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      Gastronet survey on the use of one- or two-person technique for colonoscopy insertion

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          Abstract

          Background

          Usually, colonoscopy insertion is performed by the colonoscopist (one-person technique). Quite common in the early days of endoscopy, the assisting nurse is now only rarely doing the insertion (two-person technique). Using the Norwegian national endoscopy quality assurance (QA) programme, Gastronet, we wanted to explore the extent of two-person technique practice and look into possible differences in performance and QA output measures.

          Methods

          100 colonoscopists in 18 colonoscopy centres having reported their colonoscopies to Gastronet between January and December 2009 were asked if they practiced one- or two-person technique during insertion of the colonoscope. They were categorized accordingly for comparative analyses of QA indicators.

          Results

          75 endoscopists responded to the survey (representing 9368 colonoscopies) - 62 of them (83%) applied one-person technique and 13 (17%) two-person technique. Patients age and sex distributions and indications for colonoscopy were also similar in the two groups. Caecal intubation was 96% in the two-person group compared to 92% in the one-person group (p < 0.001). Pain reports were similar in the groups, but time to the caecum was shorter and the use of sedation less in the two-person group.

          Conclusion

          Two-person technique for colonoscope insertion was practiced by a considerable minority of endoscopists (17%). QA indicators were either similar to or better than one-person technique. This suggests that there may be some beneficial elements to this technique worth exploring and try to import into the much preferred one-person insertion technique.

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          Most cited references10

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          Quality indicators for colonoscopy and the risk of interval cancer.

          Although rates of detection of adenomatous lesions (tumors or polyps) and cecal intubation are recommended for use as quality indicators for screening colonoscopy, these measurements have not been validated, and their importance remains uncertain. We used a multivariate Cox proportional-hazards regression model to evaluate the influence of quality indicators for colonoscopy on the risk of interval cancer. Data were collected from 186 endoscopists who were involved in a colonoscopy-based colorectal-cancer screening program involving 45,026 subjects. Interval cancer was defined as colorectal adenocarcinoma that was diagnosed between the time of screening colonoscopy and the scheduled time of surveillance colonoscopy. We derived data on quality indicators for colonoscopy from the screening program's database and data on interval cancers from cancer registries. The primary aim of the study was to assess the association between quality indicators for colonoscopy and the risk of interval cancer. A total of 42 interval colorectal cancers were identified during a period of 188,788 person-years. The endoscopist's rate of detection of adenomas was significantly associated with the risk of interval colorectal cancer (P=0.008), whereas the rate of cecal intubation was not significantly associated with this risk (P=0.50). The hazard ratios for adenoma detection rates of less than 11.0%, 11.0 to 14.9%, and 15.0 to 19.9%, as compared with a rate of 20.0% or higher, were 10.94 (95% confidence interval [CI], 1.37 to 87.01), 10.75 (95% CI, 1.36 to 85.06), and 12.50 (95% CI, 1.51 to 103.43), respectively (P=0.02 for all comparisons). The adenoma detection rate is an independent predictor of the risk of interval colorectal cancer after screening colonoscopy. 2010 Massachusetts Medical Society
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            Quality assessment of colonoscopic cecal intubation: an analysis of 6 years of continuous practice at a university hospital.

