Creation of an institutional preoperative checklist to support clinical risk assessment in patients with ulcerative colitis (UC) considering ileoanal pouch surgery

Background

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most established restorative operative approach for patients with ulcerative colitis. It has associated morbidity and the potential for major repercussions on quality of life. As such, patient selection is crucial to its success. The main aim of this paper is to present an institutional preoperative checklist to support clinical risk assessment and patient selection in those considering IPAA.

Methods

A literature review was performed to identify the risk factors associated with surgical complications, decreased functional outcomes/quality of life, and pouch failure after IPAA. Based on this, a preliminary checklist was devised and modified through an iterative process. This was then evaluated by a consensus group comprising the pouch multidisciplinary team (MDT) core members.

Results

The final preoperative checklist includes assessment for risk factors such as gender, advanced age, obesity, comorbidities, sphincteric impairment, Crohn's disease and pelvic radiation therapy. In addition, essential steps in the decision-making process, such as pouch nurse counselling and discussion regarding surgical alternatives, are also included. The last step of the checklist is discussion at a dedicated pouch-MDT.

Discussion

A preoperative checklist may support clinicians with the selection of patients that are suitable for pouch surgery. It also serves as a useful tool to inform the discussion of cases at the MDT meeting.

Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents from the National Reporting and Learning System (NRLS)

BACKGROUND

Despite advances in understanding and reducing the risk of endoscopic procedures, there is little consideration of the safety of the wider endoscopy service. Patient safety incidents (PSIs) still occur. We sought to identify nonprocedural PSIs (nPSIs) and their causative factors from a human factors perspective and generate ideas for safety improvement.

METHODS

Endoscopy-specific PSI reports were extracted from the National Reporting and Learning System (NRLS). A retrospective, cross-sectional human factors analysis of data was performed. Two independent researchers coded data using a hybrid thematic analysis approach. The Human Factors Analysis and Classification System (HFACS) was used to code contributory factors. Analysis informed creation of driver diagrams and key recommendations for safety improvement in endoscopy.

RESULTS

From 2017 to 2019, 1181 endoscopy-specific PSIs of significant harm were reported across England and Wales, with 539 (45.6%) being nPSIs. Five categories accounted for over 80% of all incidents, with "follow-up and surveillance" being the largest (23.4% of all nPSIs). From the free-text incident reports, 487 human factors codes were identified. Decision-based errors were the most common act prior to PSI occurrence. Other frequent preconditions to incidents were focused on environmental factors, particularly overwhelmed resources, patient factors, and ineffective team communication. Lack of staffing, standard operating procedures, effective systems, and clinical pathways were also contributory. Seven key recommendations for improving safety have been made in response to our findings.

CONCLUSIONS

This was the first national-level human factors analysis of endoscopy-specific PSIs. This work will inform safety improvement strategies and should empower individual services to review their approach to safety.

Development, validation, and results of a national endoscopy safety attitudes questionnaire (Endo-SAQ)

Background and study aims Safety attitudes are linked to patient outcomes. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) identifies the need to improve our understanding of safety culture in endoscopy. We describe the development and validation of the Endo-SAQ (endoscopy safety attitudes questionnaire) and the results of a national survey of staff attitudes. Methods Questions from the original SAQ were adapted to reflect endoscopy-specific content. This was refined by an expert group, followed by a pilot study to assess acceptability. The refined Endo-SAQ (comprising 35 questions across six domains) was disseminated to endoscopy staff across the UK and Ireland. Outcomes were domain scores and the percentage of positive responses (score ≥75/100) per domain. Descriptive and comparative analyses were performed. Binary logistic regression identified staff and service factors associated with positive scores. Validity and reliability of Endo-SAQ were assessed through psychometric analysis. Results After expert review, four questions in the preliminary Endo-SAQ were adjusted. Sixty-one participants undertook the pilot study with good acceptability. A total of 453 participants completed the refined Endo-SAQ. There were positive responses in teamwork, safety climate, job satisfaction, and working conditions domains. Endoscopists had significantly more positive responses to stress recognition and working conditions than nursing staff. JAG accreditation was associated with positive scores in safety climate and job satisfaction domains. Endo-SAQ met thresholds of construct validity and reliability. Conclusions Endoscopy staff had largely positive safety attitudes scores but there were significant differences across domains and staff. There is evidence for the validity and reliability of Endo-SAQ. Endo-SAQ could complement current measures of patient safety in endoscopy and be used in evaluation and research.

