Implementation of Video Laryngoscope-Assisted Coaching Reduces Adverse Tracheal Intubation-Associated Events in the PICU.

OBJECTIVES: To evaluate implementation of a video laryngoscope (VL) as a coaching device to reduce adverse tracheal intubation associated events (TIAEs). DESIGN: Prospective multicenter interventional quality improvement study. SETTING: Ten PICUs in North America. PATIENTS: Patients undergoing tracheal intubation in the PICU. INTERVENTIONS: VLs were implemented as coaching devices with standardized coaching language between 2016 and 2020. Laryngoscopists were encouraged to perform direct laryngoscopy with video images only available in real-time for experienced supervising clinician-coaches. MEASUREMENTS AND MAIN RESULTS: The primary outcome was TIAEs. Secondary outcomes included severe TIAEs, severe hypoxemia (oxygen saturation < 80%), and first attempt success. Of 5,060 tracheal intubations, a VL was used in 3,580 (71%). VL use increased from baseline (29.7%) to implementation phase (89.4%; p < 0.001). VL use was associated with lower TIAEs (VL 336/3,580 [9.4%] vs standard laryngoscope [SL] 215/1,480 [14.5%]; absolute difference, 5.1%; 95% CI, 3.1-7.2%; p < 0.001). VL use was associated with lower severe TIAE rate (VL 3.9% vs SL 5.3%; p = 0.024), but not associated with a reduction in severe hypoxemia (VL 15.7% vs SL 16.4%; p = 0.58). VL use was associated with higher first attempt success (VL 71.8% vs SL 66.6%; p < 0.001). In the primary analysis after adjusting for site clustering, VL use was associated with lower adverse TIAEs (odds ratio [OR], 0.61; 95% CI, 0.46-0.81; p = 0.001). In secondary analyses, VL use was not significantly associated with severe TIAEs (OR, 0.72; 95% CI, 0.44-1.19; p = 0.20), severe hypoxemia (OR, 0.95; 95% CI, 0.73-1.25; p = 0.734), or first attempt success (OR, 1.28; 95% CI, 0.98-1.67; p = 0.073). After further controlling for patient and provider characteristics, VL use was independently associated with a lower TIAE rate (adjusted OR, 0.65; 95% CI, 0.49-0.86; p = 0.003). CONCLUSIONS: Implementation of VL-assisted coaching achieved a high level of adherence across the PICUs. VL use was associated with reduced adverse TIAEs.

Transfusion medicine curricular content for general pediatricians and pediatric subspecialists: A national multi-specialty Delphi consensus study.

BACKGROUND: Although pediatric residents frequently order blood products, transfusion medicine (TM) education is both limited and unstandardized during postgraduate training. Using Delphi methodology, this study aimed to identify and prioritize which pediatric TM curricular topics are most important to inform postgraduate training in TM for general pediatricians and pediatric subspecialists. METHODS: A national panel of experts iteratively rated potential curricular topics, on a 5-point scale, to determine their priority for inclusion within a TM curriculum. After each round, responses were analyzed. Topics receiving a mean rating <3/5 were removed from subsequent rounds and remaining topics were resent to the panel for further ratings until consensus was achieved, defined as Cronbach α ≥ 0.95. At conclusion of the Delphi process, topics rated ≥4/5 were considered core curricular topics, while topics rated ≥3 to <4 were considered extended topics. RESULTS: Forty-five TM experts from 17 Canadian institutions and 12 subspecialties completed the first Delphi round and 31 completed the second. Fifty-seven potential curricular topics were generated from a systematic literature review and Delphi panelists. Two survey rounds were completed before consensus was achieved. Seventy-three topics in six domains reached consensus: 31 core curricular topics and 42 extended topics. There were no significant differences in ratings between TM and non-TM specialists. DISCUSSION: A multispecialty Delphi panel reached consensus in identification of curricular topics for pediatric resident physicians. These results set the stage to develop a pediatric TM curriculum that will be foundational for pediatric trainees to enhance learning and improve transfusion safety.

Accuracy of self-assessment in gastrointestinal endoscopy: a systematic review and meta-analysis.

