Development and validation of a nurse-assessed patient comfort score for colonoscopy

Baseline Cannabinoid Use Is Associated with Increased Sedation Requirements for Outpatient Endoscopy

Background and Aims: Given the underlying properties of cannabinoids, we aimed to assess associations between cannabinoid use and sedation requirements for esophagogastroduodenoscopy (EGD) and colonoscopy. Methods: A prospective cohort study was conducted at three endoscopy units. Adult outpatients undergoing EGD or colonoscopy with endoscopist-directed conscious sedation (EDCS) were given questionnaires on cannabinoid use and relevant parameters. Outcomes included intraprocedural midazolam, fentanyl, and diphenhydramine use, procedural tolerability, and adverse events. Multivariable logistic regression was performed to yield adjusted odds ratios (AORs) of outcomes. Results: A total of 419 patients were included. Baseline cannabinoid use was associated with high midazolam use, defined as ≥5 mg, during EGD (AOR 2.89, 95% confidence interval, CI: 1.19-7.50), but not during colonoscopy (AOR 0.89, 95% CI 0.41-1.91). Baseline cannabinoid use was associated with the administration of any diphenhydramine during EGD (AOR 3.04, 95% CI: 1.29-7.30) with a similar nonsignificant trend for colonoscopy (AOR 2.36, 95% CI: 0.81-7.04). Baseline cannabinoid use was associated with increased odds of requiring high total sedation, defined as any of midazolam ≥5 mg, fentanyl ≥100 mcg, or any diphenhydramine during EGD (AOR 3.72, 95% CI: 1.35-11.68). Cannabinoid use was not independently associated with fentanyl use, intraprocedural awareness, discomfort, or adverse events. Conclusions: Baseline cannabinoid use was associated with higher sedation use during endoscopy with EDCS, particularly with midazolam and diphenhydramine. Given increasingly widespread cannabinoid use, endoscopists should be equipped with optimal sedation strategies for this population. As part of the informed consent process, cannabis users should be counseled that they may require higher sedation doses to achieve the same effect.

British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy

Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy.This guideline covers aspects from pre-assessment of the elective 'well' patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years' time.

Optimization of colonoscopy quality: Comprehensive review of the literature and future perspectives

Colonoscopy is crucial in preventing colorectal cancer (CRC) and reducing associated mortality. This comprehensive review examines the importance of high-quality colonoscopy and associated quality indicators, including bowel preparation, cecal intubation rate, withdrawal time, adenoma detection rate (ADR), complete resection, specimen retrieval, complication rates, and patient satisfaction, while also discussing other ADR-related metrics. Additionally, the review draws attention to often overlooked quality aspects, such as nonpolypoid lesion detection, as well as insertion and withdrawal skills. Moreover, it explores the potential of artificial intelligence in enhancing colonoscopy quality and highlights specific considerations for organized screening programs. The review also emphasizes the implications of organized screening programs and the need for continuous quality improvement. A high-quality colonoscopy is crucial for preventing postcolonoscopy CRC- and CRC-related deaths. Health-care professionals must develop a thorough understanding of colonoscopy quality components, including technical quality, patient safety, and patient experience. By prioritizing ongoing evaluation and refinement of these quality indicators, health-care providers can contribute to improved patient outcomes and develop more effective CRC screening programs.

Propofol-remifentanil patient-controlled sedation for endoscopic procedures: a prospective service audit

PURPOSE

Following demand, we established a patient-controlled propofol-remifentanil sedation service for endoscopy overseen by an anesthesiologist. To assess the effectiveness of the intervention of this service and any complications, we prospectively audited the service. Our primary outcomes of interest were adequacy of sedation and patient satisfaction. Secondary outcomes included any adverse events associated with the sedation.

METHODS

Patients were referred for failure of procedure under endoscopist-administered sedation, refusal of procedure without general anesthesia (GA), or planned complex procedure. We included all 670 procedures performed between 2017 and 2021. We used a mixture of 8.9 mg·mL-1 propofol and 5.4 µg·mL-1 remifentanil with a 1-mL bolus and 20-sec lockout. We assessed the adequacy of sedation using the Modified Gloucester Scale and categorized adverse events according to the Tracking and Reporting Outcomes of Procedural Sedation.

RESULTS

All 670 procedures were accomplished with adequate sedation without the need for ventilation or GA, and all patients were satisfied with the sedation. The complication rate was low, with no sentinel airway or respiratory events. Nineteen out of 670 patients (2.8%) had an incidence of airway obstruction (requiring a simple airway maneuver). The body mass index (BMI) was documented in 18/19 of these patients and the average BMI in this group was 35 kg·m-2. Seven of the 670 patients (1%) had self-terminating apnea, 3/670 patients (0.4%) vomited, no patients aspirated, and 17/665 patients (2.6%) required a vasopressor to maintain blood pressure within 20% of preprocedure values.

CONCLUSION

The results from our prospective service audit indicate that propofol-remifentanil patient-controlled sedation is a safe and reliable technique in patients undergoing endoscopic procedures.

Evaluation of the quality of colonoscopies performed by Alberta North Zone surgeons, family physicians and internists: a quality improvement initiative

BACKGROUND

In Canada, endoscopy is primarily performed by gastroenterologists and surgeons, and some studies report that colonoscopies performed by nongastroenterologists have more complications and higher rates of future colorectal cancer. Our objective was to determine whether rural-based nongastroenterologist endoscopists are achieving quality benchmarks in colonoscopy.

METHODS

This quality improvement initiative prospectively evaluated 6 key performance indicators (KPIs) (cecal intubations, polyp detection [males and females; for first-time colonoscopies on patients aged ≥ 50 yr], bowel preparations, patient comfort and withdrawal times) on consecutive colonoscopies performed by participating Alberta North Zone endoscopists. The study period was June 2018 to March 2020. Overall and individual endoscopist's KPIs were compared with standard benchmarks. Additional performance indicators included mean number of polyps per colonoscopy and an exploration of study-defined sedation-related level of consciousness.

RESULTS

Data were collected on 6212 colonoscopies performed by 16 endoscopists (9 surgeons, 5 family physicians and 2 internists) in 6 hospitals. All 6 KPI benchmarks were achieved when results were pooled over all endoscopists in the study. Overall, cecal intubation occurred in 6006 of 6209 (96.7%, 95% confidence interval 94.5%-99.0%) cases. Polyp detection was 65.9% (592/898) and 49.8% (348/699) for male and female patients, respectively, aged 50 years or older. Variability in individual endoscopist results existed, especially for the mean number of polyps per 100 colonoscopies and sedation-related level of consciousness.

INTERPRETATION

Overall, Alberta North Zone endoscopists are performing high-quality colonoscopies, collectively achieving all 6 KPIs. To understand endoscopic performance and encourage individual and group reflection on endoscopic practices, Canadian endoscopists are encouraged to participate in similar colonoscopy quality initiative studies.

Unlocking quality in endoscopic mucosal resection

A review of the development of the key performance metrics of endoscopic mucosal resection (EMR), learning from the experience of the establishment of widespread colonoscopy quality measurements. Potential future performance markers for both colonoscopy and EMR are also evaluated to ensure continued high quality performance is maintained with a focus service framework and predictors of patient outcome.

Optimizing adenoma detection in screening-related colonoscopy

INTRODUCTION

Screening-related colonoscopy is a vital component of screening initiatives to both diagnose and prevent colorectal cancer (CRC), with prevention being reliant upon early and accurate detection of pre-malignant lesions. Several strategies, techniques, and interventions exist to optimize endoscopists' adenoma detection rates (ADR).

AREAS COVERED

This narrative review provides an overview of the importance of ADR and other colonoscopy quality indicators. It then summarizes the available evidence regarding the effectiveness of the following domains in terms of improving ADR: endoscopist factors, pre-procedural parameters, peri-procedural parameters, intra-procedural strategies and techniques, antispasmodics, distal attachment devices, enhanced colonoscopy technologies, enhanced optics, and artificial intelligence. These summaries are based on an electronic search of the databases Embase, Pubmed, and Cochrane performed on December 12, 2022.

EXPERT OPINION

Given the prevalence and associated morbidity and mortality of CRC, the quality of screening-related colonoscopy quality is appropriately prioritized by patients, endoscopists, units, and payers alike. Endoscopists performing colonoscopy should be up to date regarding available strategies, techniques, and interventions to optimize their performance.

Risk factors for underestimation of patient pain in outpatient colonoscopy

BACKGROUND

Adequate management of patient pain and discomfort during colonoscopy is crucial to obtaining a high-quality examination. We aimed to investigate the ability of endoscopists and endoscopy assistants to accurately assess patient pain in colonoscopy.

METHODS

This was a single-center, cross-sectional study including patients scheduled for an outpatient colonoscopy. Procedure-related pain, as experienced by the patient, was scored on a verbal rating scale (VRS). Endoscopists and endoscopy assistants rated patient pain likewise. Cohen's kappa was used to measure the agreement between ratings and logistic regression applied to test for potential predictors associated with underestimation of moderate-severe pain.

