation is a clinically important and meaningful pediatric quality indicator compared to only using cecal intubation rates that are more relevant for adult endoscopists in the context of bowel cancer screening. Cecal intubation rates are generally recommended to be >90% (www.thejag.org.uk). Reported ileal intubation rates in recent pediatric literature vary from 84% to 98% [3–5].

A recent North American endoscopy clinical report proposed >90% ileal intubation rate as a quality metric for pediatric colonoscopy [6]. The pediatric colonoscopy certification criteria in the UK use terminal ileal intubation rates of ≥60% and cecal intubation rates of ≥90%, amongst other criteria, for certifying pediatric gastroenterology trainees to perform independent ileocolonoscopies (www.thejag.org.uk).

Access to an electronic endoscopy reporting system is essential in all pediatric endoscopy units as this allows reliable and accurate data collection. There are other quality and safety outcomes which are important to monitor and review but due to a limited evidence base, it can be difficult to assign a standard, for example the minimum number of procedures required to maintain competence or unplanned admissions or procedures within a fixed time frame such as eight days of a gastrointestinal endoscopy or need for ventilation post gastrointestinal endoscopy performed under general anesthetic or unplanned use of reversal agents if sedation used. Other quality indicators may relate to the structure, process or staffing in a pediatric endoscopy unit.

Quality and safety indicators relating to structure can include access to age‐appropriate equipment, endoscopy reporting system, supportive anesthetic, pathology and radiology service with pediatric expertise, etc. Quality and safety indicators relating to process include having agreed policies such as for managing patients with diabetes, adherence to guidelines for endoscope decontamination, use of time‐out or WHO checklists pre‐procedure, an endoscopy user group that meets regularly, etc. Quality indicators relating to staffing include staffing levels and skill mix appropriate to the volume and types of procedures performed with pediatric competencies, identified medical and nurse leads for endoscopy with adequate managerial and clerical staff support, appropriate supervision of trainees, etc.

The National Endoscopy Database (NED), led by the Joint Advisory Group on GI Endoscopy (JAG), is a very exciting development in the UK. The NED is populated by data extracted automatically from the endoscopy reporting system at endoscopy services in the UK. It will make data available in user‐friendly outputs for clinicians, services and research purposes and enable improved quality assurance in endoscopy (https://ned.jets.nhs.uk/KPI).

Conclusion

Development of quality improvement tools like the P‐GRS, a robust quality assurance process and the regular audit of performance against quality indicators that are clinically meaningful for pediatric endoscopy will help define their importance, measure performance variability against these indicators and in time allow pediatric endoscopy units to achieve and demonstrate the highest standards of quality and patient‐centered care through repeated cycles of measurement, intervention, and evaluation.

 See companion website for videos relating to this chapter topic: www.wiley.com/go/gershman3e

REFERENCES

1 1 Petersen BT. Quality assurance for endoscopists. Best Pract Res Clin Gastroenterol 2011, 25, 349–360.

2 2 Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015, 81(1), 31–53.

3 3 Thakkar K, Holub JL, Gilger MA, et al. Quality indicators for paediatric colonoscopy: results from a multicenter consortium. Gastrointest Endosc 2016, 83, 533–541.

4 4 Singh HK, Withers GD, Ee LC. Quality indicators in paediatric colonoscopy: an Australian tertiary centre experience. Scand J Gastroenterol 2017, 52(12), 1453–1456.

5 5 Thomson M, Sharma S. Diagnostic yield of upper and lower gastrointestinal endoscopies in children in a tertiary centre. J Pediatr Gastroenterol Nutr 2017, 64(6), 903–906.

6 6 Kramer RE, Walsh CM, Lerner DG, et al. Quality improvement in paediatric endoscopy: a clinical report from the NASPGHAN endoscopy committee. J Pediatr Gastroenterol Nutr 2017, 65(1), 125–131.