Development of the "Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills" (TEAM-ENTS) behavioral marker system.

BACKGROUND: Non-technical skills (NTS) are integral to team performance and subsequent quality and safety of care. Behavioral marker systems (BMSs) are now increasingly used in healthcare to support the training and assessment of team NTS. Within gastrointestinal endoscopy, this is an area of novel research. The aims of this study were to define the core relevant NTS for endoscopy teams and develop a preliminary framework for a team-based BMS known as TEAM-ENTS (Teamwork in Endoscopy Assessment Module for Endoscopic Non-Technical Skills). METHODS: This study was conducted in two phases. In phase 1, a literature review of team-based BMSs was performed to inform an interview study of core endoscopy team members. Cognitive task analysis was used to break down the NTS relevant to endoscopy teams. Framework analysis generated the structure for the preliminary TEAM-ENTS framework. In phase 2, a modified Delphi process was undertaken to refine the items of the framework. RESULTS: Seven consultant endoscopists and six nurses were interviewed. The final coding framework consisted of 88 codes grouped into five overarching categories. In total, 58 participants were recruited to the Delphi panel. In the first round, nine elements and 37 behavioral descriptors did not meet consensus. Following item adjustment, merging and deletion, all remaining items met consensus thresholds after the second round. The refined TEAM-ENTS BMS consists of five categories, 16 elements, and 47 behavioral descriptors. CONCLUSIONS: The refined TEAM-ENTS behavioral marker system was developed to reflect the core NTS relevant to endoscopy teams. Future studies will aim to fully validate this tool.

Evaluation of a real-time computer-aided polyp detection system during screening colonoscopy: AI-DETECT study.

BACKGROUND: Polyp detection and resection during colonoscopy significantly reduce long-term colorectal cancer risk. Computer-aided detection (CADe) may increase polyp identification but has undergone limited clinical evaluation. Our aim was to assess the effectiveness of CADe at colonoscopy within a bowel cancer screening program (BCSP). METHODS: This prospective, randomized controlled trial involved all eight screening-accredited colonoscopists at an English National Health Service (NHS) BCSP center (February 2020 to December 2021). Patients were randomized to CADe or standard colonoscopy. Patients meeting NHS criteria for bowel cancer screening were included. The primary outcome of interest was polyp detection rate (PDR). RESULTS: 658 patients were invited and 44 were excluded. A total of 614 patients were randomized to CADe (n = 308) or standard colonoscopy (n = 306); 35 cases were excluded from the per-protocol analysis due to poor bowel preparation (n = 10), an incomplete procedure (n = 24), or a data issue (n = 1). Endocuff Vision was frequently used and evenly distributed (71.7 % CADe and 69.2 % standard). On intention-to-treat (ITT) analysis, there was a borderline significant difference in PDR (85.7 % vs. 79.7 %; P = 0.05) but no significant difference in adenoma detection rate (ADR; 71.4 % vs. 65.0 %; P = 0.09) for CADe vs. standard groups, respectively. On per-protocol analysis, no significant difference was observed in these rates. There was no significant difference in procedure times. CONCLUSIONS: In high-performing colonoscopists in a BCSP who routinely used Endocuff Vision, CADe improved PDR but not ADR. CADe appeared to have limited benefit in a BCSP setting where procedures are performed by experienced colonoscopists.

Implementation of optical diagnosis with a "resect and discard" strategy in clinical practice: DISCARD3 study.