RESULTS

In total, 785 patients [median age: 54 years; females: n = 413] were included. Mild, moderate, and severe pain was reported in 378/785 (48%), 168/785 (22%), and 111/785 (14%) procedures respectively. Inter-rater reliability of patient pain comparing patients with endoscopists was κ = 0.29, p < .001 and for patients with endoscopy assistants κ = 0.37, p < .001. In the 279 patients reporting moderate/severe pain, multivariable analysis showed that male gender (OR = 1.79), normal BMI (OR = 1.71), no history of abdominal surgery (OR = 1.81), and index-colonoscopy (OR = 1.81) were factors significantly associated with a risk for underestimation of moderate/severe pain by endoscopists. Young age (OR = 2.05) was the only corresponding factor valid for endoscopy assistants.

CONCLUSIONS

In a colonoscopy, estimation of patient pain by endoscopists and endoscopy assistants is often inaccurate. Endoscopists need to pay specific attention to subgroups of patients, such as male gender, and normal BMI, among whom there seems to be an important risk of underestimation of moderate-severe pain.

Colonoscopy skills improvement training improves patient comfort during colonoscopy

INTRODUCTION

We aimed to assess the effect of Colonoscopy Skills Improvement (CSI) training on patient comfort and sedation-related complications during colonoscopy.

METHODS

This retrospective cohort study was performed on 19 endoscopists practicing in a Canadian tertiary care center who completed CSI training between October 2014 and May 2016. Data from 50 procedures immediately prior to, immediately after, and eight months following CSI training were included for each endoscopist. The primary outcome variable was intraprocedural comfort, and secondary outcomes included intraprocedural hypotension and hypoxia. Data were extracted from an electronic medical record and analyzed using SPSS version 20.0. Univariate analysis and stepwise multivariable logistic regression were performed to determine if there was an association between patient comfort and CSI training. Predictors of these outcomes including patient age, gender, sedation use and dosing, procedure completion, quality of bowel preparation, endoscopist experience, and specialty were included in the analysis.

RESULTS

2533 colonoscopies were included in the study. The mean dose of sedatives was reduced immediately following CSI training and at 8 months for both Fentanyl (75.4 mcg v. 67.8 mcg v. 65.9 mcg, p < 0.001) and Midazolam (2.57 mg v. 2.27 mg v. 2.19 mg, p < 0.001). The percentage of patients deemed to have a comfortable exam improved following endoscopist participation in CSI training and remained improved at 8 months (55.1% v. 70.2% v. 69.8%, p < 0.001). No significant change in rates of intraprocedural hypoxia or hypotension were noted following CSI training.

CONCLUSION

CSI training is associated with improved patient comfort and reduced sedation requirements during colonoscopy.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopic Procedures: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality pediatric gastrointestinal procedures are performed when clinically indicated and defined by their successful performance by skilled providers in a safe, comfortable, child-oriented, and expeditious manner. The process of pediatric endoscopy begins when a plan to perform the procedure is first made and ends when all appropriate patient follow-up has occurred. Procedure-related standards and indicators developed to date for endoscopy in adults emphasize cancer screening and are thus unsuitable for pediatric medicine.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopic procedures. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 14 standards for pediatric endoscopic procedures, as well as 30 indicators that can be used to identify high-quality procedures. These were subcategorized into three subdomains: Preprocedural (3 standards, 7 indicators), Intraprocedural (8 standards, 18 indicators), and Postprocedural (3 standards, 5 indicators). A minimum target for the key indicator, "rate of adequate bowel preparation," was set at ≥80%.

DISCUSSION

It is recommended that all facilities and individual providers performing pediatric endoscopy worldwide initiate and engage with the procedure-related standards and indicators developed by PEnQuIN to identify gaps in quality and drive improvement.

Patient-Reported Experience Measures for Colonoscopy: A Systematic Review and Meta-Ethnography

Patient experience is defined as a major quality indicator that should be routinely measured during and after a colonoscopy, according to current ESGE guidelines. There is no standard approach measuring patient experience after the procedure and the comparative performance of the different colonoscopy-specific patient-reported experience measures (PREMs) is unclear. Therefore, the aim was to develop a conceptual model describing how patients experience a colonoscopy, and to compare the model against colonoscopy-specific PREMs. A systematic search for qualitative research published up to December 2021 in PubMed, Cochrane, CINAHL, and PsycINFO was conducted. After screening and quality assessment, data from 13 studies were synthesised using meta-ethnography. Similarities and differences between the model and colonoscopy-specific PREMs were identified. A model consisting of five concepts describes how patients experience undergoing a colonoscopy: health motivation, discomfort, information, a caring relationship, and understanding. These concepts were compared with existing PREMs and the result shows that there is agreement between the model and existing PREMs for colonoscopy in some parts, while partial agreement or no agreement is present in others. These findings suggest that new PREMs for colonoscopy should be developed, since none of the existing colonoscopy-specific PREMs fully cover patients’ experiences.

Psychological interventions for reducing anxiety in patients undergoing first-time colonoscopy: a pilot and feasibility study

OBJECTIVES

To assess the feasibility of a randomized controlled trial (RCT), evaluating the efficacy and patients' perceptions of a psychological intervention aimed at reducing anxiety levels in adults undergoing first-time colonoscopy.

METHODS

Adults undergoing first-time colonoscopy were randomized to a psychological intervention vs. sham intervention. The primary outcome was feasibility, defined as a recruitment rate of >50%. Patients' state anxiety was assessed before and after the intervention using the state-trait inventory for cognitive and somatic anxiety (STICSA) score. Follow-up interviews were performed within 1 week with a sample of patients and focus groups with clinical staff.

RESULTS

A total of 130 patients were recruited from 180 eligible patients (72%). Eighty were randomized and completed the study (n = 39) in the psychological intervention group and (n = 41) in the sham. In the psychological intervention group, pre- and postmedian STICSA scores were 29 and 24 (P < 0.001), respectively. In the sham group, pre- and postmedian scores were 31 and 25 (P < 0.001), respectively. Follow-up interviews with patients (n = 13) suggested that 100% of patients perceived the psychological intervention as beneficial and would recommend it to others.

CONCLUSION

The study was feasible. Patients in both groups improved their anxiety scores, but there were no significant differences between arms. Despite this, patients receiving psychological intervention perceived a benefit from the relaxation exercises.

The Newcastle ENDOPREM™: a validated patient reported experience measure for gastrointestinal endoscopy

Objectives

Measuring patient experience of gastrointestinal (GI) procedures is a key component of evaluation of quality of care. Current measures of patient experience within GI endoscopy are largely clinician derived and measured; however, these do not fully represent the experiences of patients themselves. It is important to measure the entirety of experience and not just experience directly during the procedure. We aimed to develop a patient-reported experience measure (PREM) for GI procedures.

Design

Phase 1: semi-structured interviews were conducted in patients who had recently undergone GI endoscopy or CT colonography (CTC) (included as a comparator). Thematic analysis identified the aspects of experience important to patients. Phase 2: a question bank was developed from phase 1 findings, and iteratively refined through rounds of cognitive interviews with patients who had undergone GI procedures, resulting in a pilot PREM. Phase 3: patients who had attended for GI endoscopy or CTC were invited to complete the PREM. Psychometric properties were investigated. Phase 4 involved item reduction and refinement.

Results

Phase 1: interviews with 35 patients identified six overarching themes: anxiety, expectations, information & communication, embarrassment & dignity, choice & control and comfort. Phase 2: cognitive interviews refined questionnaire items and response options. Phase 3: the PREM was distributed to 1650 patients with 799 completing (48%). Psychometric properties were found to be robust. Phase 4: final questionnaire refined including 54 questions assessing patient experience across five temporal procedural stages.

Conclusion

This manuscript gives an overview of the development and validation of the Newcastle ENDOPREM™, which assesses all aspects of the GI procedure experience from the patient perspective. It may be used to measure patient experience in clinical care and, in research, to compare patients’ experiences of different endoscopic interventions.

Endocuff Vision improves adenoma detection rate in a large screening-related cohort

Background and study aims  Endocuff Vision (ECV) increases adenoma detection rate (ADR) in randomized clinical trials; however, observational effectiveness data are lacking. We evaluated the effectiveness, safety, and practical aspects of ECV use in a large screening-related real-world cohort. Patients and methods  In this observational study, patients undergoing screening-related colonoscopy from November 2018 to April 2019 comprised the baseline period, and those undergoing it from June to November 2019 comprised the ECV period, where ECV use was discretionary. The primary outcome was ADR, compared: 1) between ECV use and standard colonoscopy across both periods; and 2) between time periods. Secondary outcomes included indication-specific ADR, sessile serrated ADR (SSADR), cecal intubation rate (CIR), procedure times, patient comfort scores, and sedation use. Multilevel logistic regression was performed, yielding adjusted odds ratios (AOR) with 95 % confidence intervals (CIs). Results  In 15,814 colonoscopies across both time periods, ADR was 46.7 % with standard colonoscopy and 54.6 % when ECV was used ( P  < 0.001). Endoscopists used ECV in 77.6 % of procedures in the ECV period, during which overall ADR rose to 53.2 % compared to 46.3 % in the baseline period ( P  < 0.001). ECV use was significantly associated with higher ADR (AOR 1.24, 95 % CI 1.10 to 1.40) after adjusting for relevant covariates including time period. ECV use did not result in lower CIR, longer procedure time, increased sedation use, or poorer comfort scores. Conclusions  ECV use is associated with improved ADR without negatively impacting other key procedure and patient-related factors. Future studies should evaluate the cost-effectiveness of incorporating ECV into routine screening-related practice.

