Improving the timeliness of procedures in a pediatric endoscopy suite

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.

Leveraging Real-world Data to Increase Procedure Room Capacity: A Multidisciplinary Quality Improvement Project

Introduction

In the current healthcare climate, the financial strain created by COVID-19, limited resources, and case backlogs highlight the need to optimize operating and procedure room efficiency and maximize capacity. At Seattle Children's, a clinical multidisciplinary team developed and implemented a data-driven protocol to improve efficiency in a high-volume gastrointestinal (GI) suite.

Methods

Key process measures, including all case on-time starts and postanesthesia care unit length of stay, were extracted from the electronic medical record and presented as Statistical Process Control (SPC) charts. Clinicians' performance was stratified by rational subgrouping to better understand variation in the system. We defined an expert clinician as one who performs beyond 3-sigma limits on funnel plot analyses. We developed clinical protocols based on expert clinician clinical practices. We gave clinicians dynamic, daily feedback on this family of measures through continuously updated SPC charts. This real-world data drove system and individual-level plan-do-check-act improvement cycles.

Results

Despite significant external challenges over 2 years, procedure volume increased by approximately 25%, on-time starts improved by 36%, turnover time decreased by 34%, and postanesthesia care unit length of stay decreased by 15%. GI laboratory revenue increased by approximately 25% (independent of increased charges per procedure), representing the potential for a $2 million increase in annual revenue.

Conclusions

A multidisciplinary clinical team improved efficiency metrics in a busy pediatric GI suite. Access to real-world data through continuously updated SPC charts enabled plan-do-check-act cycles that led to measurable improvement. This data access also served to sustain team motivation and engagement.

Pediatric endoscopy across multiple clinical settings: Efficiency and adverse events

BACKGROUND

Endoscopic procedures are becoming increasingly important for the diagnosis and treatment of gastrointestinal disorders during childhood, and have evolved from a more infrequent inpatient procedure in the operating room to a routine outpatient procedure conducted in multiple care settings. Demand for these procedures is rapidly increasing and thus there is a need to perform them in an efficient manner. However, there are little data comparing the efficiency of pediatric endoscopic procedures in diverse clinical environments. We hypothesized that there are significant differences in efficiency between settings.

AIM

To compare the efficiency and examine adverse effects of pediatric endoscopic procedures across three clinical settings.

METHODS

A retrospective chart review was conducted on 1623 cases of esophagogastroduodenoscopy (EGD) or combined EGD and colonoscopy performed between January 1, 2014 and May 31, 2018 by 6 experienced pediatric gastroenterologists in three different clinical settings, including a tertiary care hospital operating room, community hospital operating room, and free-standing pediatric ambulatory endoscopy center at a community hospital. The following strict guidelines were used to schedule patients at all three locations: age greater than 6 mo; American Society of Anesthesiologists class 1 or 2; normal craniofacial anatomy; no anticipated therapeutic intervention (e.g., foreign body retrieval, stricture dilation); and, no planned or anticipated hospitalization post-procedure. Data on demographics, times, admission rates, and adverse events were collected. Endoscopist time (elapsed time from the endoscopist entering the operating room or endoscopy suite to the next patient entering) and patient time (elapsed time from patient registration to that patient exiting the operating room or endoscopy suite) were calculated to assess efficiency.

RESULTS

In total, 58% of the cases were performed in the tertiary care operating room. The median age of patients was 12 years and the male-to-female ratio was nearly equal across all locations. Endoscopist time at the tertiary care operating room was 12 min longer compared to the community operating room (63.3 ± 21.5 min vs 51.4 ± 18.9 min, P < 0.001) and 7 min longer compared to the endoscopy center (vs 56.6 ± 19.3 min, P < 0.001). Patient time at the tertiary care operating room was 11 min longer compared to the community operating room (133.2 ± 39.9 min vs 122.3 ± 39.5 min, P < 0.001) and 9 min longer compared to the endoscopy center (vs 124.9 ± 37.9 min; P < 0.001). When comparing endoscopist and patient times for EGD and EGD/colonoscopies among the three locations, endoscopist, and patient times were again shorter in the community hospital and endoscopy center compared to the tertiary care operating room. Adverse events from procedures occurred in 0.1% (n = 2) of cases performed in the tertiary care operating room, with 2.2% (n = 35) of cases from all locations having required an unplanned admission after the endoscopy for management of a primary GI disorder.

CONCLUSION

Pediatric endoscopic procedures can be conducted more efficiently in select patients in a community operating room and endoscopy center compared to a tertiary care operating room.

