ERCP - Provision of Service and of Training in the Future

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ERCP - Provision of Service and of Training in the Future

  1. 1. ERCP – Provision of Service and of Training in the Future Jonathan GreenJonathan Green University Hospital of North StaffsUniversity Hospital of North Staffs
  2. 2. Background How it looked at the MillenniumHow it looked at the Millennium
  3. 3. Background - Service Due to NHS Plan (18/52 wait) and BCSP, bigDue to NHS Plan (18/52 wait) and BCSP, big focus onfocus on ColonoscopyColonoscopy Loss of diagnostic role (MRCP) for ERCPLoss of diagnostic role (MRCP) for ERCP Patchy growth of EUSPatchy growth of EUS Uneven (random) spread of skillsUneven (random) spread of skills Service need unclearService need unclear Service safety even more unclearService safety even more unclear Lack of guiding standards and principlesLack of guiding standards and principles
  4. 4. Background - Training Training? Yes - but focussed onTraining? Yes - but focussed on ColonoscopyColonoscopy Beginning of move from time-based toBeginning of move from time-based to competence-based trainingcompetence-based training ERCP no longer mandatory for CCTERCP no longer mandatory for CCT Few trainees capable of independent practiceFew trainees capable of independent practice at CCTat CCT Training standards loosely definedTraining standards loosely defined
  5. 5. Then -Then - - the- the ‘Killer Blow’‘Killer Blow’ -- NCEPOD 2004 – Scoping Our PracticeNCEPOD 2004 – Scoping Our Practice –– Deaths after Therapeutic EndoscopyDeaths after Therapeutic Endoscopy ““ 68% of the ERCPs undertaken68% of the ERCPs undertaken were futile”were futile”
  6. 6. How to tackle this ? A 3 pronged attackA 3 pronged attack
  7. 7. AUDIT -AUDIT - Current ERCP ServiceCurrent ERCP Service STANDARDS –STANDARDS – Clear standards forClear standards for service as well asservice as well as trainingtraining STRATEGY –STRATEGY – Clear strategy for futureClear strategy for future of service and trainingof service and training BSG ERCP AuditBSG ERCP Audit BSG Endoscopy Comm-BSG Endoscopy Comm- ittee ERCP Standards –ittee ERCP Standards – adopted by the JAGadopted by the JAG BSG EndoscopyBSG Endoscopy Committee ERCPCommittee ERCP ‘Stakeholder’ Group‘Stakeholder’ Group
  8. 8. AUDIT
  9. 9. BSG ERCP Audit - 2004 ProspectiveProspective In and Outpatient ERCPIn and Outpatient ERCP All casesAll cases 5 Regions of England5 Regions of England Data on 5264 ERCP’s by 213 ERCPistsData on 5264 ERCP’s by 213 ERCPists
  10. 10. BSG ERCP Audit - 2004 94% scheduled as therapeutic94% scheduled as therapeutic 77% of Trained Endoscopists had a77% of Trained Endoscopists had a cannulation rate of >80%cannulation rate of >80% 70% Completion of intended therapeutic70% Completion of intended therapeutic procedureprocedure 5.1% Complication rate (pancreatitis 1.6%)5.1% Complication rate (pancreatitis 1.6%) Procedure-related mortality 0.4%Procedure-related mortality 0.4%
  11. 11. STANDARDS
  12. 12. Quality Indicators in an ERCP service 1)Structure1)Structure A minimum of 2 ERCP-trained endoscopists perA minimum of 2 ERCP-trained endoscopists per centrecentre An agreed minimum workload (procedureAn agreed minimum workload (procedure type/volume) per endoscopisttype/volume) per endoscopist An Endoscopy Unit caseload of at least 150An Endoscopy Unit caseload of at least 150 procedures per yearprocedures per year A nominated radiologist to lead Imaging DepartmentA nominated radiologist to lead Imaging Department quality issuesquality issues
  13. 13. Quality Indicators in an ERCP service 2) Process2) Process Evidence of consultant involvement in every decisionEvidence of consultant involvement in every decision to perform (c/f request) ERCP e.g. by case note auditto perform (c/f request) ERCP e.g. by case note audit Pre-ERCP pre-assessment of in-patients byPre-ERCP pre-assessment of in-patients by appropriately trained staff member(s)appropriately trained staff member(s) Less than 5% of ERCP’s intended as purelyLess than 5% of ERCP’s intended as purely diagnostic examinationsdiagnostic examinations Formal recording of adverse events e.g. significantFormal recording of adverse events e.g. significant complications and mortalitycomplications and mortality
  14. 14. Quality Indicators in an ERCP service 3) Outcome3) Outcome Completion of the intended therapeutic procedure inCompletion of the intended therapeutic procedure in at least 80% of casesat least 80% of cases Clinically symptomatic pancreatitis in less than 5%Clinically symptomatic pancreatitis in less than 5% Post- sphincterotomy significant bleeding <2%Post- sphincterotomy significant bleeding <2% Sedation reversal agents used in <1%Sedation reversal agents used in <1% Evidence of patient acceptability/satisfaction e.g. fromEvidence of patient acceptability/satisfaction e.g. from audits, complaints (formal and informal)audits, complaints (formal and informal)
  15. 15. QUALITY INDICATORS IN ENDOSCOPY QUALITYQUALITY SAFETYSAFETY StructureStructure Min.Unit CaseloadMin.Unit Caseload Full Range ofFull Range of AccessoriesAccessories ProcessProcess Pre-assessmentPre-assessment of in-patientsof in-patients Adverse incidentsAdverse incidents recordrecord Qual. IndicatorsQual. Indicators 80% Completion80% Completion Panc. <5%Panc. <5% StaffingStaffing Min. 2 ERCPistsMin. 2 ERCPists Min. 3 nurse asst.Min. 3 nurse asst.