BACKGROUND: Assessment is necessary to ensure both attainment and maintenance of competency in gastrointestinal (GI) endoscopy, and this can be accomplished through self-assessment. We conducted a systematic review with meta-analysis to evaluate the accuracy of self-assessment among GI endoscopists. METHODS: This was an individual participant data meta-analysis of studies that investigated self-assessment of endoscopic competency. We performed a systematic search of the following databases: Ovid MEDLINE, Ovid EMBASE, Wiley Cochrane CENTRAL, and ProQuest Education Resources Information Center. We included studies if they were primary investigations of self-assessment accuracy in GI endoscopy that used statistical analyses to determine accuracy. We conducted a meta-analysis of studies using a limits of agreement (LoA) approach to meta-analysis of Bland-Altman studies. RESULTS: After removing duplicate entries, we screened 7138 records. After full-text review, we included 16 studies for qualitative analysis and three for meta-analysis. In the meta-analysis, we found that the LoA were wide (-41.0 % to 34.0 %) and beyond the clinically acceptable difference. Subgroup analyses found that both novice and intermediate endoscopists had wide LoA (-45.0 % to 35.1 % and -54.7 % to 46.5 %, respectively) and expert endoscopists had narrow LoA (-14.2 % to 21.4 %). CONCLUSIONS: GI endoscopists are inaccurate in self-assessment of their endoscopic competency. Subgroup analyses demonstrated that novice and intermediate endoscopists were inaccurate, while expert endoscopists have accurate self-assessment. While we advise against the sole use of self-assessment among novice and intermediate endoscopists, expert endoscopists may wish to integrate it into their practice.

Validity evidence for observational ERCP competency assessment tools: a systematic review.

BACKGROUND : Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is critical for supporting learning and documenting attainment of skill. Validity evidence supporting ERCP observational assessment tools has not been systematically evaluated. METHODS : We conducted a systematic search using electronic databases and hand-searching from inception until August 2021 for studies evaluating observational assessment tools of ERCP performance. We used a unified validity framework to characterize validity evidence from five sources: content, response process, internal structure, relations to other variables, and consequences. Each domain was assigned a score of 0-3 (maximum score 15). We assessed educational utility and methodological quality using the Accreditation Council for Graduate Medical Education framework and the Medical Education Research Quality Instrument, respectively. RESULTS : From 2769 records, we included 17 studies evaluating 7 assessment tools. Five tools were studied for clinical ERCP, one for simulated ERCP, and one for simulated and clinical ERCP. Validity evidence scores ranged from 2 to 12. The Bethesda ERCP Skills Assessment Tool (BESAT), ERCP Direct Observation of Procedural Skills Tool (ERCP DOPS), and The Endoscopic Ultrasound (EUS) and ERCP Skills Assessment Tool (TEESAT) had the strongest validity evidence, with scores of 10, 12, and 11, respectively. Regarding educational utility, most tools were easy to use and interpret, and required minimal additional resources. Overall methodological quality (maximum score 13.5) was strong, with scores ranging from 10 to 12.5. CONCLUSIONS : The BESAT, ERCP DOPS, and TEESAT had strong validity evidence compared with other assessments. Integrating tools into training may help drive learners' development and support competency decision making.

The Toronto Upper Gastrointestinal Cleaning Score: a prospective validation study.

BACKGROUND : Assessment of mucosal visualization during esophagogastroduodenoscopy (EGD) can be improved with a standardized scoring system. To address this need, we created the Toronto Upper Gastrointestinal Cleaning Score (TUGCS). METHODS : We developed the TUGCS using Delphi methodology, whereby an international group of endoscopy experts iteratively rated their agreement with proposed TUGCS items and anchors on a 5-point Likert scale. After each Delphi round, we analyzed responses and refined the TUGCS using an 80 % agreement threshold for consensus. We used the intraclass correlation coefficient (ICC) to assess inter-rater and test-retest reliability. We assessed internal consistency with Cronbach's alpha and item-total and inter-item correlations with Pearson's correlation coefficient. We compared TUGCS ratings with an independent endoscopist's global rating of mucosal visualization using Spearman's ρ. RESULTS : We achieved consensus with 14 invited participants after three Delphi rounds. Inter-rater reliability was high at 0.79 (95 %CI 0.64-0.88). Test-retest reliability was excellent at 0.83 (95 %CI 0.77-0.87). Cronbach's α was 0.81, item-total correlation range was 0.52-0.70, and inter-item correlation range was 0.38-0.74. There was a positive correlation between TUGCS ratings and a global rating of visualization (r = 0.41, P = 0.002). TUGCS ratings for EGDs with global ratings of excellent were significantly higher than those for EGDs with global ratings of fair (P = 0.01). CONCLUSION : The TUGCS had strong evidence of validity in the clinical setting. The international group of assessors, broad variety of EGD indications, and minimal assessor training improves the potential for dissemination.

