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“ENDOSCOPY & Aviation” “ENDOSCOPY & Aviation”

“ENDOSCOPY & Aviation” - PowerPoint Presentation

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“ENDOSCOPY & Aviation” - PPT Presentation

Lessons learned amp a way forward Dale Agner MD Faculty Clarkson Family Medicine Residency Nebraska Medicine Omaha NE daagnernebraskamedcom daleagnergmailcom GOALS FOR THIS AM ID: 622572

proficiency amp endoscopy faa amp proficiency faa endoscopy patient skills procedure sedation evaluation flying flight rate learning review hours

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Slide1

“ENDOSCOPY & Aviation” Lessons learned & a way forward

Dale Agner, MD

Faculty, Clarkson Family Medicine Residency

Nebraska Medicine, Omaha, NE

daagner@nebraskamed.com

dale.agner@gmail.comSlide2

GOALS FOR THIS AMImprove patient safety by applying aviation-instrument standards to endoscopyDevelop a structured teamwork approach for the endoscopic team to evaluate and prepare for a patientApplication of structured learning/mentoring for confirmation of endoscopic skills that parallels aviation proficiencyDevelop a framework that primary care endoscopists can unarguably demonstrate quality-proficiency to privileging bodiesSlide3

ABSTRACTClinicians cringe at medicine-aviation parallels; Pt perceptions, interpretations & tests do not have the same reliability-specificity of aviation instruments. Medicine parallels the need for precision flying in a storm, as Pts resemble storms more than checklists. A structured approach to personal “minimums” & review of Pt complexity & Endo Suite capabilities…akin to preparation for an instrument landing, canBetter define appropriate matched Pt complexity to endoscopist’s proficiency for exceptional Pt-safety.Flying hours & endo procedures proficiency mirrors Structured-measured pilot mentoring w/external competency verification achieves proficiency

~50

% quicker than “experienced-based” learning;

this can

…Parallel

endoscopic proficiency &

mentoring by developing similar

structured learning

goals/standards

when

measurable-quality

competencies

are defined. Slide4

Where I am Going With This…By defining standards and competenciesTo reduce diagnostic errorImprove appropriate outpatient & endoscopic evaluationProvide transparency with demonstrated proficiencyBecome the standard bearers for procedural competency Become the leaders in primary care innovation to improve outcomes Slide5

OVERVIEWWhy “Aviation & Medicine” discussions do not resonate with physiciansPatients: predictable as a weather forecastPt History/Exam/Labs/Rads widely variable“Learning to Fly” milestone competencies parallel endoscopic learning/proficiencyCompetency verification (FAA) can provide a useful model for endoscopic proficiencyTechnique of “flying by instruments” (scan, interpret, adjust) is a useful tool to prevent diagnostic errorEndoscopy: integration of the H&P, Visual & Path Diagnosis for the patient—true patient centered care Slide6

What is the Problem:GI community is responding very differently than ACOG or other professional bodiesGI “requiring” high-numbers that are difficult to obtain, without validation of improved patient safetyMANY more involved procedures require far fewer “#’s”, such as ERCP, c-sectionsStill, not everyone is being screenedSEVERAL large studies demonstrate non-superiority between specialtiesBMJ article demonstrated conscientious withdrawal, independent of specialty, to be the “best” indicator“Hospitalist” study showed FP non-inferiority with FPs taking ½ day longer to discharge, but overall less expenseFP fills an important niche Those that won’t go back to GI or will only see someone they know/trust alreadySlide7

Quality, Patient Safety, Transparency & Appropriate Referrals—the PathwayALSO© set the standard for European OBAAPCE has a unique opportunity to set the standard for innovative confirmation of training and proficiencyCommit to reducing diagnostic errorCommit to reducing inappropriate testingSet benchmarks for quality & patient safetyEmbrace video reviews/taping proceduresEmbrace appropriate lessons from aviationEndoscopy has been targeted for cost-reduction, lets set the national standard!Slide8
Slide9

Vienna School of Medicine650 Years of EducationIntegration of “lectures” with “bedside” diagnosis1st integration of the “external” with the “internal”First percussion/stethoscope (egophany) for physical diagnosis, the integration of physical findings with pathological findings (autopsy)First “Endoscope” produced to “look inside” 1806Professional racism (1938) gutted its pre-eminenceIgnac Semmelweis: first introduction of scientific findings that handwashing reduces mortalityA generation BEFORE Pasteur & Lister“Theory” from Mosaic hand-washing…it worked!He died a broken man from professional ostracismSlide10
Slide11

