10/4/2014. (Avoiding) Technical obstacles to a successful colonoscopy (quality measures in endoscopy) Disclosures. Aim of Slides

Transcription

1 (Avoiding) Technical obstacles to a successful colonoscopy (quality measures in endoscopy) Stan Feinberg MD FRCSC North York General Hospital Disclosures 20 colonoscopies per week Work in both private clinic and hospital environment Teach residents No financial disclosure Aim of Slides Discuss simple techniques to aid passage of scope CO2 insufflation Water immersion Cap fitted endoscopy Split dose prep Positioning RCT evidence for all of these. All are cheap and effective Discussion of QBP and move to Out of Hospital Premises (OHP) 1

2 The difficult scope Female Previous pelvic surgery/hysterectomy diverticulitis Abdominal wall defect Low BMI colleague Time of day affecting outcome Lee, AlexanderAm J Gastroenterol 2011; 106: ; Found that Adenoma detection rate fell in the afternoon For every hour later in the day, ADR fell by 4.5% Variable Stiffness Colonoscopes Othman MO et al. Variable stiffness colonoscope versus regular adult colonoscope: Endoscopy 2009; 41:17-24 Meta-analysis of 7 studies Higher cecal intubation rates Less pain Less sedation No difference in time of procedure 2

3 Different Scopes Paediatric vs. Adult colonoscope 11 mm vs 12.5 mm Big difference in flexibility Shown to be better in women with previous pelvic surgery (Madsen.Am J Gastroenterol 2003;98: ) Cecal intubation rate 90% vs 70% Padiatric Scope Vs. Adult Thin patient, constipated, (loopy colon) 1. Use adult bigger scope- stiffer, less looping History of diverticulitis, previous surgery ( tightly angulated) 1. Use paediatric scope more flexible Often you don t know, don t hesitate to swtich scopes. 3

4 External pressure External pressure Remember what you are trying to do Undoing loops, pull back and torque to right Split Dose Prep Enestvedt BK, Tofani C, Laine LA, Tierney A, Fennerty MBSOClin Gastroenterol Hepatol. 2012;10(11):1225. Meta-analysis of 9 RCT of bowel preps OR 3.5 improved prep with split dose No difference in patient experience Split dose give ½ the prep on morning of test Need to be NPO for 2 hours ( acceptable to anesthesia) Optimal to finish the PEG solution 3-5 hours pre procedure. 4

5 CO2 insufflation Church, Delaney 2003 DCR RCT. Improved pain scores with C02 compared to air insufflation C02 is rapidly absorbed. Less distention Cost 5k for tower modification About.80/case for medical gas Water infusion Colonoscopy First described in 1984 ( Falchuk NEJM) Many different methods Water exchange vs immersion High volume vs. low Warm water vs. room temperature Consistently shown to decrease pain and improve completion rates (FW Leung 2011, J int Gastro) Water infusion Sigmoid fills with water. Sinks into LLQ, more straight Water immersion Gas insufflation expands the colon and puts the sigmoid in the mid abdomen Making for a tighter turn Fluid immersion Colon is heavier, sinks into LLQ Not expanded Relieves spasm 5

6 Water immersion C02 vs Warm Water vs Air Amato DCR 2013 Patients randomized Attempts at unsedated colonoscopy Both CO2 and Warm water superior to air insufflation Cap Assisted Colonoscoy Westwood DCR 2012 vol 55:2 Review cap assisted colonosocpy Higher polyp detection rate Higher cecal intubation rate 6

7 Cap Fitted Endoscopy Cap fitted endoscopy Maintains the 4mm depth of field Prevents red out Straightens folds Cap Endoscopy Cap Endoscopy 7

8 Changing of Position East 2011, Gastro Endoscopy(Gastrointest Endosc 2011;73: ) Translation from BE. Having the examined area superior allows air to rise and fluid to fall away Right colon - left lateral Transverse supine Simgoid/descending right lateral Patients randomized to either left lateral or positions change and then cross over Adenoma detection rate - 34% vs. 23% The difference was seen in left colon and transverse inking 8

9 Sedation i.v. conscious sedation Benzodiazepines (Versed) Narcotics (Fentanyl) Who is likely to have difficulty Patients with past history of difficult procedure Prescribed or illicit benzo or narcotics use Heavy ETOH use Propofol Quick onset of action 2 minutes Offset very quick essentially when the drip is turned off Respiratory depressant- need for anesthesiologist No analgesic properties ( often combined with fentanyl or remi-fentanyl) Not a substitute for skill Propofol for colonoscopy Cochrane Review Use of propofol Faster recovery and discharge times Better patient satisfaction No difference in duration of procedure No difference in rate of complications 9