BACKGROUND AND AIMS: Optical diagnosis (OD) of polyps can be performed with advanced endoscopic imaging. For high-confidence diagnoses, a "resect and discard" strategy could offer significant histopathology time and cost savings. The implementation threshold is a ≥90% OD-histology surveillance interval concordance. Here we assessed the OD learning curve and feasibility of a resect and discard strategy for ≤5-mm and <10-mm polyps in a bowel cancer screening setting. METHODS: In this prospective feasibility study, 8 bowel cancer screening endoscopists completed a validated OD training module and performed procedures. All <10-mm consecutive polyps had white-light and narrow-band images taken and were given high- or low-confidence diagnoses until 120 high-confidence ≤5-mm polyp diagnoses had been performed. All polyps had standard histology. High-confidence OD errors underwent root-cause analysis. Histology and OD-derived surveillance intervals were calculated. RESULTS: Of 565 invited patients, 525 patients were included. A total of 1560 <10-mm polyps underwent OD and were resected and retrieved (1329 ≤5 mm and 231 6-9 mm). There were no <10-mm polyp cancers. High-confidence OD was accurate in 81.5% of ≤5-mm and 92.8% of 6-9-mm polyps. Sensitivity for OD of a ≤5-mm adenoma was 93.0% with a positive predictive value of 90.8%. OD-histology surveillance interval concordance for ≤5-mm OD was 91.3% (209/229) for U.S. Multi-Society Task Force, 98.3% (225/229) for European Society of Gastrointestinal Endoscopy, and 98.7% (226/229) for British Society of Gastroenterology guidelines, respectively. CONCLUSIONS: A resect and discard strategy for high-confidence ≤5-mm polyp OD in a group of bowel cancer screening colonoscopists is feasible and safe, with performance exceeding the 90% surveillance interval concordance required for implementation in clinical practice. (Clinical trial registration number: NCT04710693.).

Lower gastrointestinal polypectomy competencies in the United Kingdom: a retrospective analysis of Directly Observed Polypectomy Skills (DOPyS).

BACKGROUND: Polypectomy is often the most hazardous part of colonoscopy. There is significant variability in polypectomy training and assessment internationally. DOPyS (Directly Observed Polypectomy Skills) is a validated assessment tool and is used to demonstrate polypectomy competency in the UK. This study aimed to describe the learning curve for polypectomy competency in UK trainees. METHODS: Retrospective DOPyS data (January 2009 to September 2015) were obtained from the UK Joint Advisory Group (JAG) for intestinal endoscopy training system (JETS) national database. The number of lower gastrointestinal (LGI) procedures, overall cecal intubation rate (CIR), procedure intensity, and time in days to the first DOPyS assessment were recorded, and time to JAG certification was calculated. RESULTS: 4965 DOPyS assessments from 336 trainees were analyzed. Within the study period, 124 and 53 trainees achieved provisional and full colonoscopy certification, respectively. Trainees started formative assessment of polypectomy after > 130 LGI procedures and with a CIR of > 70 %. Within 3 years from the first DOPyS assessment, 94 % of trainees achieved provisional certification, and 50 % full certification. Higher procedure intensity at baseline DOPyS assessment was associated with a higher likelihood of obtaining certification sooner. CONCLUSION: There is a significant variation in time to competency, and this potentially reflects the time necessary to acquire polypectomy skills. There is a need to start polypectomy training earlier, once sufficient skills, such as tip control, have been achieved to shorten the time to competency. Overall, the CIR could be used as a guide for such technical skills. Increasing exposure to training lists also potentially reduces the time to polypectomy competency.

Impact of a new distal attachment on colonoscopy performance in an academic screening center.

BACKGROUND AND AIMS: Distal attachments placed on the colonoscope tip may positively affect performance by assisting insertion and polyp detection. The original Endocuff (ARC Medical Design, Leeds, United Kingdom) appears to improve adenoma detection rate (ADR), but no data assess the performance of the second-generation Endocuff Vision. METHODS: A pilot service evaluation study (April 2013 to September 2014) was conducted on patients with positive fecal occult blood tests within the National Bowel Cancer Programme during 3 consecutive periods: precuff/no device used, during-cuff/device used, and postcuff/no device used. During the middle period the use of the Endocuff Vision by the 4 screening-accredited colonoscopists was discretional (nonrandomized design). Data were analyzed using pairwise comparisons during the 3 designated periods to examine key performance indicators: adenoma detection, procedural time, sedation requirements, and patient comfort. RESULTS: Four hundred ten complete colonoscopies were performed (137 precuff, 136 cuff, and 137 postcuff period). Overall, there was a notable increase in the mean ADR of 16% (P < .03) and in the mean number adenoma per procedure (MAP) of 83% (P = .007) from precuff to cuff period. The mean cecal intubation time was statistically lower during the cuff period (7 minutes) in relation to the precuff period (8 minutes; reduction of 12.5%, P = .002) and the postcuff period (9 minutes; increase of 28.6%, P = .002). The mean negative colonoscopy withdrawal time was also significantly lower during the cuff period (8 minutes, 30 seconds) when compared with the precuff (12 minutes) or postcuff period (9 minutes, 45 seconds; P ≤ .001). Multivariate regression analysis showed that the use of the Endocuff Vision was not associated with sedation requirements or patient discomfort scores. No adverse events were reported from the use of the Endocuff Vision, although it was electively removed in 6 patients where severe sigmoid colon diverticulosis was encountered and 2 patients because of discomfort during anal insertion. CONCLUSIONS: In this pilot service evaluation study, the use of the Endocuff Vision appears to be associated with an improvement in overall colonoscopy operator performance. We found increased ADR and MAP as well as decreased time for colonoscope insertion and withdrawal time with no increase in sedation requirements or patient discomfort.