1806: Bozzini's Lichtleiter “light conductor” Introduced in ViennaSlide12

EARLY ENDOSCOPESSlide13

Lessons from the Vienna School of Medicine (Later the Josephinum)Professional & ideological hubris limited its statureIgnac Semmelweis: NOT listed among the “great” Viennese physicians at the Josephinum. He didn’t “fit” the medical paradigm of physical exam w/autopsyGREAT EXAMPLE of difficulty with admitting errorRecognizing only prestigious “breakthroughs”Failure to incorporate “how did we miss this”“Freud” came later to Vienna, the “soft” scienceOpportunity for Primary Care EndoscopyIncorporating “diagnostic error” into our lexiconIncorporating “side by side” FaceTime reviewsOutpatient protocols for evaluation & referralsDeveloping AAPCE “checklists” Slide14

How does the FAA Ensure Competency?1) Flight School with a structured curriculum and learning environment with periodic knowledge & skills assessment 2) Flight School with a “volume based” presumption of knowledge & skills that are assessed3) Standardized “FAA test” for general knowledge (ground test) and “inflight” FAA “flight evaluation” by an FAA Examiner4) Certification & review process for Certified Flight Instructors & schools by the FAASlide15

How does the FAA Ensure Competency? (cont’ed)Each pilot “certification” (private pilot, instrument rating, commercial rating, etc.) has periodic “STAGE-CHECKS”, to ensure appropriate student progression “Student” completes a “standardized ground test” at a testing center, before the “inflight” FAA evaluationBest learning is w/simultaneous ground & flight trngEach “STAGE CHECK” is performed by a flight instructor OTHER than the primary instructor, whom is recognized for being able to give “reviews”“Chief Flight Instructor” for the school confirms “end of course” review & “ready” for the FAA inflight evalEVERY TWO YEARS there is a “hands-on” in cockpit flight review by someone certified by FAA for reviews Slide16

Any FAA Crossover?Similarities with 1 hr flying to 1 Scope~35-70 hours required for a private pilot licenseAnother ~35-50 hours for instrument training (~100-140 total hours)250 hours required for a “commercial pilot license” (50 can be simulated)“the more one studies on the ground… …the less one spends in the air”Mixture of knowledge and skill assessments (ground tests and inflight evaluations)Graduated assessments accomplished via certified schools, instructors, and FAA examiners“Certified Flight Instructor” at 250 hoursFAA “Currency Requirements” are much less than GI colonoscopy “proposed” currency #’sSlide17

Private Pilot15-20 hours to “solo”35-70 hours to licenseInstrument Pilot100-150 hoursCommercial Rating250-350 hoursCertified Flight Inst (CFI)250-500 hoursBeginning Endoscopist15-20 “sigmoids”~ hours for “safe”~ “#” for privileges“tips/techniques”

~”#” in a GI Fellowship

ASGE’s “still learning”

CFI: My observation of when someone becomes a sterling teacher

Side by Side Comparison

We are “safe” when practicing “personal limits” at lower #’s

Standardizing curriculum/techniques/reviews recommendedSlide18

BOTTOM LINE:Equivalency & Currency is analogousFAA provides “experienced based” vs. “structured” pathways to ratings“Structured” pathways achieve proficiency ~40 SOONERAn AAPCE “structured-adopted” milestones & “over the shoulder” evaluation could mirror FAA “verification of proficiency”Would need to adopt structured milestonesFaceTime of the endoscopist & of the monitor is possible, and would facilitate “Video Reviews”Slide19

Future Vectors(?)Should we, AAPCE, strive to define a “practice standard” for teaching?Should we have a “benchmark” or “recognition” for demonstration of safe and quality endoscopy?Is there a way to study or demonstrate the “Minimal procedural skills required to be competent to perform routine colonoscopies”Slide20

Potential AAPCE “Recognition” for Proficiency & Excellence(?)ASCCP has a “Nurse Practioner” or “other” provider path to become “certified”, via proctor & logbookFamily Medicine now has a “pathway” for obstetrical proficiency with its “Obstetrical Fellowship”“Recognition” does not carry the “political” concernsHow to take the initiative:Commit to transparencyBe a forerunner in “taping procedures” for reviewsDesign & commit to evidenced based protocolsSlide21

