So, we'll talk about defining and measuring quality in ERCP and EUS. We'll define what the quality metrics are and how we go about them. So, these are my disclosures. So, as we were talking about, we'll talk a little bit about the background, how ERCP and EUS are similar or different from gastro, you know, EGDs and colonoscopies. What are the quality metrics for ERCP? What are the defined quality metrics for ERCP? And discuss some strategies on how to have a high-quality therapeutic practice that, you know, some pointers that you can take back, hopefully, to your practice. So, when we stop and think about it, I think our ability to deliver a high-quality procedure to a patient includes both cognitive and technical aspects and proficiency in both of those. So, these points were highlighted by both T.R. and Neil. You're doing the procedure for the right indication. You know, you're looking at the relevant diagnosis, what is and what is why we are doing the procedure and what the planned therapy that is, especially in EUS and ERCP, is appropriate and that we are doing that. And we are doing this in a safe and a consistent manner while de-risking the procedure. So, what is a quality indicator? It's really the ratio between how often we do the correct procedure or performance of the procedure versus the opportunity for the correct performance. That's where all these percentages and ratios come back. And I think this was mentioned before. You really cannot manage what you cannot measure. So that, and I really appreciate everyone being here and your interest in measuring and being involved in quality because that's what makes us better. So, I want to take a minute to talk about informed consent, especially as it relates to EUS and ERCP. These are complex procedures. These are procedures that involve, you know, interventions that have the potential for risk like with any others, but maybe at a higher level. So, it's really important that the process for informed consent is not rushed. You have a detailed discussion with what you're going to do, why you're going to do it, and many times, at least in my practice, drawing a simple picture or using a chart and just explaining to the patient goes a long way. I think we also have to recognize that we, in a truly informed consent, it involves discussion of the pros and cons of alternate procedures. Is this what you're going to do, the only way to do this, or are there other approaches to this? And the other aspect of it is a clear discussion of risks and stratified risk based on patient-specific factors and procedure-specific factors. You know, patients with anticoagulation, if you're going to do a sphincterotomy, talking to the patient about the high risk of possible delayed bleeding and making the patient really a partner in decision-making. I think that's the best way to look at it and being transparent about the risk. I think sometimes we have a tendency to undersell the risks, and patients recognize that what we are going to do is complex and it comes with risk, and being honest and transparent about this, I think is a very important quality measure, at least for USCRCB. So I'm a big fan of checklists, and I think having checklists in these complex procedures can be helpful, whether they're actual checklists or mental checklists or team huddles. Just kind of going over that, we are doing the procedure for the right indication on the right patient, so there are no contraindications, you have acceptable cardiopulmonary risk, you have the right team, you have the trained endoscopist for the kind of procedure that you're going to do, and the team includes everyone, nurses, technicians, cytotechnologists, pathologists, anesthesiologists, physicians, CRNAs, et cetera, et cetera. You have the right equipment for the therapy that you're going to do, the protocols, pre, post, and interprocedural care of the patient, and the communication with the patient, with the family, with the referring team or the physician, these are all aspects of a high-quality procedure, whether it be for USCRCB or for anything else that we do. So focusing on ERCP first, there are two papers that are very important. One is the recently published sort of the paper by Raj Keswani in 2023, which basically goes about how to improve the performance. The previous paper that was published in 2015 by Sachin Gwani and others really puts out what the quality indicators are. So we'll talk both about what the quality indicators are and how to go about achieving those quality indicators. So first, let's talk about what the ERCP quality indicators are, and this is the paper by Sachin Gwani. So again, it goes back to the same themes that were mentioned before. Are we doing it for the right indication? More than 90% of the time, was informed consent obtained and appropriate informed consent obtained greater than 98% of the time? Are we giving antibiotics for, you know, especially in ERCP where they're indicated? And we'll talk a little bit more about this. And is the ERCP being performed by an endoscopist who's fully trained, credentialed, not just in general for ERCP, but for the complexity of the ERCP that is being performed? And the frequency with which volume of ERCP is performed by ear is recorded by the endoscopist. It goes back to measuring quality. And, you know, there's a lot of concern about the overall ERCP volume versus and how it correlates with the quality of the interventions that are performed. So it's very important to really measure that. So then let's focus on what and how we go about it. When you look at this, when you look at the first question, what interventions have been shown to increase the frequency for which ERCP is performed for an appropriate indication? It comes back to measuring and the quality metrics, providing feedback. Why we are doing these procedures? Are we doing this for the right reason? And then goes into the procedural aspects of it. What interventions are associated with the rates of cannulation of the duct of interest? So these are interprocedural characteristics that are very important. One is the use of a prone position. Two is deep sedation. And, you know, familiarity with specialized cannulas and sphincteratomes, the use of guide wires, hydrophilic guide