A quality indicator or measure or metric can be used to compare actual performance against a standard defined by ideal performance or benchmark and enable potential quality improvement [1]. Clinically relevant measures should correlate with clinically relevant endpoints, be evidence based with demonstrable gaps in performance and be amenable to both measurement and improvement [1]. Quality indicators in adult endoscopy are well established and involve measures of structure, process, and outcome [2] (www.thejag.org.uk). However, there is a limited evidence base for pediatric endoscopy quality indicators.
Quality indicators may be flexible as evidence and practice evolve. In the UK, identified quality and safety indicators have been used to underpin the respective items of the Pediatric Endoscopy Global Rating Scale (P‐GRS), a quality improvement tool launched in 2017 which, amongst other measures, assesses the extent to which the audit cycle has been applied to the quality and safety indicators (www.bspghan.org.uk; www.thejag.org.uk). Suggested pediatric procedural quality indicators include procedure completion rates such as cecal intubation and terminal ileal intubation rates, appropriate diagnostic biopsies based on best evidence, adequate bowel preparation for colonoscopies, and safety indicators that relate to complication rates. These are auditable outcomes for which there is some evidence base to help recommend a minimum standard, for example, ileal intubation rates in pediatric colonoscopy. As confirmation or exclusion of inflammatory bowel disease is one of the main reasons for pediatric colonoscopy, ileal intubation is a clinically important and meaningful pediatric quality indicator compared to only using cecal intubation rates that are more relevant for adult endoscopists in the context of bowel cancer screening. Cecal intubation rates are generally recommended to be >90% (www.thejag.org.uk). Reported ileal intubation rates in recent pediatric literature vary from 84% to 98% [3–5].
A recent North American endoscopy clinical report proposed >90% ileal intubation rate as a quality metric for pediatric colonoscopy [6]. The pediatric colonoscopy certification criteria in the UK use terminal ileal intubation rates of ≥60% and cecal intubation rates of ≥90%, amongst other criteria, for certifying pediatric gastroenterology trainees to perform independent ileocolonoscopies (www.thejag.org.uk).
Access to an electronic endoscopy reporting system is essential in all pediatric endoscopy units as this allows reliable and accurate data collection. There are other quality and safety outcomes which are important to monitor and review but due to a limited evidence base, it can be difficult to assign a standard, for example the minimum number of procedures required to maintain competence or unplanned admissions or procedures within a fixed time frame such as eight days of a gastrointestinal endoscopy or need for ventilation post gastrointestinal endoscopy performed under general anesthetic or unplanned use of reversal agents if sedation used. Other quality indicators may relate to the structure, process or staffing in a pediatric endoscopy unit.
Quality and safety indicators relating to structure can include access to age‐appropriate equipment, endoscopy reporting system, supportive anesthetic, pathology and radiology service with pediatric expertise, etc. Quality and safety indicators relating to process include having agreed policies such as for managing patients with diabetes, adherence to guidelines for endoscope decontamination, use of time‐out or WHO checklists pre‐procedure, an endoscopy user group that meets regularly, etc. Quality indicators relating to staffing include staffing levels and skill mix appropriate to the volume and types of procedures performed with pediatric competencies, identified medical and nurse leads for endoscopy with adequate managerial and clerical staff support, appropriate supervision of trainees, etc.
The National Endoscopy Database (NED), led by the Joint Advisory Group on GI Endoscopy (JAG), is a very exciting development in the UK. The NED is populated by data extracted automatically from the endoscopy reporting system at endoscopy services in the UK. It will make data available in user‐friendly outputs for clinicians, services and research purposes and enable improved quality assurance in endoscopy (https://ned.jets.nhs.uk/KPI).
Conclusion
Development of quality improvement tools like the P‐GRS, a robust quality assurance process and the regular audit of performance against quality indicators that are clinically meaningful for pediatric endoscopy will help define their importance, measure performance variability against these indicators and in time allow pediatric endoscopy units to achieve and demonstrate the highest standards of quality and patient‐centered care through repeated cycles of measurement, intervention, and evaluation.
See companion website for videos relating to this chapter topic: www.wiley.com/go/gershman3e
REFERENCES
1 1 Petersen BT. Quality assurance for endoscopists. Best Pract Res Clin Gastroenterol 2011, 25, 349–360.
2 2 Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015, 81(1), 31–53.
3 3 Thakkar K, Holub JL, Gilger MA, et al. Quality indicators for paediatric colonoscopy: results from a multicenter consortium. Gastrointest Endosc 2016, 83, 533–541.
4 4 Singh HK, Withers GD, Ee LC. Quality indicators in paediatric colonoscopy: an Australian tertiary centre experience. Scand J Gastroenterol 2017, 52(12), 1453–1456.
5 5 Thomson M, Sharma S. Diagnostic yield of upper and lower gastrointestinal endoscopies in children in a tertiary centre. J Pediatr Gastroenterol Nutr 2017, 64(6), 903–906.
6 6 Kramer RE, Walsh CM, Lerner DG, et al. Quality improvement in paediatric endoscopy: a clinical report from the NASPGHAN endoscopy committee. J Pediatr Gastroenterol Nutr 2017, 65(1), 125–131.
9 e‐learning in pediatric endoscopy
Claudio Romano and Mike Thomson
Distance learning facilitated by online means can achieve faster competence not only in lesion recognition but in learning technical skills prior to hands‐on training.
Examination of knowledge and appropriate application of endoscopic techniques may be a feature of future postpandemic assessment.
Advances in pediatric endoscopy have been assured since 1960. Over the past decades, the number of endoscopies for pediatric gastrointestinal disease has increased rapidly. Diagnostic and therapeutic applications increase at a rapid pace. Hands‐on courses are the primary learning tool, along with training in dedicated training units.
Recently, with the burgeoning of information technology, teaching procedures and modalities by which to provide infomration have changed. The introduction of e‐learning platforms has led to questions arround the appropriateness of teaching methods, design of the technological infrastructure, and the interaction of students with the technology. e‐learning can be defined as learning through electronic devices using technology as a medium for online interaction and to access information. e‐learning