Skills to MasterSafe advancementLandmark identification“Tips” for when progress slows/stopsTurning patientAbdominal pressure (N, Alpha, Sigma loops)How to maintain torquePediatric & Variable stiffness scopesCecal IntubationTerminal Ileum visualizationBiopsyWire Loop Snare, hot and coldSubmucosal injectionEndomucosal resection (?)Slide22

Areas to StandardizeKnowledge assessment of sedationEndoscopy room proceduresStructured time-out that focuses on team-workFully familiar w/airway equipment & locationIncorporated a standardized simulation lab for sedation skillsGeneral skills for safe endoscopyLoop reduction, different types, one & two personHolding/advancing by different techniquesAdvanced polypectomy skillsSnare, submucosal injection/tattoo etc.Advanced tips/techniques for successSlide23

Summarizing Initial ProficiencyConcur with ASGE that there is still a “learning curve” after 140 scopes“Safe & Competent” is more than “numbers based” on the MAYO Clinic Skills Assessment ToolAdenoma detection rate is more important than “time to cecum”Concur with a 90% cecal intubation rate (Though a high ADR is more associated with reduced rates of colo-rectal cancer after colonoscopy than cecal intubation rate)I do recommend some thought into what demonstrated skills should be accomplished prior to “recommending” someone as competentSlide24

REDUCTION IN ERRORInstrument Flying as an example“Instrument Scan”“Instrument Approach” (ORM) to evaluate When to do the scope, when to referOnce started—when to “end the attempt” DIAGNOSTIC ERROR (prevention thereof) is the latest INSTITUTE OF MEDICINE concernAAPCE has opportunity to capitalizeSlide25

Instrument Flying Rating (IFR) for Flying in Instrument Meteorological Conditions (IMC)This is known as the “HARDEST” rating to learnNavigating in clouds, flying aircraft w/out visual cuesIt is known as “PRECISION FLYING”……for if you are not precise in clouds or when landingMay miss the runway, hit a building, mountain etc.May become lose flying situational awareness (SA), disoriented =>grave-yard spiral, stall, spin etc.IFR Currency is defined as (flying w/obstructed view):6 landings in 6 monthsAt least one “holding” procedureAt least on “course intercept”Requires: actual IMC or blinders with a safety pilotSlide26

Precision Flying “by the numbers” BEST KNOWN TECHNIQUE for maintaining SA…SCANINTERPRETADJUST “Briefing” the approach to land in & through clouds:Ensures all appropriate information is at handAppropriate runway “navigation” is “locked in”IF unable to “lock” on navigational aids, stay on “glideslope” or “see” runway, THEN GO AROUNDRequires defining personal minimums & proficiency“Currency” does not always mean “proficiency”Slide27

Scan, Interpret, AdjustMy “Instrument” review for medicine (long before I flew)Check (scan)Chief ComplaintProblem listMedication listVitalsAssessment & PlanDO THEY AGREE? (if not, how do I explain it?)Incorporate Patient History, Exam, Labs & RadsDo they all reasonably agree? (if not, explanation?)MANY take a short history, limited exam, and JUMP to “ordering tests; labs/rads”Physical diagnosis is often being overlookedSlide28

Scan, Interpret, AdjustSCAN (differential, EHR):I scan, because I can be wrong or miss infoI can’t diagnose it if I don’t think of itIncrease in testing is the belief it “trumps” & it can be a “time saver” for thinking/examining Scan for where info can be “hidden” in the recordINTERPRET: (CC, vitals, tests, exam, history)Nearly every test has a “normal” when it is notNearly all tests have significant false (+’s) & (-’s)How does Bayes theorem affect this patient?ADJUST: willing to be wrong or reconsiderHow have I “confirmed” stability until “seen again”Is there another perspective to consider?Slide29

More on the “Scan”Diagnostic Error & Inappropriate TestingCommon “Errors” or “Psychology of Error”Failure to consider a common diagnosis with an uncommon presentationFailure to consider a common presentation of an uncommon disease process (know the ones that bite)CONFIRM the diagnosis reasonably PFTs often absent for those with “RAD or COPD”Review when the test can look “normal” but notMove beyond treating “what” is happening to “why”Do not underestimate one’s own ability to be wrongAvoid bias: repetition, 1st diagnosis, ER diagnosis, etc.Keep the scan alive w/each Pt EncounterScan, Interpret, AdjustSlide30

