quality standards in upper gastrointestinal endoscopy: a position statement of the british society of gastroenterology (bsg) and association of upper gastrointestinal surgeons of great britain and ireland (augis) - water jet flosser

This document represents the first statement of position issued by the British digestive Society and the British and Irish Association of Upper digestive surgeons, setting out the minimum expected criteria for diagnosis of digestive endoscopy.
The reason this is needed is because it is recognized that while technological capabilities can be obtained quickly, in fact, the performance of high-tech technologies
Quality checks are variable and the failure rate to diagnose cancer in endoscopic examinations is highly unacceptable.
The importance of detecting early tumors in this minimally invasive, organ-
Preservation of endoscopic therapy
In this statement of position, we describe 38 suggestions for improving the quality of diagnostic endoscopes.
Our goal is to highlight the practice of encouraging mucosal examination and Lesion identification with the aim of optimizing the early diagnosis of upper digestive system diseases and improving the outcomes of patients.
Introdutionosophago-gastro-duodenoscopy (OGD)
Is the gold standard test for the investigation of intestines and stomach (UGI)
Symptoms, allowing direct mucosal visualization, tissue acquisition, and treatment intervention when needed.
Demand has been increasing, with an estimated number of people living with OGDs per 3000 people per year.
1 This number may increase further after the introduction of the UGI cancer awareness campaign.
2 Certification of OGD performance training and competency assessment is the terms of reference of the Joint Advisory Group (JAG)
Upper Digestive Endoscopy
The main focus of this process is on technical capabilities and program safety, and the main goal is to be able to complete the examination without complications.
The known average failure rate for the diagnosis of cancer in endoscopic examination was 11.
6%, coupled with the paradigm shift in detecting early cancers that may be suitable for organs
The quality of endoscopic therapy needs to be improved.
4-7 after auditable measures were taken, the quality of colonoscopy was significantly improved.
It is hoped that the implementation of similar standards will replicate this phenomenon in UGI endoscopy.
Objectives and Scope the purpose of this position statement is to reduce differences in practice and standards between individual endoscopic physicians and units by establishing a set of auditable key performance indicators (KPIs).
In particular, these proposals are intended to optimize the diagnosis of early tumors and pre-cancerous diseases in order to influence the Natural History of UGI malignant tumors as late detection results in poor prognosis.
These KPIs are for all UGI endoscopes doctors who should have enough skills to perform high regardless of the background
Quality diagnosis OGD before independent practice.
These KPIs are written with the consideration of standard OGD, although it is recognized that alternative patterns are being explored and some of them are being used in parallel
For example, ultra-thin nasal video endoscopy.
Where new technologies are adopted, quality should be maintained even if the technical capabilities may be different.
Specific issues related to training, specific disease process management and unit management are beyond the scope of this statement of position and are therefore not discussed here.
Most of these proposals are designed to be measurable parameters so that practice can be measured based on those parameters.
It is expected that measures should be taken to improve quality if there are deficiencies in achieving recognized goals.
The purpose of this position statement is to provide guidance for Endoscopes practicing in the UK, but as with the recent European guidelines, it has international relevance.
This statement of position was made by the British Institute of stomach diseases (BSG)
Association of UGI surgeons (UK (AUGIS)
Designed and written by a guide development team.
The group consists of 10 voting personnel, including a surgeon and a nursing representative, who are represented in all relevant disciplines.
A UGI pathologist specifically reviewed the organization's suggestions for access and interpretation.
Although this document is a statement of position and not a guide, our goal is to adopt a similar approach of rigor and transparency as described in the evaluation of the study and evaluation guide II (AGREE II).
9 at the meeting, the guidelines development team identified the high level
Quality UGI check.
The survey of the test questions puts forward the miniature used (
Population, intervention, comparison, results)
Framework to guide a comprehensive search strategy.
10 computerized literature searches using the postgraduate Medline, Embase and Cochrane Library to identify original research papers, conference summaries and existing guidelines as of January 2016.
Search is limited to articles published in English.
A Bibliography of identified clinical studies is reviewed to identify further relevant studies.