Development and validation of a patient-reported scale for tolerability of endoscopic procedures using conscious sedation

BACKGROUND AND AIMS

Patient-reported experience measures (PREMs) assessing the tolerability of endoscopic procedures are scarce. In this study, we designed and validated a PREM to assess tolerability of endoscopy using conscious sedation.

METHODS

The patient-reported scale for tolerability of endoscopic procedures (PRO-STEP) consists of questions within 2 domains and is administered to outpatients at discharge from the endoscopy unit. Domain 1 (intraprocedural) consists of 2 questions regarding discomfort/pain and awareness, whereas domain 2 (postprocedural) consists of 4 questions on pain, nausea, distention, and either throat or anal pain. All questions are scored on a Likert scale from 0 to 10. Cronbach's alpha was used to measure internal consistency of the questions. Multivariable logistic regression was performed to assess predictors of higher scores, reported using adjusted odds ratios and confidence intervals.

RESULTS

Two hundred fifty-five patients (91 colonoscopy, 73 gastroscopy, and 91 ERCP) were included. Colonoscopy was the least tolerable procedure by recall, with mean intraprocedural awareness and discomfort scores of 5.1 ± 3.8, and 2.6 ± 2.7, respectively. Consistency between intraprocedural awareness and discomfort/pain yielded an acceptable Cronbach's alpha of .71 (95% confidence interval, .62-.78). Higher use of midazolam during colonoscopy was inversely associated with an intraprocedural awareness score of 7 or higher (per additional mg: adjusted odds ratio, .23; 95% confidence interval, .09-.54).

CONCLUSIONS

PRO-STEP is a simple PREM that can be administered after multiple endoscopic procedures using conscious sedation. Future work should focus on its performance characteristics in adverse event prediction.

A randomised study of comfort during bronchoscopy comparing conscious sedation and anaesthetist-controlled general anaesthesia, including the utility of bispectral index monitoring

Background

The difference in patient comfort with conscious sedation versus general anaesthesia for bronchoscopy has not been adequately assessed in a randomised trial. This study aimed to assess if patient comfort during bronchoscopy with conscious sedation is noninferior to general anaesthesia.

Methods

96 subjects were randomised to receive conscious sedation or general anaesthesia for bronchoscopy. The primary outcome was subject comfort. Secondary outcomes included willingness to undergo a repeat procedure if necessary and level of sedation assessed clinically and by bispectral index (BIS) monitoring.

Results

There was no significant difference between subject comfort scores (difference -0.01, 95% CI -0.63-0.61 on a 10-point scale; p=0.97) or willingness to undergo a repeat procedure (97.7% versus 91.8%, 95% CI -4.8-15.5%; p=0.37). Deeper levels of sedation in the general anaesthesia cohort was confirmed with both clinical and BIS monitoring. There was no significant difference in diagnostic accuracy (conscious sedation 93.9%, 95% CI 80.4-98.3% versus general anaesthesia 86.5%, 95% CI 72.0-94.1%; p=0.43). There were more complications (29.6%, 95% CI 18.2-44.2% versus 6.1%, 95% CI 2.1-16.5%; p<0.01) in the general anaesthesia group. There was no relationship between high BIS scores and subject discomfort. BIS levels <40 during a procedure were associated with increased complications.

Conclusion

Conscious sedation is not inferior to general anaesthesia in providing patient comfort during bronchoscopy, despite lighter sedation, and is associated with fewer complications and comparable diagnostic accuracy. BIS monitoring may have a role in preventing complications associated with deeper sedation.

Quality Control in the Slovenian National Colorectal Cancer Screening Program

OBJECTIVES

The objective of the study was to assess the impact of an internal quality indicator (QI) audit on the quality level of colonoscopies in the National Colorectal Cancer Screening Program (NCCSP).

DESIGN

Sixty-eight colonoscopists from 29 endoscopic centres participated in the NCCSP from April 2009 to January 2015. Controlled QIs were the percentage of total colonoscopies, adenoma detection rate (ADR), mean adenoma per procedure (MAP), mean adenoma per positive procedure (MAP+), right-sided ADR, sessile serrated lesion (SSL) detection rate, and patient responses to post-procedural questionnaires. A group of 3 expert endoscopists from the NCCSP Council performed 91 inspections and provided education.

RESULTS

A total of 891.364 (58.2%) Slovenian citizens participated in the first 3 screening rounds of the NCCSP. Among 46.552 (6%) positive individuals, 42.866 (92.1%) underwent first colonoscopies. Total colonoscopies were performed in 98% of endoscopies (p = 0.459 between cycles), mean ADR was 51.8% (p = 0.872 between cycles), mean percentage of adenoma in the right colon was 37.5% (p = 0.227 between cycles), mean MAP was 1.1 (p = 0.981 between cycles), mean MAP+ was 2.0 (p = 0.824 between cycles), and mean SSL detection rate was 3% (p < 0.001). We observed great difference in QIs between endoscopists and a significant increase in MAP, ADR in the right colon, and SSL per endoscopist during the 6-year period. Due to quality underperformance, 3 endoscopic centres (10.3%) and 13 endoscopists (19.1%) were excluded from the program.

CONCLUSIONS

The success of the NCCSP is related to the quality of colonoscopies performed. To ensure the proper quality level, regular audit and permanent education are needed.

BowelScope: Accuracy of Detection Using Endocuff Optimisation of Mucosal Abnormalities (the B-ADENOMA Study): a multicentre, randomised controlled flexible sigmoidoscopy trial

OBJECTIVES

Adenoma detection rate (ADR) is an important quality marker at lower GI endoscopy. Higher ADRs are associated with lower postcolonoscopy colorectal cancer rates. The English flexible sigmoidoscopy (FS) screening programme (BowelScope), offers a one-off FS to individuals aged 55 years. However, variation in ADR exists. Large studies have demonstrated improved ADR using Endocuff Vision (EV) within colonoscopy screening, but there are no studies within FS. We sought to test the effect of EV on ADR in a national FS screening population.

DESIGN

BowelScope: Accuracy of Detection Using ENdocuff Optimisation of Mucosal Abnormalities was a multicentre, randomised controlled trial involving 16 English BowelScope screening centres. Individuals were randomised to Endocuff Vision-assisted BowelScope (EAB) or Standard BowelScope (SB). ADR, polyp detection rate (PDR), mean adenomas per procedure (MAP), polyp characteristics and location, participant experience, procedural time and adverse events were measured. Comparison of ADR within the trial with national BowelScope ADR was also undertaken.

RESULTS

3222 participants were randomised (53% male) to receive EAB (n=1610) or SB (n=1612). Baseline demographics were comparable between arms. ADR in the EAB arm was 13.3% and that in the SB arm was 12.2% (p=0.353). No statistically significant differences were found in PDR, MAP, polyp characteristics or location, participant experience, complications or procedural characteristics. ADR in the SB control arm was 3.1% higher than the national ADR.

CONCLUSION

EV did not improve BowelScope ADR when compared with SB. ADR in both arms was higher than the national ADR. Where detection rates are already high, EV is unable to improve detection further.

TRIAL REGISTRATION NUMBERS

NCT03072472, ISRCTN30005319 and CPMS ID 33224.

Virtual reality distraction for patients to relieve pain and discomfort during colonoscopy

Background and study aims  Colonoscopy is an invasive procedure that may cause patients pain and discomfort. Routine use of sedation, while effective, is expensive and requires logistical planning. Virtual reality (VR) offers immersive, three-dimensional experiences that distract the attention and might comfort patients. We performed a pilot study to investigate the feasibility of VR distraction during colonoscopy. Patients and methods  Adults referred for colonoscopy were considered for inclusion and divided over two groups: with and without VR glasses. The main outcome was patient acceptance of wearing VR glasses during colonoscopy without compromising the technical success of the procedure. Secondary outcomes were patient comfort, pain, and anxiety before, during and after the procedure, using validated patient questionnaires. Patient comments were collected through a qualitative interview. Results  We included 19 patients, 10 of whom were offered VR glasses. All patients accepted VR glasses without prolonging procedural time. No disadvantages of the VR glasses were reported in terms of communication or change of position of the patient. We found that patient comfort, pain, anxiety, and satisfaction in relation to the procedure were similar in both groups. Patients described a pleasant distracting effect using VR glasses. Conclusion  VR glasses during colonoscopy are accepted by patients and do not compromise endoscopic technical success. Patients reported that the VR experience was pleasant and distracting.

Understanding the patient experience of pain and discomfort during cardiac catheterization

OBJECTIVES

Patient centeredness is an essential component of high-quality care, yet little is known regarding the patient experience during procedures performed in the cardiac catheterization lab.

BACKGROUND

Available literature focuses on the safe delivery of sedation, but does not address patient-reported satisfaction or comfort. Further delineation of how procedural factors impact the patient experience is needed.

METHODS

We conducted a retrospective, exploratory analysis of adult cardiac catheterization outpatients (n = 375) receiving physician ordered, nurse administered procedural sedation (benzodiazepine and/or opioids) between April and June, 2017. Data were abstracted from the procedural database, Electronic Health Record, and Press Ganey^© surveys.

