“ENDOSCOPY & AVIATION”

LESSONS LEARNED & A WAY FORWARD

Dale Agner, MDFaculty, Clarkson Family Medicine Residency

Nebraska Medicine, Omaha, NEdaagner@nebraskamed.com

dale.agner@gmail.com

GOALS FOR THIS AM

Improve patient safety by applying aviation-instrument standards to endoscopy

Develop a structured teamwork approach for the endoscopic team to evaluate and prepare for a patient

Application of structured learning/mentoring for confirmation of endoscopic skills that parallels aviation proficiency

Develop a framework that primary care endoscopists can unarguably demonstrate quality-proficiency to privileging bodies

ABSTRACT Clinicians 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, can Better 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.

Where I am Going With This…

By defining standards and competencies To reduce diagnostic error Improve appropriate outpatient & endoscopic

evaluation Provide transparency with demonstrated

proficiency Become the standard bearers for procedural

competency Become the leaders in primary care innovation

to improve outcomes

OVERVIEW

Why “Aviation & Medicine” discussions do not resonate with physicians Patients: predictable as a weather forecast Pt History/Exam/Labs/Rads widely variable

“Learning to Fly” milestone competencies parallel endoscopic learning/proficiency

Competency verification (FAA) can provide a useful model for endoscopic proficiency

Technique of “flying by instruments” (scan, interpret, adjust) is a useful tool to prevent diagnostic error

Endoscopy: integration of the H&P, Visual & Path Diagnosis for the patient—true patient centered care

What is the Problem:

GI community is responding very differently than ACOG or other professional bodies

GI “requiring” high-numbers that are difficult to obtain, without validation of improved patient safety

MANY more involved procedures require far fewer “#’s”, such as ERCP, c-sections

Still, not everyone is being screened SEVERAL large studies demonstrate non-superiority between

specialties BMJ 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 expense FP fills an important niche

Those that won’t go back to GI or will only see someone they know/trust already

Quality, Patient Safety, Transparency & Appropriate Referrals—the Pathway

ALSO© set the standard for European OB AAPCE has a unique opportunity to set the

standard for innovative confirmation of training and proficiency Commit to reducing diagnostic error Commit to reducing inappropriate testing Set benchmarks for quality & patient safety Embrace video reviews/taping procedures Embrace appropriate lessons from aviation

Endoscopy has been targeted for cost-reduction, lets set the national standard!

Vienna School of Medicine650 Years of Education

Integration of “lectures” with “bedside” diagnosis 1st 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” 1806 Professional racism (1938) gutted its pre-eminence Ignac Semmelweis: first introduction of scientific findings

that handwashing reduces mortality A generation BEFORE Pasteur & Lister “Theory” from Mosaic hand-washing…it worked! He died a broken man from professional ostracism

1806: Bozzini's Lichtleiter “light conductor” Introduced

in Vienna

EARLY ENDOSCOPES

Lessons from the Vienna School of Medicine (Later the

Josephinum) Professional & ideological hubris limited its stature Ignac Semmelweis: NOT listed among the “great” Viennese

physicians at the Josephinum. He didn’t “fit” the medical paradigm of physical exam w/autopsy

GREAT EXAMPLE of difficulty with admitting error Recognizing only prestigious “breakthroughs” Failure to incorporate “how did we miss this” “Freud” came later to Vienna, the “soft” science

Opportunity for Primary Care Endoscopy Incorporating “diagnostic error” into our lexicon Incorporating “side by side” FaceTime reviews Outpatient protocols for evaluation & referrals Developing AAPCE “checklists”

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 assessed

3) Standardized “FAA test” for general knowledge (ground test) and “inflight” FAA “flight evaluation” by an FAA Examiner

4) Certification & review process for Certified Flight Instructors & schools by the FAA

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 evaluation

Best learning is w/simultaneous ground & flight trng Each “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 eval

EVERY TWO YEARS there is a “hands-on” in cockpit flight review by someone certified by FAA for reviews

Any FAA Crossover?Similarities with 1 hr flying to 1 Scope

~35-70 hours required for a private pilot license Another ~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 hours FAA “Currency Requirements” are much less than GI

colonoscopy “proposed” currency #’s

Private Pilot 15-20 hours to “solo” 35-70 hours to license

Instrument Pilot 100-150 hours

Commercial Rating 250-350 hours

Certified Flight Inst (CFI) 250-500 hours

Beginning Endoscopist 15-20 “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 recommended

BOTTOM LINE:Equivalency & Currency is

analogous FAA provides “experienced based” vs.

“structured” pathways to ratings “Structured” pathways achieve proficiency ~40

SOONER

An AAPCE “structured-adopted” milestones & “over the shoulder” evaluation could mirror FAA “verification of proficiency”

Would need to adopt structured milestones FaceTime of the endoscopist & of the monitor is

possible, and would facilitate “Video Reviews”

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”

Potential AAPCE “Recognition” for Proficiency & Excellence(?)

