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.

DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making

BACKGROUND AND AIMS

Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients.

METHODS

Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement.

RESULTS

In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting.

CONCLUSIONS

By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.

Cancer Biology or Ineffective Surveillance? A multicentre retrospective analysis of colitis-associated post-colonoscopy colorectal cancers

BACKGROUND AND AIMS

Inflammatory bowel disease (IBD) is associated with high rates of post-colonoscopy colorectal cancer (PCCRC), but further in-depth qualitative analyses are required to determine whether they result from inadequate surveillance or aggressive IBD cancer evolution.

METHODS

All IBD patients who had a colorectal cancer (CRC) diagnosed between January 2015 to July 2019 and a recent (<4 years) surveillance colonoscopy at one of four English hospital trusts underwent root cause analyses as recommended by the World Endoscopy Organisation to identify plausible PCCRC causative factors.

RESULTS

61% (n=22/36) of the included IBD CRCs were PCCRCs. They developed in patients with high cancer risk factors (77.8%; n=28/36) requiring annual surveillance, yet 57.1% (n=20/35) had inappropriately delayed surveillance. Most PCCRCs developed in situations where (i) an endoscopically unresectable lesion was detected (40.9%; n=9/22), (ii) there was a deviation from the planned management pathway (40.9%; n=9/22) e.g. service, clinician or patient-related delays in acting on a detected lesion, or (iii) lesions were potentially missed as they were typically located within areas of active inflammation or post-inflammatory change (36.4%; n=8/22).

CONCLUSIONS

IBD PCCRC prevention will require more proactive strategies to reduce endoscopic inflammatory burden, improve lesion optical characterisation, adherence to recommended surveillance intervals and patient acceptance of prophylactic colectomy. However, the significant proportion appearing to originate from non-adenomatous-looking mucosa which fail to yield neoplasia on biopsy yet display aggressive cancer evolution highlight the limitations of current surveillance. Emerging molecular biomarkers may play a role in enhancing cancer risk stratification in future clinical practice.

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.

Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 : Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 : Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3: A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4: Trained EMR practitioners should be familiar with the patient consent process for EMR. 5: The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6: Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7: A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8: A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9: A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10: Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11: Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document.

JAG consensus statements for training and certification in flexible sigmoidoscopy

Introduction

Joint Advisory Group (JAG) certification in endoscopy is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update standards for training and certification in flexible sigmoidoscopy (FS).

Methods

A modified Delphi process was conducted between 2019 and 2020 with multisociety representation from experts and trainees. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on FS training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer-reviewed by national stakeholders for incorporation into the JAG FS certification pathway.

Results

In total, 41 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (17), assessment of competence (7) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (A) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, rectal retroversion >90%, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (B) minimum procedure count ≥175; (C) performing 15+ procedures over the preceding 3 months; (D) attendance of the JAG Basic Skills in Lower gastrointestinal Endoscopy course; (E) satisfying requirements for formative direct observation of procedural skill (DOPS) and direct observation of polypectomy skill (SMSA level 1); (F) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool and (G) successful performance in summative DOPS.

Conclusion

The UK standards for training and certification in FS have been updated to support training, uphold standards in FS and polypectomy, and provide support to the newly independent practitioner.

JAG consensus statements for training and certification in colonoscopy

Introduction

In the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification.

Methods

Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway.

Results

In total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort <10% with moderate–severe discomfort); (2) minimum procedure count 280+; (3) performing 15+ procedures over the preceding 3 months; (4) attendance of the JAG Basic Skills in Colonoscopy course; (5) terminal ileal intubation rates of 60%+ in inflammatory bowel disease; (6) satisfying requirements for formative direct observation of procedure skills (DOPS) and direct observation of polypectomy skills (Size, Morphology, Site, Access (SMSA) level 2); (7) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool; (8) successful performance in summative DOPS.

Conclusion

The UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.

Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy

GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.

Evaluation of a real-time computer-aided polyp detection system during screening colonoscopy: AI-DETECT study

BACKGROUND

Polyp detection and resection during colonoscopy significantly reduce long-term colorectal cancer risk. Computer-aided detection (CADe) may increase polyp identification but has undergone limited clinical evaluation. Our aim was to assess the effectiveness of CADe at colonoscopy within a bowel cancer screening program (BCSP).

METHODS

This prospective, randomized controlled trial involved all eight screening-accredited colonoscopists at an English National Health Service (NHS) BCSP center (February 2020 to December 2021). Patients were randomized to CADe or standard colonoscopy. Patients meeting NHS criteria for bowel cancer screening were included. The primary outcome of interest was polyp detection rate (PDR).

RESULTS

658 patients were invited and 44 were excluded. A total of 614 patients were randomized to CADe (n = 308) or standard colonoscopy (n = 306); 35 cases were excluded from the per-protocol analysis due to poor bowel preparation (n = 10), an incomplete procedure (n = 24), or a data issue (n = 1). Endocuff Vision was frequently used and evenly distributed (71.7 % CADe and 69.2 % standard). On intention-to-treat (ITT) analysis, there was a borderline significant difference in PDR (85.7 % vs. 79.7 %; P = 0.05) but no significant difference in adenoma detection rate (ADR; 71.4 % vs. 65.0 %; P = 0.09) for CADe vs. standard groups, respectively. On per-protocol analysis, no significant difference was observed in these rates. There was no significant difference in procedure times.