wires, and then simulation training, especially for trainees to have them practice on both mechanical simulators, electronic simulators, and things like that. And then one of the important things about ERCP is you always need a backup plan. What we call advanced cannulation techniques, if the standard cannulation technique is not feasible, then is the endoscopist trained in these advanced cannulation techniques? Because the complexity of ERCPs is continuing to increase with increasingly sicker patients and the conditions that we treat today. So what is the take-home message? One is, I think, for your ERCP practice, it's very important to measure quality metrics, and it's very important to close the loop and provide feedback to the endoscopist and the team, optimizing the patient and the procedure and physician characteristics for a successful outcome. So lining up everything that gives you the highest chance of success. These procedures can be stressful, they can be complex, and really doing the same thing over and over again, optimizing these patient factors, takes out a lot of the stress associated with these procedures, especially if it's a smaller hospital, these procedures are not done frequently on a daily basis. Having a written protocol, having a dedicated team can be quite helpful. So then what are the most common ERCPs that we do are for stones. So what interventions have been shown to increase the success of stone extraction? One is, you know, these get into technical factors, but I think they're important to discuss use of an extraction balloon, use of advanced techniques such as endoscopic sphinctroplasty, which enables us to get large stones out, and then use of selective cholangioscopy, introductive ultrasound, which are advanced techniques. Then the other one is, what have been shown to increase the success of stent placement for biliary obstruction below the bifurcation? And you know, there is this artificial divide in ERCP of higher interventions and above or intrahepatic interventions, and then interventions below the hilum. The below the hilum interventions are the most common interventions that are performed, especially for stones. So even when we talk about that, it's very important that the right technique and the right equipment is utilized. I think in ERCP, the use of appropriate equipment is also a very important aspect. So using a hydrophilic guidewire, the availability of multiple dilators that will enable you to problem solve and get to sort of plan B and plan C to deliver an effective intervention for the patient. So I think the take-home message from this slide is that the team performing the ERCP, including the endoscopist and the nurses and the technicians, have a deep knowledge of all the tools, what the indications are, and some of the rescue strategies, or know when to stop and then refer the patient if the rescue strategy is not available in the unit at the time of the procedure. Using high-quality tools correlating to the complexity of the procedure, I think, is critical for success. Now you can't talk about ERCP and not talk about pancreatitis, which is the biggest or the most common problem that we anticipate and fear and do everything that we can to minimize. So how do we go about decreasing the risk of post-ERCP pancreatitis? Unfortunately, we are in an era where we have good control of this. And so one is wide-guided cannulation. It says physician control, but if you have a really experienced tech or nurse, it extrapolates to that. If you don't have a dedicated or an experienced tech or nurse, I think the physician using the wire and doing a wide-guided cannulation has been shown to decrease the risk of post-ERCP pancreatitis. Use of rectal nonsteroidals, endomethacin or diclofenac, at a minimum in high-risk patients. In our practice, all patients with a native papilla, unless they have a contraindication to nonsteroidal administration, will automatically get it, and that is a part of our pre-procedural pause checklist. Aggressive periprocedural hydration as appropriate with lactated ringer solution. There's good data to show that that decreases the risk of post-ERCP pancreatitis. And then use of a pancreatic stent in patients where you have pancreatic cannulation, especially with repeated pancreatic cannulation. And Dr. Joel Munzer and the group's recent publication in Lancet, which shows that they have an additional benefit over and about rectal NSAID. So take-home message from this, when you take it back to your ERCP practice, I call this the three tenets of current ERCP practice. One is cannulation technique, which is wide-guided cannulation, using the appropriate cannulation devices such as a sphincter tome or a taper-tip cannula and a hydrophilic guide wire. Use of rectal nonsteroidals and adequate fluid resuscitation, and then having a low threshold for pancreatic stent placement. I think these are the three tenets, which will ideally, even in a high-complexity practice, should enable us to keep our ERCP post-pancreatitis rates less than 5%. So these are the take-home messages for ERCP. And the last one is there are varying grades of ERCP, right, that ASGE has classified from grade one to grade four. So without going into a lot of detail about this, having this in your unit, knowing what the grade level difficulty of the ERCP that is being attempted, and then making sure that everything is lined up for that, appropriately for that grade level. If you're treating a grade four, you're doing a grade four ERCP, then you really need an endoscopist highly qualified in essentially all aspects of ERCP therapy, whereas if you're doing a grade one ERCP with biliary stent removal, things like that, that's a completely different level of complexity. So really, the team should know their limits, and if it's a more complex procedure, then refer it appropriately to someone, to a tertiary center, or someone with expertise at that level, at that grade level. So that was about ERCP. Let's sort of then shift focus to endoscopic ultrasound, and talk about quality in endoscopic ultrasound, and how we go about defining that. So similar to ERCP, I think the EOS quality indicators are, can be defined as pre-procedure and interprocedural. So pre-procedure comes down to