1. How to improve ERCP service provision in a District General Hospital (DGH): Lessons learned from a geographically isolated unit.
Miss Marina Yiasemidou, MBBS, MSc, MRCS
Academic Clinical Fellow in GI Surgery
Leeds Teaching Hospitals

2. Contents Background Aim Materials and Methods Results Conclusion
ERCP service provision
2004 Report of The National Confidential Enquiry into Patient Outcome and Death
The future of service and training in ERCP in the UK – A strategy. UK ERCP stakeholders working party. 2007
Joint Advisory Group (JAG) Quality and safety standards for ERCP report
American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) Task Force – Minnesota Study
Aim
Materials and Methods
Results
Conclusion

3. Background
2004 Report of The National Confidential Enquiry into Patient Outcome and Death
68% of the ERCPs undertaken were futile,
48% of cases endoscopists were unable to provide crucial information about the procedure
Training for ERCP was deemed suboptimal
Internal or inter-hospital referrals are recommended
Future of ERCP (UK ERCP stakeholders 2007)
48,000 ERCPs/year in the UK (BSG Audit). Expected to increase by 1000 cases a year.
Networks with nearby hospitals to allow for a case load of 150 procedures/year

4. Background
Joint Advisory Group (JAG) Quality and safety standards for ERCP report
Quality
Pre-ERCP assessment of all patients by appropriately trained staff
ƒIndications for ERCP and place of ERCP in the management pathway to be agreed locally
ƒEvidence of consultant involvement in every decision to perform ERCP
For each case, a minimum of 3 endoscopy assistants with appropriate competences
>90% of ERCPs intended as therapeutic
ƒ Completion of the intended therapeutic procedure at, at least 80% of cases
Safety
Sphincterotomy bleeding requiring transfusion < 2%
ƒ Perforation rate <2%
ƒ Clinically symptomatic pancreatitis <5%
ƒ Procedure related mortality <1%

5. Background
American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) Task Force
Success rates: Cannulation of bile duct: 90%, Bile duct stone removal: 85%, Bile duct drainage of blocked duct: 90%
Minnesota Study
Prospective study
Eight community hospitals in the Minneapolis-St. Paul, Minnesota, area.
Complication rates compare very favourably with those of academic centres.
Technical success rates achieved or exceeded rates recommended by the ASGE/American College of Gastroenterology Task Force
Overall complication rate: 5%

6. Aim
Assess efficiency and safety of ERCP service provision in a geographically isolated district general hospital.
Identify the ways Nobles Hospital, Isle of Man has improved ERCP service provision
Nobles hospital is located on the Isle of Man, serving a population of 80,000.

7. Materials and Methods December 2010 and December 2011
42 ERCPs were performed on 36 patients (F:M 24:12, Mean age: 69.8)
Retrospective data collection - ERCP reports on electronic data base (Unisoft's GI Reporting Tool) and clinical notes.
Qualitative and Quantitive Indices were compared with JAG and ASGE recommendations.
Chi square test was used to assess any possible statistical difference between success rates in our unit and competency levels (SPSS 20 Software (IBM®)).

8. Results

9. A diagnostic ERCP was defined by injection of contrast dye into either the pancreatic duct or bile duct without performing a therapeutic manoeuvre

10. Comparison to JAG and ASGE guidelines
Variable
JAG guidelines
Nobles Hospital
Therapeutic ERCPs
>90%
97.6%
Successful procedures
80%
85.7%
Variable
ASGE/ACG Task force guidelines
Nobles Hospital
Chi-square test p-value
Cannulation of the bile duct
90% (of 42) 38
88.1% 37
0.724
Bile duct stone removal
85% (of 21) 18
81% 17
0.679
Bile duct drainage of a blocked duct
90% (of 20)
90%
Values are identical

11. Qualitative indices
ERCP requests discussed in MDT meeting (Surgical/radiology) – Part of referral system
JAG recommendation: Evidence of Consultant involvement
Permanent endoscopy staff (Surgical Nurse practitioner and 2 other nurses) appropriately trained in endoscopic procedures and trouble shooting of endoscopic equipement.
JAG recommendation: 3 endoscopy assistants.

12. Complications Complication Number of cases Pancreatitis 2 – 4.76%
Respiratory complication
1 – 2.38%
30 day post procedure deaths

13. Results Comparison to JAG guidelines:
Therapeutic/Diagnostic ERCPs in Nobles Hospital exceeded the JAG recommended minimum percentage by 7.6%.
ERCP success rate in Nobles exceeded the JAG recommended rate by 5.7%
Comparison to ASGE/ACG Task force guidelines:
There is no statistically significant difference between ASGE/ACG Taskforce recommended percentage and Nobles Hospital figures.

14. Conclusion
ERCP service provision in a DGH can be both efficient and safe.
Geographically isolated units can successfully seek and implement ways of improving their service. (Referral process, employment of appropriately trained staff)
Recommendation: Audit service provision in DGHs in the UK, make recommendations based on service provided in each unit.

15. Thank you