Now we're going to talk about quality indicators for EGD, ERCP, and EUS, and we are going to start with a few polling questions. Do you believe your unit averages a 90% native papilla cannulation rate, a 90% success rate at removing biliary stones less than one centimeter, and a 90% success rate at stenting extrahepatic biliary strictures? Yes, no, or ERCP is not performed in our unit. Of those performing ERCP, you are all meeting these. That's great. All right, let's go to our next question. Do you formally track your unit's post-ERCP pancreatitis rates? Great, so about 20% are doing that, about a little over 40% are not, and then about a third are not performing ERCP. All right, excellent. So we're going to move on and talk a little bit more about the quality indicators, like I said, for the advanced procedures in upper GI, and we will explore these polling questions further during this talk. We're now going to talk about the quality indicators for the advanced procedures, including ERCP and EUS, and also upper GI bleeding. You previously heard about the quality indicators for colonoscopy, and now we're going to round this out by talking about these other procedures. For this talk, we're going to go over a little bit of background about what quality indicators are and why they're important, then we're going to go over the specific quality indicators for ERCP, EUS, and upper GI bleeding, and then we will wrap up. So why do we care about this topic? Well, I think we can all agree that patients should have access to high-quality endoscopic procedures, and these are procedures where the procedure is indicated, correct and relevant diagnoses are made or excluded, the therapy provided is appropriate, and all steps to minimize risk have been taken. So how are we going to make sure that we are providing high-quality care? Well, we can measure performance of an individual or a group with a benchmark or a quality indicator in order to identify poor performers and retrain or educate them in order to meet performance targets. You can think of a quality indicator as the ratio between the incidence of correct performance and the opportunity for correct performance. So the first set of these quality indicators was developed in 2006 by the ASGE ACG Task Force on Quality in Endoscopy. In 2015, the task force published six updated documents. These documents discuss quality in endoscopy in general, quality indicators for all procedures, and then quality indicators for specific procedures, so EGD, colonoscopy, which you heard about previously, ERCP, and then EUS. For today's lecture, we're going to focus on the quality indicators for ERCP, EUS, and then the specifics for upper GI bleeding. But I really encourage all of you to take a look at each of these documents at some point. They contain a wealth of knowledge and are very important. I also did want to mention that our ASGE Quality Committee is currently working on a number of documents that augment these papers. Really what the focus will be is on interventions to improve the quality of performance for ERCP, EUS, upper endoscopy, and colonoscopy. And these will be excellent resources for providers and units who are not meeting quality standards. The quality indicators are divided into three time periods, pre-procedure, intra-procedure, and post-procedure. The quality indicators are also given a grade of recommendation based on the strength of the supporting evidence. This is the grade of recommendation based on levels of evidence. First you can see that there's a 1A, 1B, 1C+, and 1C. 1A is the strongest evidence that's randomized trials without important limitations. 1B is randomized trials with some limitations. 1C plus is evidence from observational studies, and 1C is also from observational studies without overwhelming evidence. For 2, 2A is randomized trials without important limitations, 2B is randomized trials with important limitations, and 2C is observational studies. The difference between this 2A, 2B, and 2C from the 1A, 1B, and 1C is that the clarity of benefit is clear for the 1s and is unclear for this grade of recommendations, the 2A through 2C. And then finally, 3, again, clarity of benefit unclear, but this is basically based on expert opinion only. And finally, all indicators are given a performance target. The performance targets are designed to serve as specific goals to direct quality improvement efforts and were taken from benchmarking data in the literature. When data weren't available, you will see NA or not available listed. And really what's important to know is that when you see greater than 98%, as you see here, these are really things that should be done all of the time. Lastly, the task force selected a number of priority indicators that's designated with the circle here, and you'll see that listed in each of these documents. And basically, this is based on the clinical relevance and importance of those quality indicators. These are items I suggest everyone really focus on, and you should ensure that you or your endoscopist first measure performance relative to these priority indicators. And if you and your endoscopist are meeting these priority indicators, that's excellent. Then you can start assessing performance relative to the other indicators. But these priority indicators are a great place to start to ensure that we're all meeting these. We're now going to discuss the specific quality indicators for ERCP. This is very important because ERCP is one of the most technically demanding and high-risk procedures performed by GI endoscopists. It requires significant focus, training, and