BSG cross-sectional survey on impact of COVID-19 recovery on workforce, workload and well-being

Objective

The aim of this survey was to understand the impact of the COVID-19 pandemic and recovery phase on workload, well-being and workforce attrition in UK gastroenterology and hepatology.

Design/method

A cross-sectional survey of British Society of Gastroenterology physician and trainee members was conducted between August and October 2021. Multivariable binary logistic regression and qualitative analyses were performed.

Results

The response rate was 28.8% (180/624 of opened email invites). 38.2% (n=21/55) of those who contracted COVID-19 felt pressured to return to work before they felt ready. 43.8% (71/162) had a regular increase in out-of-hours working. This disproportionately affected newly appointed consultants (OR 5.8), those working full-time (OR 11.6), those who developed COVID-19 (OR 4.1) and those planning early retirement (OR 4.0). 92% (150/164) believe the workforce is inadequate to manage the service backlog with new consultants expressing the highest levels of anxiety over this. 49.1% (80/163) felt isolated due to remote working and 65.9% (108/164) felt reduced face-to-face patient contact made their job less fulfilling. 34.0% (55/162) planned to work more flexibly and 54.3% (75/138) of consultants planned to retire early in the aftermath of the pandemic. Early retirement was independently associated with male gender (OR 2.5), feeling isolated from the department (OR 2.3) and increased anxiety over service backlog (OR 1.02).

Conclusion

The pandemic has placed an additional burden on work-life balance, well-being and workforce retention within gastroenterology and hepatology. Increased aspirations for early retirement and flexible working need to be explicitly addressed in future workforce planning.

'Case of the month': a novel way to learn from endoscopy-related patient safety incidents

Patient safety incidents (PSIs) are unintended or unexpected incidents which can or do lead to patient harm. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) acknowledges that PSIs should be reviewed by endoscopy services and learning shared among staff. It is recognised that more could be done to promote shared learning as outlined by the JAG 'Improving Safety and Reducing Error in Endoscopy' strategy. The 'Case of the month' series aims to provide a broad selection of cases and subsequent learning that can be shared among services and their workforce. This review focuses on five case vignettes that highlight a variety of PSIs in endoscopy. A structured approach, based on incident analysis methodology, is applied to each case to categorise PSIs and develop learning points. Learning is directed toward the individual, team and healthcare organisation. A selection of methods to disseminate learning at local, regional and national levels are also described.

Teamworking in endoscopy: a human factors toolkit for the COVID-19 era

BACKGROUND

Endoscopy services have had to rapidly adapt their working practices in response to COVID-19. As recovery of endoscopy services proceeds, our workforce faces numerous challenges that can impair effective teamworking. We designed and developed a novel toolkit to support teamworking in endoscopy during the pandemic.

METHODS

A human factors model was developed to understand the impact of COVID-19 on endoscopy teams. From this, we identified a set of key teamworking goals, which informed the development of a toolkit to support several team processes. The toolkit was refined following expert input and refinement over a 6-week period.

RESULTS

The toolkit consists of four cognitive aids that can be used to support team huddles, briefings, and debriefs, alongside techniques to optimize endoscopic nontechnical skills across the patient-procedure pathway. We describe the processes that local endoscopy units can employ to implement this toolkit.

CONCLUSION

A toolkit of cognitive aids, based on human factors principles, may be useful in supporting teams, helping them adapt to working safely in the era of COVID-19.

Diagnostic ileocolonoscopy: getting the basics right

Proficient colonoscopy technique that optimises patient comfort while simultaneously enhancing the timely detection of pathology and subsequent therapy is an aspirational and achievable goal for every endoscopist. This article aims to provide strategies to improve colonoscopy quality for both endoscopists and patients.