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.

Musculoskeletal injury and ergonomics in pediatric gastrointestinal endoscopic practice.

BACKGROUND AND AIMS: Endoscopy-related musculoskeletal injuries (ERI) are increasingly prevalent in adult endoscopists; however, there are no studies that have evaluated ERI and ergonomic practices among pediatric gastroenterologists and trainees. We aimed to examine the prevalence, nature, and impact of musculoskeletal injuries in pediatric endoscopic practice and assess attitudes towards ergonomic training needs. METHODS: Pediatric gastroenterologists and trainees were surveyed to collect information on endoscopist and practice characteristics, the prevalence, nature, and impacts of ERI, ergonomics strategies employed in practice, previous ergonomics training, and perceptions of ergonomics training (elicited using a 1 (strongly disagree) to 5 (strongly agree) Likert scale). Responses were analyzed using descriptive statistics, and bivariate analyses were conducted to explore correlates of ERI. RESULTS: Among 146 survey respondents, 50 (34.2%) were trainees and 96 (65.8%) were practicing endoscopists with a mean duration of endoscopic practice of 9.7 ± 9.4 years. Overall, 55.6% (n = 80/144) reported experiencing a musculoskeletal injury, with 34.7% (n = 50/144) reporting an injury attributable to endoscopy. Among those with ERI, the most common sites were the neck/upper back (44.0%), thumb (42.0%), hand/finger (38.0%), and lower back (36.0%). Women were more likely to experience ERI compared to men (43.4% vs. 23.4%; p = 0.013). Only 20.9% of participants had formal training in ergonomics. Respondents reported being motivated to implement practice changes to prevent ERI (4.41 ± 0.95) and perceived ergonomics training as important (4.37 ± 0.96). CONCLUSIONS: Pediatric endoscopists, and particularly women, experience significant ERI; however, formal endoscopy ergonomics training is rare. Improved ergonomics training is needed for both practicing pediatric gastroenterologists and trainees.

The influence of resident and faculty gender on assessments in anesthesia competency-based medical education.

PURPOSE: Competency-based medical education (CBME) relies on frequent workplace-based assessments of trainees, providing opportunities for conscious and implicit biases to reflect in these assessments. We aimed to examine the influence of resident and faculty gender on performance ratings of residents within a CBME system. METHODS: This retrospective cohort study took place from August 2017 to January 2021 using resident assessment data from two workplace-based assessments: the Anesthesia Clinical Encounter Assessment (ACEA) and Entrustable Professional Activities (EPAs). Self-reported gender data were also extracted. The primary outcome-gender-based differences in entrustment ratings of residents on the ACEA and EPAs-was evaluated using mixed-effects logistic regression, with differences reported through odds ratios and confidence intervals (α = 0.01). Gender-based differences in the receipt of free-text comments on the ACEA and EPAs were also explored. RESULTS: In total, 14,376 ACEA and 4,467 EPA assessments were analyzed. There were no significant differences in entrustment ratings on either assessment tool between men and women residents. Regardless of whether assessments were completed by men or women faculty, entrustment rates between men and women residents were not significantly different for any postgraduate year level. Additionally, men and women residents received strengths-related and actions-related comments on both assessments at comparable frequencies, irrespective of faculty gender. CONCLUSION: We found no gender-based differences in entrustment ratings for both the ACEA and EPAs, which suggests an absence of resident gender bias within this CBME system. Given considerable heterogeneity in rater leniency, future work would be strengthened by using rater leniency-adjusted scores rather than raw scores.