The impact of chromoendoscopy for surveillance of the duodenum in patients with MUTYH-associated polyposis and familial adenomatous polyposis.

BACKGROUND AND AIMS: Duodenal polyposis and cancer have become a key issue for patients with familial adenomatous polyposis (FAP) and MUTYH-associated polyposis (MAP). Almost all patients with FAP will develop duodenal adenomas, and 5% will develop cancer. The incidence of duodenal adenomas in MAP appears to be lower than in FAP, but the limited available data suggest a comparable increase in the relative risk and lifetime risk of duodenal cancer. Current surveillance recommendations, however, are the same for FAP and MAP, using the Spigelman score (incorporating polyp number, size, dysplasia, and histology) for risk stratification and determination of surveillance intervals. Previous studies have demonstrated a benefit of enhanced detection rates of adenomas by use of chromoendoscopy both in sporadic colorectal disease and in groups at high risk of colorectal cancer. We aimed to assess the effect of chromoendoscopy on duodenal adenoma detection, to determine the impact on Spigelman stage and to compare this in individuals with known pathogenic mutations in order to determine the difference in duodenal involvement between MAP and FAP. METHODS: A prospective study examined the impact of chromoendoscopy on the assessment of the duodenum in 51 consecutive patients with MAP and FAP in 2 academic centers in the United Kingdom (University Hospital Llandough, Cardiff, and St Mark's Hospital, London) from 2011 to 2014. RESULTS: Enhanced adenoma detection of 3 times the number of adenomas after chromoendoscopy was demonstrated in both MAP (P = .013) and FAP (P = .002), but did not affect adenoma size. In both conditions, there was a significant increase in Spigelman stage after chromoendoscopy compared with endoscopy without dye spray. Spigelman scores and overall adenoma detection was significantly lower in MAP compared with FAP. CONCLUSIONS: Chromoendoscopy improved the diagnostic yield of anomas in MAP and FAP 3-fold, and in both MAP and FAP this resulted in a clinically significant upstaging in Spigelman score. Further studies are required to determine the impact of improved adenoma detection on the management and outcome of duodenal polyposis.

Evaluation of a minimally invasive cell sampling device coupled with assessment of trefoil factor 3 expression for diagnosing Barrett's esophagus: a multi-center case-control study.

