A93 IMPROVING INPATIENT ENDOSCOPY PROCEDURAL THROUGHPUT: A QUALITY IMPROVEMENT INITIATIVE AT AN ACADEMIC MEDICAL CENTER

Background

Currently, due to pandemic-related supply and personnel constraints, increased strain is being placed on inpatient endoscopic services. At our academic center, inpatient procedural throughput/efficiency is only 65%, which is leading to excess procedures being completed on-call or on weekends.

Purpose

Our quality improvement study attempted to improve throughput of the inpatient endoscopy suite by 1 additional procedure completed per day, over a period of 12 months of study.

Method

An interprofessional team of gastroenterology fellows, attending physicians, nurses and nurse managers was created to investigate throughput concerns. Baseline data was collected via direct observation and completion of a time study over a period of 1-2 months.

Subsequently, a process flow diagram was completed. A combination of root cause analysis tools (ie. Stakeholder interviews, Pareto chart and Driver Diagram were then utilized to identify areas for improvement. A delay in procedural start time was identified as a strong culprit for reduced patient throughput. Potential interventions proposed included: early physician handover start time, constructing a standardized patient procedure list, and improving timeliness of patient transfer to the endoscopy suite.

Result(s)

Stakeholder Interview(s): Completed via Anonymous Survey/Google Forms:

See

https://docs.google.com/forms/d/e/1FAIpQLSe-PDL31ClU8g-BChdBoBYhPoBhGBZVmlToTTZJnYKlEHz-GQ/viewform?usp=sf_link

Concerns:

- Inpatient procedure list not consistently being completed prior to starting endoscopy

- Physician handover in the morning can cause significant delays in starting inpatient endoscopy

- Concern patient/porter transfer related delays

Conclusion(s)

Our current data identifies that the most effective intervention included developing a standardized procedure list and mandating the first case is an EGD, minimizing delay due to inadequate bowel preparation. Concordantly, arranging timely patient transfer to the endoscopy suite, thereby minimizing delays due to patient portering services, was also found to be effective. Our average procedural time for completion of an EGD and associated recovery is approximately 25-30 minutes. After multiple interventions/PDSA cycles we obtained a more optimized procedural suite start time of 08:22 am, on average, which resulted in the completion of an additional procedure and increased the throughput of our endoscopy unit.

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None

Disclosure of Interest

None Declared

Association of Trainee Participation in Colonoscopy Procedures With Quality Metrics

IMPORTANCE

Trainees routinely participate in colonoscopy procedures, yet whether their involvement is positively or negatively associated with procedural quality is unknown because prior studies involved small number of trainees and/or supervisors, lacked generalizability, and/or failed to adjust for potential confounders.

OBJECTIVE

To assess the association between trainee participation and colonoscopy quality metrics.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter population-based cohort study was conducted at 21 academic and community hospitals between April 1, 2017, and October 31, 2018, among consecutive adult patients undergoing colonoscopy. Procedures performed by endoscopists who did not supervise trainees were excluded. Statistical analysis was performed from April 3, 2017, to October 31, 2018.

EXPOSURE

Participation by a trainee, defined as a resident or fellow enrolled in a gastroenterology or general surgery training program.

MAIN OUTCOMES AND MEASURES

The primary outcome was the adenoma detection rate (ADR), and secondary outcomes were sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), cecal intubation rate (CIR), and perforation rate.

RESULTS

A total of 35 499 colonoscopies (18 989 women [53.5%]; mean [SD] patient age, 60.0 [14.1] years) were performed by 71 physicians (mean [SD] time in practice, 14.0 [9.3] years); 5941 colonoscopies (16.7%) involved trainees. There were no significant differences in the ADR (26.4% vs 27.3%; P = .19), CIR (96.7% vs 97.2%; P = .07), and perforation rate (0.05% vs 0.06%; P = .82) when trainees participated vs when they did not participate, whereas the the ssPDR (4.4% vs 5.2%; P = .009) and PDR (39.2% vs 42.0%; P < .001) were significantly lower when trainees participated vs when they did not. After adjustment for potential confounders, the ADR (risk ratio [RR], 0.97; 95% CI, 0.91-1.03; P = .30), PDR (RR, 0.98; 95% CI, 0.93-1.04; P = .47), and CIR (RR, 0.93; 95% CI, 0.78-1.10; P = .38) were not associated with trainee participation, although the ssPDR remained significantly lower (RR, 0.79; 95% CI, 0.64-0.98; P = .03).

CONCLUSIONS AND RELEVANCE

This study suggests that trainee involvement during colonoscopy was associated with reduced ssPDR but not other colonoscopy outcome measures. Extra care should be exercised when examining the right colon when trainees are involved.

A218 THE RISK OF RECURRENT HEPATOCELLULAR CARDINOMA IN POST-LIVER TRANSPLANT PATIENTS RECEIVING CAPECITABINE TREATMENT

Background

Little is known on how to reduce the risk of hepatocellular carcinoma (HCC) recurrence post liver transplantation (LT). We examined if adjuvant oral Capecitabine reduces the risk of recurrent HCC in a high-risk group post-LT.

Aims

To examine if adjuvant oral Capecitabine reduces the risk of recurrent HCC in a high-risk group post-LT.