CONCLUSIONS

In high-performing colonoscopists in a BCSP who routinely used Endocuff Vision, CADe improved PDR but not ADR. CADe appeared to have limited benefit in a BCSP setting where procedures are performed by experienced colonoscopists.

Implementation of optical diagnosis with a "resect and discard" strategy in clinical practice: DISCARD3 study

BACKGROUND AND AIMS

Optical diagnosis (OD) of polyps can be performed with advanced endoscopic imaging. For high-confidence diagnoses, a "resect and discard" strategy could offer significant histopathology time and cost savings. The implementation threshold is a ≥90% OD-histology surveillance interval concordance. Here we assessed the OD learning curve and feasibility of a resect and discard strategy for ≤5-mm and <10-mm polyps in a bowel cancer screening setting.

METHODS

In this prospective feasibility study, 8 bowel cancer screening endoscopists completed a validated OD training module and performed procedures. All <10-mm consecutive polyps had white-light and narrow-band images taken and were given high- or low-confidence diagnoses until 120 high-confidence ≤5-mm polyp diagnoses had been performed. All polyps had standard histology. High-confidence OD errors underwent root-cause analysis. Histology and OD-derived surveillance intervals were calculated.

RESULTS

Of 565 invited patients, 525 patients were included. A total of 1560 <10-mm polyps underwent OD and were resected and retrieved (1329 ≤5 mm and 231 6-9 mm). There were no <10-mm polyp cancers. High-confidence OD was accurate in 81.5% of ≤5-mm and 92.8% of 6-9-mm polyps. Sensitivity for OD of a ≤5-mm adenoma was 93.0% with a positive predictive value of 90.8%. OD-histology surveillance interval concordance for ≤5-mm OD was 91.3% (209/229) for U.S. Multi-Society Task Force, 98.3% (225/229) for European Society of Gastrointestinal Endoscopy, and 98.7% (226/229) for British Society of Gastroenterology guidelines, respectively.

CONCLUSIONS

A resect and discard strategy for high-confidence ≤5-mm polyp OD in a group of bowel cancer screening colonoscopists is feasible and safe, with performance exceeding the 90% surveillance interval concordance required for implementation in clinical practice. (Clinical trial registration number: NCT04710693.).

Development of the "Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills" (TEAM-ENTS) behavioral marker system

BACKGROUND

Non-technical skills (NTS) are integral to team performance and subsequent quality and safety of care. Behavioral marker systems (BMSs) are now increasingly used in healthcare to support the training and assessment of team NTS. Within gastrointestinal endoscopy, this is an area of novel research. The aims of this study were to define the core relevant NTS for endoscopy teams and develop a preliminary framework for a team-based BMS known as TEAM-ENTS (Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills).

METHODS

This study was conducted in two phases. In phase 1, a literature review of team-based BMSs was performed to inform an interview study of core endoscopy team members. Cognitive task analysis was used to break down the NTS relevant to endoscopy teams. Framework analysis generated the structure for the preliminary TEAM-ENTS framework. In phase 2, a modified Delphi process was undertaken to refine the items of the framework.

RESULTS

Seven consultant endoscopists and six nurses were interviewed. The final coding framework consisted of 88 codes grouped into five overarching categories. In total, 58 participants were recruited to the Delphi panel. In the first round, nine elements and 37 behavioral descriptors did not meet consensus. Following item adjustment, merging and deletion, all remaining items met consensus thresholds after the second round. The refined TEAM-ENTS BMS consists of five categories, 16 elements, and 47 behavioral descriptors.

CONCLUSIONS

The refined TEAM-ENTS behavioral marker system was developed to reflect the core NTS relevant to endoscopy teams. Future studies will aim to fully validate this tool.

National census of UK endoscopy services 2021

INTRODUCTION

The Joint Advisory Group on Gastrointestinal (GI) Endoscopy (JAG) biennial census provides a unique view of UK endoscopy. The 2021 census was conducted to understand the impact of ongoing pressures, highlighted in the previous census, as well as COVID-19.

METHODS

The census was sent to all JAG-registered services in April 2021. Data were analysed across the domains of activity, waiting time targets, workforce, COVID-19, safety, GI bleeding, anaesthetic support, equipment and decontamination. Statistical methods were used to determine associations between domain-specific outcome variables and core demographic data.

RESULTS

321 services completed the census (79.2% response rate). In the first 3 months of 2021, 57.9% of NHS services met urgent cancer waits, 17.9% met routine waits and 13.4% met surveillance waits. Workforce redeployment was the predominant reason cited for not meeting targets. There were significant regional differences in the proportion of patients waiting 6 or more weeks (p=0.001). During the pandemic, 64.8% of NHS services had staff redeployed and there was a mean sickness rate of 8.5%. Services were, on average, at 79.3% activity compared with 2 years ago. JAG-accredited services are more likely to meet urgent cancer waits, with a lower proportion of patient waiting 6 weeks or more (p=0.03). Over 10% of services stated that equipment shortage interfered with service delivery.

CONCLUSIONS

Services are adapting to continued pressure and there are signs of a focused response to demand at a time of ongoing uncertainty. This census' findings will inform ongoing guidance from JAG and relevant stakeholders.