RESULTS

The mean age was 63 (SD 12.2), a majority were male (n = 226; 60%), white (n = 271; 73%), and overweight (mean body mass index = 29, SD 6.8). Patient-reported satisfaction with pain control and perceived staff concern for comfort were >75th percentile (Press Ganey^© survey), with no difference in preprocedure and postprocedure pain scores (p = .596). Intraprocedural medication dose range and mean frequency were highly variable: midazolam (0.25-5.5 mg; 1.48); fentanyl (12.5-200 mcg; 1.63); and hydromorphone (0.5-2.5 mg; 1.33). Median time interval between administration of initial sedation and local anesthetic was 6 min. Patients with longer intervals had less frequent dosing (p < .001) and less total procedural sedation (p < .001). Sensitivity analysis revealed that trainee/fellow involvement (p = .001), younger age (p = .002), and shorter time intervals (p < .001) were associated with increased frequency and larger total dose.

CONCLUSIONS

Waiting to gain vascular access following administration of procedural was associated with less frequent subsequent dosing, lower overall administration, and similar patient satisfaction. Optimizing processes for administering periprocedural sedation may allow for less medication without impacting patient experience.

Patient experience of gastrointestinal endoscopy: informing the development of the Newcastle ENDOPREM™

BACKGROUND

Measuring patient experience is important for evaluating the quality of patient care, identifying aspects requiring improvement and optimising patient outcomes. Patient Reported Experience Measures (PREMs) should, ideally, be patient derived, however no such PREMs for gastrointestinal (GI) endoscopy exist. This study explored the experiences of patients undergoing GI endoscopy and CT colonography (CTC) in order to: identify aspects of care important to them; determine whether the same themes are relevant across investigative modalities; develop the framework for a GI endoscopy PREM.

METHODS

Patients aged ≥18 years who had undergone oesophagogastroduodenoscopy (OGD), colonoscopy or CTC for symptoms or surveillance (but not within the national bowel cancer screening programme) in one hospital were invited to participate in semi-structured interviews. Recruitment continued until data saturation. Inductive thematic analysis was undertaken.

RESULTS

35 patients were interviewed (15 OGD, 10 colonoscopy, 10 CTC). Most patients described their experience chronologically, and five 'procedural stages' were evident: before attending for the test; preparing for the test; at the hospital, before the test; during the test; after the test. Six themes were identified: anxiety; expectations; choice & control; communication & information; comfort; embarrassment & dignity. These were present for all three procedures but not all procedure stages. Some themes were inter-related (eg, expectations & anxiety; communication & anxiety).

CONCLUSION

We identified six key themes encapsulating patient experience of GI procedures and these themes were evident for all procedures and across multiple procedure stages. These findings will be used to inform the development of the Newcastle ENDOPREM™.

Oral Lorazepam is not Superior to Placebo for Lowering Stress in Children Before Digestive Endoscopy: A Double-Blind, Randomized, Controlled Trial

BACKGROUND

Digestive endoscopies must be performed within a safe and comfortable environment. We have previously shown that the quality of intravenous sedation is influenced by preoperative stress.

AIM

Our primary objective was to compare the effects of oral lorazepam and placebo on the salivary cortisol response of children undergoing a digestive endoscopy. Secondary objectives were the assessment of procedural pain and comfort as well as the occurrence of adverse events.

METHODS

Participants were randomized and received either lorazepam, placebo, or no premedication. Saliva was collected upon arrival at the hospital and 1 h following randomization. The sedation protocol included midazolam and fentanyl ± ketamine. Procedural pain was evaluated with the Nurse Assessed Patient Comfort Score (NAPCOMS). Patients completed a postoperative questionnaire. The primary outcome was defined as the proportion of children having a cortisol decrease ≥ 15 nmol/L.

RESULTS

101 participants (54 females) were included. The rate of children having a cortisol decrease ≥ 15 nmol/L was 27.3%, 35.3%, and 19.4% for lorazepam, placebo, and no premedication, respectively (p = 0.356). The median (IQR) NAPCOMS pain score was 3.0 (0-6) for lorazepam, 4.4 (0-6) for placebo, and 3.4 (3-4) for no premedication (p = 0.428). With lorazepam, 75.9% of children reported experiencing a comfortable procedure, compared with 41.9% taking placebo and 34.5% with no premedication (p = 0.013). Transient tachycardia was the most frequent intraoperative adverse event, particularly with lorazepam (62.5%, p = 0.029).

CONCLUSIONS

Oral lorazepam had no effect on patients' preoperative stress, as measured by salivary cortisol, but was associated with a higher rate of comfortable procedures.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, Identifier NCT03180632.

The performance indicator of colonic intubation (PICI) in a FIT-based colorectal cancer screening program

Objective: Cecal intubation rate (CIR) is known to be inversely associated with interval colorectal cancer (CRC) risk. Cecal intubation may be achieved by the use of force and sedation jeopardizing patient safety. The Performance Indicator of Colonic Intubation (PICI) is defined as the proportion of colonoscopies achieving cecal intubation with use of ≤2 mg midazolam and no-mild patient-experienced discomfort. We aimed (i) to measure the variation of PICI between colonoscopists and colonoscopy units; (ii) to assess the correlation between the individual components of PICI; and (iii) to evaluate the association between PICI and commonly used performance indicators. Materials and methods: For the period 1 July 2015 through 30 June 2017 of the prevalent round of the Danish FIT-based CRC screening program, we included colonoscopies performed at four units in the Central Denmark Region within 60 days after a positive FIT-test. The PICI variation was evaluated using rates and ranges. Correlations between individual PICI components were assessed using Pearson correlation coefficients. Polyp detection rate (PDR), Adenoma detection rate (ADR), Polyp retrieval rate (PRR) and Withdrawal time (WT) were assessed within PICI quartiles. Results: The overall PICI was 78.7% with substantial variation between colonoscopists (40.0-91.9%) and units (72.6-82.0%). CIR was significantly correlated with patient-experienced comfort (r = 0.49, n = 73, p < .0001) and we observed that colonoscopists with a PICI between 79.9% and 84.3%) had the highest ADR. Conclusion: We found a substantial variation in PICI between colonoscopists and between colonoscopy units, which may reflect potential for quality improvements.

Impact of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) on endoscopy services in the UK and beyond

The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) was initially established in 1994 to standardise endoscopy training across specialties. Over the last two decades, the position of JAG has evolved to meet its current role of quality assuring all aspects of endoscopy in the UK to provide the highest quality, patient-centred care. Drivers such as changes to healthcare agenda, national audits, advances in research and technology and the advent of population-based cancer screening have underpinned this shift in priority. Over this period, JAG has spearheaded various quality assurance initiatives with support from national stakeholders. These have led to the achievement of notable milestones in endoscopy quality assurance, particularly in the three major areas of: (1) endoscopy training, (2) accreditation of endoscopy services (including the Global Rating Scale), and (3) accreditation of screening endoscopists. These developments have changed the landscape of UK practice, serving as a model to promote excellence in endoscopy. This review provides a summary of JAG initiatives and assesses the impact of JAG on training and endoscopy services within the UK and beyond.

Assessment of the Quality of Outpatient Endoscopic Procedures by Using a Patient Satisfaction Questionnaire

INTRODUCTION

Endoscopic procedures represent an important part of daily practice, both for gastroenterologists and nurses, enabling diagnosis and treatment of digestive diseases. An optimal level of quality needs to be obtained for endoscopic procedures to be efficient, which is reflected directly by patient satisfaction. The Gastrointestinal Endoscopy Satisfaction Questionnaire (GESQ) has already been validated in a multicenter trial as an efficient method for measuring patient satisfaction. Aim The aim of our study was to evaluate the quality of endoscopic procedures and patient satisfaction by applying a modified version of the GESQ in an outpatient facility, with or without deep sedation performed under the supervision of an anesthesiologist.

MATERIAL AND METHODS

Our study included 552 patients undergoing diagnostic and therapeutic upper and lower GI endoscopies, including endoscopic ultrasound procedures (EUS) performed under propofol sedation, from September 2015 to February 2016. Consecutive patients examined during these 6 months received the questionnaire which was handed by the endoscopy nurse two hours after procedure. The GESQ was modified to include different sections for: 1) communication skills with questions regarding the quantity and clarity of the information delivered to the patient before and after the procedures; 2) pain and discomfort related to the examination with an added question about the specific procedure the patient had undergone; 3) staff manners; 4) physician's technical skills; 5) facility organization (waiting time, comfort in the recovery room, good facilities and equipment) and 6) overall satisfaction. The questionnaire did not include personal data, while answers were analyzed in a confidential manner.

RESULTS

A total number of 552 patients agreed to answer our questionnaire, 192 (34,7%) underwent gastroscopies, 288 (52,1%) colonoscopies and 72 (13,2%) EUS examinations. Regarding the overall level of satisfaction (assessed on a five-point scale), 476 (86,2%) were very satisfied or satisfied, 69 (12,5%) dissatisfied and the remainder 7 (1,3%) were indifferently. For the communication section 16 (3%) patients were not satisfied with the explanations received before the procedure or with the answers to their questions. Pain and discomfort were mentioned by 29 (5,2%) of the patients, usually related to colonoscopies or EUS examinations. 13 (2,3%) of the patients considered the comfort or intimacy of the recovery room to be poor, and 11 (2%) patients were not satisfied with the waiting time before the procedure.