RéSUMé: OBJECTIF: La formation médicale fondée sur les compétences (FMFC) repose sur des évaluations fréquentes des stagiaires en milieu de travail, ce qui donne l'occasion de refléter les préjugés conscients et implicites dans ces évaluations. Notre objectif était d'examiner l'influence du genre des résident·es et des professeur·es sur les évaluations de la performance des résident·es au sein d'un système de FMFC. MéTHODE: Cette étude de cohorte rétrospective s'est déroulée d'août 2017 à janvier 2021 à l'aide des données d'évaluation des résident·es provenant de deux évaluations en milieu de travail : L'évaluation de l'anesthésie clinique par événement (ACEA ­ Anesthesia Clinical Encounter Assessment) et les Actes professionnels non supervisés (APNS). Des données autodéclarées sur le genre ont également été extraites. Le critère d'évaluation principal, soit les différences fondées sur le genre dans les cotes de confiance des résident·es sur l'ACEA et les APNS, a été évalué à l'aide d'une régression logistique à effets mixtes, les différences étant rapportées par les rapports de cotes et les intervalles de confiance (α = 0,01). Les différences fondées sur le genre dans la réception des commentaires en texte libre sur l'ACEA et les APNS ont également été explorées. RéSULTATS: Au total, 14 376 évaluations ACEA et 4467 évaluations APNS ont été analysées. Il n'y avait pas de différences significatives dans les cotes de confiance obtenues avec l'un ou l'autre des outils d'évaluation entre les résidents et les résidentes. Indépendamment du genre de la personne réalisant l'évaluation, les taux de confiance entre les résidentes et les résidents n'étaient pas significativement différents pour toutes les années de formation postdoctorale. De plus, les résident·es ont reçu des commentaires liés à leurs forces et leurs actes sur les deux évaluations à des fréquences comparables, quel que soit le genre du corps professoral. CONCLUSION: Nous n'avons constaté aucune différence fondée sur le genre dans les cotes de confiance telles qu'évaluées par les ACEA et les APNS, ce qui suggère une absence de préjugés genrés envers les résident·es au sein de ce système de FMFC. Compte tenu de l'hétérogénéité considérable en matière de clémence des évaluateurs et évaluatrices, les travaux futurs seraient plus fiables s'ils utilisaient des scores ajustés en fonction de ladite clémence plutôt que des scores bruts.

Pediatric Endoscopy Quality Improvement Network (PEnQuIN) quality standards and indicators for pediatric endoscopy: an ASGE-endorsed guideline.

BACKGROUND AND AIMS: Current endoscopy quality guidelines largely focus on cancer screening-related metrics that are not applicable to pediatric populations. Through an international Pediatric Endoscopy Quality Improvement Network (PEnQuIN), quality standards and indicators for pediatric endoscopic procedures were developed and endorsed by the American Society for Gastrointestinal Endoscopy (ASGE). METHODS: The Appraisal of Guidelines for REsearch and Evaluation II instrument guided PEnQuIN members, from 31 centers representing 11 countries, in generating and refining proposed quality standards and indicators. Quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development, and Evaluation approach. Consensus on reporting elements was sought with an iterative online Delphi process. RESULTS: Forty-nine quality standards and 47 indicators, encompassing pediatric endoscopy facilities, procedures, and endoscopists, as well as 30 reporting elements essential for inclusion within a pediatric endoscopy report reached consensus. Minimal acceptable standards were defined for 3 key indicators related to pediatric lower endoscopy: terminal ileal intubation rate ≥85%, cecal intubation rate ≥90%, and rate of adequate bowel preparation ≥80%. There was strong consensus that terminal ileal intubation, rather than cecal intubation, is integral to ensuring high-quality endoscopic care in children. CONCLUSIONS: The PEnQuIN guidelines establish international agreement on clinically meaningful metrics tailored to pediatric endoscopy that can be used to promote safe, high-quality, patient- and family-centered endoscopic care. Moving forward, it is recommended that all providers and facilities involved in endoscopy service for children adopt the PEnQuIN standards, indicators, and key reporting elements outlined in these ASGE-endorsed guidelines.