  16. 16. STRATEGY The ‘Stakeholder Group’The ‘Stakeholder Group’
  17. 17. STAKEHOLDER GROUP The constitution of the Group was as follows:- Jonathan Green Chairman Miles Allison BSG Endoscopy Committee Howard Smart BSG Endoscopy Committee Roland Valori National Endoscopy Team Martin Lombard BSG ERCP Audit Kel Palmer Chairman of JAG (till 12/06) Roger Barton Chairman of JAG (from 12/06) Derrick Martin Royal College of Radiologists Nick Hayes AUGIS Don Menzies AUGIS
  18. 18. The full group met twice – February 2006 and March 2007 – Sub-group meeting - October 2006.
  19. 19. Stakeholder Group Summary ofSummary of recommendations andrecommendations and conclusionsconclusions
  20. 20. Question 1 Is there a future for ERCP?Is there a future for ERCP?
  21. 21. Future Need for ERCP Likely future incidence of ERCP 0.9 per 1,000 per year equating to 54,000 ERCP’s per year across the UK. Importantly, the Group did not foresee a reduction in the numbers of ERCP’s performed over time.
  22. 22. Question 2 What specific standards shouldWhat specific standards should define an ERCP service and andefine an ERCP service and an individual ERCP endoscopist?individual ERCP endoscopist?
  23. 23. ERCP Service An ERCP Service should perform a minimum of 150 procedures per year and there must be more than one trained service deliverer to ensure continuity of service.
  24. 24. When an endoscopic service performs less procedures than this, The Group recommends a network with nearby hospitals - to allow these minimum standards to be achieved.
  25. 25. ERCP Endoscopists ERCP is currently performed by:- Medical Gastroenterologists (75%) Upper GI surgeons (13%) Others (12%) - including radiologists
  26. 26. ERCP Endoscopists The Group felt that the only criteria for performing ERCP were:- Medical (c/f non-medical) background Proper (JAG defined) training Certified competence Adequate continued experience
  27. 27. ERCP Endoscopists • ERCP endoscopists who wish to continue to partake in the ERCP service should currently aim to achieve a minimum of 75 cases per year. This minimum standard will within a timeframe to be decided likely increase • Those not currently achieving these aspirational numbers should not stop ERCP immediately - but should consider how they might reconfigure their work and job plans to achieve this in future.
  28. 28. Revalidation / Recertification •The Group recognises that ERCP endoscopists will in future require specialist recertification in ERCP. •The main tools of recertification in ERCP are unlikely to involve DOPS (direct observation)
  29. 29. Question 3 What is the future of trainingWhat is the future of training for ERCP?for ERCP?
  30. 30. TRAINING Standards -Standards - for training andfor training and accreditation to be determined byaccreditation to be determined by competence –based assessmentscompetence –based assessments NumberNumber - of trainees to be trained is- of trainees to be trained is determined bydetermined by FUTURE SERVICEFUTURE SERVICE NEEDNEED
  31. 31. Definition of Competence at CCT - 1 •The Stakeholder Group would wish that at CCT an ERCP trainee would be competent to perform independent Level 1 ERCP . •Level 1 includes selective deep cannulation, biliary sphincterotomy and clearance of bile duct stones <10mm diameter and placement of stents for low pancreatic tumours
  32. 32. Definition of Competence at CCT - 2  80% successful completion of the intended procedure of Level 1 difficulty. Required minimum performance of 200 procedures Post-ERCP complication rate of < 5%. Complications defined as pancreatitis, significant haemorrhage, perforation or infection. Probationary period
  33. 33. Trainee Numbers • UK incidence of ERCP is expected to be 54,000 •Future expectation that a trained ERCP endo- scopist will perform at least 100 ERCP’s per year, •National requirement for maximum of 540 trained ERCPists to deliver the service.