CONCLUSION

Our modified questionnaire showed good overall patient satisfaction with our endoscopy unit, while also suggesting some areas in need of improvement, such as staff communication skills, better time management and reorganization of the recovery area. Our study demonstrates the importance of such questionnaires in providing feedback information meant to improve standards in endoscopy, including staff skills and organization.

Simulation in endoscopy: Practical educational strategies to improve learning

In gastrointestinal endoscopy, simulation-based training can help endoscopists acquire new skills and accelerate the learning curve. Simulation creates an ideal environment for trainees, where they can practice specific skills, perform cases at their own pace, and make mistakes with no risk to patients. Educators also benefit from the use of simulators, as they can structure training according to learner needs and focus solely on the trainee. Not all simulation-based training, however, is effective. To maximize benefits from this instructional modality, educators must be conscious of learners' needs, the potential benefits of training, and associated costs. Simulation should be integrated into training in a manner that is grounded in educational theory and empirical data. In this review, we focus on four best practices in simulation-based education: deliberate practice with mastery learning, feedback and debriefing, contextual learning, and innovative educational strategies. For each topic, we provide definitions, supporting evidence, and practical tips for implementation.

Protocol for a randomised trial evaluating the effect of applying gamification to simulation-based endoscopy training

BACKGROUND

Simulation-based training (SBT) provides a safe environment and effective means to enhance skills development. Simulation-based curricula have been developed for a number of procedures, including gastrointestinal endoscopy. Gamification, which is the application of game-design principles to non-game contexts, is an instructional strategy with potential to enhance learning. No studies have investigated the effects of a comprehensive gamification curriculum on the acquisition of endoscopic skills among novice endoscopists.

METHODS AND ANALYSIS

Thirty-six novice endoscopists will be randomised to one of two endoscopy SBT curricula: (1) the Conventional Curriculum Group, in which participants will receive 6 hours of one-on-one simulation training augmented with expert feedback and interlaced with 4 hours of small group teaching on the theory of colonoscopy or (2) the Gamified Curriculum Group, in which participants will receive the same curriculum with integration of the following game-design elements: a leaderboard summarising participants' performance, game narrative, achievement badges and rewards for top performance. In line with a progressive learning approach, simulation training for participants will progress from low to high complexity simulators, starting with a bench-top model and then moving to the EndoVR virtual reality simulator. Performance will be assessed at three points: pretraining, immediately post-training and 4-6 weeks after training. Assessments will take place on the simulator at all three time points and transfer of skills will be assessed during two clinical colonoscopies 4-6 weeks post-training. Mixed factorial ANOVAs will be used to determine if there is a performance difference between the two groups during simulated and clinical assessments.

ETHICS AND DISSEMINATION

Ethical approval was obtained at St. Michael's Hospital. Results of this trial will be submitted for presentation at academic meetings and for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03176251.

Improved adenoma detection with Endocuff Vision: the ADENOMA randomised controlled trial

OBJECTIVE

Low adenoma detection rates (ADR) are linked to increased postcolonoscopy colorectal cancer rates and reduced cancer survival. Devices to enhance mucosal visualisation such as Endocuff Vision (EV) may improve ADR. This multicentre randomised controlled trial compared ADR between EV-assisted colonoscopy (EAC) and standard colonoscopy (SC).

DESIGN

Patients referred because of symptoms, surveillance or following a positive faecal occult blood test (FOBt) as part of the Bowel Cancer Screening Programme were recruited from seven hospitals. ADR, mean adenomas per procedure, size and location of adenomas, sessile serrated polyps, EV removal rate, caecal intubation rate, procedural time, patient experience, effect of EV on workload and adverse events were measured.

RESULTS

1772 patients (57% male, mean age 62 years) were recruited over 16 months with 45% recruited through screening. EAC increased ADR globally from 36.2% to 40.9% (P=0.02). The increase was driven by a 10.8% increase in FOBt-positive screening patients (50.9% SC vs 61.7% EAC, P<0.001). EV patients had higher detection of mean adenomas per procedure, sessile serrated polyps, left-sided, diminutive, small adenomas and cancers (cancer 4.1% vs 2.3%, P=0.02). EV removal rate was 4.1%. Median intubation was a minute quicker with EAC (P=0.001), with no difference in caecal intubation rate or withdrawal time. EAC was well tolerated but caused a minor increase in discomfort on anal intubation in patients undergoing colonoscopy with no or minimal sedation. There were no significant EV adverse events.

CONCLUSION

EV significantly improved ADR in bowel cancer screening patients and should be used to improve colonoscopic detection.

TRIAL REGISTRATION NUMBER

NCT02552017, Results; ISRCTN11821044, Results.

The Colonoscopy Satisfaction and Safety Questionnaire (CSSQP) for Colorectal Cancer Screening: A Development and Validation Study

Colonoscopy services working in colorectal cancer screening programs must perform periodic controls to improve the quality based on patients' experiences. However, there are no validated instruments in this setting that include the two core dimensions for optimal care: satisfaction and safety. The aim of this study was to design and validate a specific questionnaire for patients undergoing screening colonoscopy after a positive fecal occult blood test, the Colonoscopy Satisfaction and Safety Questionnaire based on patients' experience (CSSQP). The design included a review of available evidence and used focus groups to identify the relevant dimensions to produce the instrument (content validity). Face validity was analyzed involving 15 patients. Reliability and construct and empirical validity were calculated. Validation involved patients from the colorectal cancer screening program at two referral hospitals in Spain. The CSSQP version 1 consisted of 15 items. The principal components analysis of the satisfaction items isolated three factors with saturation of elements above 0.52 and with high internal consistency and split-half readability: Information, Care, and Service and Facilities features. The analysis of the safety items isolated two factors with element saturations above 0.58: Information Gaps and Safety Incidents. The CSSQP is a new valid and reliable tool for measuring patient' experiences, including satisfaction and safety perception, after a colorectal cancer screening colonoscopy.

Gastroscopy Should Come Before Colonoscopy Using CO2 Insufflation in Same Day Bidirectional Endoscopies: A Randomized Controlled Trial

Background and Aims

Same day bidirectional endoscopies (esophagogastroduodenoscopies [EGD]s and colonoscopies) are routinely performed. However, the best sequence of procedures is unknown, as is whether the use of carbon dioxide (CO₂) affects the preferred sequence of procedures. This study aims to determine the preferred sequence of procedures and choice of insufflation gas (air or CO₂) in patients undergoing same day bidirectional endoscopies.

Methods

Two hundred adults with a clinical indication for same day bidirectional endoscopies were randomized equally into four groups: A1 (EGD first, CO₂ as insufflator); A2 (EGD first, air as insufflator); B1 (colonoscopy first, CO₂ as insufflator); and B2 (colonoscopy first, air as insufflator). All procedures were performed with conscious sedation (Midazolam/Fentanyl). The primary outcome was patients’ overall comfort/satisfaction with the procedures and sedation received, as assessed by questionnaires and validated scoring scales (Nurse-Assessed Patient Comfort Score [NAPCOMS], La Crosse [WI]) collected during the procedures, before discharge, and on day 7 postprocedure.

Results

Two hundred patients were randomized, with data available for 186. Mean Midazolam dose between groups was significantly less in the EGD first groups (P=0.01). During the procedures, no differences were found in patients’ comfort as per the nurse reported NAPCOMS scores (P=0.19) or the Lacrosse (WI) endoscopy scores (P=0.05). On postprocedure days 0 and 7, no differences were found in the patients’ reported Lacrosse (WI) scores, nausea, sore throat, dizziness, satisfaction with sedation or overall level of procedural satisfaction (P>0.05 for each). However, bloating and discomfort were significantly lower in the CO₂ arms (P<0.001).

Conclusions

This randomized controlled trial using validated patient comfort scoring assessments for same day bidirectional endoscopies demonstrated that the sequence of procedures affects the sedation used but does not affect overall patient comfort or satisfaction. Lesser sedation is needed in the EGD first group, and less postprocedural abdominal pain/discomfort and bloating is seen with CO₂ insufflation.

Quality assurance of colonoscopy within the Dutch national colorectal cancer screening program

Colorectal cancer (CRC) screening is capable of reducing CRC-related morbidity and mortality. Colonoscopy is the reference standard to detect CRC, also providing the opportunity to detect and resect its precursor lesions: colorectal polyps. Therefore, colonoscopy is either used as a primary screening tool or as a subsequent procedure after a positive triage test in screening programs based on non-invasive stool testing or sigmoidoscopy. However, in both settings, colonoscopy is not fully protective for the occurrence of post-colonoscopy CRCs (PCCRCs). Because most PCCRCs are the result of colonoscopy-related factors, a high-quality procedure is of paramount importance to assure optimal effectiveness of CRC screening programs. For this reason, at the start of the Dutch fecal immunochemical test (FIT)-based screening program, quality criteria for endoscopists performing colonoscopies in FIT-positive screenees, as well as for endoscopy centers, were defined. In conjunction, an accreditation and auditing system was designed and implemented. In this report, we describe the quality assurance process for endoscopists participating in the Dutch national CRC screening program, including a detailed description of the evidence-based quality criteria. We believe that our experience might serve as an example for colonoscopy quality assurance programs in other CRC screening programs.