ASCCP has a “Nurse Practioner” or “other” provider path to become “certified”, via proctor & logbook

Family Medicine now has a “pathway” for obstetrical proficiency with its “Obstetrical Fellowship”

“Recognition” does not carry the “political” concerns

How to take the initiative: Commit to transparency Be a forerunner in “taping procedures” for reviews Design & commit to evidenced based protocols

Skills to Master

Safe advancement Landmark identification “Tips” for when progress slows/stops

Turning patient Abdominal pressure (N, Alpha, Sigma loops)

How to maintain torque Pediatric & Variable stiffness scopes Cecal Intubation Terminal Ileum visualization Biopsy

Wire Loop Snare, hot and cold Submucosal injection Endomucosal resection (?)

Areas to Standardize

Knowledge assessment of sedation Endoscopy room procedures

Structured time-out that focuses on team-work Fully familiar w/airway equipment & location Incorporated a standardized simulation lab for sedation

skills General skills for safe endoscopy

Loop reduction, different types, one & two person Holding/advancing by different techniques

Advanced polypectomy skills Snare, submucosal injection/tattoo etc.

Advanced tips/techniques for success

Summarizing Initial Proficiency

Concur 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 Tool

Adenoma 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 competent

REDUCTION IN ERROR

Instrument Flying as an example “Instrument Scan” “Instrument Approach” (ORM) to evaluate

When to do the scope, when to refer Once started—when to “end the attempt”

DIAGNOSTIC ERROR (prevention thereof) is the latest INSTITUTE OF MEDICINE concern

AAPCE has opportunity to capitalize

Instrument Flying Rating (IFR) for Flying in Instrument

Meteorological Conditions (IMC) This is known as the “HARDEST” rating to learn Navigating in clouds, flying aircraft w/out visual cues It is known as “PRECISION FLYING”… …for if you are not precise in clouds or when landing

May 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 months At least one “holding” procedure At least on “course intercept” Requires: actual IMC or blinders with a safety pilot

Precision Flying “by the numbers”

BEST KNOWN TECHNIQUE for maintaining SA… SCAN INTERPRET ADJUST

“Briefing” the approach to land in & through clouds: Ensures all appropriate information is at hand Appropriate runway “navigation” is “locked in” IF unable to “lock” on navigational aids, stay on

“glideslope” or “see” runway, THEN GO AROUND Requires defining personal minimums & proficiency

“Currency” does not always mean “proficiency”

Scan, Interpret, AdjustMy “Instrument” review for medicine (long

before I flew)

Check (scan) Chief Complaint Problem list Medication list Vitals Assessment & Plan DO THEY AGREE? (if not, how do I explain it?)

Incorporate Patient History, Exam, Labs & Rads Do 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 overlooked

Scan, Interpret, Adjust

SCAN (differential, EHR): I scan, because I can be wrong or miss info I can’t diagnose it if I don’t think of it Increase 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 record

INTERPRET: (CC, vitals, tests, exam, history) Nearly every test has a “normal” when it is not Nearly all tests have significant false (+’s) & (-’s) How does Bayes theorem affect this patient?

ADJUST: willing to be wrong or reconsider How have I “confirmed” stability until “seen again” Is there another perspective to consider?

More on the “Scan”Diagnostic Error & Inappropriate Testing

Common “Errors” or “Psychology of Error”

Failure to consider a common diagnosis with an uncommon presentation

Failure 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 not

Move beyond treating “what” is happening to “why” Do not underestimate one’s own ability to be wrong Avoid bias: repetition, 1st diagnosis, ER diagnosis, etc.

Keep the scan alive w/each Pt EncounterScan, Interpret, Adjust

Classification of Errors or Complications

Inappropriate 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 adenoma

Perforations (“x”/500 or 1000?) Bleeding complications (repeat scope/clip) Sedation reversals, lost airway, OSA, hypertensive Anesthesia/sedation issues (aspiration, hypoxic) Issues not defined for referrals: how good was the prep for

“next in 10 years”? Post-polypectomy syndrome

ORM: Operational Risk Management (risk reduction)

Patient Complexity ASA Staff Capabilities Number of people training Experience of the Staff Experience of the resident Experience of the endoscopist

“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 patient Cardiac or hemodynamic issues (vagal w/CAD, Paroxysmal

a-fib, “bleeding”, “melena” Opiate tolerance BMI, 40, 50 etc. with or w/out OSA Abdominal/pelvic surgery &/or radiation Extensive diverticulosis or advanced age Previous inability to complete a scope Dementia (longevity, informed consent) Length or procedure or amounts of sedation

“Crew Resource Management” (CRM) in the Endoscopy Suite

Endoscopy “Time-Outs” Used in my last Endoscopy Suite

Nurse: Confirms patient & procedure using full name & DOB

Verbally confirms procedure w/Patient, MD-DO, & rest of team

Confirms sedation cart “open” w/airway adjuncts/meds available

Confirms signed pre-op assessment & consent signed/witnessed

MD-DO: Confirms to the team the procedure and indication

Med 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)33

“Checklists(?)” ACOG has designed many …So can we…some suggestions:

Outpatient evaluation of abdominal pain* What to consider &/or evaluate prior to EGD

Endoscopy specific “time-out”* Reviewing indications for procedure (for all) Ensure ALL are introduced in the room

Promotes “Crew Resource Management/CRM” 16% reduction in major surgical errors/NEJM

Pre-procedure “evaluation/checklist”* Ensures available records reviewed Assists appropriate procedure selection Helps ensure appropriate sedation selection

Primary care NEEDS protocols/checklists for Evaluation of anemia (workup & when to refer) When to refer for hematochezia

“Quality Indicators” to Competency & Proficiency

Adenoma Detection Rate Recommend tracking this Individual and Group Many GI groups do not track this, as “Provation” does not

calculate “Appropriateness of referral” can be a confounder

Perf Rate: Greatest Risk is in the 1st 100 Should be <1/1,000 >1:500 should prompt an evaluation (suggested)

Adverse Events Tracked Sedation reversals Hospitalization/re-procedure Bleeding Post-polypectomy syndrome

Lessons from the Vienna School of Medicine (Later the

Josephinum) Professional & ideological hubris limited its stature Ignac Semmelweis: NOT listed among the “great” Viennese

physicians at the Josephinum. He didn’t “fit” the medical paradigm of physical exam w/autopsy

GREAT EXAMPLE of difficulty with admitting error Recognizing only prestigious “breakthroughs” Failure to incorporate “how did we miss this” “Freud” came later to Vienna, the “soft” science

Opportunity for Primary Care Endoscopy Incorporating “diagnostic error” into our lexicon Incorporating “side by side” FaceTime reviews Outpatient protocols for evaluation & referrals Developing AAPCE “checklists”

Concrete Potential “Action Points”

Define a “Quality Recognition” Coordinate with AAFP Surrogate for proficiency Demonstrate quality without “high numbers”

Find a journal for AAPCE Quarterly review of complications Quarterly “tip/technique”

Develop standards for video review Consider ability for remote review/proctor(?) Consider “senior reviewers/mentors” Develop “milestones” for training Consider setting “considerations” for complexity of

patients for those with low numbers or low volume

Examples of Potential “AAPCE FORMS” &/or Adaptable to Protocols ENDOSCOPY PRE-PROCEDURE EVAL FORM

Background info ASA evaluation

EGD Referral Worksheet Based upon ACP Best Practice Advice for EGD Assists work-up & other diagnostic information

ENDOSCOPY TIME-OUT Developed after several equipment miscues Ensure ALL are introduced in the room (++EBM)

NEEDED PROTOCOLS &/OR BEST PRACTICE ADVICE Outpatient anemia evaluation Hematochezia (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”

POTENTIAL ENDOSCOPYPRE-SCREENING FORM

POTENTIAL EGDPRE-SCREENING FORM

POTENTIAL ENDOSCOPYTIME-OUT TEMPLATE

BACKUP SLIDES

FAA “WINGS” Proficiency

Regular seminars are held that review important aspects of flight safety.

Often adverse events are reviewed for applicable lessons learned

Certain number of “WINGS Points” counts for an “annual review” by the FAA

Regular 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)

Goals in Teaching Colonoscopy (Screening & Diagnostic)

First of all, Patient Safety Sedation Patient selection Technique

Adequate screen Respectable adenoma detection rate Respectable cecal intubation rate

Respectable fund of knowledge Indications (diagnostic, screening, Follow-up) Anatomy & Pathophysiology Equipment (procedure & sedation)

Mayo Colonoscopy Skills Assessment Tool (MCSAT)

Structured tool to assess advancement Useful to design curriculum and gauge

assessment As 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”

“A Classification of the Verbal Methods Currently Used to Teach Endoscopy”

BMC Med Educ. 2014 Aug 9; 14:163Endoscopy 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 informationMAYO Clinic Skills Assessment

General Info: 2.8/1,000 for all Major Complications

~90% of perforations occur during the first 100 scopes (surgical resident literature) Tears Perforation from snares/instrumentation Barotrauma

Sedation complications Hypoxia, aspiration Painful experience

Polypectomy 7 fold increase in complications Not distinguished in literature from “screening”

Endomucosal resection (5-10% rate for bleeding or perforation)

MAYO Skills Assessment

“Training to Competency”ASGE—GIE 2011

The 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].

REX-TIPS

Anticipate Altered Sigmoid Anatomy Never push against fixed resistance MAXIMIZE scope sensory feedback Master the left colon Problem solve in algorithmic fashion Change solutions quickly Change instruments in the difficult sigmoid Be subtle in passing the hepatic flexure See the medial cecal wall Be willing to quit

My Experience Teaching “100% positive control” of the scope, …combined

with loop reduction, is the difference between those achieving 90% vs 95% cecal intubation rates

Water immersion greatly assists proficiency I 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” tip Time to cecum is similar to GI; our withdrawal times are

longer Provide 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