A prospective study of patient safety incidents in gastrointestinal endoscopy

Background and study aims Medical error occurs frequently with significant morbidity and mortality. This study aime to assess the frequency and type of endoscopy patient safety incidents (PSIs). Patients and methods A prospective observational study of PSIs in routine diagnostic and therapeutic endoscopy was undertaken in a secondary and tertiary care center. Observations were undertaken within the endoscopy suite across pre-procedure, intra-procedure and post-procedure phases of care. Experienced (Consultant-level) and trainee endoscopists from medical, surgical, and nursing specialities were included. PSIs were defined as any safety issue that had the potential to or directly adversely affected patient care: PSIs included near misses, complications, adverse events and "never events". PSIs were reviewed by an expert panel and categorized for severity and nature via expert consensus. Results One hundred and forty procedures (92 diagnostic, 48 therapeutic) over 37 lists (experienced operators n = 25, trainees n = 12) were analyzed. One hundred forty PSIs were identified (median 1 per procedure, range 0 - 7). Eighty-six PSIs (61 %) occurred in 48 therapeutic procedures. Zero PSIs were detected in 13 diagnostic procedures. 21 (15 %) PSIs were categorized as severe and 12 (9 %) had the potential to be "never events," including patient misidentification and wrong procedure. Forty PSIs (28 %) were of intermediate severity and 78 (56 %) were minor. Oxygen monitoring PSIs occurred most frequently. Conclusion This is the first study documenting the range and frequency of PSIs in endoscopy. Although many errors are minor without immediate consequence, further work should identify whether prevention of such recurrent errors affects the incidence of severe errors, thus improving safety and quality.

The endoscopy safety checklist: A longitudinal study of factors affecting compliance in a tertiary referral centre within the United Kingdom

Gastrointestinal endoscopy is a widely used diagnostic and therapeutic procedure both within the United Kingdom and worldwide. With an increasingly older population the potential for complications is increased. The Wolfson Unit for Endoscopy at St. Mark's Hospital in London is a tertiary referral centre, which conducts over 14,000 endoscopic procedures annually. However, despite this high throughput, our baseline observations were that the procedure for safety checks was highly variable.

Over a seven-day period we conducted a questionnaire-based survey to all staff members involved with endoscopy within our unit. We found that there was little consensus between team members, both in terms of essential safety checks and designating responsibility for the checks. A panel of experts was convened in order to devise a safety checklist and a strategy for increasing compliance with the checklist among all staff members. Using a combination of electronic and physical reminders and incentives, we found that there was a significant increase in completed checklist (53% to 66%, p = 0.021) and decrease in the number of checklists left blank post intervention (10% to 2%, p=0.03). We believe that post implementation validation of safety checklists is an important method to ensure their proper use.

Endoscopic non-technical skills team training: The next step in quality assurance of endoscopy training

AIM: To investigate whether novel, non-technical skills training for Bowel Cancer Screening (BCS) endoscopy teams enhanced patient safety knowledge and attitudes.

METHODS: A novel endoscopy team training intervention for BCS teams was developed and evaluated as a pre-post intervention study. Four multi-disciplinary BCS teams constituting BCS endoscopist(s), specialist screening practitioners, endoscopy nurses and administrative staff (A) from English BCS training centres participated. No patients were involved in this study. Expert multidisciplinary faculty delivered a single day’s training utilising real clinical examples. Pre and post-course evaluation comprised participants’ patient safety awareness, attitudes, and knowledge. Global course evaluations were also collected.

RESULTS: Twenty-three participants attended and their patient safety knowledge improved significantly from 43%-55% (P≤ 0.001) following the training intervention. 12/41 (29%) of the safety attitudes items significantly improved in the areas of perceived patient safety knowledge and awareness. The remaining safety attitude items: perceived influence on patient safety, attitudes towards error management, error management actions and personal views following an error were unchanged following training. Both qualitative and quantitative global course evaluations were positive: 21/23 (91%) participants strongly agreed/agreed that they were satisfied with the course. Qualitative evaluation included mandating such training for endoscopy teams outside BCS and incorporating team training within wider endoscopy training. Limitations of the study include no measure of increased patient safety in clinical practice following training.

CONCLUSION: A novel comprehensive training package addressing patient safety, non-technical skills and adverse event analysis was successful in improving multi-disciplinary teams’ knowledge and safety attitudes.

Implementation of an endoscopy safety checklist

Patient safety and quality improvement are increasingly prioritised across all areas of healthcare. Errors in endoscopy are common but often inconsequential and therefore go uncorrected. A series of minor errors, however, may culminate in a significant adverse event. This is unsurprising given the rising volume and complexity of cases coupled with shift working patterns. There is a growing body of evidence to suggest that surgical safety checklists can prevent errors and thus positively impact on patient morbidity and mortality. Consequently, surgical checklists are mandatory for all procedures. Many UK hospitals are mandating the use of similar checklists for endoscopy. There is no guidance on how best to implement endoscopy checklists nor any measure of their usefulness in endoscopy. This article outlines lessons learnt from innovating service delivery in our unit.