Validation of the St. Paul's Endoscopy Comfort Scale (SPECS) for Colonoscopy

Aims

Patient comfort during colonoscopy is an important measure of quality, which can improve patient satisfaction and compliance with future procedures. Our aim was to develop and validate a pain assessment tool based on objective behavioural cues tailored to outpatients undergoing colonoscopy: St. Paul’s endoscopy comfort score (SPECS).

Methods

A single-centre, prospective study was conducted in consecutive adults undergoing planned outpatient colonoscopy. Patient comfort was independently assessed by the physician, nurse and a research assistant (observer) using the SPECS and the Gloucester scale (GS). In addition, the nurse-assessed patient comfort score (NAPCOMS), nonverbal pain Assessment tool (NPAT) and Richmond agitation sedation scale (RASS) were completed by the observer. Data on subject demographics, sedation dose and duration of the procedure were collected. Following the procedure, patients completed a patient satisfaction questionnaire, including a visual analogue scale (VAS) to measure their overall perceived pain during the procedure.

Results

The study enrolled 350 subjects. The SPECS showed excellent inter-rater reliability among all three raters with an intra-class coefficient (ICC) of 0.81 (95% CI, 0.78–0.84), while the GS showed good reliability with an ICC of 0.77 (95% CI, 0.73–0.80). The SPECS demonstrated moderate agreement with the patient-reported VAS ratings.

Conclusions

The St. Paul’s endoscopy comfort score was successfully validated, demonstrating excellent inter-rater reliability.

Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy

BACKGROUND

Endoscopy has traditionally been taught with novices practicing on real patients under the supervision of experienced endoscopists. Recently, the growing awareness of the need for patient safety has brought simulation training to the forefront. Simulation training can provide trainees with the chance to practice their skills in a learner-centred, risk-free environment. It is important to ensure that skills gained through simulation positively transfer to the clinical environment. This updated review was performed to evaluate the effectiveness of virtual reality (VR) simulation training in gastrointestinal endoscopy.

OBJECTIVES

To determine whether virtual reality simulation training can supplement and/or replace early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy, and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience.

SEARCH METHODS

We searched the following health professions, educational, and computer databases until 12 July 2017: the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, BIOSIS Previews, CINAHL, AMED, ERIC, Education Full Text, CBCA Education, ACM Digital Library, IEEE Xplore, Abstracts in New Technology and Engineering, Computer and Information Systems Abstracts, and ProQuest Dissertations and Theses Global. We also searched the grey literature until November 2017.

SELECTION CRITERIA

We included randomised and quasi-randomised clinical trials comparing VR endoscopy simulation training versus any other method of endoscopy training with outcomes measured on humans in the clinical setting, including conventional patient-based training, training using another form of endoscopy simulation, or no training. We also included trials comparing two different methods of VR training.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility and methodological quality of trials, and extracted data on the trial characteristics and outcomes. We pooled data for meta-analysis where participant groups were similar, studies assessed the same intervention and comparator, and had similar definitions of outcome measures. We calculated risk ratio for dichotomous outcomes with 95% confidence intervals (CI). We calculated mean difference (MD) and standardised mean difference (SMD) with 95% CI for continuous outcomes when studies reported the same or different outcome measures, respectively. We used GRADE to rate the quality of the evidence.

MAIN RESULTS

We included 18 trials (421 participants; 3817 endoscopic procedures). We judged three trials as at low risk of bias. Ten trials compared VR training with no training, five trials with conventional endoscopy training, one trial with another form of endoscopy simulation training, and two trials compared two different methods of VR training. Due to substantial clinical and methodological heterogeneity across our four comparisons, we did not perform a meta-analysis for several outcomes. We rated the quality of evidence as moderate, low, or very low due to risk of bias, imprecision, and heterogeneity.Virtual reality endoscopy simulation training versus no training: There was insufficient evidence to determine the effect on composite score of competency (MD 3.10, 95% CI -0.16 to 6.36; 1 trial, 24 procedures; low-quality evidence). Composite score of competency was based on 5-point Likert scales assessing seven domains: atraumatic technique, colonoscope advancement, use of instrument controls, flow of procedure, use of assistants, knowledge of specific procedure, and overall performance. Scoring range was from 7 to 35, a higher score representing a higher level of competence. Virtual reality training compared to no training likely provides participants with some benefit, as measured by independent procedure completion (RR 1.62, 95% CI 1.15 to 2.26; 6 trials, 815 procedures; moderate-quality evidence). We evaluated overall rating of performance (MD 0.45, 95% CI 0.15 to 0.75; 1 trial, 18 procedures), visualisation of mucosa (MD 0.60, 95% CI 0.20 to 1.00; 1 trial, 55 procedures), performance time (MD -0.20 minutes, 95% CI -0.71 to 0.30; 2 trials, 29 procedures), and patient discomfort (SMD -0.16, 95% CI -0.68 to 0.35; 2 trials, 145 procedures), all with very low-quality evidence. No trials reported procedure-related complications or critical flaws (e.g. bleeding, luminal perforation) (3 trials, 550 procedures; moderate-quality evidence).Virtual reality endoscopy simulation training versus conventional patient-based training: One trial reported composite score of competency but did not provide sufficient data for quantitative analysis. Virtual reality training compared to conventional patient-based training resulted in fewer independent procedure completions (RR 0.45, 95% CI 0.27 to 0.74; 2 trials, 174 procedures; low-quality evidence). We evaluated performance time (SMD 0.12, 95% CI -0.55 to 0.80; 2 trials, 34 procedures), overall rating of performance (MD -0.90, 95% CI -4.40 to 2.60; 1 trial, 16 procedures), and visualisation of mucosa (MD 0.0, 95% CI -6.02 to 6.02; 1 trial, 18 procedures), all with very low-quality evidence. Virtual reality training in combination with conventional training appears to be advantageous over VR training alone. No trials reported any procedure-related complications or critical flaws (3 trials, 72 procedures; very low-quality evidence).Virtual reality endoscopy simulation training versus another form of endoscopy simulation: Based on one study, there were no differences between groups with respect to composite score of competency, performance time, and visualisation of mucosa. Virtual reality training in combination with another form of endoscopy simulation training did not appear to confer any benefit compared to VR training alone.Two methods of virtual reality training: Based on one study, a structured VR simulation-based training curriculum compared to self regulated learning on a VR simulator appears to provide benefit with respect to a composite score evaluating competency. Based on another study, a progressive-learning curriculum that sequentially increases task difficulty provides benefit with respect to a composite score of competency over the structured VR training curriculum.

AUTHORS' CONCLUSIONS

VR simulation-based training can be used to supplement early conventional endoscopy training for health professions trainees with limited or no prior endoscopic experience. However, we found insufficient evidence to advise for or against the use of VR simulation-based training as a replacement for early conventional endoscopy training. The quality of the current evidence was low due to inadequate randomisation, allocation concealment, and/or blinding of outcome assessment in several trials. Further trials are needed that are at low risk of bias, utilise outcome measures with strong evidence of validity and reliability, and examine the optimal nature and duration of training.

Patient comfort scores do not affect endoscopist behavior during colonoscopy, while trainee involvement has negative effects on patient comfort

INTRODUCTION

Patient comfort is an important part of endoscopy and reflects procedure quality and endoscopist technique. Using the validated, Nurse Assisted Patient Comfort Score (NAPCOMS), this study aimed to determine whether the introduction of NAPCOMS would affect sedation use by endoscopists.

PATIENTS AND METHODS

The study was conducted over 3 phases. Phase One and Two consisted of 8 weeks of endoscopist blinded and aware data collection, respectively. Data in Phase Three was collected over a 5-month period and scores fed back to individual endoscopists on a monthly basis.

RESULTS

NAPCOMS consists of 3 domains - pain, sedation, and global tolerability. Comparison of Phase One and Two, showed no significant differences in sedative use or NAPCOMS. Phase Three data showed a decline in fentanyl use between individual months ( P  = 0.035), but no change in overall NAPCOMS. Procedures involving trainees were found to use more midazolam ( P  = 0.01) and fentanyl ( P  = 0.01), have worse NAPCOMS scores, and resulted in longer procedure duration ( P  < 0.001). Data comparing gastroenterologists and general surgeons showed increased fentanyl use ( P  = 0.037), decreased midazolam use ( P  = 0.001), and more position changes ( P  = 0.002) among gastroenterologists.

CONCLUSIONS

The introduction of a patient comfort scoring system resulted in a decrease in fentanyl use, although with minimal clinical significance. Additional studies are required to determine the role of patient comfort scores in quality control in endoscopy. Procedures completed with trainees used more sedation, were longer, and had worse NAPCOMS scores, the implications of which, for teaching hospitals and training programs, will need to be further considered.

Simulation-Based Training of Non-Technical Skills in Colonoscopy: Protocol for a Randomized Controlled Trial

Background

Non-technical skills (NTS), such as communication and professionalism, contribute to the safe and effective completion of procedures. NTS training has previously been shown to improve surgical performance. Moreover, increases in NTS have been associated with improved clinical endoscopic performance. Despite this evidence, NTS training has not been tested as an intervention in endoscopy.

Objective

The aim of this study is to evaluate the effectiveness of a simulation-based training (SBT) curriculum of NTS on novice endoscopists’ performance of clinical colonoscopy.