Multicentre derivation and validation of a colitis-associated colorectal cancer risk prediction web tool

OBJECTIVE

Patients with ulcerative colitis (UC) diagnosed with low-grade dysplasia (LGD) have increased risk of developing advanced neoplasia (AN: high-grade dysplasia or colorectal cancer). We aimed to develop and validate a predictor of AN risk in patients with UC with LGD and create a visual web tool to effectively communicate the risk.

DESIGN

In our retrospective multicentre validated cohort study, adult patients with UC with an index diagnosis of LGD, identified from four UK centres between 2001 and 2019, were followed until progression to AN. In the discovery cohort (n=246), a multivariate risk prediction model was derived from clinicopathological features using Cox regression. Validation used data from three external centres (n=198). The validated model was embedded in a web tool to calculate patient-specific risk.

RESULTS

Four clinicopathological variables were significantly associated with AN progression in the discovery cohort: endoscopically visible LGD >1 cm (HR 2.7; 95% CI 1.2 to 5.9), unresectable or incomplete endoscopic resection (HR 3.4; 95% CI 1.6 to 7.4), moderate/severe histological inflammation within 5 years of LGD diagnosis (HR 3.1; 95% CI 1.5 to 6.7) and multifocality (HR 2.9; 95% CI 1.3 to 6.2). In the validation cohort, this four-variable model accurately predicted future AN cases with overall calibration Observed/Expected=1.01 (95% CI 0.64 to 1.52), and achieved 100% specificity for the lowest risk group over 13 years of available follow-up.

CONCLUSION

Multicohort validation confirms that patients with large, unresected, multifocal LGD and recent moderate/severe inflammation are at highest risk of developing AN. Personalised risk prediction provided via the Ulcerative Colitis-Cancer Risk Estimator ( www.UC-CaRE.uk ) can support treatment decision-making.

Validation of post-colonoscopy colorectal cancer (PCCRC) cases reported at national level following local root cause analysis: REFLECT study

OBJECTIVE

Our aim was to determine aetiology of post-colonoscopy colorectal cancers (PCCRCs) identified from population-based data through local root cause analysis at a high-volume mixed secondary and tertiary referral centre.

DESIGN/METHOD

A subset of national cancer registration data, collected by the National Cancer Registration and Analysis Service, was used to determine PCCRCs diagnosed between 2005 and 2013 at our centre.Root cause analysis was performed for each identified PCCRC, using World Endoscopy Organisation recommendations, to validate it and assess most plausible explanation. We also assessed whether patient, clinician and/or service factors were primarily responsible.

RESULTS

Of 107 'PCCRC' cases provided from the national dataset, 20 were excluded (16 missing data, 4 duplicates). 87 'PCCRC' cases were included of which 58 were true PCCRCs and 29 false PCCRCs.False PCCRCs comprised 17 detected cancers (cancer diagnosed within 6 months of negative colonoscopy) and 12 cases did not meet PCCRC criteria. Inflammatory bowel disease was the most common risk factor (18/58) and the most common site was rectum (19/58). The most common explanation was 'possible missed lesion, prior examination negative but inadequate' (23/58) and clinician factors were primarily responsible for PCCRC occurrence in most cases (37/58).

CONCLUSION

Our single-centre study shows, after local analysis, there was misclassification of PCCRCs identified from a population-based registry. The degree of such error will vary between registries. Most PCCRCs occurred in cases of sub-optimal examination as indicated by poor photodocumentation. Effective mechanisms to feedback root cause analyses are critical for quality improvement.

Perception of Cancer Risk and Management Practice for Colitis-associated Dysplasia Is Influenced by Colonoscopy Experience and Workplace Affiliation: Results of an International Clinician Survey

BACKGROUND AND AIMS

A successful colitis cancer surveillance programme requires effective action to be taken when dysplasia is detected. This is the first international cross-sectional study to evaluate clinician understanding of dysplasia-cancer risk and management practice since the most recent international guidelines were introduced in 2015.

METHODS

A 15-item international online survey was disseminated to gastroenterologists and colorectal surgeons.

RESULTS

A total of 294 clinicians [93.5% gastroenterologists] from 60 countries responded; 23% did not have access to high-definition chromoendoscopy. University hospitals were more likely than non-academic workplaces to provide second expert histopathologist review [67% vs 46%; p = 0.002] and formal multidisciplinary team meeting discussion [73% vs 52%; p = 0.001] of dysplasia cases. Perceptions of 5-year cancer risk associated with endoscopically unresectable low-grade dysplasia varied between 0% and 100%. Non-academic hospital affiliation was predictive of lower perceived cancer risks. Although most [98.4%] respondents advised a colectomy for endoscopically unresectable visible high-grade dysplasia, only 34.4% advised a colectomy for unresectable visible low-grade dysplasia. Respondents from university hospitals were more likely to consider colectomy for multifocal low-grade dysplasia (odds ratio [OR] 2.17). If invisible unifocal low-grade dysplasia was detected, continued surveillance over colectomy was the preferred management among clinicians working mainly in private clinics [OR 9.4] and least preferred in those who had performed more than 50 surveillance colonoscopies [OR 0.41].

CONCLUSIONS

Clinicians with less surveillance colonoscopy experience and from non-academic centres appear to have lower cancer risk perceptions and are less likely to advocate colectomy for higher-risk low-grade dysplasia. Further education may align current management practice with clinical guidelines.