Evolution of International Pediatric Endoscopic Practice Changes During the Coronavirus Disease 2019 Pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has drastically altered endoscopic practices. We initially reported the international impact of COVID-19 on pediatric endoscopic practice. This follow-up study aimed to assess changes 7 months following the initial survey to delineate practice change patterns as the pandemic evolved. METHODS: Pediatric gastroenterologists who responded to the initial survey were re-surveyed seven months later using Research Electronic Data Capture (REDCap). The survey recorded information on changes in pediatric endoscopic practice patterns, including COVID-19 screening and testing processes and personal protective equipment (PPE) utilization. Additionally, endoscopists' risk tolerance of COVID-19 transmission was evaluated. RESULTS: Seventy-five unique institutions from 21 countries completed surveys from the 145 initial responses (51.7% response rate). Procedural volumes increased at most institutions (70.7%) and most were performing previously postponed cases (90.7%). Ninety-seven percent of institutions were performing pre-endoscopy screening with 78.7% testing all patients. Many institutions (34.7%) have performed procedures on COVID-19 positive patients. There was significantly less PPE reuse (P  < 0.05) and fewer institutions recommending full PPE for all endoscopies (43.2% vs 59.2%, P = 0.013). Overall, pediatric endoscopists' risk tolerance of COVID-19 transmission is low. CONCLUSIONS: This is the first survey to highlight the evolution of pediatric endoscopic practices related to the COVID-19 pandemic, underscoring the need for ongoing pandemic-related guidance for pediatric endoscopic practice.

Postpyloric Feeding Access in Infants and Children: A State of the Art Review.

Achieving postpyloric feeding access is a clinical challenge faced by the pediatric gastroenterologist in everyday practice. Currently, there is limited literature published on the topic. This article provides a practical summary of the literature on the different methods utilized to achieve postpyloric feeding access including bedside, fluoroscopic, endoscopic and surgical options. Indications and complications of these methods are discussed as well as a general approach to infants and children that require intestinal feeding.

Overview of the Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopy: A Joint NASPGHAN/ESPGHAN Guideline.

INTRODUCTION: Pediatric-specific quality standards for endoscopy are needed to define best practices, while measurement of associated indicators is critical to guide quality improvement. The international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) working group was assembled to develop and define quality standards and indicators for pediatric gastrointestinal endoscopic procedures through a rigorous guideline consensus process. METHODS: The Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument guided PEnQuIN members, recruited from 31 centers of various practice types representing 11 countries, in generating and refining proposed quality standards and indicators. Consensus was sought via an iterative online Delphi process, and finalized at an in-person conference. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. RESULTS: Forty-nine quality standards and 47 indicators reached consensus, encompassing pediatric endoscopy facilities, procedures, endoscopists, and the patient experience. The evidence base for PEnQuIN standards and indicators was largely adult-based and observational, and downgraded for indirectness, imprecision, and study limitations to "very low" quality, resulting in "conditional" recommendations for most standards (45/49). CONCLUSIONS: The PEnQuIN guideline development process establishes international agreement on clinically meaningful metrics that can be used to promote safety and quality in endoscopic care for children. Through PEnQuIN, pediatric endoscopists and endoscopy services now have a framework for auditing, providing feedback, and ultimately, benchmarking performance. Expansion of evidence and prospective validation of PEnQuIN standards and indicators as predictors of clinically relevant outcomes and high-quality pediatric endoscopic care is now a research priority.

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

INTRODUCTION: There is increasing international recognition of the impact of variability in endoscopy facilities on procedural quality and outcomes. There is also growing precedent for assessing the quality of endoscopy facilities at regional and national levels by using standardized rating scales to identify opportunities for improvement. 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 facilities where endoscopic care is provided to children. Consensus was reached via an iterative online Delphi process and subsequent in-person meeting. 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 27 standards for facilities supporting pediatric endoscopy, as well 10 indicators that can be used to identify high-quality endoscopic care in children. These standards were subcategorized into three subdomains: Quality of Clinical Operations (15 standards, 5 indicators); Patient and Caregiver Experience (9 standards, 5 indicators); and Workforce (3 standards). DISCUSSION: The rigorous PEnQuIN process successfully yielded standards and indicators that can be used to universally guide and measure high-quality facilities for procedures around the world where endoscopy is performed in children. It also underscores the current paucity of evidence for pediatric endoscopic care processes, and the need for research into this clinical area.

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.

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.

Pediatric Endoscopy Quality Improvement Network Pediatric Endoscopy Reporting Elements: A Joint NASPGHAN/ESPGHAN Guideline.

