Audit of endoscopy safety in a District General hospital rated ‘inadequate’ by the CQC

Dr A. Crawford, Dr E. Connor, Dr Z Carter Tai . Supervisors: Dr C.Rossi, Mr N.Chandratreya

In June 2021 the overall CQC rating of Weston General Hospital (WGH) was ‘inadequate’. Changes over the past couple of years, including th e merger of Bristol and Weston -Super-Mare trusts, has aimed to improve services across the board. The endoscopy service at WGH offers inpatient and outpatient investigations to thousands of patients every year. We aimed to evaluate the safety of the service offered over a 12 month period. We used measures set out by the Joint Advisory Group on GI Endoscopy and other published statistics.

Background

For identifying, reviewing and reporting deaths and unplanned admissions related to endoscopy the Joint Advisory Group on GI Endoscopy: Global Rating Scale (2021) is used.

STATISTICS FOR PERI-ENDOSCOPIC COMPLICATIONS AND MORTALITY

Cardio-pulmonary complications account for approximately 50% of all procedure -related deaths associated with GI Endoscopy (1)

ERCP:

Mortality <1%, perforation <0.5% (1,6)

Pancreatitis rates ~5% (data obtained during ERCP safety audits)

Bleeding rate post-sphincterotomy ~2% (data obtained during ERCP safety audits)

Upper GI endoscopy:

There is an overall complication rate (including mucosal biopsy) of 0 13% and an associated mortality of 0.004%(2) Acutely bleeding oesophageal varices: overall mortality remains ~20% (2); mostly due to underlying liver disease

Colonoscopies and flexible sigmoidoscopies.

Frequency of perforation varies; related to case -mix and experience of endoscopist. Perforation rate of 1/1000 and post-polypectomy bleeding rate <1/200 (3,5,6)

Results

Total number endoscopic procedures June 2021 to May 2022: 3428

Readmissions:

Of these 3428 there were 58 re admissions within 8 days of the procedure, 6 of which were deemed to be related to the original endoscopic procedure. Re-admissions were split between procedures, ERCP – 1, OGD – 1, Colonoscopy – 4, nil related to flexi-sigmoidoscopy.

Mortality:

There were a total of 38 deaths identified within 30 days of the procedure, only one of which was related to the initial procedure

The death was related to ERCP: the patient presented initially with abdominal pain and choledocholithiasis ERCP found a 10mm stone in the CBD – extraction was not possible due to distal CBD stenosis

Following a sphincterotomy, a stent was placed in the distal CBD PostERCP, the patient developed jaundice and haematemasis Pancreatitis was confirmed on CT and cause of death recorded as post-ERCP pancreatitis

One set of paper case notes was lost and therefore not analysed

Re admission rate for 2021-22: 0 18%, mortality rate: 0 029%

113 ERCP procedures were performed, with 1 death (0 88%) and 1 readmission (0 88%) with post-ERCP perforation (localised, contained around duodenal stent) There were no lower GI perforations, 2 cases of post-polypectomy bleeding (approximately ~0 25% incidence)

Methods & Materials

Inclusion Criteria: Readmission within 8 days of procedure. Mortality within 30 days of procedure. Included procedures:

OGD

ERCP

Flexible sigmoidoscopy

Colonoscopy

We acquired a list of all patients who underwent an endoscopic procedure in the 12 months between June 2021 and May 2022, including inpatient and outpatient procedures

All patients who met the inclusion criteria for readmission or mortality were identified and their case notes obtained

Patients’ paper case notes, Evolve and GP records were reviewed in order to evaluate whether the death or re admissions was related to the endoscopic procedure

The indications for endoscopy, outcome of procedures and reasons for readmissions or deaths were also noted

Discussion

Each case of mortality and readmission was analysed using electronic records, GP records, paper case notes, radiological reports clinical documentation to evaluate the clinical course, learning points and clinical outcomes for each patient

This data is not a representation of total complication rate: immediate complications when patient remains an inpatient have not been included Additionally, we only have information about readmissions to UHBW hospitals: patients may have been re-admitted to different hospital trusts for which we do not have easy access to records

BSG minimum standards for post polypectomy bleeding is <0 5% with aspirational target <0 1% We do not have exact data about number of procedures with polypectomies but approximate a postpolypectomy bleeding rate of ~0 25% More data/analysis of this would be useful

There is poor data to compare our rates of complications to the national average – much comes from diagnostic endoscopies, not treatment, and is from retrospective and older case studies, making comparison difficult(5,6)

Conclusions

It was concluded that the endoscopy service at WGH was safe and viable The number of readmissions and deaths related to endoscopy were similar to previous audits and well below the published rates of complications in literature

A review of individual cases for all complications, readmissions and deaths showed that issues were identified and treated appropriately in a timely manner