experience to maximize success and to minimize poor outcomes. All right, so let's go through each of these. ERCP should be performed for an appropriate indication, and the indication should be documented in greater than 90% of cases. This is a priority indicator. Appropriate and inappropriate indications for ERCP are well-defined in the literature. This table contains a list of the vast majority of acceptable or appropriate indications for ERCP. It's very important to look through these lists and make sure you familiarize yourself with them. A common theme is that ERCP is not being performed for diagnostic indications anymore. MRCP and cross-sectional imaging has really taken over that role. And the target is set high at 90% in these quality indicators, and that's because the risks of ERCP are very high, so we want to make sure that we are doing these procedures for an appropriate indication. And a lot of the lawsuits or litigations related to ERCP are related to procedures being performed for inappropriate indications, so you do really want to make sure you're meeting this quality indicator. The next quality indicator is the frequency with which informed consent is obtained, including specific discussions of risks associated with ERCP and with which they're fully documented. And this should really happen greater than 98% of the time. At least six possible adverse events should be discussed prior to performing an ERCP, and I have them listed here. The first is pancreatitis. I put a rate of about 8% or less for pancreatitis in patients who are at average risk. Of course, if I'm going to do pancreatic endotherapy or this is a sphincter of OD patient, the risk could be much higher, up to 30% for SOD patients. So I try and target this to the patient I'm doing, but for average risk patients, I say about 8% or less. Bleeding, typically less than 1% to 2%, and normally related to sphincterotomy. Infection, generally less than 1%. Cardiopulmonary events, allergic reactions, and then perforation, I say less than 1%. And that, again, can be due to the scope itself, related to sphincterotomy or related to the guidewire. And then I also tell patients, I have this listed in parentheses here, that the procedure may not be successful and what will happen if that's the case. Will they need a procedure by IR? Are we going to try again? Things like that. Performing a good informed consent is super important for these riskier procedures. It's important that the process isn't rushed, and if at all possible, it's good to do this in person instead of over the phone, for example. Keep an open mind to safer alternatives. Sometimes we get in the mode that we can do everything, but if this patient might be more safe undergoing an IR procedure, that is something to discuss with the patient and to keep an open mind about. Try and stratify risk based on patient-specific and procedure-specific risk factors. So is this patient on anticoagulation? When did they last take it? Does this patient have comorbidities that may make them higher risk for anesthesia? Does this patient have a duodenal stricture that you're going to have to dilate to get the ERCP down? Are you doing pancreatic endotherapy? All these sorts of patient-specific and procedure-specific things can vary the risk that you quote. So the risks on the prior page are in general, but they can vary dramatically based on some specifics about the patient. So try and quote those as well. Don't undersell the risks. Of course, we don't want to scare our patients, but it's very, very important that patients know that ERCP and EUS with interventions are not the same as a regular upper endoscopy or a colonoscopy. They carry significantly more risk and the risk can lead to some significant morbidity and very rarely, but possible mortality. And then consent for failed procedure or failed diagnosis. So you may not get the diagnosis of the pancreatic mass and they may need to come back. So let the patient know that. You may not be able to cannulate the duct when doing an ERCP. So what's your backup plan? I try and tell patients that what my backup plan would be. They may need to come back for another procedure. If I fail, I'm going to plan to try again, or I'm going to plan to send them to IR. So these are good things to mention to the patient before getting started. The frequency with which appropriate antibiotics for ERCP are administered for settings in which they are indicated, this should be happening greater than 98% of the time. I've listed the indications in which antibiotics should be given. These include patients with PSC, post-liver transplant patients, patients with higher obstruction, any patients with inadequate biliary drainage. And then in cases of PD access, when there's a pseudocyst, of course, if you get into the duct and you see pus and the patient isn't already on antibiotics, I also give antibiotics in that setting. We typically use Unison 3 grams IV. If the patient is penicillin allergic, we'll use Ciprofloxacin 400. But some of this depends on your local antibiotic resistance patterns. Frequency with which ERCP is performed by an endoscopist who is fully trained and credentialed to perform ERCP should be happening greater than 98% of the time. And frequency with which the volume of ERCPs performed per year is recorded per endoscopist should also be happening greater than 98% of the time. This is because data indicate that operators of varying skill, experience, and procedure volume have varying outcomes with respect to adverse events. Individual endoscopist ERCP case volume has also been associated with variance