Guidance http://www.bsg.org.uk/clinical-guidance/endoscopy/index.html Tue, 23 May 2017 10:30:58 +0000 Joomla! 1.5 - Open Source Content Management en-gb BSG statement on "Use of intravenous Hyoscine Butylbromide (Buscopan) during Gastrointestinal Endoscopy" http://www.bsg.org.uk/clinical-guidance/endoscopy/bsg-statement-on-use-of-intravenous-hyoscine-butylbromide-buscopan-during-gastrointestinal-endoscopy.html http://www.bsg.org.uk/clinical-guidance/endoscopy/bsg-statement-on-use-of-intravenous-hyoscine-butylbromide-buscopan-during-gastrointestinal-endoscopy.html The MHRA has recently circulated a Drug Safety Update regarding the risk of serious adverse events following the use of intravenous Hyoscine Butylbromide (Buscopan) in patients with underlying cardiac disease.

Buscopan is commonly used during endoscopic procedures. It induces smooth muscle relaxation and reduces spasm in the gastrointestinal tract. It is used during upper GI Endoscopy and small bowel enteroscopy to reduce contraction and aid mucosal visualisation. During endoscopic retrograde cholangiopancreatography, it is used to facilitate access to the common bile duct during cannulation of the Ampulla of Vater. During colonoscopy, it is used to reduce haustral definition to optimise mucosal visualisation and lesion detection.

 

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h.ellison@bsg.org.uk (howard) Endoscopy Tue, 04 Apr 2017 11:02:03 +0000
Rapid Colorectal Diagnostic Pathway http://www.bsg.org.uk/clinical-guidance/endoscopy/rapid-colorectal-diagnostic-pathway.html http://www.bsg.org.uk/clinical-guidance/endoscopy/rapid-colorectal-diagnostic-pathway.html Following extensive discussion and a multi-stakeholder workshop with NHS England in late 2016 a set of principles has been agreed for a Rapid Colorectal Diagnostic Pathway following the introduction of a non-mandated Best Practice Tariff in England.

The BSG recommends that members or services that are involved in the discussion of or establishment of such a diagnostic pathway follow the principles outlined in the document below and ensure they are fully evaluated. Wherever possible the BSG would like to be kept updated of the development of services to ensure successes and learning can be shared nationally.

 

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h.ellison@bsg.org.uk (howard) Endoscopy Mon, 27 Feb 2017 12:49:03 +0000
UK Key Performance Indicators and Quality Assurance Standards for Colonoscopy http://www.bsg.org.uk/clinical-guidance/endoscopy/uk-key-performance-indicators-and-quality-assurance-standards-for-colonoscopy.html http://www.bsg.org.uk/clinical-guidance/endoscopy/uk-key-performance-indicators-and-quality-assurance-standards-for-colonoscopy.html Rees CJ, Thomas-Gibson S, Rutter MD, Baragwanath P, Pullan R, Feeney M, Haslam N.

Colonoscopy is the 'gold standard' investigation for assessment of the large bowel allowing diagnosis, biopsying, and therapy to be undertaken. Colonoscopy detects and prevents colorectal cancer, and is important tin the diagnosis and treatment of non-neoplastic conditions. Colonoscopy can lead to rare but serious complications and poor quality colonoscopy is associated with increased rates of interval cancers. The quality of UK colonoscopy has improved over recent years but unacceptable variation in practice still exists. Additionally the demand for colonoscopy is increasing.

In 2013 The Joint Advisory Group on GI Endoscopy, the British Society of Gastroenterology and the Association of Coloproctology commissioned a group to review existing and define new quality measures and key performance indicators for colonoscopy. For each standard a review of existing literature and evidence was undertaken. Where evidence exists it has been used to frame the standards. Where no clear evidence exists then existing standards and expert opinion have been used to arrive at agreed standards.

This document establishes clear minimal standards for KPI and QA measures. Where practice falls below these levels then interventions are required to raise the performance of those colonoscopists. Where the authors believed that higher standards would be ideal an aspirational target has been set. The authors believe that this is the level that all colonoscopists should be aiming for to provide the highest quality of practice.