Lower gastrointestinal polypectomy competencies in the United Kingdom: a retrospective analysis of Directly Observed Polypectomy Skills (DOPyS)

BACKGROUND

Polypectomy is often the most hazardous part of colonoscopy. There is significant variability in polypectomy training and assessment internationally. DOPyS (Directly Observed Polypectomy Skills) is a validated assessment tool and is used to demonstrate polypectomy competency in the UK. This study aimed to describe the learning curve for polypectomy competency in UK trainees.

METHODS

Retrospective DOPyS data (January 2009 to September 2015) were obtained from the UK Joint Advisory Group (JAG) for intestinal endoscopy training system (JETS) national database. The number of lower gastrointestinal (LGI) procedures, overall cecal intubation rate (CIR), procedure intensity, and time in days to the first DOPyS assessment were recorded, and time to JAG certification was calculated.

RESULTS

4965 DOPyS assessments from 336 trainees were analyzed. Within the study period, 124 and 53 trainees achieved provisional and full colonoscopy certification, respectively. Trainees started formative assessment of polypectomy after > 130 LGI procedures and with a CIR of > 70 %. Within 3 years from the first DOPyS assessment, 94 % of trainees achieved provisional certification, and 50 % full certification. Higher procedure intensity at baseline DOPyS assessment was associated with a higher likelihood of obtaining certification sooner.

CONCLUSION

There is a significant variation in time to competency, and this potentially reflects the time necessary to acquire polypectomy skills. There is a need to start polypectomy training earlier, once sufficient skills, such as tip control, have been achieved to shorten the time to competency. Overall, the CIR could be used as a guide for such technical skills. Increasing exposure to training lists also potentially reduces the time to polypectomy competency.

Joint Advisory Group on Gastrointestinal Endoscopy (JAG) framework for managing underperformance in gastrointestinal endoscopy

Underperformance can be defined as performance which persistently falls below a desired minimum standard considered acceptable for patient care. Within gastrointestinal endoscopy, underperformance may be multifactorial, related to an individual's knowledge, skills, attitudes, health or external factors. If left unchecked, underperformance has the potential to impact on care and ultimately patient safety. Managing underperformance should be a key attribute of high-quality endoscopy service, as recognised in the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation process. However, it is recognised that not all services have robust mechanisms to do this. This article provides the JAG position on managing underperformance in endoscopy, defined through a practical framework. This follows a stepwise process of detecting underperformance, verification, identification of additional causative factors, providing support and reassessment. Detection and verification of issues may require use of multiple evidence sources, including performance data, feedback and appraisal reports. Where technical underperformance is identified, this should be risk stratified by potential risk to patient safety. Support should be tailored to each individual case based on the type of underperformance detected, any causative factors with an action plan developed. Support may include coaching, mentoring, training and upskilling. Wider support from the medical director's office or external services may also be required. Monitoring and reassessment is a crucial part of the overall process.

When and How To Use Endoscopic Tattooing in the Colon: An International Delphi Agreement

BACKGROUND & AIMS

There is a lack of clinical studies to establish indications and methodology for tattooing, therefore technique and practice of tattooing is very variable. We aimed to establish a consensus on the indications and appropriate techniques for colonic tattoo through a modified Delphi process.

METHODS

The baseline questionnaire was classified into 3 areas: where tattooing should not be used (1 domain, 6 questions), where tattooing should be used (4 domains, 20 questions), and how to perform tattooing (1 domain 20 questions). A total of 29 experts participated in the 3 rounds of the Delphi process.

RESULTS

A total of 15 statements were approved. The statements that achieved the highest agreement were as follows: tattooing should always be used after endoscopic resection of a lesion with suspicion of submucosal invasion (agreement score, 4.59; degree of consensus, 97%). For a colorectal lesion that is left in situ but considered suitable for endoscopic resection, tattooing may be used if the lesion is considered difficult to detect at a subsequent endoscopy (agreement score, 4.62; degree of consensus, 100%). A tattoo should never be injected directly into or underneath a lesion that might be removed endoscopically at a later point in time (agreement score, 4.79; degree of consensus, 97%). Details of the tattoo injection should be stated clearly in the endoscopy report (agreement score, 4.76; degree of consensus, 100%).

CONCLUSIONS

This expert consensus has developed different statements about where tattooing should not be used, when it should be used, and how that should be done.

Management of inflammatory bowel disease associated colonic dysplasia: factors predictive of patient choice and satisfaction

AIM

In cases of prognostic uncertainty and equipoise as to the best management (prophylactic colectomy vs. surveillance) for dysplasia in inflammatory bowel disease (IBD), individualized discussion with the patient is required. Further understanding of patients' preferences is needed.

METHODS

A nationwide cross-sectional survey was distributed to adult IBD patients who had never been diagnosed with dysplasia (dysplasia-naïve) and those who had (dysplasia-experienced). Risk perceptions and factors that influence management choices were explored.

RESULTS

There were 123 respondents. A substantial proportion (29%) of the dysplasia-experienced respondents did not feel well informed about the associated cancer risk and/or its management by their clinical team. Contributing themes included contradictory advice and lack of personalized information regarding their cancer risk, alternative management options and impact on long-term quality of life. Decisional regret and health-related quality of life amongst those who chose either surveillance or surgery were comparable, but cancer-related worry scores were elevated in the surveillance group. The dysplasia-naïve respondents reported that they would only consider having a prophylactic colectomy if they had on average a 50% or even higher risk of developing cancer. On multivariable logistic regression analyses, predictors of colectomy or surveillance preference included ethnicity, personality traits such as health locus of control (whether health status is influenced by luck) and differences in perception of what a low risk of cancer is.