BACKGROUND: Barrett's esophagus (BE) is a commonly undiagnosed condition that predisposes to esophageal adenocarcinoma. Routine endoscopic screening for BE is not recommended because of the burden this would impose on the health care system. The objective of this study was to determine whether a novel approach using a minimally invasive cell sampling device, the Cytosponge, coupled with immunohistochemical staining for the biomarker Trefoil Factor 3 (TFF3), could be used to identify patients who warrant endoscopy to diagnose BE. METHODS AND FINDINGS: A case-control study was performed across 11 UK hospitals between July 2011 and December 2013. In total, 1,110 individuals comprising 463 controls with dyspepsia and reflux symptoms and 647 BE cases swallowed a Cytosponge prior to endoscopy. The primary outcome measures were to evaluate the safety, acceptability, and accuracy of the Cytosponge-TFF3 test compared with endoscopy and biopsy. In all, 1,042 (93.9%) patients successfully swallowed the Cytosponge, and no serious adverse events were attributed to the device. The Cytosponge was rated favorably, using a visual analogue scale, compared with endoscopy (p < 0.001), and patients who were not sedated for endoscopy were more likely to rate the Cytosponge higher than endoscopy (Mann-Whitney test, p < 0.001). The overall sensitivity of the test was 79.9% (95% CI 76.4%-83.0%), increasing to 87.2% (95% CI 83.0%-90.6%) for patients with ≥3 cm of circumferential BE, known to confer a higher cancer risk. The sensitivity increased to 89.7% (95% CI 82.3%-94.8%) in 107 patients who swallowed the device twice during the study course. There was no loss of sensitivity in patients with dysplasia. The specificity for diagnosing BE was 92.4% (95% CI 89.5%-94.7%). The case-control design of the study means that the results are not generalizable to a primary care population. Another limitation is that the acceptability data were limited to a single measure. CONCLUSIONS: The Cytosponge-TFF3 test is safe and acceptable, and has accuracy comparable to other screening tests. This test may be a simple and inexpensive approach to identify patients with reflux symptoms who warrant endoscopy to diagnose BE.

The development of a virtual reality training curriculum for colonoscopy.

OBJECTIVES: The development of a structured virtual reality (VR) training curriculum for colonoscopy using high-fidelity simulation. BACKGROUND: Colonoscopy requires detailed knowledge and technical skill. Changes to working practices in recent times have reduced the availability of traditional training opportunities. Much might, therefore, be achieved by applying novel technologies such as VR simulation to colonoscopy. Scientifically developed device-specific curricula aim to maximize the yield of laboratory-based training by focusing on validated modules and linking progression to the attainment of benchmarked proficiency criteria. METHODS: Fifty participants comprised of 30 novices (<10 colonoscopies), 10 intermediates (100 to 500 colonoscopies), and 10 experienced (>500 colonoscopies) colonoscopists were recruited to participate. Surrogates of proficiency, such as number of procedures undertaken, determined prospective allocation to 1 of 3 groups (novice, intermediate, and experienced). Construct validity and learning value (comparison between groups and within groups respectively) for each task and metric on the chosen simulator model determined suitability for inclusion in the curriculum. RESULTS: Eight tasks in possession of construct validity and significant learning curves were included in the curriculum: 3 abstract tasks, 4 part-procedural tasks, and 1 procedural task. The whole-procedure task was valid for 11 metrics including the following: "time taken to complete the task" (1238, 343, and 293 s; P < 0.001) and "insertion length with embedded tip" (23.8, 3.6, and 4.9 cm; P = 0.005). Learning curves consistently plateaued at or beyond the ninth attempt. Valid metrics were used to define benchmarks, derived from the performance of the experienced cohort, for each included task. CONCLUSIONS: A comprehensive, stratified, benchmarked, whole-procedure curriculum has been developed for a modern high-fidelity VR colonoscopy simulator.

JAG consensus statements for training and certification in oesophagogastroduodenoscopy.

Introduction: Training and quality assurance in oesophagogastroduodenoscopy (OGD) is important to ensure competent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for OGD training and certification. Methods: Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted with stakeholder representation from British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on OGD training and certification were formulated following literature review and appraised using Grading of Recommendations Assessment, Development and Evaluation. These were subjected to electronic voting to achieve consensus. Accepted statements were incorporated into the updated certification pathway. Results: In total, 32 recommendation statements were generated for the following domains: definition of competence (4 statements), acquisition of competence (12 statements), assessment of competence (10 statements) and post-certification support (6 statements). The consensus process led to following certification criteria: (1) performing ≥250 hands-on procedures; (2) attending a JAG-accredited basic skills course; (3) attainment of relevant minimal performance standards defined by British Society of Gastroenterology/Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, (4) achieving physically unassisted D2 intubation and J-manoeuvre in ≥95% of recent procedures, (5) satisfactory performance in formative and summative direct observation of procedural skills assessments. Conclusion: The JAG standards for diagnostic OGD have been updated following evidence-based consensus. These standards are intended to support training, improve competency assessment to uphold standards of practice and provide support to the newly-independent practitioner.