INTRODUCTION: High-quality procedure reports are a cornerstone of high-quality pediatric endoscopy as they ensure the clear communication of procedural events and outcomes, guide patient care and facilitate continuous quality improvement. The aim of this document is to outline standardized reporting elements that achieved international consensus as requirements for high-quality pediatric endoscopy procedure reports. 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 Delphi methodology to identify key elements that should be found in all pediatric endoscopy reports. Item reduction was attained through iterative rounds of anonymized online voting using a 6-point scale. Responses were analyzed after each round and items were excluded from subsequent rounds if ≤50% of panelists rated them as 5 ("agree moderately") or 6 ("agree strongly"). Reporting elements that ≥70% of panelists rated as "agree moderately" or "agree strongly" were considered to have achieved consensus. RESULTS: Twenty-six PEnQuIN group members from 25 centers internationally rated 63 potential reporting elements that were generated from a systematic literature review and the Delphi panelists. The response rates were 100% for all three survey rounds. Thirty reporting elements reached consensus as essential for inclusion within a pediatric endoscopy report. DISCUSSION: It is recommended that the PEnQuIN Reporting Elements for pediatric endoscopy be universally employed across all endoscopists, procedures and facilities as a foundational means of ensuring high-quality endoscopy services, while facilitating quality improvement activities in pediatric endoscopy.

Validity evidence for the Anesthesia Clinical Encounter Assessment (ACEA) tool to support competency-based medical education.

BACKGROUND: Workplace-based assessment (WBA) is key to a competency-based assessment strategy. Concomitantly with our programme's launch of competency-based medical education, we developed an entrustment-based WBA, the Anesthesia Clinical Encounter Assessment (ACEA), to assess readiness for independent practice of competencies essential to perioperative patient care. This study aimed to examine validity evidence of the ACEA during postgraduate anaesthesiology training. METHODS: The ACEA comprises an eight-item global rating scale (GRS), an overall independence rating, an eight-item checklist, and case details. ACEA data were extracted for University of Toronto anaesthesia residents from July 2017 to January 2020 from the programme's online assessment portal. Validity evidence was generated following Messick's validity framework, including response process, internal structure, relations with other variables, and consequences. RESULTS: We analysed 8664 assessments for 137 residents completed by 342 assessors. From generalisability analysis, 10 independent observations (two assessments each from five assessors) were sufficient to achieve a reliability threshold of ≥0.70 for in-training assessments. A composite GRS score of 3.65/5 provided optimal sensitivity (93.6%) and specificity (90.8%) for determining entrustment on receiver operator characteristic curve analysis. Test-retest reliability was high (intraclass correlation coefficient [ICC2,1]=0.81) for matched assessments within 14 days of each other. Composite GRS scores differed significantly between residents based on their training level (P<0.0001) and correlated highly with overall independence (0.91, P<0.001). The internal consistency of the GRS (α=0.96) was excellent. CONCLUSIONS: This study supports the validity of the ACEA for assessing the competence of residents performing perioperative care and supports its use in competency-based anaesthesiology training.

A prospective observational study of video laryngoscopy-guided coaching in the pediatric intensive care unit.

BACKGROUND: There are limited data on the use of video laryngoscopy for pediatric patients outside of the operating room. AIM: Our primary aim was to evaluate whether implementation of video laryngoscopy-guided coaching for tracheal intubation is feasible with a high level of compliance and associated with a reduction in adverse tracheal intubation-associated events. METHODS: This is a pre-post observational study of video laryngoscopy implementation with standardized coaching language for tracheal intubation in a single-center, pediatric intensive care unit. The use of video laryngoscopy as a coaching device with standardized coaching language was implemented as a part of practice improvement. All patients in the pediatric intensive care unit were included between January 2016 and December 2017 who underwent primary tracheal intubation with either video laryngoscopy or direct laryngoscopy. The uptake of the implementation, sustained compliance, tracheal intubation outcomes including all adverse tracheal intubation-associated events, oxygen desaturations (<80% SpO2), and first attempt success were measured. RESULTS: Among 580 tracheal intubations, 284 (49%) were performed during the preimplementation phase, and 296 (51%) postimplementation. Compliance for the use of video laryngoscopy with standardized coaching language was high (74% postimplementation) and sustained. There were no statistically significant differences in adverse tracheal intubation-associated events between the two phases (pre- 9% vs. post- 5%, absolute difference -3%, CI95 : -8% to 1%, p = .11), oxygen desaturations <80% (pre- 13% vs. post- 13%, absolute difference 1%, CI95 : -6% to 5%, p = .75), or first attempt success (pre- 73% vs. post- 76%, absolute difference 4%, CI95 : -3% to 11%, p = .29). Supervisors were more likely to use the standardized coaching language when video laryngoscopy was used for tracheal intubation than with standard direct laryngoscopy (80% vs. 43%, absolute difference 37%, CI95 : 23% to 51%, p < .001). CONCLUSIONS: Implementation of video laryngoscopy as a supervising device with standardized coaching language was feasible with high level of adherence, yet not associated with an increased occurrence of any adverse tracheal intubation-associated events and oxygen desaturation.

