I think we'll move on to the next one before our panel discussion, which will be given by Dr. David Armstrong. And Dr. David Armstrong is a professor of medicine at McMaster University and a consultant gastroenterologist at Hamilton Health Services. His clinical and research interests include GERD, dyspepsia, IBD, nutrition, short bowel syndrome, colorectal cancer screening, and quality in endoscopy with 220 peer-reviewed publications and over 100 invited articles and chapters. He has been a principal investigator for numerous clinical trials and taken part in many guidelines and consensus conferences. So welcome, David, to give us a talk about smart endoscopy suites. Good morning. My name is David Armstrong, and I'm a gastroenterologist in Hamilton at Hamilton Health Sciences and McMaster University. I'm grateful to Drs. Sharma and Wallace for the invitation to speak on smart endoscopy suites and how they should look. Here you can see my disclosures. So when I started out, I thought perhaps that there was an easy answer to what makes a smart endoscopy suite. And I thought I had the answer. A smart endoscopy suite is one where all staff wear a bow tie. Now obviously, this is very simplistic, and in fact, a picture of a busy endoscopy room is also a rather simplistic view of what constitutes a smart endoscopy suite. There is a lot more wrapped up in having a smart endoscopy suite and many aspects to consider. So I started out by asking, what is an endoscopy suite? And you can see here that there was a publication now over 20 years ago from the ASGE on establishment of gastrointestinal endoscopy areas. And they listed a number of the attributes of an endoscopy suite. An endoscopy suite consists of the structure, preparation, procedural and recovery areas, disinfection and cleaning areas for equipment. It consists of endoscopy equipment, and it also consists of staff, trained and accredited endoscopists, trained nursing and additional staff, emergency personnel and equipment, and above all, a program for quality assurance. So if we look at an endoscopy suite, Tan and Raoul published on the ergonomics of an endoscopy suite a couple of years ago, and this is obviously important. It's key to have an endoscopy suite which is developed to enable safe and appropriate patient flow. It should enable safe and appropriate endoscope transport from the clean areas to the dirty areas and back again. And the endoscopy rooms should be set up ergonomically to allow for patient monitoring, equipment accessibility and operator comfort. However, an endoscopy suite is not just the structure, the bricks and mortars. One needs also to ask what is the function of an endoscopy suite. And I would argue that the function of an endoscopy suite is to provide access to endoscopy for diagnosis or therapy that is appropriate, safe, accurate, effective and resource appropriate. From a patient point of view also, the procedures need to be timely, they need to be comfortable, they need to be convenient and accessible and they need to be acceptable. So there are a number of elements of a high quality endoscopy service that is provided in an endoscopy suite. And a lot of this is founded on the availability of a quality assurance program. So what do I mean by a quality assurance program? Well, in Canada, we collaborated with the UK and the National Health Service, Roland Veloury, Deb Johnson and many others who had set up a quality assurance program, which they termed the Global Rating Scale. And in Canada, with Donald McIntosh and colleagues, the Canadian Association of Gastroenterology developed the CGRS to assess the quality of services provided within an endoscopy unit. And this quality assurance program is based on a quality construct that is patient-centred. It has two domains and 12 items and the domains are clinical quality, which includes consent process, safety, comfort, quality of the procedure, appropriateness and communicating results. And then a quality of the patient experience domain that includes the items of equality of access, timeliness, booking and choice, privacy and dignity, aftercare and the ability to provide feedback. Now, as endoscopists, we often tend to think of quality really in terms of the things that we do with our procedures, looking at safety, for example, perforation or complication rates and the quality of the procedure. For example, sequel intubation rate, withdrawal time, adenoma detection rate. But there is, in fact, much more to delivering high-quality endoscopy service. And in fact, this has been recognised with a number of publications, again, from the American Society for Gastrointestinal Endoscopy, as well as the European and British Societies of Gastroenterology. This, from Luke John Day and colleagues, used a modified Delphi process to look at endoscopy unit quality indicators. They identified 155 quality indicators across five domains. And to summarise, they identified five priority quality indicators, which included, one, whether the endoscopy unit had a defined leadership structure, and two, whether there were regular education and training programmes for staff with respect to the equipment that they used. But the next three quality indicators, their priority quality indicators, are important because they really speak to the importance of data collection. The third priority that they identified was that the endoscopy unit records, tracks and monitors procedure quality indicators for both the endoscopy unit and individual endoscopists. They further stated the procedure reports are to be communicated to referring providers and that there is a process in place for patients to receive a copy of their endoscopy report. And finally, that there is a process in place to track each specific endoscope from storage, use, reprocessing and back to storage. So these are highlighted in yellow because these are really speaking now to the need to collect data continuously during the delivery of an endoscopy service. The ASG also had other publications a few years prior to that, which looked at quality indicators with respect to the procedures themselves. For all endoscopic procedures, they had 22 recommendations and prioritised the recording of the appropriate indication for the procedure, the recording of whether or not antibiotics and antithrombotics were given appropriately. Looking specifically at upper endoscopy, they had 22 recommendations and prioritised antibiotics for cirrhosis with upper GI bleeds, PPIs prescribed for suspected non-viraceal upper GI bleeding, whether or not a bleeding lesion or visible vessel was