  34. 34. Trainee Numbers •If each trained ERCP endoscopist has a 20 year service span • Need for a minimum of 30 new trained ERCPists to enter the service each year to balance retirement. The suggested number of entrants ranged from 20-40 with a consensus of around 30.
  35. 35. Trainee Numbers 30 new entrants each year in the whole UK30 new entrants each year in the whole UK means:-means:- Training places restrictedTraining places restricted Regional allocation – 1-2 places per regionRegional allocation – 1-2 places per region How selected?How selected?
  36. 36. Trainee Selection No evidence-based method for reliablyNo evidence-based method for reliably selecting those with the greatest potential ofselecting those with the greatest potential of developing ERCP-related skillsdeveloping ERCP-related skills Can be Top Down – regulated – restricted slotsCan be Top Down – regulated – restricted slots or Bottom Up – free marketor Bottom Up – free market It is not yet possible to determine which modelIt is not yet possible to determine which model will predominatewill predominate
  37. 37. Mode of Training Current ERCP training isCurrent ERCP training is haphazardhaphazard CCT currently gives no indication of eitherCCT currently gives no indication of either exposure to or level of competence at ERCPexposure to or level of competence at ERCP An alternative model is suggestedAn alternative model is suggested Concept ofConcept of ‘fellowship’ in specialised‘fellowship’ in specialised endoscopyendoscopy training – 6-12 months of 6-7training – 6-12 months of 6-7 weekly sessions of specialist endoscopy –weekly sessions of specialist endoscopy – across the network – integral part of STacross the network – integral part of ST
  38. 38. Trainer Requirements Criteria for ERCP trainer endoscopists :Criteria for ERCP trainer endoscopists : Participation in at least 75 procedures per yearParticipation in at least 75 procedures per year Working in a network with a workload ofWorking in a network with a workload of averaging over 150 procedures per yearaveraging over 150 procedures per year Continuous auditContinuous audit  complication rates of < 5%complication rates of < 5% >>90%90% completion of intended therapy @ level 1completion of intended therapy @ level 1 Faculty or Observer at ERCP Training EventsFaculty or Observer at ERCP Training Events outside own network at least once every 5 yrs.outside own network at least once every 5 yrs.
  39. 39. Progress and Status of Recommendations
  40. 40. PROGRESS Full document nowFull document now approvedapproved by:-by:- Endoscopy CommitteeEndoscopy Committee BSG CouncilBSG Council Royal College of RadiologistsRoyal College of Radiologists AUGISAUGIS So nowSo now endorsedendorsed byby the JAGthe JAG Will shortly appear on BSG and JAGWill shortly appear on BSG and JAG websiteswebsites
  41. 41. Next Steps TRAININGTRAINING *Strategy document now submitted now to*Strategy document now submitted now to SACsSACs in Gastro., Surgery and Radiologyin Gastro., Surgery and Radiology *SACs – to report back:-*SACs – to report back:- ‘‘upwards’upwards’ - to Joint Training Boards (eg JRCPTB)- to Joint Training Boards (eg JRCPTB) ‘‘downwards’downwards’ - to the JAG (‘sideways’ actually!)- to the JAG (‘sideways’ actually!) *Recommendations to be forwarded to PMETB.*Recommendations to be forwarded to PMETB. In particular, the 6In particular, the 6 or 12 month ‘fellowship’ training periods need to be includedor 12 month ‘fellowship’ training periods need to be included (and thus funded by PMETB) as a standard option in the later(and thus funded by PMETB) as a standard option in the later years of Higher Specialist Training for appropriate traineesyears of Higher Specialist Training for appropriate trainees
  42. 42. Next Steps SERVICESERVICE The JAG:-The JAG:- Now incorporatesNow incorporates all the service standards intoall the service standards into its accreditation criteria of Endoscopy Unitsits accreditation criteria of Endoscopy Units NotesNotes that the methodology used in a complexthat the methodology used in a complex area of specialist endoscopy can equally bearea of specialist endoscopy can equally be applied to other areas of specialist endoscopyapplied to other areas of specialist endoscopy in need of similar reviewin need of similar review
  43. 43. SUMMARY Considerable progress achieved in the last 2-3Considerable progress achieved in the last 2-3 years:-years:- We now know what goes on in ERCPWe now know what goes on in ERCP We have set credible standards both for serviceWe have set credible standards both for service and trainingand training We have set a framework for the future of bothWe have set a framework for the future of both But this is just the first few steps –But this is just the first few steps – more needed!more needed!
  44. 44. ERCP – A vision of the future?
  45. 45. SpRRep Bored nurses Ageing Stressed consultant TEAMWORK

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