Development and validation of a training module on the use of narrow-band imaging in differentiation of small adenomas from hyperplastic colorectal polyps.

BACKGROUND: Experts are accurate in differentiating small adenomas from hyperplastic polyps at colonoscopy by using narrow-band imaging (NBI). OBJECTIVE: To prospectively evaluate the effectiveness of an NBI training module on individuals with varying colonoscopy experience. DESIGN: Prospective educational evaluation study. SETTING: Academic endoscopy unit. PARTICIPANTS: Twenty-one participants of varying colonoscopy experience (novices, trainees, and experienced gastroenterologists) and 5 experts in NBI. INTERVENTION: Participants completed a computer-based test module consisting of 30 NBI polyp images. No feedback was given. They then completed a computer-based training module on the use of NBI in the differentiation of adenomas and hyperplastic polyps. The test module was then completed a second time. MAIN OUTCOME MEASUREMENTS: Construct validity (the difference in baseline accuracy on the test module between different groups of participants) and content validity (difference in accuracy achieved on the test module before and after training) of the training module. RESULTS: There was a significant difference in the baseline accuracy (P < .001) between experts (0.95; 95% confidence interval [CI], 0.92-0.97), experienced colonoscopists (0.68; 95% CI, 0.68-0.74), trainees (0.75; 95% CI, 0.67-0.82), and novices (0.62; 95% CI, 0.46-0.77). Accuracy increased significantly (P < .001) for all 3 groups after training (novices 0.84; 95% CI, 0.78-0.88, trainees 0.90; 95% CI, 0.84-0.93, and experienced colonoscopists 0.84; 95% CI, 0.76-0.89). After training, the agreement was moderate at least (κ = 0.56 for novices, κ = 0.70 for trainees, and κ = 0.54 for experienced colonoscopists). LIMITATIONS: This study did not assess the accuracy of optical diagnosis in routine clinical practice. CONCLUSION: A short, computer-based training module can improve the diagnostic accuracy and interobserver agreement for the use of NBI to differentiate adenomas from hyperplastic polyps and could be used for the initial training in optical diagnosis.

Development and impact of an endoscopic non-technical skills (ENTS) behavioural marker system.

Background: Non-technical skills (NTS) are crucial to effective team working in endoscopy. Training in NTS has been shown to improve team performance and patient outcomes. As such, NTS training and assessment are now considered essential components of the endoscopy quality assurance process. Across the literature, other specialties have achieved this through development of behavioural marker systems (BMS). BMS provide a framework for assessing, training and measuring the NTS relevant to healthcare individuals and team. This article describes the development and impact of a novel BMS for endoscopy: the endoscopic non-technical skills (ENTS) system. Methods: The initial NTS taxonomy for endoscopy was created through a combination of literature review, staff focus groups and semi-structured interviews, incorporating the critical decision method. Framework analysis was conducted with three individual coders and generated a skills list which formed the preliminary taxonomy. Video observation of Bowel Cancer Screening endoscopists was used to identify exemplar behaviours which were mapped to relevant skills in the NTS taxonomy. Behavioural descriptors, derived from video data, were added to form the basis of the ENTS system. Results: A taxonomy of 33 skills in 14 separate categories were identified through framework analysis. Following video analysis and behaviour mapping, 4 overarching categories and 13 behavioural elements were identified which formed the ENTS framework. The endoscopy (directly observed procedural skills) 4-point rating scale was added to create the final ENTS system. Since its development in 2010, the ENTS system has been validated in the assessment of endoscopy for trainees nationally. ENTS informs a number of training initiatives, including a national strategy to improve NTS for all endoscopists. Conclusions: The ENTS system is a clinically relevant tool, validated for use in trainee assessment. The use of ENTS will be important to the future of training and quality assurance in endoscopy.

Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training.

