9 WORLD GASTROENTEROLOGY NEWS SEPTEMBER 2015 Editorial | Expert Point of View | Gastro 2015: AGW/WGO | WDHD News | WGO & WGOF News | WGO Global Guidelines | Calendar of Events document the last oral intake. The endoscopist or the anesthetist, will perform and document a risk assessment for sedation related adverse events, using the American Society of Anesthesiologists (ASA) score or the Mallampati Score (assesses the upper airway)11,12. This information will be useful for decision making with regard to proceeding or deferring the endoscopy as well as modifying the procedure sedation plan. The intended level of sedation must be specified (no sedation, minimal, moderate, deep sedation, or general anesthesia) and it should be documented. The ASA recommends that, because sedation is a continuum, the endoscopist or anes-thetist should be able to rescue patients whose level of sedation becomes deeper than initially intended.13 2d. Antibiotics and Antithrombotic Medications Prophylactic antibiotics for preven-tion of bacterial endocarditis are not indicated in the vast majority of endoscopic procedures, only being administered for selected settings for which they are indicated (priority indicator). Antithrombotic medication used by the patient should be recorded, and the plan for the management of the specific medication should be docu-mented and communicated to the patient and health care team (priority indicator). This will vary with the patients underlying conditions, the procedure being performed, the risk of events and the medication(s) being used. Patients who are at high risk for thromboembolic events may require bridge therapy, or the endoscopy may need to be deferred. Such decisions may need consultation with a cardi-ologist or other physicians caring for the patient. After endoscopic therapy, the timing of resumption has to be individualized, depending on the type of endoscopic procedure and the risk of thromboembolism. 2e. Quality of the Procedure Before administration of sedation or insertion of the endoscope, the endoscopy team pauses to verify that the correct patient will be undergoing the correct procedure, and this should be recorded. A quality endoscopy procedure is one performed by an endoscopist who has met objective measures for competency. Achieving the desired objectives and minimizing adverse events define the quality of an endoscopic procedure. The American Society for Gastrointestinal Endosco-py (ASGE) has published training and credentialing guidelines that establish basic principles of competency; these should be applied to the credential-ing process wherever GI endoscopy is performed. Several important themes in this regard deserve emphasis: 1) objec-tive measures of performance and not simply the number of procedures performed in training should be used to define competency, 2) measures of competence using well established benchmarks should be universal and not vary by specialty, 3) competency in one procedure should not neces-sarily imply competency in another, 4) competency in an endoscopic procedure should require that the endoscopist should be able to perform minimum therapeutic maneuvers specific to that procedure (e.g. pol-ypectomy in colonoscopy and stent placement for distal biliary obstruc-tion in ERCP).14, 15 The intraprocedure period extends from the administration of sedation or insertion of the endoscope when no sedation is given, until the endoscope is removed. It includes all the techni-cal aspects of the procedure, including completion of the examination and therapeutic maneuvers. 3. Post Procedure The post-procedure period extends from the time the endoscope is removed to subsequent follow-up. It includes providing instructions to the patient, documentation of the procedure, recognition and documen-tation of adverse events, pathology follow-up, communication with refer-ring physicians, and assessing patient satisfaction. The procedure report should be accurate and succinct.16 Standardiza-tion of the language and structure of endoscopic reports may improve com-munication between physicians. Elec-tronic medical records and comput-erized endoscopic report generating systems may be of great help. Quality assessment and “pay for performance” programs that depend on the collec-tion of reliable, reproducible data ben-efit from such standardization. 3a. Adverse events Adverse events must be documented, and should be classified according to their timing, level of certainty of attri-bution to the endoscopic procedure, and degree of consequent disturbance to the patient. To standardize data collection and reporting, an ASGE Task Force has proposed definitions and classification of endoscopy-related adverse events.17 An adverse event is one that prevents completion of the planned procedure or results in admission to the hospital, prolongation of existing hospital stay, another procedure, or subsequent medical consultation. Based on timing they can be subdivided as preproce-dure, intraprocedure, postprocedure (up to 14 days), or late (any time after 14 days). A level of certainty of at-tribution to the endoscopic procedure as definite, probable, possible or unlikely should be recorded. Severity of adverse events should be graded by the degree of consequent disturbance to the patient and any changes in the plan of care as mild, moderate, severe, or fatal.
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