CONCLUSIONS

This study identifies predictive factors that can influence decision-making and satisfaction with the counselling process when IBD dysplasia is diagnosed. Further qualitative exploration of cultural themes would be informative.

Bowel cancer screening workforce survey: developing the endoscopy workforce for 2025 and beyond

AIM

The demand for bowel cancer screening (BCS) is expected to increase significantly within the next decade. Little is known about the intentions of the workforce required to meet this demand. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG), the British Society of Gastroenterology (BSG) and Association of Coloproctology of Great Britain and Ireland (ACPGBI) developed the first BCS workforce survey. The aim was to assess endoscopist career intentions to aid in future workforce planning to meet the anticipated increase in BCS colonoscopy.

METHODS

A survey was developed by JAG, BSG and ACPGBI and disseminated to consultant, clinical and trainee endoscopists between February and April 2020. Descriptive and comparative analyses were undertaken, supported with BCS data.

RESULTS

There were 578 respondents. Screening consultants have a median of one programmed activity (PA) per week for screening, accounting for 40% of their current endoscopy workload. 38% of current screening consultants are considering giving up colonoscopy in the next 2-5 years. Retirement (58%) and pension issues (23%) are the principle reasons for this. Consultants would increase their screening PAs by 70% if able to do so. The top three activities that endoscopists would relinquish to further support screening were outpatient clinics, acute medical/surgical on call and ward cover. An extra 155 colonoscopists would be needed to fulfil increased demand and planned retirement at current PAs.

CONCLUSION

This survey has identified a serious potential shortfall in screening colonoscopists in the next 5-10 years due to an ageing workforce and job plan pressures of aspirant BCS colonoscopists. We have outlined potential mitigations including reviewing job plans, improving workforce resources and supporting accreditation and training.

'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.

Systematic literature review of learning curves for colorectal polyp resection techniques in lower gastrointestinal endoscopy

AIM

The performance of therapeutic procedures in lower gastrointestinal endoscopy (LGI) can be challenging and carries an increased risk of adverse events. There is increasing demand for the training of endoscopists in these procedures, but limited guidelines exist concerning procedural competency. The aim of this study was to assess the learning curves for LGI polypectomy, colorectal endoscopic mucosal resection (EMR) and colorectal endoscopic submucosal dissection (ESD).

METHOD

A systematic review of electronic databases between 1946 and September 2019 was performed. Citations were included if they reported learning curve data. Outcome measures that defined the success of procedural competency were also recorded.

RESULTS

A total of 34 out of 598 studies met the inclusion criteria of which 28 were related to ESD, three to polypectomy and three to EMR. Outcome measures for polypectomy competency (en bloc resection, delayed bleeding and independent polypectomy rate) were achieved after completion of between 250 and 400 polypectomies and after 300 colonoscopies. EMR outcome measures, including complete resection and recurrence, were achieved variably between 50 and 300 procedures. Outcome measures for ESD included efficiency (resection rates and procedural speed) and safety (adverse events). En bloc resection rates of over 80% and R0 resection rates of over 70% were achieved at 20-40 cases and procedural speed increased after 30 ESD cases. Competency in safety metrics was variably achieved at 20-200 cases.

CONCLUSION

There is a paucity of data on learning curves in LGI polypectomy, EMR and ESD. Despite limited evidence, we have identified relevant outcome measures and threshold numbers for the most common LGI polyp resection techniques for potential inclusion in training programmes/credentialing guidelines.

Improving safety and reducing error in endoscopy (ISREE): a survey of UK services

BACKGROUND

The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) 'Improving Safety and Reducing Error in Endoscopy' (ISREE) strategy was developed in 2018. In line with the strategy, a survey was conducted within the JAG census in 2019 to gain further insights and understanding of key safety-related areas within UK endoscopy.

METHODS

Questions were developed using the ISREE strategy as a guide and adapted by key JAG stakeholders. They were incorporated into the 2019 JAG census of UK endoscopy services. Quantitative and qualitative statistical methods were employed to analyse the results.

RESULTS

There was a 68% response rate. There was regional variability in the provision of out-of-hours GIB services (p<0.001). Across 1 month, 1535 incidents were reported across all services. There was a significantly higher proportion of reported incidents in acute services compared with others (p<0.001). Technical and training incidents were likely to be reported significantly differently to all other incident types. 74% of services have an endoscopy-specific sedation policy and 42% have a named sedation or anaesthetic lead for endoscopy. Services highlighted a desire for more anaesthetic-supported lists. Only 66% of services stated they have an effective strategy for supporting upskilling of endoscopists. Across acute services, 56% have access to human factors and endoscopic non-technical skills (ENTS) training. Patient feedback is used in several ways to improve services, develop training and promote shared learning among endoscopy users.

CONCLUSIONS

The census provides a benchmark for key safety-related characteristics of endoscopy services. These results have highlighted key areas to develop, guided by the ISREE strategy.

Systematic review with meta-analysis: IBD-associated colonic dysplasia prognosis in the videoendoscopic era (1990 to present)

INTRODUCTION

The prognosis of dysplasia in patients with IBD is largely determined from observational studies from the pre-videoendoscopic era (pre-1990s) that does not reflect recent advances in endoscopic imaging and resection.