Methods

A retrospective study was performed from a pre-existing liver transplant database from the Liver Transplant Unit at London Health Sciences Center, London; Canada. This database contains demographic, clinical parameters and follow-up of all patients transplanted for HCC. Data was extracted for patients who underwent LT between January 2000 – April 2018 and included follow up until May 31^st, 2020. High-risk of tumor recurrence was defined as a RETREAT score ≥5 or PARFITT score ≥10.5. Log rank test compared the recurrence of HCC or death among patients who were and were not prescribed Capecitabine.

Results

Out of 168 LT for HCC, 25 patients were identified as high-risk group for recurrence. The median age was 63 years (IQR=60–65). 19 (76%) patients had viral hepatitis including Hepatitis B and Hepatitis C as their primary disease while 4 (16%) patients had NASH. The remaining 2 (8%) patients had Autoimmune Hepatitis. 7 (28%) patients received Capecitabine while 18 (72%) did not. All patients were followed for a median of 22 months (IQR=8.9–57.5). No statistical significance difference was found between the two groups with respect to HCC recurrence or death (p=0.56).

Conclusions

Among patients with high risk features for recurrence of HCC, adding Capecitabine therapy added to conventional immunosuppression had no overall effect on reducing overall tumor recurrence or survival.

Funding Agencies

None

Liver transplantation in adult polycystic liver disease: the Ontario experience

BACKGROUND

Liver transplantation (LT) remains the curative treatment for symptomatic Polycystic Liver Disease (PCLD) patients and is associated with excellent survival rates. The aim of the study is to review the Ontario experience in LT for PCLD.

METHODS

A retrospective study was performed from pre-existing LT databases from the LT Units at Toronto General Hospital and London Health Sciences Center, which are the two LT programs in Ontario, Canada. This database contains demographic, clinical parameters and follow-up of all patients transplanted for PCLD. Data was extracted for patients who underwent LT between January 2000-April 2017 and included follow up until December 31st, 2018.

RESULTS

A total of 3560 patients underwent LT, of whom 51 (1.4%) had PCLD and met inclusion criteria. 43 (84%) of these patients were female. The median physiologic Model for End Stage Liver Disease (MELD-Na) score at time of referral was 13 (IQR = 7-22), however all patients required MELD-Na exception points to receive LT. The median age of transplant was 62 years (IQR = 59-64) for male vs. 52 (IQR = 45-56) for female patients. 33 (65%) of our cohort had PCLD while 9 (17.5%) had ADPKD and 9 (17.5%) had both diseases. 39 (76%) had LT due to symptoms of mass effect, while 8 (16%) had portal hypertensive complications. After a median follow-up of 6.3 (IQR = 2.9-12.5) years, the probability of survival was 96% (95% CI: 90%, 100%). Log-rank test, comparing survival analysis between males and females did not show a statistically significant difference (p = 0.26).

CONCLUSION

Most patients underwent LT for PCLD due to symptoms of mass effect with women being more likely than men to undergo LT. LT for PCLD had excellent long-term survival.

A113 ANNUAL COLONOSCOPY VOLUME IS NOT PREDICTIVE OF COLONOSCOPY QUALITY - FINDINGS FROM THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Background

Performing a minimum number of colonoscopies annually has been proposed by some jurisdictions as a requirement for maintaining privileges. However, this practice is supported by limited evidence.

Aims

The objective of this study was to determine if annual colonoscopy volume was associated with colonoscopy quality metrics.

Methods

A population-based study was performed using the Southwest Ontario Colonoscopy cohort, which consists of all adult patients who underwent colonoscopy between April 2017 and Oct 2018 at 21 academic and community hospitals within the health region. Data were collected through a mandatory quality assurance form completed after each procedure and pathology reports were manually reviewed. Physician annualized colonoscopy volumes were compared by correlation analysis to each quality-related outcome, by means of the area under the receiver operating characteristics curve (AUROC), and logistic regression. The prognostic value of colonoscopy volume was also adjusted for case-mix and potential confounders in separate regression analyses for each outcome. The primary outcome was ADR. Secondary outcomes were polyp detection rate (PDR), sessile serrated polyp detection rate (SSPDR), and cecal intubation.

Results

A total of 47,195 colonoscopies were performed by 75 physicians (37.5% by gastroenterologists, 60% by general surgeons, 2.5% others). There were no clear relationships between annual colonoscopy volumes and study outcomes. Colonoscopy volume was not associated with ADR (OR 1.03, 95% CI 0.96–1.10, p=0.48) and corresponded to an AUROC not significantly different from the null (AUROC 0.52, 95% CI 0.43–0.61, p=0.65). Multi-variable regression adjusting for case-mix also demonstrated no predictive value of annual colonoscopy volume for the primary outcome (OR 1.03, 95% CI 0.94–1.12, p=0.55). Similarly, analyses of secondary outcomes failed to find an association between colonoscopy volume and PDR, SSPDR, or cecal intubation (Table 1).

Conclusions

Annual colonoscopy volumes do not predict ADR, PDR, SSPDR, or cecal intubation rate.

Results of unconditional and conditional approaches for examining the predictive value of annual colonoscopy volume for quality related outcomes.

Funding Agencies

None