in both procedure success rates and adverse events rates. And that's why these should be recorded. In an Austrian group, they show that endoscopists with less than 50 annual ERCPs had lower success rates and more adverse events during ERCP than physicians who performed greater numbers of procedures. Similarly, other investigations have shown that endoscopists who perform at least one sphincterotomy per week had significantly fewer ERCP-related adverse events. So these quality indicators, number four and number five, really reflect this data that volume and experience make a difference with success rates and adverse events. And that's why it's important for us to have endoscopists who are well-trained and who have higher volume of procedures. This is a meta-analysis that looked at ERCP procedural success and adverse events among high- and low-volume endoscopists and endoscopy units. In the study, low-volume endoscopists were defined as performing less than 156 annual ERCPs, and centers were low-volume if less than 200 ERCPs were performed. And basically, the punchline is that the study showed a significant relationship between increasing endoscopist ERCP volume and center ERCP volume with overall procedure success with an odds ratio of 1.6 and 2, respectively. And adverse events were also lower for high-volume endoscopists. So just important, again, to note that these are difficult procedures, and success and training takes time. Frequency with which deep cannulation of the ductive interest is documented should be done greater than 98% of the time. And then frequency with which deep cannulation of the ductive interest in patients with native papillae without surgically altered anatomy is achieved and documented should be done greater than 90% of the time. And this is a priority indicator. Successful cannulation of the ductive interest is the cornerstone of successful ERCP. Again, patients with altered anatomy are excluded in this case. And then also cases that fail because of inadequate sedation, retained gastric contents, or obstruction of the antrum or the proximal duodenum are also excluded in this case. Not all ERCPs are created equal. It's important to know that the ERCP difficulty grades range from grade 1 to grade 4, grade 1 being the easiest, grade 4 being the most difficult, and that success rates are dependent on these grades and also your level of expertise or volume. Successful endoscopists should be able to do grade 1 cases successfully 80 to 90% of the time, and that's for deep cannulation of the ductive interest or biliary stent removal or exchange, whereas tertiary care experts should be doing grade 1 cases successfully 96% of the time. Grade 3 and grade 4 cases have very low rates of success among most average endoscopists, and the rates are higher among tertiary care experts. Frequency with which fluoroscopy time and radiation dose are measured and documented should be done greater than 98% of the time. Radiation exposure should be reduced to the lowest level to allow the procedure to be completed successfully in a timely manner, and this is in accordance with the ALARA principle or as low as reasonably achievable principle. Fluoroscopy time and radiation dose are typically recorded by the fluoro machine and they can be incorporated into the ERCP procedure note. Frequency with which common bile duct stones less than 1 centimeter in patients with normal bile duct anatomy are extracted successfully and documented. This is a priority indicator. This should be done successfully 90% of the time or greater, and this is typically done by using sphincterotomy and balloon or basket stone extraction. And frequency with which stent placement for biliary obstruction in patients with normal anatomy whose obstruction is below the bifurcation is successfully achieved and documented. This is also a priority indicator and this should be done 90% of the time or greater. Typically stents are placed in cases where there's a biliary structure. This can be due to malignancy or something benign like chronic pancreatitis. It can also be done in cases where there are large stones or in cases where the patient is cholanginic and not stable enough for prolonged procedures. Regardless, this should be done successfully 90% of the time or greater. The next quality indicator is the frequency with which a complete ERCP report that details the specific techniques performed, particular accessories used, and all intended outcomes is prepared. And this should happen in greater than 98% of cases. This quality indicator is basically saying that all ERCP documentation needs to be thorough and detail-oriented and really include everything that was done during the procedure. The quality indicators from 11 to 15 are about adverse events. For 11, the frequency with which acute adverse events in hospital transfers are documented should occur in greater than 98% of cases. For 12, the rate of post-ERCP pancreatitis. This is a priority indicator. The current rate of ERCP-induced pancreatitis in clinical practice is variable and is affected by operator skill and experience, as well as the type of ERCP procedure being undertaken. And really for that reason, it's difficult to set a single performance target for all ERCPs for this indicator, which is why you see NA listed. But you should know for your endoscopist what their rates of post-ERCP pancreatitis are. In terms of indomethacin, I have that listed here. There's strong data to show that patients at high risk of post-ERCP pancreatitis, these are patients undergoing pancreatic endotherapy or sphincter of OD dysfunction