All members of the panel reviewed and evaluated the resulting evidence, using the grading of the proposed assessment, development and assessment (GRADE)tool.
9 in the absence of sufficient clinical evidence to support a statement, the expert reached a recommendation by consensus.
Each member of the group voted on each statement, using five-point scale (
1 = Strongly disagree 5 = strongly agree)
, Contains the required protocol ≥ 80%.
A review of the evidence and a preliminary vote were conducted separately.
In the absence of consensus, the statement was reviewed, revised and re-established
Evaluate using the Delphi process until there is sufficient agreement to include or abandon the statement.
The process was carried out by email, Conference Call and face-to-faceto-
12-meeting facingmonth period (figure 1).
Download the figure 1 flow chart of the development process of the figure open statement in the new tabDownload powerpoint. OGD, oesophago-gastro-duodenoscopy;
PICO, population, intervention, comparison, results.
The result of this process is a series of proposals, with experts at the corresponding level agreeing and grading the relevant evidence (table 1).
After the panel discussion, a smaller number of KPIs were selected from these reports.
These are chosen based on the potential to influence patient outcomes and the possibility of being pragmatic and auditable.
It was recognized that, given the nature of some of the areas covered, the evidence supporting the specific presentation could be limited or weak.
Despite the lack of evidence, strong proposals were made through expert consensus based on pragmatic approaches.
These statements were peer reviewed by the BSG endoscope board, AUGIS and BSG clinical services and Standards Board.
In most cases, we have indicated acceptable targets for achieving measurable parameters, which should be subject to internal audits (table 2).
Part of these proposals is either inherently more difficult to measure, or is designed with the latest developments in endoscopic examination in mind, and can therefore be considered ambitious.
When the evaluation of the literature found a lack of evidence in areas related to the diagnosis of OGD, we raised research questions that the answers to these questions may change future practice.
We logically divide the advice on patient pathways into: the pre-program disease-specific post-program.
View this table: View summary of digestive endoscopy quality standards and related recommended strength on inline View pop-up table 1 View this table: looking at the inline View popupTable 2 should evaluate the minimum expected achievement of the key performance indicators for Upper Digestive Endoscopy to accommodate acceptance of diagnostic OGD.
Consistency: 100% level of evidence: weak recommendation: strongAn pre-evaluation
Prior to OGD, existing conditions and medication should be performed.
This can be integrated into booking-
To avoid duplication, in the process or in the pre-program list.
If changes in anti-platelet or anti-coagulation therapy are shown in accordance with existing guidelines, management strategies should be documented and communicated to patients.
Prior to receiving OGD, 12 patients should receive appropriate information about the procedure.
Level of agreement: 100% level of evidence: weak strength of Recommendation: in order to be able to give informed consent, information about the proposed procedure and its associated risks must be explained.
13 14 since most OGDs are carried out on a selective basis, information should be provided before the date of the operation and an opportunity to ask questions.
There is evidence that information can improve the patient's experience.
15-19 the combined written and oral information appears to be easier to understand than the individual oral information, and there is little evidence of the use of the video information.
The 20-22 evidence suggests that patients prefer more information than less.
However, it has been noted that anxiety is related to age and gender and may affect the way information is transmitted.
It is rarely suggested who is best suited to provide patient information, but in most cases it should be a referrer who proposes or arranges an investigation.
Appropriate time periods should be allocated according to surgical indications and patient features.
Degree of consistency: 100% level of evidence: weak strength of Recommendation: strongIt is considered to be the time required to perform OGD varies depending on indications, pathology, and patient factors.
Some clinical indications
For example, monitoring of pre-cancer conditions requires careful examination and may require the use of advanced imaging, so it is expected to take longer.
24. in Barrett's monitoring, there is some evidence that "Barrett inspection time" and high-
Dysplasia and adenocarcinoma.
25 We recommend assigning a standard diagnostic endoscope to slots for at least 20 minutes depending on monitoring or highRisk conditions.
Prior to the OGD, informed consent should be obtained.