10 Propofol and Perforation Adeyamo. ASCRS meeting 2013 Detroit Royal Oak Hospital 110,000 scopes Perforation rate 0.048% 2.5 fold increase in perforation rate with use of propofol Downsides to Propofol Increased risk of aspiration Review of 165,000 colonoscopies Increased risk of aspiration, Not perforation Cooper Jama (7) pg Professional Fees- increased costs of endoscopy will eventually impact access Difficulty moving patients. RN vs. RPN model Retroflexion Advantages Able to see rectum better Remove certain polyps Disadvantages Accounts for 10% of colonic perforations Adequate luminal diameter 10

11 Retroflex in Cecummax up, max left counterclockwise Tips for Better Colonoscopy Rex, Bourke Am J Gastro 2012;107: Anticipate the difficult sigmoid Diverticular disease, radiation, pelvic surgery Torque steer ( clockwise rotation) rather than push Don t push against fixed resistance Looping in sigmoid Straighten with withdrawl and clockwise rotation Reinsert with external pressure Change in position Tips for Better Colonoscopy Rex, Bourke Am J Gastro 2012;107: If you are not progressing do something different after 2 attempts Straighten out loop Stiffener Change in position ( supine, right lateral, prone) Change in scope size Difficulty passing the hepatic flexure Move patient to supine Be subtle, if you move quickly, reform loop 11

12 Tips for Better Colonoscopy Rex, Bourke Am J Gastro 2012;107: If you aren t progressing after 20 minutes Quit or get someone else to give it a shot CO2 inflation Water immersion scoping Will help get through sigmoid and through a redundant sigmoid Cold snare of small polyps Clipping of large polyps bases Summary Split dose prep- especially for afternoon cases CO2 insufflation- cheap, no change in your technique Water immersion- give it a try for the difficult sigmoid Change the position of patient Use different scopes Thin person- large scope Diverticular disease- smaller scope Summary Cap fitted endoscopy Adds to cost of case but nice to have available for difficult case If you are having difficulty. Try something different 12

13 Where is the direction of the Ministry If a routine, low-risk procedure can be done outside of a hospital, it s good for patients, the health care system and taxpayers. We want to build on the success of existing specialty clinics like the Kensington Eye Institute to improve the patient experience while at the same time providing better value for Ontario taxpayers. Deb Matthews Minister of Health and Long-Term Care Health System Funding Reform Global Funding Traditional Hospital received fixed budget, often unrelated to community need Tight times- cut down on service budget remained Patient Based Funding-hospitals funded for patients they take care of. If you do things efficiently/quality/few complications you come out ahead HBAM- utilizes complexity and demograhics Quality based procedures Quality Based Programs Best practice has been established High volume Areas are chosen 1. Standardize care 2. Minimize variation 3. Improve quality and safety 13

14 Quality Based Program Set standards/guidelines for procedure Cost out delivery cost of procedure Carve out from Hospital Budget a percentage of the endoscopy budget. i.e. $230 X 1000 cases Transfer of Cases to Community Based Specialty Clinic or maintain them in hospital Transfer of resources i.e. $230 X 1000 Needs to be in agreement with LHIN and Transferring Hospital Players in the Colonoscopy Field Cancer Care Ontario CPSO set standards for OHP Quality Management Partnership ( QMP) CCO and CPSO Focus is on Quality Are there quality issues in Colonoscopy Followup interval Training/qualifications of endoscopists Polyp detection rates in province Rates of missed cancers Routine tatooing of lesions 14

15 Quality issues in colonoscopy PCCRC (post colonoscopy colorectal cancer) NN Baxter, Gastro patients with Cancer Defined as having PCCRC if scope 7 months -36 months before DX 9% rate of PCCRC Proximal (12.4%) Distal (6.8%) Post Colonoscopy CRC Higher rates of PCCRC if 1. Endoscopist had a completion rate of less than 80% 2. Polypectomy rate of less than 10% 3. Office based rather than Hospital based 4. Non-Surgeon. Non-gastroenterologist 15

16 46 Training Required Current State 2 months of endo as a PGY scopes Variable experience as a senior Cecal intubation rate Recommended 6 months of training 300 scopes during training/50 polypectomies Cecal intubation rate of 85% Training Challenge Colonoscopy is a key competency according to Royal College Simulation gives a head start Surgery is a technical skill. Colonoscopy skills should be acquired throughout training Royal College is going towards competency based training rather than numbers/duration Biggest risk is movement of endoscopy to Community Clinics from Teaching Centers 16

17 Quality indicators ( targets to be set) Cecal Intubation rate- 95% Bleeding rate post polypectomy- <1/100 Perforation rate- <1/1000 Auditable Outcomes ( no targets but measure) Adenoma Detection rate Polyp detection rate Bowel preparation Post colonoscopy CRC Summary QBP We need to measure our outcomes Demonstrate quality Scope the right patient Endoscopy is recognized to be a key part of cancer care Funding for outpatient clinics is sure to come but with strings 17