patients, they have lower rates of post-ERCP pancreatitis if they're given indomethacin 100 milligrams per rectum. But there's newer data showing that patients at low to moderate risk of post-ERCP pancreatitis with native papilla also benefit from indomethacin. So since this drug is low cost and has low adverse events, in our practice we're giving all patients that don't have contraindications and who have native papilla, we are giving them indomethacin 100 milligrams per rectum. The rate and type of perforation should also be documented. Rates of perforation should be less than or equal to 0.2%. Perforation may result from mechanical rupture of the esophagus, stomach, or duodenum. This can happen from scope passage, from sphincterotomy, or passage of guide wires, or other therapeutic procedures. Perforation can be intra-abdominal or retroperitoneal. And then for number 14, the rate of clinically significant hemorrhage after sphincterotomy or sphincteroplasty in patients undergoing ERCP, this should be 1% or lower. Aspirin can be used safely in patients undergoing ERCP. For patients getting sphincterotomy or sphincteroplasty, we try to hold the other anticoagulants as possible. Post-sphincterotomy bleeding is generally defined as immediate bleeding that requires endoscopic or other interventions, or delayed bleeding that's recognized by clinical evidence, such as melanin, with a drop in hemoglobin level or need for blood transfusion within 10 days after ERCP. And then finally, for number 15, the frequency with which patients are contacted at or greater than 14 days to detect and record the occurrence of delayed events after ERCP. This should be occurring in greater than 90% of patients. This will help identify any adverse events and help with overall data tracking. The top five things that you should take away from this ERCP section, these are the five ERCP priority indicators. These are one, the frequency with which ERCP is done for an appropriate indication and documented. Two, the frequency of cannulation of ductive interest in patients with native papillae and normal anatomy. Three, success rate for less than one centimeter stones with normal biliary anatomy. Four, success rate for stenting extrahepatic biliary obstruction in those with normal anatomy. And five, the rate of post-ERCP pancreatitis. We're now going to shift gears and talk about quality indicators for EUS. Okay, similar to ERCP, the frequency with which EUS is performed for an indication that is included in a published standard list of appropriate indications and the indication is documented. This should be happening in greater than 80% of cases. If you're not doing it for one of these listed indications, again, it should be justified in your documentation. Here are the appropriate indications for EUS. Staging of tumors, evaluating lesions, sampling lesions in the pancreas, biliary, tree, esophagus, treatment of symptomatic pseudocysts, access into bile ducts, pancreatic duct, evaluating perianal and perirectal disorders, celiac plexus block, or neuralysis. So take a look at these list of indications. This will be helpful in guiding you and making sure you have the appropriate documentation if you're doing something that's not listed here. Frequency with which consent is obtained including specific discussions of risks associated with EUS and their full documentation should happen in greater than 98% of cases. In this bubble are listed some of the risks associated with EUS. Perforations are rare and happen less than 1% of the time. Bleeding risk is increased with sampling with FNA or FNB, but clinically significant bleeding requiring an admission or blood transfusions, etc. happens less than 1% of the time. Infection risk is less than 1% and pancreatitis is less than about 2%. This risk is increased with sampling of cystic lesions in the pancreas compared with solid lesions. Tumor seeding can happen along the needle track, but it's very, very rare. And then celiac plexus blocks or neuralysis carries some risks including hypotension, diarrhea, and they can be ineffective. The consent should be comprehensive and you should go over these risks in details with your patient. Frequency with which appropriate antibiotics are administered in the setting of FNA of cystic lesions. Most EUS practitioners are giving antibiotics before sampling cystic lesions in the mediastinum, pancreas, peripancreas, or peri-rectal space, and typically these are continued for about three to five days post procedure. And then it's beyond the scope of this talk to discuss training requirements and competency assessment, but it goes without saying that EUS should be performed by trained providers. And a sonographer must visualize specific structures depending on the disease process being investigated and should subsequently document these findings in writing or with photographic documentation more than 98 percent of the time. So a list of the relevant structures that should be examined can be found in the quality indicator document. So for example, for esophageal staging, the location of the GEJ should be noted if the mass can be traversed, the celiac axis should be evaluated, and the left lobe of the liver. So take a look at this document and I will say for each of these things that you're evaluating with EUS, the structures that should be seen and documented. Currently, the TNM systems are the most widely used methods for staging GI malignancies. Therefore, to maximize the utility of EUS in the setting of cancer staging, the elements necessary to assign both T and N stages should be attained during the procedure and