Agreement level: 100% level of evidence: insufficient recommendation: as outlined in the General Medical Council document "consent guidelines", obtaining informed consent from mentally competent persons is a legal requirement: legal Framework and BSG's "Guidelines for obtaining effective consent for elective endoscopic surgery ".
It is generally believed that a certain degree of risk is involved in the OGD and therefore written consent should be recorded.
Consent is available to those with adequate training and sufficient knowledge of surgery and potential complications.
Mailing information and consent forms before surgery may be a practical way to ensure that patients have enough time to read and consider the required information.
26 27 if it has been shown that there is no capacity, the doctor, preferably the recommender, should decide whether to perform OGD for the best interests of the patient.
13. the safety checklist should be completed before OGD is started.
Degree of agreement: 100% level of evidence: recommended moderate intensity: it is strongly believed that the incidence of serious complications associated with major surgery is 3-16%, half of which are considered preventable.
This caused 20-
As part of the "safe surgery to save lives" initiative, point the preoperative checklist.
The use of this tool has been tested in various surgical departments.
Recently, a variant of this tool has been adopted in a higher version
Risk medical interventions including endoscopic examinations.
29-33 there is no standardized endoscopic checklist, however, the domains that we recommend should be examined before starting the OGD include 31 34: Patient Identifier (
Name/hospital number/date of birth)
Allergic drugs/conditions that may exclude any interventionanticoagulants)
There is an important understanding of the proposed test completion of the consent form for co-patients.
After completing the OGD, a checklist should be made before the patient leaves the room.
Degree of consent: 90% level of evidence: weak recommendation strength: strong ability to complete OGD, the following details should be reviewed and confirmed 28: the number of histological samples correctly labeled for histological samples was given to patients with any specific postoperative recommended dose of calm and/or pain reliefArranged.
The procedure quality standard can only be performed independently by an endoscopic physician with appropriate training and related capabilities.
Consistency: 100% level of evidence: insufficient recommendation: strongOGD training is registered and certified by JAG.
3 in order to gain the ability, at least 200 diagnostic procedures must be performed before using structured objective assessment tools for summative assessment.
At present, despite the assessment of technical capabilities, Lesion identification is not an integral part of the specific assessment in the certification process.
The lesions of the UGI tract are diverse and may be subtle in nature, which makes it difficult to measure objectively the quality.
Therefore, we suggest that the course on Lesion identification and management is part of the continuing professional development of UGI endoscopes.
37 more experience may be required in Lesion identification
Risk and crowd monitoring.
With this in mind, it is better to make sure that patients with increased risk are assigned to the planning of services of an endoscopic physician with the most relevant experience.
There is some evidence of an increase in the rate of return on dysplasia associated with the dedicated Barrett list.
38 if there is no expertise, the recommendation of a tertiary center should be considered.
39 we suggest that endoscopes should do at least 100 OGDs ayear to keep it high
Quality inspection standards.
Consistency: 100% level of evidence: weak strength of Recommendation: weak ability we believe to be able to maintain a higher level of execution
Quality check, OGDs should be carried out regularly.
There is no evidence to support the specific minimum number of procedures required to maintain OGD proficiency once a person is considered competent.
There is some data, mainly from military and surgical specialties, that is interrupted when performing any given task, resulting in a "skill drop ".
The speed at which this happens depends on the complexity of the task, the duration of the interruption, and the level previously achieved.
Of the trainees, 40-44 have shown that the interruption of colonoscopy training can lead to a decline in ability.
45 we recommend that endoscopic physicians perform OGDs at least 100 times a year to ensure that high levels can be performed
Quality diagnostic examination.
We have received a number of therapeutic endoscopes performed by some endoscopes doctors in other aspects of the endoscopes examination, with relatively few diagnoses at the same time.
These endoscopes should not be prevented from performing UGI endoscopes, but we recommend auditing their practices as described in these criteria.
UGI endoscopy should be high-
A high-definition video endoscope system capable of capturing images and performing biopsy.
Degree of consistency: 90% level of evidence: weak recommended strength: strongAll diagnostic OGDs should be performed using a device that can achieve the intended purpose.
