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ACCREDITATION IN PATIENTS’ SAFETY IN ENDOSCOPY

You are listening to ReachMD XM157, The Channel for Medical Professionals. Welcome to GI Insights, where we cover the latest clinical issues, trends, and technologies in Gastroenterological Practice. GI Insights is brought to you by AGA Institute and sponsored by Takeda Pharmaceuticals, North America.

Your host for GI Insights is Professor of Medicine and Director of the Digestive Disease Center at Medical University of South Carolina, Dr. Mark Delegge.

Gastroenterologists have relied on endoscopy for decades for the diagnosis of GI disorders. Where patients’ safety is still a significant concern with the procedure. Joining us to discuss accreditation in patients’ safety in endoscopy is Dr. Lawrence Kim, a gastroenterologist practicing in Colorado, at South Denver Gastroenterology and Governing Council Member of the American Gastroenterological Association.

DR. MARK DELEGGE:

Welcome Larry.

DR. LAWRENCE KIM:

His Mark, thank you very much for having me.

DR. MARK DELEGGE:

Larry, I have to ask, as a gastroenterologist, I perceive the endoscopic procedure by and large being pretty safe in major adverse events are quite rare. Given this, why is patients’ safety such an issue in gastrointestinal endoscopy?

DR. LAWRENCE KIM:

Well, I have to agree with you Mark that endoscopy really is extremely safe, at least when it is performed by qualified gastroenterologist. Instead, I think this is mainly a question of public perception. As you know, public concern about patients’ safety has increased dramatically since the report from the Institute of Medicine in 1999. This report made a fairly dramatic comparison of the number of deaths due to inpatient errors to the crashing of commercial airliner each and every day, and although this report focussed only on hospital errors, this comparison, I think, clearly inflamed public opinion on the issues of patients’ safety. Public attitudes also tend to shaped by highly publicized individual events such as the recent Nevada case in which patient undergoing colonoscopy were apparently infected with hepatitis C because of unsafe sedation practices, and although extremely isolated, such events lead to safety concerns, which then have important public health ramification, you know, such as willingness to undergo screening for colorectal cancer. I think there is also an important competitive issue which they care. Given that a significant proportion of endoscopy in US is performed actually by non-gastroenterologists. I think it really precludes that there is a profession to put for the high standards for quality in an endoscopy.

DR. MARK DELEGGE:

Larry, I have seen that a number of procedures that I did as a gastroenterologist in my training and then in my practice in the hospital have now been pushed out to an endoscopy center or perhaps also called an ambulatory center. Should some of the procedures that we do still be done at the hospital? Should they all be done at these ambulatory centers?

DR. LAWRENCE KIM:

I think it really depends upon what kinds of infrastructure and personnel are available. From strictly patients’ safety standpoint, really any endoscopic procedure can be performed safely in and ASC setting, provided that the proper procedures are in place. Some procedures, however, such as ERCP would be the most obvious one coming to mind, such procedures are associated with a higher risk and complications as well as higher capital infrastructure requirements and supply cost, and I think its primarily for these reasons that those procedures are usually done in the hospital setting.

DR. MARK DELEGGE:

Do you think patients today perceive the hospital being safer than we will say endoscopy center or ASC, or do you think they don’t have an opinion?

DR. LAWRENCE KIM:

I think that patients utilize ASC settings for several reasons, primarily being convenience and lower cost. I don’t think that in a properly run ASC with good quality procedures and processes policies in place that safety is a major concern or should be a major concern to the patients.

DR. MARK DELEGGE:

What are the really tragic things that can happen or the one that gets my nerves on edge is when you are sedating somebody for an endoscopy and we’ll say you lose the airway, meaning you are having some difficulty breathing and you are trying to do rescue and some people will say that, you know, in a hospital setting, boy you are surrounded by a bunch of very trained personnel and can handle this and if this happened in an ASC or and endoscopy center, perhaps you wouldn’t have that sort of personnel around. Do you have any concerns about losing airways and sedation in these ASCs as a part of safety?

DR. LAWRENCE KIM:

I think it’s fair to say that all endoscopists, who are administering sedative agents, really need to be prepared to manage the patient’s airway and provide ventilation support during an emergency. As we know, this happens extremely rarely, but an assessment of airway risk prior to administering sedation, such as the Mallampati classification or others that are widely available and widely used are definitely recommended in part of our procedures. The routine use of anesthesiologist for endoscopy has clearly been shown, at least in my opinion, to be unnecessary from a medical standpoint and arguably a pretty poor use of limited healthcare resources. However, I will say that high-risk patients clearly should be referred for anesthesia consultation prior to undergoing their procedure.

DR. MARK DELEGGE:

Larry, probably in my practice and I am seeing somebody in the office that is very obese and has a bull-like neck and I am worried about airway during the procedure, meaning the fact that losing airway or stop breathing, is that the type of patient I should be doing in a hospital like setting?