Development of the Diabetic Wound Assessment Learning Tool (DiWALT) and validity evidence.

OBJECTIVE: Diabetic foot wounds account for up to one-third of diabetes-related health care expenditure and are the greatest cause of extremity amputation in Canada. Physicians encounter patients with such wounds in all specialties, particularly as generalists in medical wards and emergency departments. However, there is a dearth of literature on the optimal way to teach and to assess the management of these patients. Given the importance of assessment for learning in the shift toward competency-based medical education, we aimed to develop an assessment tool and to build validity evidence for its use in this context. METHODS: A consensus process involving nine Canadian experts in diabetic wound management was used to develop the Diabetic Wound Assessment Learning Tool (DiWALT) items and two 10-minute simulation-based testing scenarios. The simulators used were modified from commercially available models to serve the testing scenarios. Validity evidence for the DiWALT was subsequently evaluated by assessing 24 physician participants' performance during the two scenarios. All participants were novices (<50 cases managed). Two assessors independently rated participants using the DiWALT. Evidence was organized using Kane's validity framework and included Cronbach α for interitem consistency as well as test-retest and inter-rater reliability using the intra-class correlation coefficient (ICC). RESULTS: Cronbach α was 0.92, implying high internal consistency. Test-retest reliability was also excellent with ICC of 0.89 (confidence interval [CI], 0.76-0.95) for single measures and ICC of 0.94 (CI, 0.86-0.98) for average measures. Inter-rater reliability was fair for single measures with ICC of 0.68 (CI, 0.65-0.71) and good for average measures with ICC of 0.81 (CI, 0.79-0.83). CONCLUSIONS: These results demonstrate that the DiWALT consistently and reliably evaluates competence in diabetic wound management during simulated cases using a small, homogeneous sample of physicians. Further work is necessary to quantify sources of error in the assessment scores, to establish validity evidence when it is used to assess larger and more heterogeneous participants, and to identify how well the DiWALT differentiates between different experience levels.

Development and initial validation of an instrument for video-based assessment of technical skill in ERCP.

BACKGROUND AND AIMS: The accurate measurement of technical skill in ERCP is essential for endoscopic training, quality assurance, and coaching of this procedure. Hypothesizing that technical skill can be measured by analysis of ERCP videos, we aimed to develop and validate a video-based ERCP skill assessment tool. METHODS: Based on review of procedural videos, the task of ERCP was deconstructed into its basic components by an expert panel that developed an initial version of the Bethesda ERCP Skill Assessment Tool (BESAT). Subsequently, 2 modified Delphi panels and 3 validation exercises were conducted with the goal of iteratively refining the tool. Fully crossed generalizability studies investigated the contributions of assessors, ERCP performance, and technical elements to reliability. RESULTS: Twenty-nine technical elements were initially generated from task deconstruction. Ultimately, after iterative refinement, the tool comprised 6 technical elements and 11 subelements. The developmental process achieved consistent improvements in the performance characteristics of the tool with every iteration. For the most recent version of the tool, BESAT-v4, the generalizability coefficient (a reliability index) was .67. Most variance in BESAT scores (43.55%) was attributed to differences in endoscopists' skill, indicating that the tool can reliably differentiate between endoscopists based on video analysis. CONCLUSIONS: Video-based assessment of ERCP skill appears to be feasible with a novel instrument that demonstrates favorable validity evidence. Future steps include determining whether the tool can discriminate between endoscopists of varying experience levels and predict important outcomes in clinical practice.