documented in writing and with saved images. This includes measurement of the mass because T staging may depend on the tumor size. So TNM staging should be done in greater than 98 percent of cases and this is a priority indicator. The frequency with which pancreatic mass measurements are documented along with evaluation for vascular involvement, lymphadenopathy, and distal mesh should be happening in 98 percent of cases. And then the frequency with which the EUS wall layers involved by subepithelial masses are documented should be happening in 98 percent of the time. And this is because in the setting of subepithelial lesions, the differential diagnosis is based on the wall layer of origin and the echo characteristics. The percentage of patients with distant METS, CITES, and lymphadenopathy undergoing EUS-guided FNA who have tissue sampling of both the primary tumor and lesions outside of the primary field when this would alter patient management should be happening in 98 percent of cases. So for example, if you see a pink mass and you see liver lesions, you should be sampling the liver lesions as well so that upstaging can be done. Diagnostic rate of adequate sample in all solid lesions undergoing EUS-FNA should be happening in greater than 85 percent or more of cases. Of note, the involvement of an on-site cytopathologist during EUS-FNA may help limit the number of FNA passes. However, their impact in terms of diagnostic yield, number of passes, repeat procedures, and procedure time has not been studied in a randomized control trial. For situations in which an on-site cytopathologist or cytotech is not available, five to seven FNA passes for pink masses and two to four passes for lymph nodes or suspected liver METS are advised. Basically, so that you don't find out that you have an inadequate sample or you didn't get the diagnosis and have to bring that patient back. And finally, this last one is a priority indicator. The diagnostic rates of malignancy should be 70 percent or greater in patients undergoing EUS-FNA of all pancreatic masses with a sensitivity for malignancy of 85 percent or greater among all pancreatic cancers. So basically, if you have a pink mass, you should be able to come up with an answer for what that mass is 70 percent of the time. And if it's cancer, you should be able to identify that 85 percent of the time. The frequency with which the incidence of adverse events after EUS-FNA is documented should be happening in 98 percent of the time. And then again, a little bit more about adverse events. We touched about those before, but this is a priority indicator. You should know your incidence of adverse events after EUS-FNA. So pancreatitis, bleeding, perforation, and infection. We want an acute pancreatitis rate of less than 2 percent, perforation less than 0.5 percent, and clinically significant bleeding less than 1 percent. So you should document these so that risks related to these procedures and adverse events can be calculated. So for EUS, there are three priority indicators. These are the frequency with which cancers are staged with TNM staging. This should be happening greater than 98 percent of the time. The diagnostic rate slash sensitivity for cancer and pancreatic masses greater than or equal to 70 percent and greater than or equal to 85 percent. And then adverse events rates, pancreatitis less than 2 percent, PERF less than 0.5 percent, and clinically significant bleeding less than 1 percent. So these are the three things that you should focus on. Make sure you are meeting all of these targets before trying to meet the rest of the quality indicators for EUS. All right, let's now move on to quality indicators for upper GI bleeding. So there are a number of quality indicators for EGD, but here we're going to focus on those relevant to upper GI bleeding. The first is a frequency with which appropriate prophylactic antibiotics are given in patients with cirrhosis with acute upper GI bleeding before EGD. This is a priority indicator. This has been shown to decrease mortality. Most people give ceftriaxone IV one gram per day for about seven days, but it depends on your local antibiotics resistance patterns. The second indicator is the frequency with which a PPI is used for suspected peptic ulcer bleeding. This is also a priority indicator. When possible, IV PPI should be started on presentation when someone comes with bleeding and before EGD. IV PPI treatment before EGD reduces the proportion of high-risk stigmata seen at index endoscopy and the need for endoscopic therapy when you compare them with controls. Another quality indicator is frequency with which vasoactive drugs are initiated before EGD for suspected variceal bleeding. So in a meta analysis of over 30 clinical trials in 3,000 patients, the use of vasoactive medications and their analogs such as terlopresin and octreotide was associated with a lower risk of seven-day mortality. No significant difference was seen between the different vasoactive agents, but typically most in the U.S. are giving octreotide IV 50 microgram bolus followed by 50 microgram per hour infusion, and most continue this for three to five days after endoscopy. This is not a priority indicator, but the other two I just mentioned were. Okay, the frequency with which the type of upper GI bleeding lesion is described and the location is documented. In the majority of patients, a bleeding site can be determined after careful examination. The bleeding site's description should be detailed enough to allow a subsequent endoscopist to find the site. And then the next one is the frequency with which