As a minimum, an endoscope with production capacity
Define images should be used.
Equipment to obtain sufficient mucosal views and to obtain tissue samples should be available. Complete OGD should evaluate all relevant anatomical signs and highrisk stations.
Consistency: 100% level of evidence: weak strength of Recommendation: a standardized set of landmarks should be inspected in order to conduct a complete inspection of UGI Road.
The procedure should start the upper esophagus anus and reach the second part of the duodenum, including the upper esophagus, the stomach
The junction of the esophagus, the bottom of the stomach, the stomach body, the notch, the stomach cavity, the ball of the duodenum and the distal end of the duodenum.
The fundus should be J-
Operations are performed in all patients, and if there is a rip hernia, the diaphragm clamp point should be checked when bending backwards. Photo-
Relevant anatomical signs and any damage detected shall be recorded.
Degree of consistency: 100% level of evidence: weak recommendation strength: strong, without evidence to support the practice of photos
Documentation, this practice encourages mucosal cleaning, mucosal examination and it is intuitive to ensure a complete examination.
In addition to the documentation, frozen images provide an opportunity for endoscopes to examine areas of interest without creating artifacts due to patient movement. Photo-
Documents can also be used as legal records for proper/complete procedures.
European Society of digestive endoscopy (ESGE)
The guide describes a systematic method of taking picturesdocumentation (figure 2)
8 anatomical landmarks are recommended.
46 note that countries with high incidence of gastric cancer have adopted a stricter approach to photographing
Optimize documentation for early diagnosis.
The wide use of electronic image acquisition system makes this an achievable goal.
Download figureOpen in figure 2 of the new tabDownload powerpoint. The schematic diagram shows the recommended site of the photo
Documentation during the diagnosis of oesophago-gastro-duodenoscopy. (
Copy from Thieme [with permision]43]).
The quality of mucosal visualization should be reported.
Degree of consistency: 100% level of evidence: weak recommended strength: in order to be able to exclude early UGI lesions, it is necessary to be able to check the mucosa without bubbles and fragments.
Compared to the report on the quality of bowel preparation during colonoscopy, the quality of the obtained views was not routinely stated.
We recommend rating the quality of the obtained views based on a valid scale and recording as part of the report.
49-51 if it is not possible to get a full view, it should be documented and it is recommended that the program need to be repeated.
If a complete examination is excluded from the patient's agitation or intolerance, repeated OGD with optimal calm should be considered.
Adequate mucosal visualization should be achieved through adequate air blowing, suction and the use of mucosal cleaning techniques.
Degree of consistency: 100% level of evidence: recommended moderate intensity: clear mucosal view can be obtained by pumping debris and flushing water through the accessory channel of the endoscope to rinse the surface of the mucosa.
Use the pump to clean the mucosa more conveniently
Control the water jet, allowing the use of accessories at the same time through the working channel.
Addition of anti-adhesive agents such as simethone and N-ketone and Defoamer
Ammonia cysteine or enzymes disperse bubbles and mucous membranes.
It has been shown that pre-medication for swallowing mucus dissolved can reduce the need for washing between programs, thereby reducing program time, and seems to provide a better view of the mucosa.
50 52-59 the best time for pre-operative consumption of these drugs seems to be 10-30 min and can therefore be included in the admission process.
58. it is recommended that the time of examination during the diagnosis of OGD be recorded for monitoring procedures such as Barrett's esophagus and gastric atrophy/bowel monitoring.
Consistency: 90% level of evidence: weak recommendation strength: Although various tasks need to be completed within the allocated endoscopic examination time period, the time required to perform the procedure itself should not be compromised. A high-
Quality checks including mucosal cleaning and examination take time.
We believe that the complete OGD started with intubation after the upper esophagus anus, and then progressed to the distal duodenum before careful withdrawal and examination began.
The whole process takes an average of 7 minutes.
A single study showed that endoscopic physicians who took an average of> 7 minutes of OGD increased by three times over those who took an average of 7 minutes of OGD increased by three times over those who took an average of