Quality in endoscopy - is it applicable in developing countries? An Egyptian experience|
Over the last decade there has been increasing interest in quality issues in endoscopy .
Our gastrointestinal (GI) endoscopy unit was formally opened on 1 November 1999 in Bolak EL-Dakror Hospital, Giza, Egypt. Bolak EL-Dakror Hospital is a 400 bed, secondary-care governmental hospital that serves a population of 1 million people. I had the privilege to be the first director of the GI endoscopy unit.
Average endoscopy volume is 368 procedures per year. 85% are esophago-gastro-duodenoscopy and 15% lower GI endoscopy. Average colonoscopy volume is 27 procedures per year.
In 2002, a sedation-related mortality from cardiopulmonary complications occurred in our unit. A number of mistakes had been made because formal training in sedation and monitoring techniques had not been instituted.
A few months later Professor Axon from Leeds in the UK presented a lecture on quality assurance in GI endoscopy during an international conference held in Cairo . On the basis of his information and from citations in the literature, I instituted a quality-assurance program with data being collected using electronic databases. The quality standards developed by the American Society of Gastrointestinal Endoscopy and British Society of Gastroenterology were implemented [3,4]. Although we could not achieve 100% compliance with every one, in every patient for each procedure we made an enthusiastic start.
Setting up a quality assurance program
I established protocols, briefings, checklists, an adverse event reporting system and annual reports. Training took place within the context of an approved training program. The team was strengthened by high level consultant input. Quality indicators (QI) were identified for monitoring and improving performance.
For easy application, QI were identified for 5 major groups: patients, procedures, endoscopists, assistant staff and equipment. Newly developed QI were continuously added. Twenty-one measured parameters were recorded in 2003 and increased consistently reaching 39, 47, 57 and 70 in years 2004, 2005, 2006 and 2007 respectively (Fig 1).Figure 1 Number of measured parameters added by year
The evaluation of our endoscopy service was performed with complete openness. Benchmarking was used to adjust our practices for maximum efficiency within the available resources. A continuous quality improvement process was implemented, this involved changing some of our management practices and the way we performed our endoscopic procedures. Staff and assistant staff were encouraged to identify areas that needed improvement and to report any error. This policy was considered to be a learning opportunity. Documentation was regularly checked.
Difficulties encountered in applying quality assurance
Government spending on quality assurance has been negligible when compared with the supply of drugs, diagnostic and therapeutic equipment. Donations were a significant source for many of the necessary supplies.
There is an absence of set standards for most procedures in government hospitals. Setting standards in our unit represents a major step forward. Nevertheless, it was not accepted easily and was even resisted. Many physicians consider the effort spent on quality and documentation to be relatively unnecessary and a waste of time. They are more interested in maximizing endoscopic through-put.
I was able to overcome all of these challenges with belief, enthusiasm, perseverance and an insistence on doing the right things right.
Improving performance and patient outcome
In 2003 I assessed the quality of our colonoscopic procedures with the goal of improving clinical performance. The initial crude colonoscopy completion rate (CCR) was 50%. The main determinants of lack of completion were poor bowel preparation, poor patient tolerance and operator inexperience.
A number of changes were implemented. The crude CCR improved consistently. CCR was 52% in 2004, 60% in 2005, 67% in 2006, 71% in 2007 and 95% in 2008. This trend was confirmed when adjusted completion rates (ACR) were calculated. ACR was 60% in 2004, 73% in 2005, 69% in 2006, and 100% in 2007 and 2008 (Fig 2).Figure 2 Crude completion rates (CCR) and adjusted completion rates (ACR)
Polypectomy was performed in 40% of patients with detected polyps. Excision of all polyps became standard practice in 2005. The percentage of procedures in which all polyps were resected and recovered for pathological examination increased consistently reaching 25%, 50% and 75% in years 2006, 2007 and 2008 respectively (Fig 3).Figure 3 Percentage of procedures in which all polyps were resected and recovered for pathological examination
We audited patient experience and satisfaction in patients who underwent a successful total colonoscopy. Discomfort was driven up by excessive concentration on completion rate as the main quality indicator. Frequently the endoscopist continued to attempt to reach the caecum even when patients were distressed. Discomfort was ameliorated in 2008 when the endoscopist concentrated on both completion rate and patient comfort (Fig 4). Figure 4 Comparison between percentage of pain estimated by the patients and ACR
Quality is applicable in developing countries
Quality is being applied in our endoscopy unit in spite of constrains typical of a developing country. Assessment, monitoring and improved technical performance enabled us to improve the quality of our endoscopic care and patient outcome.
Our annual report for 2008 provides a snapshot of our endoscopy practice following the institution of the quality assurance program. If you are interested, or wish to find out more, a link to my full report is available at www.itqan-egy.com/gado and my email address is firstname.lastname@example.org.
- Johanson JF, Schmitt CM, Deas TM Jr et al. Quality and outcomes assessment in Gastrointestinal Endoscopy. Gastrointest Endosc 2000; 52(6 Pt 1): 827-30.
- O'Mahony S, Naylor G, Axon A. Quality assurance in gastrointestinal endoscopy. Endoscopy 2000; 32(6): 483-8.
- Bjorkman D, Popp J Jr. Measuring the quality of endoscopy. Am J Gastroenterol 2006; 101(4): 864–5.
- Valori R. Quality and safety indicators for endoscopy. http://www.grs.scot.nhs.uk/.