BACKGROUND: The Olympus colonoscopy simulator provides a high-fidelity training platform designed to develop knowledge and skills in colonoscopy. It has the potential to shorten the learning process to competency. OBJECTIVE: To investigate the efficacy of the simulator in training novices in colonoscopy by comparing training outcomes from simulator training with those of standard patient-based training. DESIGN: Multinational, multicenter, single-blind, randomized, controlled trial. SETTING: Four academic endoscopy centers in the United Kingdom, Italy, and The Netherlands. PARTICIPANTS AND INTERVENTION: This study included 36 novice colonoscopists who were randomized to 16 hours of simulator training (subjects) or patient-based training (controls). Participants completed 3 simulator cases before and after training. Three live cases were assessed after training by blinded experts. MAIN OUTCOME MEASUREMENTS: Automatically recorded performance metrics for the simulator cases and blinded expert assessment of live cases using Direct Observation of Procedural Skills and Global Score sheets. RESULTS: Simulator training significantly improved performance on simulated cases compared with patient-based training. Subjects had higher completion rates (P=.001) and shorter completion times (P < .001) and demonstrated superior technical skill (reduced simulated pain scores, correct use of abdominal pressure, and loop management). On live colonoscopy, there were no significant differences between the 2 groups. LIMITATIONS: Assessment tools for live colonoscopies may lack sensitivity to discriminate between the skills of relative novices. CONCLUSION: Performance of novices trained on the colonoscopy simulator matched the performance of those with standard patient-based colonoscopy training, and novices in the simulator group demonstrated superior technical skills on simulated cases. The simulator should be considered as a tool for developing knowledge and skills prior to clinical practice.

Development of a novel esophageal stricture simulation.

BACKGROUND AND STUDY AIMS: Esophageal stricture dilatation has a significant morbidity and mortality and training can be difficult to obtain. The aim of the study was to investigate the face validity of a novel stricture simulation and evaluate its utility for training in balloon-dilatation technique. METHODS: Single-use stricture simulations were used to adapt a mechanical model for use in esophageal stricture dilatation. Face validity was evaluated using a questionnaire survey following a 40-min hands-on training session. Performance improvement was evaluated as part of a randomized blinded controlled trial. RESULTS: Face validity was established, with all trainees and instructors rating it as good or excellent overall and as adequately realistic or better in appearance. About 74% found it fairly or very realistic to dilate and 91% found it fairly or very useful for learning balloon-dilatation technique. Significant improvements in performance compared with controls were found following use of the simulation in a training episode. CONCLUSIONS: The novel esophageal stricture simulation had good face validity and has been shown to improve performance when used for training in balloon-dilatation technique. Its use allows practice without risk to patients or the need for animal cadavers.

Computer-aided learning in capsule endoscopy leads to improvement in lesion recognition ability.

BACKGROUND: The rapid expansion in use of capsule endoscopy (CE) has led to discussion about training needs and provision. The lesion recognition skills required for CE are ideally suited to computer-based training. OBJECTIVE: The aim of this study was to prospectively evaluate the educational effectiveness of a computer-based CE training and testing module on trainees with varying experience. DESIGN: This was a prospective educational evaluation study. SETTING: Academic endoscopy unit. PATIENTS: This study involved 28 trainees of varying CE experience (medical students, gastroenterology trainees) and 4 CE experts. INTERVENTION: Trainees (medical students and gastroenterology trainees) without CE experience completed a 60-question, computer-based test module consisting of 30-second video clips and multiple-choice questions. Without feedback, trainees then completed a comprehensive, menu-driven, computer-based CE training module. The test module was then completed a second time and feedback was given. Expert performance on the test module was benchmarked by 4 CE experts. MAIN OUTCOME MEASUREMENTS: The first measure was the difference in baseline performance on the test module between trainees and experts (to determine construct validity). The second measure was a change in performance on the test module after training (to determine content validity of the training module). RESULTS: A significant difference was noted in baseline performance (P < .001) among CE experts (mean 73.8% +/- 8.0%), gastroenterology trainees (49.5% +/- 10.9%), and medical students (29.5% +/- 3.3%). Performance improved significantly (P < .001) in both trainee groups after training (gastroenterology trainees' posttraining score 62.1% +/- 7.7%; medical students' 46.7% +/- 6.8%). CONCLUSION: Computer-based learning has a potentially significant role in the development of a training syllabus for CE and in CE accreditation.