            Despite increased emphasis on endoscopic performance indicators, e.g., cecal intubation rates, limited data from actual clinical practice have been published. Retrospective database review to determine the rate and documentation of cecal intubation during colonoscopy at the University of Maryland Medical Center. We reviewed 5,477 consecutive colonoscopies performed by 10 faculty gastroenterologists at a University hospital over a 6-yr period (March 1, 1999 to February 28, 2005). Unadjusted cecal intubation rates were analyzed as were rates that were adjusted based on the U.S. Multi-Society Task Force on Colorectal Cancer recommendations. We analyzed trends in overall and individual cecal intubation rates, circumstances that impact these rates, and the quality of documentation of cecal intubation. The overall adjusted cecal intubation rate for the entire 6 yr was 90.3%, and increased over the study period with the highest adjusted rate (93.7%) in the most recent year studied. There was no correlation between cecal intubation rate and patient age, gastroenterology fellow involvement, or endoscopist experience and number of procedures/year. In contrast, colon cancer screening, male gender, outpatient colonoscopy, and adequate bowel preparation predicted a higher cecal intubation rate. Written and photographic documentation of cecal intubation improved significantly after 2002. Our analysis revealed cecal intubation and documentation rates that meet current guidelines, and identified factors that may cause substantial variance in these rates depending on the nature of the practice. The present analysis confirms that computerized databases can be used to assess individual and group cecal intubation and documentation rates on an annual basis, and to make these data available to the public.
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              The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres.

              The burden on colonoscopy capacity is considerable and expected to increase further as colorectal cancer screening programmes gain a foothold in Europe. In this situation, it is particularly important to evaluate the quality of the service given. In this article we present our first year of experience with a quality network of endoscopy centres in Norway (Gastronet). A questionnaire focusing on caecal intubation rate and pain was completed by the endoscopist (on site) and patient (on the day after the examination). Fourteen centres participated with registration of 7370 colonoscopies by 73 endoscopists. There was 100% endoscopist participation, 87% coverage of colonoscopies and an estimated 76% questionnaire coverage of the patient population. Overall caecal intubation rate was 91%, range 83% to 97% between centres (p < 0.001). Patients reporting severe pain during colonoscopy differed from 2 to 24% between centres (p < 0.001). Variations could only partly be explained by differences in procedure practice (sedation, CO2 insufflation). For individual endoscopists, improvement after feedback on performance was restricted to the group of endoscopists having contributed with only 50-99 registered colonoscopies. In quality assurance programmes we recommend a limited number of variables for registration in order to secure high compliance by endoscopists and patients. One year of experience with Gastronet disclosed a satisfactory overall caecal intubation rate, but considerable variation between centres in practice and ability to offer painless colonoscopy. This suggests a need for formal, centralized training of colonoscopists or the development of quality standards for colonoscopy training and practice.
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                Author and article information

                Journal
                BMC Gastroenterol
                BMC Gastroenterology
                BioMed Central
                1471-230X
                2011
                14 June 2011
                : 11
                : 73
                Affiliations
                [1 ]Dept of Medicine, Telemark Hospital, 3710 Skien, Norway
                [2 ]Cancer Registry of Norway, Oslo University Hospital, Montebello, 0304 Oslo, Norway
                [3 ]Oslo University Hospital Rikshospitalet, Dept of Medicine, 0027 Oslo, Norway
                [4 ]Dept of Medicine, Sørlandet Hospital Arendal, 4809 Arendal, Norway
                [5 ]Dept of Medicine, Bærum Hospital Vestre Viken HF, 1309 Rud, Norway
                [6 ]Dept of Medicine, Helse Sunnmøre HF, Ålesund Hospital, 6026 Ålesund, Norway
                [7 ]Telemark Hospital Kragerø, 3770 Kragerø, Norway
                [8 ]Dept of Surgery, Stavanger University Hospital, 4068 Stavanger, Norway
                [9 ]Dept of Medicine, Telemark Hospital, 3710 Skien, Norway
                [10 ]Dept of Medicine, Molde Hospital, Dept of Medicine, 6407 Molde, Norway
                [11 ]Dept of Medicine, Østfold Hospital Trust, 1603 Fredrikstad, Norway
                Article
                1471-230X-11-73
                10.1186/1471-230X-11-73
                3142529
                21672243
                ee1c3b8d-4a2b-4128-81b1-99b05812ffcc
                Copyright ©2011 Hoff et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 9 February 2011
                : 14 June 2011
                Categories
                Research Article

                Gastroenterology & Hepatology
                Gastroenterology & Hepatology

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