Methods

Novice endoscopists were randomized to 2 groups. The control group received 4 hours of interactive didactic sessions on colonoscopy theory and 6 hours of SBT. Hours 5 and 6 of the SBT were integrated scenarios, wherein participants interacted with a standardized patient and nurse, while performing a colonoscopy on the virtual reality (VR) simulator. The NTS (intervention) group received the same teaching sessions but the last hour was focused on NTS teaching. The NTS group also reviewed a checklist of tasks relevant to NTS concepts prior to each integrated scenario case and was provided with dedicated feedback on their NTS performance during the integrated scenario practice. All participants were assessed at baseline, immediately after training, and 4 to 6 weeks post-training. The primary outcome measure is colonoscopy-specific performance in the clinical setting.

Results

In total, 42 novice endoscopists completed the study. Data collection and analysis is ongoing. We anticipate completion of all assessments by August 2017. Data analysis, manuscript writing, and subsequent submission for publication is expected to be completed by December 2017.

Conclusions

Results from this study may inform the implementation of NTS training into postgraduate gastrointestinal curricula. NTS curricula may improve attitudes towards patient safety and self-reflection among trainees. Moreover, enhanced NTS may lead to superior clinical performance and outcomes in colonoscopy.

Trial Registration

Clinicaltrial.gov NCT02877420; https://www.clinicaltrials.gov/ct2/show/NCT02877420 (Archived by WebCite at http://www.webcitation.org/6rw94ubXX NCT02877420)

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the US Food and Drug Administration, convened a meeting of sedation experts from a variety of clinical specialties and research backgrounds with the objective of developing recommendations for procedural sedation research. Four core outcome domains were recommended for consideration in sedation clinical trials: (1) safety, (2) efficacy, (3) patient-centered and/or family-centered outcomes, and (4) efficiency. This meeting identified core outcome measures within the efficacy and patient-centered and/or family-centered domains. Safety will be addressed in a subsequent meeting, and efficiency will not be addressed at this time. These measures encompass depth and levels of sedation, proceduralist and patient satisfaction, patient recall, and degree of pain experienced. Consistent use of the recommended outcome measures will facilitate the comprehensive reporting across sedation trials, along with meaningful comparisons among studies and interventions in systematic reviews and meta-analyses.

Use of warm carbon dioxide insufflators does not affect intra-colonic gas temperature and has no effect on polyp detection rate during colonoscopy - a randomized controlled trial

BACKGROUND AND STUDY AIMS

Methods to improve polyp detection during colonoscopy have been investigated, with conflicting results for warm water irrigation. Carbon Dioxide (CO ₂₎ warmed to 37 °C may have similar or more pronounced effects on bowel motility. This study aimed to assess whether warmed CO ₂ would improve polyp detection compared to room temperature air insufflation.

PATIENTS AND METHODS

 This was a double-blind, randomized controlled trial that enrolled 204 patients undergoing screening or surveillance outpatient colonoscopy. The primary outcome was polyp per patient detection rate. Secondary outcomes included adenoma per patient detection rates, bowel spasm, and patient comfort.

RESULTS

 The trial was terminated after an interim analysis determined futility. Between the warmed CO ₂ and room air groups, no significant differences were found in the per-colonoscopy polyp detection rate ( P  = 0.57); overall polyp detection rate ( P  = 0.69); or adenoma detection rates ( P  = 0.74). More patients in the room temperature group had lower spasm scores (p = 0.02); however, there was a trend towards greater patient comfort in the warmed CO ₂ group ( P  = 0.054). An ex-vivo study showed a significant difference between exiting CO ₂ temperature at the insufflator end vs. delivered CO ₂ temperature at the colonoscope tip end. The temperature of insufflation at the tip of the colonoscope was not different when using warmed vs. unwarmed insufflation ( P  = 0.62).

CONCLUSION

 When compared with room air insufflation, warmed CO ₂ insufflation did not affect polyp detection rates.

Effect of operating room care combined with home care for the postoperative rehabilitation and prognosis of gastric cancer patients with low PTEN gene expression

The aim of the present study was to analyze the effect of operating room (OR) care combined with home care on postoperative rehabilitation and prognosis of gastric cancer patients with low PTEN gene expression. Ninety-six gastric cancer patients with low PTEN gene expression, who underwent surgical treatment in our hospital were recruited. PTEN expression was measured by semi-quantitative polymerase chain reaction. Participants were randomized into the observation and control groups, with 48 cases each. Participants in the two groups received the same preoperative examination, gastric cancer surgery, postoperative drug therapy, and general care, while observation group participants were provided more comprehensive OR care combined with home care. After 1 year of home care, the self-rating anxiety scale (SAS) and Hamilton anxiety scale (HAMA) scores, rehabilitation status, overall quality of life, and Family Adaptability and Cohesion Scale were applied to compare postoperative rehabilitation and prognosis status in both groups. Data were statistically analyzed. Patients were followed up for 3 years, and survival time was analyzed. The operative time and bleeding volume between the two groups were not significantly different (p>0.05). The time of extubation and postoperative recovery time in the observation group were shorter than in the control group (p<0.01). The postoperative SAS and HAMA scores in both groups were significantly decreased compared with those preoperatively (p<0.01). Additionally, these scores were significantly lower in the observation than in the control group (p<0.01). The rehabilitation status of body function in the observation group was better than in the control group (p<0.01). Regarding the overall quality of life score and family adaptability and cohesion score, the observation group was better than the control group (p<0.01). In conclusion, OR care combined with home care was effective for the care of gastric cancer patients with low PTEN expression. Improving patient mood and mental state played a positive role in postoperative rehabilitation and prognosis.

Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for lower gastrointestinal endoscopy. We recommend that endoscopy services across Europe adopt the following seven key performance measures for lower gastrointestinal endoscopy for measurement and evaluation in daily practice at a center and endoscopist level: 1 rate of adequate bowel preparation (minimum standard 90%); 2 cecal intubation rate (minimum standard 90%); 3 adenoma detection rate (minimum standard 25%); 4 appropriate polypectomy technique (minimum standard 80%); 5 complication rate (minimum standard not set); 6 patient experience (minimum standard not set); 7 appropriate post-polypectomy surveillance recommendations (minimum standard not set). Other identified performance measures have been listed as less relevant based on an assessment of their importance, scientific acceptability, feasibility, usability, and comparison to competing measures.

Expert opinions and scientific evidence for colonoscopy key performance indicators

Colonoscopy is a widely performed procedure with procedural volumes increasing annually throughout the world. Many procedures are now performed as part of colorectal cancer screening programmes. Colonoscopy should be of high quality and measures of this quality should be evidence based. New UK key performance indicators and quality assurance standards have been developed by a working group with consensus agreement on each standard reached. This paper reviews the scientific basis for each of the quality measures published in the UK standards.

What do patients want from their endoscopy experience? The importance of measuring and understanding patient attitudes to their care

Understanding and addressing patient attitudes to their care facilitates their engagement and attendance, improves the quality of their experience and the appropriate utilisation of resources. Gastrointestinal endoscopy is a commonly performed medical procedure that can be associated with patient anxiety and apprehension. Measuring patient attitudes to endoscopy can be undertaken through a number of approaches with contrasting benefits and limitations. Methodological validation is necessary for accurate interpretation of results and avoiding bias. Retrospective post-procedure questionnaires measuring satisfaction are easily undertaken but have limited value, particularly in directing service improvements. Patient experience questionnaires indicate areas of poor care but may reflect the clinician's not the patient's perspective. Directly assessing patient priorities and expectations identifies what is important to patients in their healthcare experience (patient-reported value) that can also provide a basis for other forms of evaluation. Published studies of patient attitudes to their endoscopy procedure indicate the importance of ensuring that endoscopists and their staff control patient discomfort, have adequate technical skill and effectively communicate with their patient relating to the procedure and results. Environmental factors, including noise, privacy and the single-sex environment, are considered to have less value. There are contrasting views on patient attitudes to waiting times for the procedure. Implementing patient-centred care in endoscopy requires an understanding of what patients want from their healthcare experience. The results from available studies suggest implications for current practice that relate to the training and practice of the endoscopist and their staff.

Efficacy Outcome Measures for Procedural Sedation Clinical Trials in Adults: An ACTTION Systematic Review

Successful procedural sedation represents a spectrum of patient- and clinician-related goals. The absence of a gold-standard measure of the efficacy of procedural sedation has led to a variety of outcomes being used in clinical trials, with the consequent lack of consistency among measures, making comparisons among trials and meta-analyses challenging. We evaluated which existing measures have undergone psychometric analysis in a procedural sedation setting and whether the validity of any of these measures support their use across the range of procedures for which sedation is indicated. Numerous measures were found to have been used in clinical research on procedural sedation across a wide range of procedures. However, reliability and validity have been evaluated for only a limited number of sedation scales, observer-rated pain/discomfort scales, and satisfaction measures in only a few categories of procedures. Typically, studies only examined 1 or 2 aspects of scale validity. The results are likely unique to the specific clinical settings they were tested in. Certain scales, for example, those requiring motor stimulation, are unsuitable to evaluate sedation for procedures where movement is prohibited (e.g., magnetic resonance imaging scans). Further work is required to evaluate existing measures for procedures for which they were not developed. Depending on the outcomes of these efforts, it might ultimately be necessary to consider measures of sedation efficacy to be procedure specific.