Simulator training improves practical skills in therapeutic GI endoscopy: results from a randomized, blinded, controlled study.

BACKGROUND: Therapeutic endoscopic procedures are technically challenging and have higher complication rates than diagnostic procedures. Less-experienced practitioners are significantly more likely to have a complication, yet there is very limited evidence of the efficacy of training in such procedures. OBJECTIVE: To evaluate the effect of knowledge-based teaching and hands-on, simulation-based skills training in 4 therapeutic endoscopic procedures: control of nonvariceal upper GI bleeding, polypectomy, stricture dilation, and percutaneous endoscopic gastrostomy (PEG) tube insertion. DESIGN: Single-blind, randomized, controlled trial. SETTING: Nationally accredited therapeutic endoscopy course. PARTICIPANTS AND INTERVENTION: Participants were randomized into groups to assess the effect of knowledge-based teaching and into subjects or controls to assess skills-based training. All delegates had an initial knowledge and skills assessment by blinded experts. Subjects received one-half day of hands-on skills training, whereas the controls did not. All delegates were retested on their procedural skills. MAIN OUTCOME MEASUREMENTS: Knowledge was assessed by using a multiple-choice questionnaire. Practical skills were assessed using station-specific checklists and a global score. RESULTS: Twenty-eight participants were randomized. There was no significant effect of knowledge-based teaching on the participants' practical skills or initial multiple-choice questionnaire score, although there was a trend toward improvement. There was a significant improvement in the subjects compared with the controls in the performance of polypectomy, control of upper GI bleeding, and esophageal dilation. There were no significant differences for PEG tube insertion. LIMITATIONS: The 2-person nature of PEG tube insertion may have resulted in performance improvement despite a lack of training. CONCLUSION: Hands-on skills training significantly improved performance in 3 therapeutic modalities. Knowledge-based teaching alone did not have a measurable effect. These results strongly support the benefit of intensive hands-on, simulation-based courses for endoscopic skills training.

How should we train capsule endoscopy? A pilot study of performance changes during a structured capsule endoscopy training program.

There are no validated training/accreditation guidelines for capsule endoscopy. We assessed the utility of a structured training program on two experienced gastroenterologists and one endoscopy nurse. Validated studies were standardized for difficulty in blocks of three. Trainees completed a standardized data sheet for each study reported (12 studies for the physicians, 22 studies for the nurse). After each block the trainer graded performance and highlighted learning points. Statistical analysis was performed. Physician trainees accurately identified landmarks throughout, while the nurse made errors even at the end of training. Improvement in lesion detection and diagnostic accuracy improved in the nurse, but in only one of the physician trainees, highlighting the variability in learning curves. Overall performance improved in all trainees but was most marked for the nurse trainee (correlation coefficient 0.41, P = 0.06). Improvements in lesion recognition and diagnosis can be demonstrated in senior trainees and nurses following a structured training program; however, there is considerable variability.

Training and assessment in flexible sigmoidoscopy: using a novel direct observation of procedural skills (DOPS) assessment tool.

BACKGROUND AND AIMS: Data supporting milestone development during flexible sigmoidoscopy (FS) training are lacking. We aimed to present validity evidence for our formative direct observation of procedural skills (DOPS) assessment in FS, and use DOPS to establish competency benchmarks and define learning curves for a national training cohort. METHODS: This prospective UK-wide (211 centres) study included all FS formative DOPS assessments submitted to the national e-portfolio. Reliability was estimated from generalisability theory analysis. Item and global DOPS scores were correlated with lifetime procedure count to study learning curves, with competency benchmarks defined using contrasting groups analysis. Multivariable binary logistic regression was performed to identify independent predictors of DOPS competence. RESULTS: This analysis included 3,616 DOPS submitted for 468 trainees. From generalisability analysis, sources of overall competency score variance included: trainee ability (27%), assessor stringency (15%), assessor subjectivity attributable to the trainee (18%) and case-to-case variation (40%), which enabled the modelling of reliability estimates. The competency benchmark (mean DOPS score: 3.84) was achieved after 150-174 procedures. Across the cohort, competency development occurred in the order of: pre-procedural (50-74), non-technical (75-149), technical (125-174) and post-procedural (175-199) skills. Lifetime procedural count (p<0.001), case difficulty (p<0.001), and lifetime formative DOPS count (p=0.001) were independently associated with DOPS competence, but not trainee or assessor specialty. CONCLUSION: Sigmoidoscopy DOPS can provide valid and reliable assessments of competency during training and can be used to chart competency development. Contrary to earlier studies, based on destination-orientated endpoints, overall competency in sigmoidoscopy was attained after 150 lifetime procedures.