AIMS

To better understand the risk of synchronous colorectal cancer and metachronous advanced neoplasia (ie high-grade dysplasia or cancer) associated with dysplasia diagnosed in the videoendoscopic era, and to stratify risk according to a lesion's morphology, endoscopic resection status or whether it was incidentally detected on biopsy of macroscopically normal colonic mucosa (ie invisible).

METHODS

A systematic search of original articles published between 1990 and February 2020 was performed. Eligible studies reported on incidence of advanced neoplasia at follow-up colectomy or colonoscopy for IBD-dysplasia patients. Quantitative and qualitative analyses were performed.

RESULTS

Thirty-three studies were eligible for qualitative analysis (five for the meta-analysis). Pooled estimated proportions of incidental synchronous cancers found at colectomy performed for a pre-operative diagnosis of visible high-grade dysplasia, invisible high-grade dysplasia, visible low-grade dysplasia and invisible low-grade dysplasia were 13.7% (95% CI 0.0-54.1), 11.4% (95% CI 4.6-20.3), 2.7% (95% CI 0.0-7.1) and 2.4% (95% CI 0.0-8.5) respectively. The lowest incidences of metachronous advanced neoplasia, for dysplasia not managed with immediate colectomy but followed up with surveillance, tended to be reported by the studies where high definition imaging and/or chromoendoscopy was used and endoscopic resection of visible dysplasia was histologically confirmed.

CONCLUSIONS

The prognosis of IBD-dysplasia diagnosed in the videoendoscopic era appears to have been improved but the quality of evidence remains low. Larger, prospective studies are needed to guide management. PROSPERO registration no: CRD42019105736.

National census of UK endoscopy services in 2019

INTRODUCTION

The 2017 Joint Advisory Group on Gastrointestinal (GI) Endoscopy (JAG) census highlighted the pressure endoscopy services were under in meeting national targets and the factors behind this. In 2019, JAG conducted a further national census of endoscopy services to understand trends in activity, workforce and waiting time targets.

METHODS

In April 2019, the census was sent to all eligible JAG-registered services. Collated data were analysed through various statistical methods. A further comparative dataset was created using available submissions from the 2017 census matched to services in the current census.

RESULTS

There was a 68% response rate (322/471). There has been a 12%-15% increase in activity across all GI procedures with largest increases in bowel cancer screening. Fewer services are meeting waiting time targets compared with 2017, with endoscopist, nursing and physical capacity cited as the main reasons. Services are striving to improve capacity: 80% of services have an agreed business plan to meet capacity and the number using insourcing has increased from 13% to 20%. The workforce has increased, with endoscopist numbers increasing by 15%, nurses and allied health professionals by 14% and clerical staff by 30%.

CONCLUSIONS

The 2019 JAG census is the most recent and extensive survey of UK endoscopy services. There is a clear trend of increasing activity with fewer services able to meet national waiting time targets than 2 years ago. Services have increased their workforce and improved planning to stem the tide but there remains a continued pressure to deliver high quality, safe endoscopy. In light of the COVID-19 pandemic, JAG recognises that these pressures will be severely exacerbated and waiting time targets for accreditation will need adjustment and tolerance during the evolution and recovery from the pandemic.

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.

Development and impact of an endoscopic non-technical skills (ENTS) behavioural marker system

Background

Non-technical skills (NTS) are crucial to effective team working in endoscopy. Training in NTS has been shown to improve team performance and patient outcomes. As such, NTS training and assessment are now considered essential components of the endoscopy quality assurance process. Across the literature, other specialties have achieved this through development of behavioural marker systems (BMS). BMS provide a framework for assessing, training and measuring the NTS relevant to healthcare individuals and team. This article describes the development and impact of a novel BMS for endoscopy: the endoscopic non-technical skills (ENTS) system.

Methods

The initial NTS taxonomy for endoscopy was created through a combination of literature review, staff focus groups and semi-structured interviews, incorporating the critical decision method. Framework analysis was conducted with three individual coders and generated a skills list which formed the preliminary taxonomy. Video observation of Bowel Cancer Screening endoscopists was used to identify exemplar behaviours which were mapped to relevant skills in the NTS taxonomy. Behavioural descriptors, derived from video data, were added to form the basis of the ENTS system.

Results

A taxonomy of 33 skills in 14 separate categories were identified through framework analysis. Following video analysis and behaviour mapping, 4 overarching categories and 13 behavioural elements were identified which formed the ENTS framework. The endoscopy (directly observed procedural skills) 4-point rating scale was added to create the final ENTS system. Since its development in 2010, the ENTS system has been validated in the assessment of endoscopy for trainees nationally. ENTS informs a number of training initiatives, including a national strategy to improve NTS for all endoscopists.

Conclusions

The ENTS system is a clinically relevant tool, validated for use in trainee assessment. The use of ENTS will be important to the future of training and quality assurance in endoscopy.