Sedation practice and comfort during colonoscopy: lessons learnt from a national screening programme

AIM

Medication may be used to manage discomfort during colonoscopy but practice varies. The relationship between medication use and comfort during colonoscopy was examined in the English Bowel Cancer Screening Programme.

METHODS

Data related to patient comfort and medication use from all 113,316 examinations performed within the English Bowel Cancer Screening Programme between 1 January 2010 and 31 December 2012 were analysed. Comfort was rated on the five-point Modified Gloucester Comfort Scale: 1, no discomfort; 5, severe discomfort. Scores of 4 and 5 were considered to indicate significant discomfort. Correlations between the proportion of examinations associated with significant discomfort and the amounts of medication used by colonoscopists were assessed using Spearman's ρ. Logistic regression modelling examined the independent predictors of significant discomfort.

RESULTS

Patients had a mean age of 65.7 years, and 58% were male. Examinations were performed by 290 endoscopists. In 91% of examinations, there was no significant discomfort reported during examination; however, there was considerable variation between individual colonoscopists (range 76.1-99.2%).Intravenous sedation and opiate analgesia were used during most examinations, but there was wide variation between colonoscopists, with a median (range) usage of 95.1% (4.1-100%) and 97.3% (5.6-100%), respectively. There was no association between the amount of sedation and analgesia used and significant discomfort (ρ<0.2). On multivariate analysis, significant discomfort was found to be more common among female individuals [odds ratio (OR)=2.0], on incomplete examinations (OR=6.7), and among patients with diverticulosis (OR=1.4).

CONCLUSION

There was wide variation in medication practice among English screening colonoscopists, but this was unrelated to the occurrence of significant discomfort.

Patient-derived measures of GI endoscopy: a meta-narrative review of the literature

BACKGROUND AND AIMS

GI endoscopy (GIE) is widely performed, with 1 in 3 people requiring an endoscopic procedure at some point. Patient experience of medical procedures is important, but, to date, experience measures of GIE are derived from clinician opinion rather than from patients themselves. In this meta-narrative review, the literature on methods of assessing patient experience in GIE is reported.

METHODS

ScienceDirect, MEDLINE, Web of Knowledge, Web of Science, CINAHL, and PsycINFO were searched to November 2013 using meta-narrative standards. Search terms included those related to endoscopic procedures, combined with those related to patient experience.

RESULTS

A total of 3688 abstracts were identified and reviewed for relevance. A total of 3549 were excluded, leaving 139 for full-text review. We subsequently included 48 articles. Three sub-groups of studies were identified--those developing original measures of endoscopy-specific patient experience (27 articles), those modifying existing measures (10 articles), and those testing existing measures for reliability or validity (11 articles). Most measures focused on pain, discomfort, anxiety, and embarrassment. Three studies explored wider aspects of experience, including preparation, unit organization, and endoscopist preference. Likert scales, visual analog scale scores, and questionnaires were used most commonly. The Global Rating Scale was validated for use in 2 studies, confirming that those domains cover all aspects of endoscopy experience. Other measures were modified to assess endoscopic experience, such as the modified Group Health Association of America survey (mGHAA-9) (modified by 5 studies).

CONCLUSIONS

No patient-derived and validated endoscopy-specific experience measures were found. Patient-derived and validated experience measures should be developed and used to model optimal healthcare delivery.

Quality of colonoscopy and advances in detection of colorectal lesions: a current overview

Colonoscopy is the gold standard for the detection of colorectal cancer and its precursors. Nevertheless multiple studies have demonstrated a significant miss-rate for polyps and, more importantly, demonstrated the occurrence of interval cancers in the years after colonoscopy. This imperfect protection against colorectal cancer can be explained by multiple factors related to both the endoscopist and the equipment. To ensure the quality of colonoscopy, several quality indicators have been described. These include bowel preparation, cecal intubation rate, withdrawal time, adenoma detection rate and complication rate. Measurement of these quality indicators, followed by awareness, benchmarking and additional training will hopefully optimize daily practice. If these basic quality parameters are well taken care of, advanced colonoscopic techniques will aim at further increasing the detection and differentiation of colonic lesions. In this review, the authors discuss the literature on quality indicators for colonoscopy and give a comprehensive overview of the advanced colonoscopic techniques currently available.

Time trends in quality indicators of colonoscopy

BACKGROUND

There is considerable variation in the quality of colonoscopy performance. The Norwegian quality assurance programme Gastronet registers outpatient colonoscopies performed in Norwegian endoscopy centres. The aim of Gastronet is long-term improvement of endoscopist and centre performance by annual feedback of performance data.

OBJECTIVE

The objective of this article is to perform an analysis of trends of quality indicators for colonoscopy in Gastronet.

METHODS

This prospective cohort study included 73,522 outpatient colonoscopies from 73 endoscopists at 25 endoscopy centres from 2003 to 2012. We used multivariate logistic regression with adjustment for relevant variables to determine annual trends of three performance indicators: caecum intubation rate, pain during the procedure, and detection rate of polyps ≥5 mm.

RESULTS

The proportion of severely painful colonoscopies decreased from 14.8% to 9.2% (relative risk reduction of 38%; OR = 0.92 per year in Gastronet; 95% CI 0.86-1.00; p = 0.045). Caecal intubation (OR = 0.99; 95% CI 0.94-1.04; p = 0.6) and polyp detection (OR = 1.03; 95% CI 0.99-1.07; p = 0.15) remained unchanged during the study period.

CONCLUSIONS

Pain at colonoscopy showed a significant decrease during years of Gastronet participation while caecal intubation and polyp detection remained unchanged - independent of the use of sedation and/or analgesics and level of endoscopist experience. This may be due to the Gastronet audit, but effects of improved endoscopy technology cannot be excluded.

Development and validation of the PROcedural Sedation Assessment Survey (PROSAS) for assessment of procedural sedation quality

BACKGROUND

More than 20 million invasive procedures are performed annually in the United States. The vast majority are performed with moderate sedation or deep sedation, yet there is limited understanding of the drivers of sedation quality and patient satisfaction. Currently, the major gap in quality assurance for invasive procedures is the lack of procedural sedation quality measures.

OBJECTIVE

To develop and validate a robust, patient-centered measure of procedural sedation quality, the PROcedural Sedation Assessment Survey (PROSAS).

DESIGN

Through a series of interviews with patients, proceduralists, nurses, anesthesiologists, and an interactive patient focus group, major domains influencing procedural sedation quality were used to create a multipart survey. The pilot survey was administered and revised in sequential cohorts of adults receiving moderate sedation for GI endoscopy. After revision, the PROSAS was administered to a validation cohort.

SETTING

GI endoscopy unit.

PATIENTS

A expert panel of proceduralists, nurses, and anesthesiologists, an initial survey development cohort of 40 patients, and a validation cohort of 858 patients undergoing sedation for outpatient GI endoscopy with additional surveys completed by the gastroenterologist, procedure nurse, and recovery nurse.

MAIN OUTCOMES AND MEASUREMENTS

Survey characteristics of the PROSAS.

RESULTS

Patients were able to independently complete the PROSAS after procedural sedation before discharge. Of the patients, 91.6% reported minimal discomfort; however, 8.4% of patients reported significant discomfort and 2.4% of patients experienced hemodynamic and/or respiratory instability. There was a high correlation between patient-reported intraprocedure discomfort and both clinician assessments of procedural discomfort and patient recall of procedural pain 24 to 48 hours post procedure (P < .001 for all), suggesting high external validity.

LIMITATIONS

Single-center study, variability of sedation technique between providers, inclusion of patients with chronic pain taking analgesics.

CONCLUSIONS

The PROSAS is a clinically relevant, patient-centered, easily administered instrument that allows for standardized evaluation of procedural sedation quality. The PROSAS may be useful in both research and clinical settings.

Quality in colonoscopy: European perspectives and practice

Colonoscopy is the 'gold standard' investigation of the colon. High quality colonoscopy is essential to diagnose early cancer and reduce its incidence through the detection and removal of pre-malignant adenomas. In this review, we discuss the key components of a high quality colonoscopy, review methods for improving quality, emerging technologies that have the potential to improve quality and highlight areas for future work.

Endoscopy and polyps-diagnostic and therapeutic advances in management

Despite multiple efforts aimed at early detection through screening, colon cancer remains the third leading cause of cancer-related deaths in the United States, with an estimated 51000 deaths during 2013 alone. The goal remains to identify and remove benign neoplastic polyps prior to becoming invasive cancers. Polypoid lesions of the colon vary widely from hyperplastic, hamartomatous and inflammatory to neoplastic adenomatous growths. Although these lesions are all benign, they are common, with up to one-quarter of patients over 60 years old will develop pre-malignant adenomatous polyps. Colonoscopy is the most effective screening tool to detect polyps and colon cancer, although several studies have demonstrated missed polyp rates from 6%-29%, largely due to variations in polyp size. This number can be as high as 40%, even with advanced (> 1 cm) adenomas. Other factors including sub-optimal bowel preparation, experience of the endoscopist, and patient anatomical variations all affect the detection rate. Additional challenges in decision-making exist when dealing with more advanced, and typically larger, polyps that have traditionally required formal resection. In this brief review, we will explore the recent advances in polyp detection and therapeutic options.