Increasing Access or Improving Mortality in Endoscopy
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The document discusses the impact of endoscopy on mortality rates in both elective and emergency settings, highlighting the importance of improving access to and the effectiveness of endoscopic treatments. It presents statistics indicating improved outcomes with timely interventions, while also addressing issues of futility and the potential risks associated with improper endoscopic practices. The conclusions emphasize the need for enhanced training, facilities, and protocols to optimize patient safety and reduce mortality.
Increasing Access or Improving Mortality in Endoscopy
- 1. Debate: Increasing Access or Improving Mortality in Endoscopy Elective v Acute Dr Sanchoy Sarkar FRCP. PhD Endoscopy Services Lead Consultant Gastroenterologist Senior Lecturer
- 2. Content • Improving Mortality • Futility • Adversely Effecting Mortality
- 3. Improving Mortality EMERGENCY-IN-PATIENT ELECTIVE-OPD or DAY-CASE Therapeutic UPPER ENDOSCOPY LOWER ENDOSCOPY: GASTROSCOPY COLONOSCOPY/FLEXI
- 4. EMERGENCY & IN-PATIENT ENDOSCOPY SERVICES
- 5. Upper GI Bleed BSG Audit When Things Done Badly 206 Hospitals: UK • On call: Half hospitals BUT mortality 20% lower if present • High Risk Patients (Scope 12hrs) – 1/2 scoped 24hrs • High risk Bleed lesions- treatment – ¾ Given any endoscopic treatment – Only 1/3 given optimal “Goals & Opportunities are Missed !!’ • Inappropriate Drugs – ¼ used correct use GUT 2010(59) 1022-1029
- 6. Evolving Endoscopy Services (20 yrs) Daily Consultant In-patient Middle Grade In-Patient Lists Sunday Day time plus Day-Time Saturday 24/7 Rota Lists Middle Grade Evening Lists lists In-patient 24/7 Rota Coordinator National Training Centre 93 99 06 07 09 11 12 13 Fellow Surv Consultant Expansion Consultant 3 Session Colonoscopy BCSP Flexi Bowel nurse Endoscopists Day Centre Screening Cancer Screening x3
- 7. Expertise & Infra-structure • Endoscopy Training Centre & Tertiary Referral Centre • Personnel – SpR/Fellow – Consultant On-Call Rota & Consultant Endoscopists • Equipment – Endoscopic Equipment – Haemostatic Equipment (Technologies) • Facilities – Theatre/Endoscopy Unit Access – High Dependency Bleed Unit & Gastro Ward Base • Service provision – 24/7 On Call Service (Consultant & Middle Grade) – In-Patient Lists (Day & Evening) – Weekend In-Patient Lists • Back-Up – Interventional Radiology – Specialty Based Surgery
- 8. UGI Bleeding Mortality Comparison National & RLH Mortality 1993 2007 2009 2011 National 14% 10% N/A N/A RLH 5% 3% 0% 0%
- 10. Lower Endoscopy- Screening Diagnostic Therapeutic
- 11. Screening Improving Mortality • Colonoscopy + FOBT – Reduce incidence CRC by 20% – Reduce CRC mortality by 28% • Flexi-Sigmoidoscopy – Reduced incidence by 33% – Reduced CRC mortality 43% – Saved lives (1 in 200)
- 12. Futility- E.g. Colonoscopy Surveillance Pathology Mortality 16 None due to CRC % 12 30 day 8 6 month 4 0 Fit Un-Fit (not scoped) Sarkar et al: Frontline Gastroenterology 2011
- 13. Elective Endoscopy Emergency Readmissions & Mortality If you have access to this article through your institution, you can view this article in OvidSP. European Journal of Gastroenterology & Hepatology: December 2012 - Volume 24 - Issue 12 - p 1438–1446 doi: 10.1097/MEG.0b013e3283582db0 Original Articles: Endoscopy A multicentre study to determine the incidence, demographics, aetiology and outcomes of 6-day emergency readmission following day-case endoscopy Sarkar, Sanchoya; Geraghty, Joea; Moore, Andrew R.a; Lal, Simonc; Ramesh, Jayapald; Bodger, Keithb; CERT-N: Collaboration in Endoscopy, Research & Training-North-West Readmission Rate 0.5% but if readmitted Mortality 6.8%
- 14. Adverse Events TOTAL % Rate Standards Details/Comments Perforations OGD-Therapy 1 0.1 1/1000 OGD-Diagnostic 1 0.02 1/6000 Colonoscopy- Diagnostic 0 0 N/A Colonoscopy-Therapy 2 0.14 1/725 Flexi-Diagnostic 3 0.08 1/1800 ( Bleeding ERCP-Sphincterotomy 4 0.26 1/100 Post-polypectomy- EMR 4 0.2 1/450 OGD-Diagnostic 1 0.002 1/6000 (
- 15. Hidden Health Costs Other Complications No % Rate Comment CVS-Resp 16 0.1 1/1000 Arrest 2 All OGD Aspiration 2 All OGD Pneumonia 3 All Colon MI/ACS/Angina 8 0.05 1/2000 CVA 1 Preciptated Obstruction 7 0.1 1/850 All after diagnostic OGD Bowel Prep 4 0.1 1/900
- 16. Conclusions • Improve Mortality – Emergency/In-Patients: Therapeutic Upper Endoscopy – Elective: Asymptomatic: Lower GI Endoscopy • Adversely Effect Mortality – Futility & Risk to Benefit Ratio – Hidden Costs; Patient safety – APPROPRIATENESS
- 17. Thank You Sanchoy.Sarkar@rlbuht.nhs.uk www.liverpoolgastroenterology.nhs.uk