Certification of UK gastrointestinal endoscopists and variations between trainee specialties: results from the JETS e-portfolio.

Introduction In the UK, endoscopy certification is administered by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG). Since 2011, certification for upper and lower gastrointestinal endoscopy has been awarded via a national (JETS) e-portfolio to the main training specialties of: gastroenterology, gastrointestinal surgeons (GS) and non-medical endoscopists (NME). Trends in endoscopy certification and differences between trainee specialties were analyzed. Methods This prospective UK-wide observational study identified trainees awarded gastroscopy, sigmoidoscopy, colonoscopy (provisional and full) certification between June 2011 - 2017. Trends in certification, procedures and time-to-certification, and key performance indicators (KPIs) in the 3-month pre- and post-certification period were compared between the three main training specialties. Results Three thousand one hundred fifty-seven endoscopy-related certifications were awarded to 1928 trainees from gastroenterology (52.3 %), GS (28.4 %) and NME (16.5 â€Š%) specialties. During the study period, certification numbers increased for all modalities and specialties, particularly NME trainees. For gastroscopy and colonoscopy, procedures-to-certification were lowest for GS ( P  < 0.001), whereas time-to-certification was consistently shortest in NMEs ( P  < 0.001). A post-certification reduction in mean cecal intubation rate (95.2 % to 93.8 %, P  < 0.001) was observed in colonoscopy, and D2 intubation (97.6 % to 96.2 %, P  < 0.001) and J-maneuver (97.3 % to 95.8 %, P  < 0.001) in gastroscopy. Overall, average pre- and post-certification KPIs still exceeded national minimum standards. There was an increase in PDR for NMEs after provisional colonoscopy certification but a decrease in PDR for GS trainees after sigmoidoscopy and full colonoscopy certification. Conclusion Despite variations among trainee specialties, average pre- and post-certification KPIs for certified trainees met national standards, suggesting that JAG certification is a transparent benchmark which adequately safeguards competency in endoscopy training.

A prospective study of patient safety incidents in gastrointestinal endoscopy.

Background and study aims Medical error occurs frequently with significant morbidity and mortality. This study aime to assess the frequency and type of endoscopy patient safety incidents (PSIs). Patients and methods A prospective observational study of PSIs in routine diagnostic and therapeutic endoscopy was undertaken in a secondary and tertiary care center. Observations were undertaken within the endoscopy suite across pre-procedure, intra-procedure and post-procedure phases of care. Experienced (Consultant-level) and trainee endoscopists from medical, surgical, and nursing specialities were included. PSIs were defined as any safety issue that had the potential to or directly adversely affected patient care: PSIs included near misses, complications, adverse events and "never events". PSIs were reviewed by an expert panel and categorized for severity and nature via expert consensus. Results One hundred and forty procedures (92 diagnostic, 48 therapeutic) over 37 lists (experienced operators n = 25, trainees n = 12) were analyzed. One hundred forty PSIs were identified (median 1 per procedure, range 0 - 7). Eighty-six PSIs (61 %) occurred in 48 therapeutic procedures. Zero PSIs were detected in 13 diagnostic procedures. 21 (15 %) PSIs were categorized as severe and 12 (9 %) had the potential to be "never events," including patient misidentification and wrong procedure. Forty PSIs (28 %) were of intermediate severity and 78 (56 %) were minor. Oxygen monitoring PSIs occurred most frequently. Conclusion This is the first study documenting the range and frequency of PSIs in endoscopy. Although many errors are minor without immediate consequence, further work should identify whether prevention of such recurrent errors affects the incidence of severe errors, thus improving safety and quality.