British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland/Public Health England post-polypectomy and post-colorectal cancer resection surveillance guidelines

These consensus guidelines were jointly commissioned by the British Society of Gastroenterology (BSG), the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and Public Health England (PHE). They provide an evidence-based framework for the use of surveillance colonoscopy and non-colonoscopic colorectal imaging in people aged 18 years and over. They are the first guidelines that take into account the introduction of national bowel cancer screening. For the first time, they also incorporate surveillance of patients following resection of either adenomatous or serrated polyps and also post-colorectal cancer resection. They are primarily aimed at healthcare professionals, and aim to address:Which patients should commence surveillance post-polypectomy and post-cancer resection?What is the appropriate surveillance interval?When can surveillance be stopped? two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument provided a methodological framework for the guidelines. The BSG's guideline development process was used, which is National Institute for Health and Care Excellence (NICE) compliant.two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps The key recommendations are that the high-risk criteria for future colorectal cancer (CRC) following polypectomy comprise either:two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps This cohort should undergo a one-off surveillance colonoscopy at 3 years. Post-CRC resection patients should undergo a 1 year clearance colonoscopy, then a surveillance colonoscopy after 3 more years.

Evaluation of an early-stage innovation for full-thickness excision of benign colonic polyps using the IDEAL framework

AIMS

Colectomy is the current approach for patients with endoscopically unresectable benign polyps but risks considerable morbidity. Full-thickness laparoendoscopic excision (FLEX) is a novel procedure, specifically developed to treat endoscopically unresectable benign colonic polyps, which could reduce the treatment burden of the current approach and improve outcomes. However, traditional evaluations of surgical innovations lack methodological rigour. This study reports the development and feasibility of the FLEX procedure in selected patients.

METHOD

A prospective development study using the Idea, Development, Evaluation, Assessment, Long-term study (IDEAL) framework was undertaken, by one surgeon, of the FLEX procedure in selected patients with endoscopically unresectable benign colonic polyps. Three-dimensional (3D)-CT colonography reconstructions were used preoperatively to rehearse patient-specific, critical manoeuvres. Targetted, full-thickness excision was performed: after marking the margin of the caecal polyp using circumferential endoscopic argon plasma coagulation, transmural endoscopic sutures were used to evert the bowel and resection was undertaken by laparoscopic linear stapling. Feasibility outcomes (establishing 'local success') included evidence of complete polyp resection without adverse events (especially safe closure of the excision site).

RESULTS

Ten patients [median (interquartile range) age: 74 (59-78) years] with polyp median diameters of 35 (30-41) mm, were referred for and consented to receive the FLEX procedure. During the same time frame, no patient underwent colectomy for benign polyps. One further patient received FLEX for local excision of a presumed malignant polyp because severe comorbidity prohibited standard procedures. The FLEX procedure was successfully performed locally, with complete resection of the polyp and safe closure of the excision site, in eight patients. Three noncompleted procedures were converted to laparoscopic segmental colectomy under the same anaesthetic because of endoscopic inaccessibility (two patients) and transcolonic suture failure (one patient).

CONCLUSIONS

The FLEX procedure is still under development. Early data demonstrate that it is safe for excision of selected benign polyps. Modifications to transcolonic suture delivery are now required and there is a need for wider adoption before more definitive evaluation can be performed.

Curriculum review: serrated lesions of the colorectum

Colorectal cancer (CRC) is the second leading cause of death from cancer in the UK. Sporadic CRC evolves by the cumulative effect of genetic and epigenetic alterations. Typically, over the course of several years, this leads to the transformation of normal colonic epithelium to benign adenomatous polyp, low-grade to high-grade dysplasia and finally cancer-the adenoma-carcinoma sequence. Over the last decade, the serrated neoplasia pathway which progresses by methylation of tumour suppressing genes has been increasingly recognised as an important alternative pathway accounting for up to 30% of CRC cases. Endoscopists should be aware of the unique features of serrated lesions so that their early detection, appropriate resection and surveillance interval can be optimised.

Certification of UK gastrointestinal endoscopists and variations between trainee specialties: results from the JETS e-portfolio

Introduction  In the UK, endoscopy certification is administered by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG). Since 2011, certification for upper and lower gastrointestinal endoscopy has been awarded via a national (JETS) e-portfolio to the main training specialties of: gastroenterology, gastrointestinal surgeons (GS) and non-medical endoscopists (NME). Trends in endoscopy certification and differences between trainee specialties were analyzed. Methods  This prospective UK-wide observational study identified trainees awarded gastroscopy, sigmoidoscopy, colonoscopy (provisional and full) certification between June 2011 - 2017. Trends in certification, procedures and time-to-certification, and key performance indicators (KPIs) in the 3-month pre- and post-certification period were compared between the three main training specialties. Results  Three thousand one hundred fifty-seven endoscopy-related certifications were awarded to 1928 trainees from gastroenterology (52.3 %), GS (28.4 %) and NME (16.5  %) specialties. During the study period, certification numbers increased for all modalities and specialties, particularly NME trainees. For gastroscopy and colonoscopy, procedures-to-certification were lowest for GS ( P  < 0.001), whereas time-to-certification was consistently shortest in NMEs ( P  < 0.001). A post-certification reduction in mean cecal intubation rate (95.2 % to 93.8 %, P  < 0.001) was observed in colonoscopy, and D2 intubation (97.6 % to 96.2 %, P  < 0.001) and J-maneuver (97.3 % to 95.8 %, P  < 0.001) in gastroscopy. Overall, average pre- and post-certification KPIs still exceeded national minimum standards. There was an increase in PDR for NMEs after provisional colonoscopy certification but a decrease in PDR for GS trainees after sigmoidoscopy and full colonoscopy certification. Conclusion  Despite variations among trainee specialties, average pre- and post-certification KPIs for certified trainees met national standards, suggesting that JAG certification is a transparent benchmark which adequately safeguards competency in endoscopy training.