Classification of Errors or ComplicationsInappropriate referral (too soon, missed gallstones)Procedure performed with incomplete information (was the “polyp” hyperplastic or a serrated adenoma? Did I “wait” to track down the path report)Procedure performed not within guidelines; e.g 1 yr F/U for 5mm cecal tubular adenomaPerforations (“x”/500 or 1000?)Bleeding complications (repeat scope/clip)Sedation reversals, lost airway, OSA, hypertensiveAnesthesia/sedation issues (aspiration, hypoxic)Issues not defined for referrals: how good was the prep for “next in 10 years”?Post-polypectomy syndromeSlide31

ORM: Operational Risk Management (risk reduction)Patient ComplexityASAStaff CapabilitiesNumber of people trainingExperience of the StaffExperience of the residentExperience of the endoscopistSlide32

“Personal Minimums”, Proficiency or When it is “Time to Call It”Ensuring an upper is not indicated when referred only for a lower. Will you do a lower only when an EGD is also indicated?ASA II, III with or without “other issues”Sedation available to patientCardiac or hemodynamic issues (vagal w/CAD, Paroxysmal a-fib, “bleeding”, “melena”Opiate toleranceBMI, 40, 50 etc. with or w/out OSAAbdominal/pelvic surgery &/or radiationExtensive diverticulosis or advanced agePrevious inability to complete a scopeDementia (longevity, informed consent)Length or procedure or amounts of sedationSlide33

“Crew Resource Management” (CRM) in the Endoscopy SuiteEndoscopy “Time-Outs” Used in my last Endoscopy SuiteNurse: Confirms patient & procedure using full name & DOBVerbally confirms procedure w/Patient, MD-DO, & rest of teamConfirms sedation cart “open” w/airway adjuncts/meds availableConfirms signed pre-op assessment & consent signed/witnessedMD-DO: Confirms to the team the procedure and indicationMed record reviewed: e.g. Meds, pertinent

PMHx

& Labs

Ensures all are introduced in the room

Confirms staff/resident/students aware of airway cart/adjuncts

Technician/s: Confirms &/or demonstrates

All necessary

equipment was available and

operational

Correct patient

position (e.g. head

of bed at

30° for EGD

)

33Slide34

“Checklists(?)” ACOG has designed many …So can we…some suggestions:Outpatient evaluation of abdominal pain*What to consider &/or evaluate prior to EGDEndoscopy specific “time-out”*Reviewing indications for procedure (for all)Ensure ALL are introduced in the roomPromotes “Crew Resource Management/CRM”16% reduction in major surgical errors/NEJMPre-procedure “evaluation/checklist”*Ensures available records reviewedAssists appropriate procedure selectionHelps ensure appropriate sedation selectionPrimary care NEEDS protocols/checklists forEvaluation of anemia (workup & when to refer)When to refer for hematocheziaSlide35

“Quality Indicators” to Competency & ProficiencyAdenoma Detection RateRecommend tracking thisIndividual and GroupMany GI groups do not track this, as “Provation” does not calculate“Appropriateness of referral” can be a confounderPerf Rate: Greatest Risk is in the 1st 100Should be <1/1,000>1:500 should prompt an evaluation (suggested)Adverse Events TrackedSedation reversalsHospitalization/re-procedure BleedingPost-polypectomy syndromeSlide36

Lessons from the Vienna School of Medicine (Later the Josephinum)Professional & ideological hubris limited its statureIgnac Semmelweis: NOT listed among the “great” Viennese physicians at the Josephinum. He didn’t “fit” the medical paradigm of physical exam w/autopsyGREAT EXAMPLE of difficulty with admitting errorRecognizing only prestigious “breakthroughs”Failure to incorporate “how did we miss this”“Freud” came later to Vienna, the “soft” scienceOpportunity for Primary Care EndoscopyIncorporating “diagnostic error” into our lexiconIncorporating “side by side” FaceTime reviewsOutpatient protocols for evaluation & referralsDeveloping AAPCE “checklists” Slide37

Concrete Potential “Action Points”Define a “Quality Recognition”Coordinate with AAFPSurrogate for proficiencyDemonstrate quality without “high numbers”Find a journal for AAPCEQuarterly review of complicationsQuarterly “tip/technique”Develop standards for video reviewConsider ability for remote review/proctor(?)Consider “senior reviewers/mentors”Develop “milestones” for trainingConsider setting “considerations” for complexity of patients for those with low numbers or low volumeSlide38