Badge sign-in and report cards improve first case start times in gastrointestinal endoscopy: A prospective quality improvement study

Background and study aims  First case start (FCS) time is often a key metric used to gauge efficiency in an endoscopy suite. There are limited data on tools and methods to improve the FCS time in the endoscopy suite. Methods  A prospective observational cohort study was conducted in an academic tertiary care endoscopy suite examining the effect of badge sign-in (Period 2) and badge sign-in coupled with report cards (Period 3) compared to an initial observational period (Period 1). Results  After the badge sign-in reader was introduced in P2, the unit experienced a mean time savings of 5 ± 18 minutes in FCS delays compared to P1 ( P  = .03). In P3, an 8 ± 17-minute time savings in FCS time delay was observed compared to P1 ( P  = 0.0006). Sign-in compliance significantly increased for the overall unit between P2 and P3 (49 % vs. 59 %, P  = .002). Increases in first case on-time start (FCOTS) rates compared to P1 were observed for the unit, with a 14% absolute increase in P2 ( P  < .0001) and a 17 % absolute increase in P3 ( P  < .0001). FCS delays for on-time badge sign-ins were significantly lower compared to FCS delays for missed badge sign-ins and late badge sign-ins ( P  < .0001). Conclusions  The use of badge sign-in and report cards improve endoscopy unit efficiency as it can increase FCOTS rates and decrease FCS time delays.

Using Lean Six Sigma to Improve First-Case Delays in Pediatric Endoscopy

Pediatric endoscopy is an essential clinical practice used to diagnose and treat gastrointestinal diseases in children. Moreover, pediatric endoscopy programs require a clinically and technically specialized unit organized around performing endoscopic procedures with high levels of training and skill. With the volume of endoscopic procedures steadily rising in large academic medical centers each year, achieving operational efficiency has become critical to running a successful endoscopy program.

A Multimodal Interdisciplinary QI Intervention Is Associated with Reduction in After Hours Inpatient Endoscopy Cases

Background and Aims

Increasing demand for inpatient endoscopic services results in performing more non-emergent endoscopic cases after-hours, which poses risks to patient safety and negatively impacts patient and provider satisfaction. This study sought to quantify the existing state using quality improvement (QI) methodology, design targeted interventions, and determine their effectiveness.

Methods

We conducted an existing state evaluation through a process map, time-series study, and caseload analysis from 7/2017-12/2018. Using end-of-workday (EOW) as a proxy for patient/provider dissatisfaction and risk for patient safety events, we performed a prospective evaluation of a staged interdisciplinary multimodal intervention aimed to decrease the proportion of days with EOW after 7PM, decrease the proportion of cases begun after 5PM, and decrease EOW variability. The post-intervention period was 6/2019-2/2020.

Results

Based on existing state analyses, we implemented a series of targeted interventions: (1) provider workflow tips, (2) expedited transport for select patients, (3) pathway to reschedule appropriate cases to outpatient endoscopy, and (4) increased staffing for high caseload days through resource pooling. The proportion of days with EOW after 7PM decreased from 42.4% to 29.3% (caseload-adjusted odds ratio of 0.39, p< 0.001). Despite increased caseload, cases begun after 5PM decreased from 17.5% to 14.2% (OR 0.75, p = 0.009). EOW SD decreased from 2:20 hours to 1:36 hours.

Conclusions

The multimodal intervention reduced days with EOW after 7PM and the proportion of cases begun after 5PM, despite increased caseload. This study shows how applying research methods to implement QI interventions successfully decreases late inpatient endoscopic cases.

Creating a Culture of Continuous Improvement in Outpatient Laboratories: Effects on Wait Times, Employee Engagement, and Efficiency

Transforming health care remains a challenge as many continuous improvement (CI) initiatives fail or are not sustained. Although the literature suggests the importance of culture, few studies provide evidence of cultural change creating sustained CI. This improvement initiative focused on creating cultural change through goal alignment, visual management, and empowering frontline employees. Data included 113 133 encounters. Cochran-Armitage tests and X-bar charting compared wait times during the CI initiative. Odds of waiting <15 minutes increased in both phase 2 (odds ratio = 3.57, 95% confidence interval = [3.43-3.71]) and phase 3 (odds ratio = 5.39, 95% confidence interval = [5.07, 5.74]). At 3 years follow-up, 95% of wait times were <15 minutes. Productivity increased from 519 to 644 patients/full-time equivalent/month; 33/42 Press Ganey employee engagement components significantly improved. This study demonstrates the efficacy of a culture of CI approach to sustain wait time improvement in outpatient laboratory services, and should be considered for application in other areas of health care quality.

Creatively Improving Care Delivery

The medical community has been challenged to improve upon deficiencies in the delivery of patient care. Quality improvement methods are therefore increasingly used in everyday clinical practice. As demonstrated in this review, creative and impactful improvement projects within pediatric gastroenterology can be successfully achieved as either multicenter projects or single-center efforts. Through our willingness to accept the challenge to improve, practitioners within the pediatric gastroenterology community have become leaders in using quality improvement to change practice and improve clinical outcomes.