treated and whether or not the patient was tested for Helicobacter pylori if they had peptic ulcer disease. And then finally, for colonoscopy, they had 15 recommendations and they prioritised collecting data on the proper repeat colonoscopy interval, whether or not SQL features were documented and adenoma detection rate. All of these require data. These require data to be collected during the delivery of endoscopy service. And so if we go back to the question about what is the function of an endoscopy unit, the question then is how should this function be assessed in a smart suite? And I would argue that we need data collected on indications for procedure, the accounts of complications, the documented diagnosis, whether or not the cecum was intubated and whether or not polyps were removed completely, and also procedure duration. We need patient-centred data on wait times, comfort scores, travel times to endoscopy and patient satisfaction. So you can see that a smart endoscopy suite has a requirement for a collection of a lot of data. And I'm now going to move on with the next few slides to some of the challenges in evaluating these quality indicators. For example, in our unit for tracking vital signs and equipment, we have a quality indicator really quite advanced vital sign monitors that have USB ports, Ethernet ports, wireless access, Bluetooth access, and the blood pressure, heart rate, respiratory rate, and oxygen saturation are all recorded manually. Similarly, we have endoscopy technicians who keep track of the endoscopy ID numbers as they go through cleaning and reprocessing. And again, these numbers are recorded manually. In a recent study from colleagues in Kingston at Queen's University, Laurence Hookey, Bill Patterson, and others, they looked at the appropriate use of the endoscopy room, and they did a patient flow analysis following patients from registration through to completion of the procedure. To highlight some of their data, they looked at endoscopy room utilisation with 129 procedures, and they reported that on average, patients spent about 45 minutes in the endoscopy room of which only 19 minutes were used for the procedure itself from start to end of the endoscopy. Thus, the proportion of time that the patient is in the room that is used for endoscopy is less than half. And if one then factors in room turnover time, then this valuable resource is probably used only for about a third of the time. So how did they come up with these data? Well, all of these times are recorded manually by a research assistant employed specifically for the task. One of the key things that was highlighted in the endoscopy unit quality indicators was endoscopy reporting and provision of the report to the patient. And we did a survey a few months ago with 47 endoscopists in North America, and we asked them, how are your endoscopy reports generated? Only 34% actually had a structured electronic report that could be searched electronically. We asked them, how do you produce your final endoscopy report, or when do you produce it? And they reported only about 57% actually completed the report immediately after the procedure, nearly half reported later in the day or even later in the week. We then asked them, do you use the standard terminology to identify and describe lesions when completing endoscopy reports? Only 45% said that they did this all of the time. And when they were asked, how confident are you that other endoscopists would agree with the lesion descriptions and diagnoses in your endoscopy report, less than two-thirds were extremely or very confident. So endoscopy reporting is often non-standardized, non-searchable, and inaccurate or incomplete. So to paraphrase Ziad Jalad when he was talking about efficiency metrics, the hardest thing for endoscopists who are interested in quality improvement is actually obtaining the data. The hardest thing for endoscopists who are interested in quality improvement is actually obtaining the data. So now to summarize, I would argue that a smart endoscopy suite should look rather like this in the future. There are a number of elements that need to be incorporated. Firstly, the smart endoscopy suite must embed and facilitate data collection in all of its activities. The data collection should be easy and should not interfere with workflow. And we need data on patient referral date, indications for procedure prioritization, and procedure date. We also need data on patient flow through the suite from admission to discharge with automated time stamping at key transit points, very much like the sort of processes that are in place for industrial manufacturing processes. I would argue that we need real-time reporting and image annotation during the procedure using standard terms. And I think this is an area where we can look at artificial intelligence for voice recognition for real-time data acquisition during the procedure rather than having reports completed after the fact. We can also, as has been developed to date, use artificial intelligence for polyp detection and lesion characterization. We need to link endoscopic diagnoses to outcomes, for example, histology or treatment outcomes. And we need that to provide feedback to endoscopists for skills enhancement so that they can improve the quality of their procedure and their diagnoses. And then to be patient-centered, we need tablet-based surveys for regular patient feedback rather than one-off paper-based surveys that are not sustainable. So if we look at this from a practice-pearls point of view, practice-pearls for a smart endoscopy suite, or perhaps an outline of a roadmap for the future, is that high-quality endoscopy service delivery is an exceedingly complex undertaking. It is not just a little operating room. Procedural quality is, in fact, a major part of endoscopy service delivery, and procedural quality is only one part of endoscopy service delivery. Access to accurate, reliable, relevant data is essential for quality insurance and quality improvement, and intermittent opportunistic data collection is insufficient to support long-term sustainable quality improvement. So smart endoscopy suites in the future will have to automate and standardize data collection across all aspects of endoscopy service delivery, and artificial intelligence cannot be applied without acquisition of data in an efficient manner. So my thanks again to the ASGE and to the chairs of the session for the invitation to speak today.

smart endoscopy suites

data collection

quality assurance program

standardized endoscopy reporting

artificial intelligence