during EGD exam revealing peptic ulcers, at least one of the following stigmata is noted, active peptic ulcers, non-bleeding visible vessel, adherent clot, flat spot, and clean-based ulcer. And so this is the force classification. The force classification should be used. That's because it's correlated with the risk of re-bleeding after endoscopic therapy. So ulcer should be classified again as actively bleeding, non-bleeding visible vessel, adherent clot, flat spot, and clean-based ulcer. These stigmata provide prognostic information on re-bleeding rates and need for subsequent intervention. And this is based on 1A level of evidence. So this is the strongest level of evidence we can have. And they dictate management strategies, including the level of care and need for endoscopic therapy. Okay. The next quality indicator is a priority indicator. This is the frequency with which, unless contraindicated, endoscopic treatment is given to ulcers with active bleeding or with non-bleeding visible vessels. So in general, endoscopic attempts at hemostasis should be performed in those with spurting or oozing ulcers or in those with non-bleeding visible vessels. If there's an adherent clot, you should try and remove it to see high-risk stigmata below. And really the reason for this is that because a meta-analysis of multiple trials demonstrated that endoscopic therapy markedly decreases the risk of further bleeding and also decreases the need for surgery. The next indicator is the frequency with which achievement of primary hemostasis in cases of attempted hemostasis of upper GI bleedings is lesions is documented. This should be happening in greater than 98% of cases. This is basically because the prognosis in patients with active GI bleeding depends in part on the success of initial endoscopic interventions. Patients in whom hemostasis is not achieved are more likely to require subsequent interventional radiology or surgery procedures and are at increased risk of mortality compared with those undergoing successful endoscopic interventions. In many prospective series evaluating various modalities for managing actively bleeding upper GI lesions, primary hemostasis rates range from 90 to 100%. So endoscopists should record whether or not their efforts to achieve primary hemostasis in high-risk endoscopic stigmata are successful. The next one is frequency with which a second treatment modality is used when epinephrine injection is used to treat actively bleeding or non-bleeding visible vessels in patients with bleeding peptic ulcers. So current practices include the use of epi-injection in conjunction with a second modality like multipolar coagulation, so bipolar, heater probe, thermotherapy, coag grasper, clipping, APC, etc. Epi alone should not be considered adequate because multiple studies have documented the superiority of combined modality therapy over epi alone. And then the last indicator here is frequency with which variceal ligation is used as the first modality of treatment for the endoscopic treatment of esophageal varices. That's because in bleeding with esophageal varices, banding is preferred over sclerotherapy for safety and for efficacy. Frequency with which patients diagnosed with gastric or duodenal ulcers are instructed to take PPI or an H2 antagonist. This should be happening in 98% of patients. Frequency with which plans to test for H. pylori infection are documented for patients diagnosed with gastric or duodenal ulcers. This is a priority indicator that should be happening really all the time, so we should be testing our patients for H. pylori if they have these upper GI ulcers. And then finally, despite adequate endoscopic therapy for a bleeding peptic ulcer, re-bleeding can occur in up to one-third of patients. Repeat endoscopy for recurrent bleeding is effective and it should be done unless there's a contrary indication. Routine second look endoscopy in absence of re-bleeding is not recommended. There are four priority indicators for upper GI bleeding and EGD. These are the frequency with which, unless contraindicated, endoscopic treatment is performed for ulcers with active bleeding or with non-bleeding visible vessels. This should happen in greater than 98% cases. The frequency with which plans to test for H. pylori infection are documented for patients diagnosed with gastric or duodenal ulcers. Happens greater than 98% of the time. The frequency with which appropriate prophylactic antibiotics are given in patients with cirrhosis with acute upper GI bleeding who undergo EGD. Again, this should happen greater than 98% of the time. And finally, the frequency with which PPI is used for suspected peptic ulcer bleeding, and this should happen greater than 98% of the time. So in summary, let's go over some take-home points. It's important that we maintain the highest level of quality. It's really important to take some time to read these quality indicator documents. There are six of them. They are long. It's about 80 pages total, but it's really, really worth it. Focus on meeting targets for priority indicators for ERCP, EUS, and this upper GI bleeding. And then if you're meeting all of those, by all means, try and meet all the rest of them. And if you aren't meeting these targets, these should be the focus of quality improvement initiatives. Stay tuned, like I mentioned at the beginning of the talk, for the release of documents from the ASGE Quality Committee for Interventions to improve these quality indicators. Thank you very much.

quality indicators

ERCP

EUS

upper GI bleeding

cannulation

pancreatitis rates

procedure documentation