Examples of Potential “AAPCE FORMS” &/or Adaptable to ProtocolsENDOSCOPY PRE-PROCEDURE EVAL FORMBackground infoASA evaluationEGD Referral WorksheetBased upon ACP Best Practice Advice for EGDAssists work-up & other diagnostic informationENDOSCOPY TIME-OUTDeveloped after several equipment miscuesEnsure ALL are introduced in the room (++EBM) NEEDED PROTOCOLS &/OR BEST PRACTICE ADVICEOutpatient anemia evaluationHematochezia (outpt clinic eval & when to refer)

FORM to assist with nuance of colon cancer screening (e.g. Lynch Syndrome, true “+”

Fam

Hx

)

Operational Risk Management form for “minimums”Slide39

POTENTIAL ENDOSCOPYPRE-SCREENING FORMSlide40
Slide41
Slide42

POTENTIAL EGDPRE-SCREENING FORMSlide43
Slide44
Slide45
Slide46
Slide47

POTENTIAL ENDOSCOPYTIME-OUT TEMPLATESlide48

BACKUP SLIDESSlide49

FAA “WINGS” ProficiencyRegular seminars are held that review important aspects of flight safety. Often adverse events are reviewed for applicable lessons learnedCertain number of “WINGS Points” counts for an “annual review” by the FAARegular participation in the “WINGS” program has shown a decreased rate of accidents (FAA self-acknowledges potential for selection bias)There is an aspect of “forgiveness” if one “self-declares” an error in pilot/airspace safety (allowed up to one every 6 months)Slide50

Goals in Teaching Colonoscopy (Screening & Diagnostic) First of all, Patient SafetySedationPatient selectionTechniqueAdequate screenRespectable adenoma detection rateRespectable cecal intubation rateRespectable fund of knowledgeIndications (diagnostic, screening, Follow-up)Anatomy & PathophysiologyEquipment (procedure & sedation)Slide51

Mayo Colonoscopy Skills Assessment Tool (MCSAT)Structured tool to assess advancementUseful to design curriculum and gauge assessmentAs per the ASGE literature“Learning Curve” may be “more” than previously thought I.e. more than 140 [250, 500?]QUESTION TO PONDER: How do we “assess” when one is able to be “safe” & “competent”Slide52

“A Classification of the Verbal Methods Currently Used to Teach Endoscopy”BMC Med Educ. 2014 Aug 9; 14:163

Endoscopy

does not lend itself well to assisting or exposure by the teacher, most of the teaching is, by necessity, done

verbally [Six types

of

verbal]

Demonstration

by the

teacher

Motor instructions

Broad tips/tricks/pointers

Verbal

feedback,

questioning

Non-procedural information

MAYO Clinic Skills AssessmentSlide53

General Info: 2.8/1,000 for all Major Complications~90% of perforations occur during the first 100 scopes (surgical resident literature)TearsPerforation from snares/instrumentationBarotraumaSedation complicationsHypoxia, aspirationPainful experiencePolypectomy7 fold increase in complicationsNot distinguished in literature from “screening”Endomucosal resection (5-10% rate for bleeding or perforation)Slide54

MAYO Skills AssessmentSlide55

“Training to Competency”ASGE—GIE 2011The learning curves of the core motor and cognitive skills required to perform colonoscopy are described and the minimal competency criteria for these skills are defined.The average number of procedures required to achieve these minimal competency thresholds are identified.These training volumes are much more than current training guidelines recommend [250-500].Slide56

REX-TIPSAnticipate Altered Sigmoid AnatomyNever push against fixed resistanceMAXIMIZE scope sensory feedbackMaster the left colonProblem solve in algorithmic fashionChange solutions quicklyChange instruments in the difficult sigmoidBe subtle in passing the hepatic flexureSee the medial cecal wallBe willing to quitSlide57

My ExperienceTeaching “100% positive control” of the scope, …combined with loop reduction, is the difference between those achieving 90% vs 95% cecal intubation ratesWater immersion greatly assists proficiencyI take the more advanced residents to our hospital based location (for ASA III patients), where we keep to a 30 minute schedule for colonoscopies“Touch” the scope usually to only demonstrate an advanced “Rex” tipTime to cecum is similar to GI; our withdrawal times are longerProvide a letter of reference for those that desire (a letter signed by the Chief of the Medical Staff has some weight. I will cite the:Adenoma detection rate Cecal intubation rate“No Complications” as appropriate