Developing the Pediatric Gastrointestinal Endoscopy Unit: A Clinical Report by the Endoscopy and Procedures Committee

There is significant variability in the design and management of pediatric endoscopy units. Although there is information on adult endoscopy units, little guidance is available to the pediatric endoscopy practitioner. The purpose of this clinical report, prepared by the NASPGHAN Endoscopy and Procedures Committee, is to review the important considerations for setting up an endoscopy unit for children. A systematic review of the literature was undertaken in the preparation of this report regarding the design, management, needed equipment, motility setup, billing and coding, and pediatric specific topics.

Evaluation of interventional endoscopy unit efficiency metrics at a tertiary academic medical center

BACKGROUND AND STUDY AIMS

There is an increasing demand for interventional endoscopic services and the need to develop efficient endoscopic units. The aim of this study was to analyze performance data and define metrics to improve efficiency in a single academic interventional endoscopy center. ]

PATIENTS AND METHODS

The prospective operations performance data (6-month period) of our interventional endoscopy unit (EU) was analyzed. First-case start time (FIRST) delay was defined as any time the first patient of the day entered the endoscopy room after the scheduled time. Non-endoscopy time (NET) and total time (TT) were defined as non-procedural and total time elapsed in the EU, respectively. Time-interval between successive patients (TISP) was defined as the time from one patient departure from the room until the time of arrival of the next patient in the room.

RESULTS

A total of 1421 patients underwent 1635 endoscopic procedures. FIRST was delayed (54.2 % cases) by 13.6 min (range 1 - 53), but started within 15 min of the scheduled time in 85 % of the cases. NET accounted for 9.1 hours (67.2 %) of 13.5 hours TT/day. TISP (37.1 min, range 5 - 125) comprised 54.2 % of the NET, and was delayed (> 30 min) in 49.8 % of cases. "Patient flow" processes (registration, admission, transportation, scheduling) accounted for 50.1 % of TISP delays.

CONCLUSIONS

Delays in NET, specifically TISP, rather than FIRST, were identified as a cause for decreased efficiency. "Patient flow" processes were the main reasons for delays in TISP. This study identifies potential process measures that can be used as benchmarks to improve efficiency in the EU.

Improving Nonattendance at Outpatient Pediatric Endoscopy Unit of a Tertiary Center

BACKGROUND AND OBJECTIVES

Failure to attend pediatric outpatient endoscopic procedures leads to inefficient use of resources, longer wait-list times, and delay in diagnoses. The causes for pediatric endoscopy nonattendance are not well studied. The aim of the study was to identify factors associated with failure to attend endoscopic procedures and to assess the value of quality improvement (QI) interventions implemented to improve pediatric endoscopy attendance.

METHODS

This was a continuous QI project. We collected nonattendance data from November 2011 to November 2013. Information collected included procedure type, age, sex, time on the waiting list, history of previous procedures, and reason for nonattendance. The following QI interventions were implemented sequentially: an appointment reminder letter, a telephone call 1 week before procedure, and creation of an electronic medical note dedicated to endoscopy appointment. Pareto charts and statistical process control charts were used for analysis.

RESULTS

From November 2011 to November 2013, we were able to decrease nonattendance from 17% to 11% (P = 0.005). No-show rate was reduced from 5% to 0.9% (P = 0.00001). There was no significant difference between attendees and nonattendees in relation to sex, age, or having a previous procedure. Longer waiting time (33 vs 26 days) was associated with increased risk for nonattendance (P = 0.0007). The most common causes for nonattendance were illness (31.5%), followed by caregiver/patients who no longer wanted the procedure (17.7%), and patients who improved (12.9%).

CONCLUSIONS

Applying QI methods and tools improved pediatric endoscopy attendance. Longer wait time for endoscopic procedures is associated with nonattendance. Given the increased pediatric endoscopy demand, strategies should be implemented to reduce wait time for pediatric endoscopy.

Impact of Pre-Procedure Interventions on No-Show Rate in Pediatric Endoscopy

Pediatric endoscopy has evolved into an indispensable tool in the diagnosis and management of gastrointestinal diseases in children. However, there is limited literature focusing on quality improvement initiatives in pediatric endoscopy. The primary goal of this project was to reduce the no-show rate in the pediatric endoscopy unit. Also, we aimed to improve patient and family satisfaction with the procedure by identifying opportunities for improvement. A checklist was designed based on the potential causes of no-show. The endoscopy nurse coordinator reviewed the checklist when scheduling the procedure to identify patients at high risk for non-compliance. Once a risk factor was identified, appropriate actions were taken. She also made a pre-procedure phone call as a reminder and to address any of these risks for non-compliance if present. A patient satisfaction survey was used to identify potential areas for improvement. The no-show rate decreased from an average of 7% in the pre-intervention phase to 2% in the post-intervention phase (p = 0.009). 91% of the patients/family recorded an overall satisfaction of 4 or 5 on a scale of 1-5 5 being best). Quality improvement strategies decreased the no-show rate in the pediatric endoscopy unit. A patient satisfaction survey helped in identifying areas for improvement.