DR. LAWRENCE KIM:

It’s a very individualized decision Mark. I think it has to do with your physical examination and the assessment of how difficult it would be to provide emergency ventilatory support if you were to brunt problems during a procedure. Obviously, comorbidities, the patient’s body habitus, all play a role in making that assessment objectively. I think if there is anything concern, that you cannot safely manage that patient’s airway in the outpatient setting, in the ASC setting, clearly that patient should be referred for anesthesia consultation.

DR. MARK DELEGGE:

Larry, I know that from a perspective of a hospital or a hospital-based endoscopy suite, there are some very specific accreditation rules that we all have to play by through JCAHO for better or worse. What role does accreditation of endoscopy said is playing in ensuring patient’s safety?

DR. LAWRENCE KIM:

Well, in contrast to the inpatient arena, there are 3 primary accreditors that work in the outpatient ASC environment, and I will just go through some of the differences between the 3 organizations. The largest accreditor of Ambulatory Health Facilities is AAAHC, the Association for Accreditation of Ambulatory Health Care. AAAHC probably accredits the lion’s share of endoscopy centers in this country at this time and this organization does have deemed status by CMS, so that in many states AAAHC accreditation consent in place of a separate Medicare survey. The philosophy of AAAHC is that the accreditation process should be educational and consultative, that is there is a process of continuous improvement in quality in patient’s safety. The accreditation surveyors with AAAHC are volunteers who have had intimate experience in the outpatient delivery setting, and I think it is for these reasons the AAAHC is usually viewed or is fairly widely viewed as the most “user-friendly accreditor.”

If you’re just tuning in, you are listening to GI Insights on ReachMD XM 157, the Channel for Medical Professionals. I am your host, Dr. Mark Delegge, and joining me to discuss accreditation and patients’ safety in endoscopy is Dr. Lawrence Kim, a gastroenterologistpracticing in Colorado at South Denver Gastroenterology and Governing Council Member of the AGA.

DR. MARK DELEGGE:

So, you were telling us about a couple of the accreditation societies that are available. Won’t you go ahead and elaborate on that.

DR. LAWRENCE KIM:

Okay. So, we are just touching on sort of the 3 major outpatient accreditors and the first, as I said, was AAAHC or the Accreditation Association for Ambulatory Health Care, which is the largest accreditor. The oldest accreditor, as we know, is the Joint Commission, formerly known as JCAHO, and JCAHO clearly dominates the inpatient arena, and more recently, has expanded to outpatient facilities. Although, in fact, the actual accreditation standards are quite similar to those of AAAHC, JCAHO surveyors are professional quadrates and the application of the standards by the surveyors is viewed often as overly prescriptive and bureaucratic, and so there is sort of a somewhat negative perception of JCAHO in the ASC environment as a result of this. Although, in fact, as I said, the accreditation standards themselves are largely quite the same. The third organization is much smaller and this is the American Association for Accreditation of Ambulatory Surgery Facilities, otherwise known as AAAASF. This accreditor was created by the Plastic Surgery Community and such facilities really at this point make up the bulk of its own accreditated organizations. AAAASF like JCAHO and AAAHC also has Medicare deemed status, but thus far, I think it’s fair to say that it has played a very small role in accreditation of Standalone Endoscopy Centers.

DR. MARK DELEGGE:

What sort of documentation should my endoscopy center have available to make the accreditation process easier?

DR. LAWRENCE KIM:

Well, AAAHC and I think, all of the accreditors publish a fair amount of literature. AAAHC has an actual accreditation handbook and conducts numerous seminars to educate organization without the sort of details of the process to begin accrediting, but basically, their organization should have complete policies and procedures, really which ideally address each of the published accreditation standards. Though, AGA recently has published the templates, which I think can serve as a very useful starting point for creating or fine-tuning your own policies and procedures to match what the accreditors are looking for. In addition, as we mentioned, quality improvement is really gaining increasingly important focus for accreditors and so the organization should expect accreditation survey as to look pretty closely at this area and what they are looking forward is that the organization buys into the process of looking at their own quality measures and that they commit to perform a minimum number of surveys of quality improvement studies annually.

DR. MARK DELEGGE:

I would like to thank my guest from South Denver Gastroenterology, Dr. Lawrence Kim. Dr. Kim, thank you very much for being our guest this week on GI Insights.

DR. LAWRENCE KIM:

Mark, it was a true pleasure, thank you very much.

You had been listening to GI Insights on ReachMD XM157, the Channel for Medical Professionals. GI insights is brought to you by AGA Institute and sponsored by Takeda Pharmaceuticals, North America. For additional information on this program and on demand pod cast, visit us at www.reachmd.com and use promo code AGA.

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