Improving safety and reducing error in endoscopy: simulation training in human factors

Patient safety incidents occur throughout healthcare and early reports have exposed how deficiencies in 'human factors' have contributed to mortality in endoscopy. Recognising this, in the UK, the Joint Advisory Group for Gastrointestinal Endoscopy have implemented a number of initiatives including the 'Improving Safety and Reducing Error in Endoscopy' (ISREE) strategy. Within this, simulation training in human factors and Endoscopic Non-Technical Skills (ENTS) is being developed. Across healthcare, simulation training has been shown to improve team skills and patient outcomes. Although the literature is sparse, integrated and in situ simulation modalities have shown promise in endoscopy. Outcomes demonstrate improved individual and team performance and development of skills that aid clinical practice. Additionally, the use of simulation training to detect latent errors in the working environment is of significant value in reducing error and preventing harm. Implementation of simulation training at local and regional levels can be successfully achieved with collaboration between organisational, educational and clinical leads. Nationally, simulation strategies are a key aspect of the ISREE strategy to improve ENTS training. These may include integration of simulation into current training or development of novel simulation-based curricula. However used, it is evident that simulation training is an important tool in developing safer endoscopy.

Deep sedation and anaesthesia in complex gastrointestinal endoscopy: a joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA)

In the UK, more than 2.5 million endoscopic procedures are carried out each year. Most are performed under conscious sedation with benzodiazepines and opioids administered by the endoscopist. However, in prolonged and complex procedures, this form of sedation may provide inadequate patient comfort or result in oversedation. As a result, this may have a negative impact on procedural success and patient outcome. In addition, there have been safety concerns on the high doses of benzodiazepines and opioids used particularly in prolonged and complex procedures such as endoscopic retrograde cholangiopancreatography. Diagnostic and therapeutic endoscopy has evolved rapidly over the past 5 years with advances in technical skills and equipment allowing interventions and procedural capabilities that are moving closer to minimally invasive endoscopic surgery. It is vital that safe and appropriate sedation practices follow the inevitable expansion of this portfolio to accommodate safe and high-quality clinical outcomes. This position statement outlines the current use of sedation in the UK and highlights the role for anaesthetist-led deep sedation practice with a focus on propofol sedation although the choice of sedative or anaesthetic agent is ultimately the choice of the anaesthetist. It outlines the indication for deep sedation and anaesthesia, patient selection and assessment and procedural details. It considers the setup for a deep sedation and anaesthesia list, including the equipment required, the environment, staffing and monitoring requirements. Considerations for different endoscopic procedures in both emergency and elective setting are also detailed. The role for training, audit, compliance and future developments are discussed.

Impact of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) on endoscopy services in the UK and beyond

The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) was initially established in 1994 to standardise endoscopy training across specialties. Over the last two decades, the position of JAG has evolved to meet its current role of quality assuring all aspects of endoscopy in the UK to provide the highest quality, patient-centred care. Drivers such as changes to healthcare agenda, national audits, advances in research and technology and the advent of population-based cancer screening have underpinned this shift in priority. Over this period, JAG has spearheaded various quality assurance initiatives with support from national stakeholders. These have led to the achievement of notable milestones in endoscopy quality assurance, particularly in the three major areas of: (1) endoscopy training, (2) accreditation of endoscopy services (including the Global Rating Scale), and (3) accreditation of screening endoscopists. These developments have changed the landscape of UK practice, serving as a model to promote excellence in endoscopy. This review provides a summary of JAG initiatives and assesses the impact of JAG on training and endoscopy services within the UK and beyond.

Cumulative burden of inflammation predicts colorectal neoplasia risk in ulcerative colitis: a large single-centre study

OBJECTIVE

Ulcerative colitis (UC) is a dynamic disease with its severity continuously changing over time. We hypothesised that the risk of colorectal neoplasia (CRN) in UC closely follows an actuarial accumulative inflammatory burden, which is inadequately represented by current risk stratification strategies.

DESIGN

This was a retrospective single-centre study. Patients with extensive UC who were under colonoscopic surveillance between 2003 and 2012 were studied. Each surveillance episode was scored for a severity of microscopic inflammation (0=no activity; 1=mild; 2=moderate; 3=severe activity). The cumulative inflammatory burden (CIB) was defined as sum of: average score between each pair of surveillance episodes multiplied by the surveillance interval in years. Potential predictors were correlated with CRN outcome using time-dependent Cox regression.

RESULTS

A total of 987 patients were followed for a median of 13 years (IQR, 9-18), 97 (9.8%) of whom developed CRN. Multivariate analysis showed that the CIB was significantly associated with CRN development (HR, 2.1 per 10-unit increase in CIB (equivalent of 10, 5 or 3.3 years of continuous mild, moderate or severe active microscopic inflammation); 95% CI 1.4 to 3.0; P<0.001). Reflecting this, while inflammation severity based on the most recent colonoscopy alone was not significant (HR, 0.9 per-1-unit increase in severity; 95% CI 0.7 to 1.2; P=0.5), a mean severity score calculated from all colonoscopies performed in preceding 5 years was significantly associated with CRN risk (HR, 2.2 per-1-unit increase; 95% CI 1.6 to 3.1; P<0.001).

CONCLUSION

The risk of CRN in UC is significantly associated with accumulative inflammatory burden. An accurate CRN risk stratification should involve assessment of multiple surveillance episodes to take this into account.