the same themes. We talked about indications, we talked about, you know, informed consent, appropriate use of antibiotics, and then the training of the endoscopist and training of the team, so that the endoscopist is adequately or appropriately trained for the level of complexity of the endoscopic ultrasound that is being performed. Is it a diagnostic? Is it a therapeutic? And do we have the right skills to do this procedure appropriately? What are the appropriate indications for EOS? This is changing rapidly, so I won't go through this. This is an old paper, but just knowing that we are doing the endoscopic ultrasound for the right indication, and know what therapy we are going to, or what sampling we are going to do. Now what are the interprocedural character, you know, quality indicators for endoscopic ultrasound? One is the frequency with which the appearance of relevant structures, why you're doing the endoscopic ultrasound is being documented. So, for example, if you're doing it for a pancreatic cyst, are we documenting greater than 98% of the time what the characteristics of the cyst are, how it relates to the pancreatic duct, and so on and so forth. Now the other thing that EOS is very unique is staging. And the reason why we do EOS for staging is because it has a high sensitivity for many luminal cancers and for pancreatic cancer, but we need to deliver that high level of detail to the referring physician so that they can plan the treatment. So the staging is very important, endoscenographers should be very familiar with the AJCC staging and the TNM staging system for all of the cancers that they routinely see. For pancreatic masses, it goes back to staging again, I'll be talking about vascular involvement, distant metastases, lymphadenopathy, kind of comes down to are you doing a comprehensive examination for that specific cancer and are you reporting on the exam that you're performing. And then for subepithelial lesions, the wall layers and where the lesion is coming from becomes important. The other interprocedural characteristics are really percentage of patients with distant metastases, EOS guided FNA. So the common theme there is, are you sampling the right target of interest? So for example, in a patient with pancreatic cancer, you pick up a liver metastases on your EOS, are you sampling that liver metastases and potentially in addition to the primary pancreatic mass if needed. And the other aspect is if you, when you sample, what is their adequacy? And, you know, the, it's about greater than 85% here, but in our practice, essentially there's an expectation of greater than 95 to 98% that you're providing an adequate diagnostic sample with the current tools that we have. Finally, the other aspect is adverse events, really EOS is a very safe procedure, the overall risk of adverse events should be quite low. The numbers are listed here. So typically I quote about one to 2% risk, overall risk for patients, especially with pancreatic sampling and measuring adverse events after EOS becomes important and monitoring those adverse events become important. Now let's shift to just like we did with the RCP of how we go about it. So what techniques can improve diagnostic rates and sensitivity? There's some data to suggest deep sedation, such as with propofol compared to moderate sedation. Again, the data is limited. The other aspect is technique. There's multiple studies showing how to increase the yield and essentially a slow stylet pool seems to have become sort of the generalized standard, though it's not established in stone, but whatever you do in your practice, do it consistently and do it the same way. And I think almost all practices really in today's day and age with the use of molecular and genetic testing and things like that, for solid masses, we've gone to fine needle biopsy over fine needle aspiration needles. And this is especially true when you don't have onsite cytopathology available. So if you don't have onsite cytopathology available, seriously consider using a fine needle biopsy, especially for solid lesions, especially in pancreatic lesions and subepithelial tumors. Now antibiotic use is very important. The overall with antimicrobials stewardship, the number of instances where antibiotics are absolutely mandated is going down and down. But things like mediastinal cysts, perirectal abscesses, pancreatic cysts are very important to give antibiotics. And then anticoagulation management is important just like with any procedure. So what are the take home messages? I think for solid masses, strongly consider the use of a core biopsy needle, especially if you don't have rapid onsite cytopathology, optimize your patient and procedure factors such as antibiotics, anticoagulation, things like that. And then review metrics, both for ERCP but also for EOS, and closing the loop and providing feedback is very important. So summary in terms of EOS and ERCP, I think the themes are the same. Are we doing the right procedure for the right indication on the right patient and do we have the right team in place to do this procedure? Therapeutic endoscopy is expanding rapidly. I think it's measuring your quality, closing the loop, giving feedback to the team in terms of the quality metrics that they're achieving is very important. Having a quality champion in your team who drives a culture of quality and safety where a high quality and a high safety culture is valued and appreciated and people are open to feedback and the feedback that's given is given in a non-punitive and a very open and transparent manner is extremely important. As the complexity of our procedures increase, I think it's important to both focus on the cognitive aspects and the technical aspects of the procedure. And again, I'll close by saying that, especially for these complex procedures, stopping thinking about do we have the right composition and making the patient an active participant in the decision making, explaining these procedures to the patient really leads to a safe and a measurably defined high quality outcome. So I'll stop there. Thank you very much for your kind attention and hopefully we can discuss more in the Q&A.

ERCP

EUS

quality metrics

informed consent

risk stratification

post-ERCP pancreatitis