Paediatric Colonoscopy Direct Observation of Procedural Skills: Evidence of Validity and Competency Development

Pediatric endoscopy: how can we improve patient outcomes and ensure best practices?

INTRODUCTION

Strategies to promote high-quality endoscopy in children require consensus around pediatric-specific quality standards and indicators. Using a rigorous guideline development process, the international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) was developed to support continuous quality improvement efforts within and across pediatric endoscopy services.

AREAS COVERED

This review presents a framework, informed by the PEnQuIN guidelines, for assessing endoscopist competence, granting procedural privileges, audit and feedback, and for skill remediation, when required. As is critical for promoting quality, PEnQuIN indicators can be benchmarked at the individual endoscopist, endoscopy facility, and endoscopy community levels. Furthermore, efforts to incorporate technologies, including electronic medical records and artificial intelligence, into endoscopic quality improvement processes can aid in creation of large-scale networks to facilitate comparison and standardization of quality indicator reporting across sites.

EXPERT OPINION

PEnQuIN quality standards and indicators provide a framework for continuous quality improvement in pediatric endoscopy, benefiting individual endoscopists, endoscopy facilities, and the broader endoscopy community. Routine and reliable measurement of data, facilitated by technology, is required to identify and drive improvements in care. Engaging all stakeholders in endoscopy quality improvement processes is crucial to enhancing patient outcomes and establishing best practices for safe, efficient, and effective pediatric endoscopic care.

Promoting Research that Supports High-Quality Gastrointestinal Endoscopy in Children

PURPOSE OF REVIEW

Defining and measuring the quality of endoscopic care is a key component of performing gastrointestinal endoscopy in children. The purpose of this review is to discuss quality metrics for pediatric gastrointestinal endoscopy and identify where additional research is needed.

RECENT FINDINGS

Pediatric-specific standards and indicators were recently defined by the international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) working group through a rigorous guideline consensus process. Although the aim of these guidelines is to facilitate best practices for safe and high-quality gastrointestinal endoscopy in children, they highlight the pressing need to expand upon the body of evidence supporting these standards and indicators as predictors of clinically relevant outcomes. In this review, we propose and discuss ideas for several high-yield research topics to engage pediatric endoscopists and promote best practices in pediatric endoscopy.

A journey towards pediatric gastrointestinal endoscopy and its training: a narrative review

Background and aims

Gastrointestinal (GI) endoscopy in pediatric setting has unique features and, therefore, requires an approach that is tailored to pediatric practice. There is still heterogeneity between training programs worldwide in terms of duration, number of procedures and assessment during and at the end of the training process.

Methods

We conducted a narrative review aiming to describe and summarize the existing literature on the various training methods for pediatric GI endoscopy to highlight the significance of specific pediatric endoscopy training.

Results

Simulation-based tools have been implemented in several training programs, providing a safer learning environment for trainees, especially in their earlier stages of training. Assessment of competence is gradually shifting from the sole evaluation of procedural numbers towards the development of more reliable and valid tools that can accurately measure technical competence. Despite such seismic shift, there is still a need for a standardized and comprehensive pediatric-oriented endoscopy curriculum that incorporates acquisition of procedural skills education and is built on the current competency-based model of training. All the above must sink their roots in trainees and to ensure that the endoscopists of tomorrow are capable of delivering high quality of care for children undergoing endoscopy.

Conclusion

It is crucial to parallelly focus on the way trainers teach trainees. In this context, the implementation of "train the trainers" courses has improved important quality meters in GI endoscopy. Future research should put the focus on the potential subsequent favorable benefits of these changes on child health.

Upskilling Pediatric Ileocolonoscopy

Upskilling in ileocolonoscopy is an important aspect of pediatric endoscopic practice as it enables endoscopists to learn additional skills through education and training to improve outcomes. With the advent of technologies, endoscopy is continuously evolving. Many devices can be applied to improve endoscopy quality and ergonomics. In addition, techniques such as dynamic position change can be employed to increase procedural efficiency and completeness. Key to upskilling is enhancing endoscopists' cognitive, technical and nontechnical skills and the concept of "training the trainer" to ensure trainers have the requisite skills to teach endoscopy effectively. This chapter details aspects of upskilling pediatric ileocolonoscopy.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopists and Endoscopists in Training: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality pediatric endoscopy requires reliable performance of procedures by competent individual providers who consistently uphold all standards determined to assure optimal patient outcomes. Establishing consensus expectations for ongoing monitoring and assessment of individual pediatric endoscopists is a method for confirming the highest possible quality of care for such procedures worldwide. We aim to provide guidance to define and measure quality of endoscopic care for children.

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 endoscopists. 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 6 standards that all providers who perform pediatric endoscopy should uphold and 2 standards for pediatric endoscopists in training, with 7 corresponding indicators that can be used to identify high-quality endoscopists. Additionally, these can inform continuous quality improvement at the provider level. Minimum targets for defining high-quality pediatric ileocolonoscopy were set for 2 key indicators: cecal intubation rate (≥90%) and terminal ileal intubation rate (≥85%).

DISCUSSION

It is recommended that all individual providers performing or training to perform pediatric endoscopy initiate and engage with these international endoscopist-related standards and indicators developed by PEnQuIN.

Colonoscopy competence assessment tools: a systematic review of validity evidence

BACKGROUND

Assessment tools are essential for endoscopy training, being required to support feedback provision, optimize learner capabilities, and document competence. We aimed to evaluate the strength of validity evidence that supports the available colonoscopy direct observation assessment tools using the unified framework of validity.

METHODS

We systematically searched five databases for studies investigating colonoscopy direct observation assessment tools from inception until 8 April 2020. We extracted data outlining validity evidence (content, response process, internal structure, relations to other variables, and consequences) from the five sources and graded the degree of evidence, with a maximum score of 15. We assessed educational utility using an Accreditation Council for Graduate Medical Education framework and methodological quality using the Medical Education Research Quality Instrument (MERSQI).

RESULTS

From 10 841 records, we identified 27 studies representing 13 assessment tools (10 adult, 2 pediatric, 1 both). All tools assessed technical skills, while 10 each assessed cognitive and integrative skills. Validity evidence scores ranged from 1-15. The Assessment of Competency in Endoscopy (ACE) tool, the Direct Observation of Procedural Skills (DOPS) tool, and the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT) had the strongest validity evidence, with scores of 13, 15, and 14, respectively. Most tools were easy to use and interpret, and required minimal resources. MERSQI scores ranged from 9.5-11.5 (maximum score 14.5).

CONCLUSIONS

The ACE, DOPS, and GiECAT have strong validity evidence compared with other assessments. Future studies should identify barriers to widespread implementation and report on the use of these tools in credentialing examinations.

Innovative Techniques Associated with Traditional Abdominal Surgery in Complex Pediatric Cases: A Tertiary Center Experience

Pediatric abdominal surgery is constantly evolving, alongside the advent of new surgical technologies. A combined use of new tools and traditional surgical approaches can be useful in the management of complex cases, allowing less invasive procedures and sometimes even avoiding multiple interventions. This combination of techniques has implications even from the anesthetic point of view, especially in post-operative pain control. Thereby, tertiary level centres, including highly-specialized professionals and advanced equipment, can maximize the effectiveness of treatments to improve the final outcomes. Our paper aims to present some possible combinations of techniques recently used at our institution to provide a one-session, minimally invasive treatment within different areas of abdominal surgery.