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h.ellison@bsg.org.uk (howard) Endoscopy Tue, 27 Oct 2015 11:07:41 +0000
Guidance for Decontamination of Equipment for Gastrointestinal Endoscopy http://www.bsg.org.uk/clinical-guidance/endoscopy/guidelines-for-decontamination-of-equipment-for-gastrointestinal-endoscopy.html http://www.bsg.org.uk/clinical-guidance/endoscopy/guidelines-for-decontamination-of-equipment-for-gastrointestinal-endoscopy.html Guidance on Decontamination of Equipment for Gastrointestinal Endoscopy: 2017 Edition

The Report of a Working Party of the British Society of Gastroenterology Endoscopy Committee

April 2017

Flexible endoscopes are complex reusable instruments that require unique consideration with respect to decontamination. Their external surfaces and internal channels for air, water, aspiration and accessories are all potentially exposed to body fluids and other contaminants.

In contrast to rigid endoscopes, flexible endoscopes are heat labile and cannot be autoclaved. Most flexible endoscopes are classed as "semi-critical devices" as they come into contact with mucous membranes during use and present a moderate degree of infection risk if contaminated at the time of use. The process of flexible endoscope decontamination is referred to as "high level disinfection". This is the term given to a process that eliminates or kills all vegetative bacteria, mycobacteria, fungi and viruses, except for small numbers of bacterial spores.

The Health and Social Care Act: Code of Practice on the prevention and control of infections and related guidance was published in England in 2008 (updated in 2015). This stipulates the roles of decontamination leads and decontamination programmes. It emphasises the need for staff to be trained in decontamination processes and to hold appropriate competencies for their role. It decrees the need for monitoring systems to ensure that decontamination processes are fit for purpose and meet required standards. Finally it requires that there are systems in place for tracking reusable medical devices (such as endoscopes and reusable accessories) through decontamination processes, not only to assist with assuring their quality, but also to enable the identification of patients on whom the medical devices have been used. Similar guidance is employed in the other UK devolved nations.

The BSG first published guidelines on decontamination in 1998. Over the years many changes have occurred in recommendations for the decontamination of flexible endoscopes. In order to be responsive to these changes this document has been revised as guidance, this allows the flexibility to update this document in line with changes issued by Government agencies and other professional bodies.


Simethicone Residue in Endoscopes

March 2017

Dr Helen Griffiths, Nurse Consultant & Decontamination Advisor British Society of Gastroenterology

A publication in 2016 in the American Journal of Infection control (Ofstead et al) outlined a potential risk following the identification of residual simethicone in endoscopes following the decontamination process in the United States.

At that time expert opinion in the UK concluded that the decontamination process was not well described and that bacteria found on processed scopes were suggestive of operator contamination and not compromised decontamination. Whilst not seen as a basis for modifying the use of simethicone at that time it has continued to be monitored.

Recently there has been an issue identified in the Republic of Ireland when a colonoscope was sent to Olympus for repair. Preliminary investigation showed what appeared to be signs of Simethicone residue ( Hypromellose, an ingredient of Infacol) in the auxiliary water channel of that colonoscope and subsequently a further two colonoscopes. At this time investigation is ongoing but evidence suggests that scopes were reprocessed in accordance with manufacturers instructions including use of MH-946 injection tube (octopus device).

Simethicone was administered via the flushing pump at a dilution of 25mls (40mgs/ml) in 2 litres of water.

There has been no evidence of resultant infection but until further investigation and testing on compatibility and following discussion with the Decontamination Professional Expert Communication Forum (DPECF) it is advised that Simethicone is administered either orally or via the biopsy port of endoscopes and NOT via either the water bottle or flushing pump devices. This will ensure that manual brushing of relevant channels can take place post procedure. The strength of the dilutent should also be kept to a minimum to achieve the desired effect.


Potential transmission of multi resistant bacteria and duodenoscopes.

October 2015

Recent reports in the media have highlighted the potential for transmission of infection associated with duodenoscopes. A recent peer reviewed publication (Endoscopy (2015) 47: 493-502) described an outbreak of VIM-2 producing Pseudomonas aeruginosa and identified an issue with the design and reprocessing of a recently introduced duodenoscope with a specific modified design. This may be similar to the outbreaks in the US (Gastrointestinal Endoscopy (2015) 82(3): 477-83).

The BSG would like to highlight the following points to staff carrying out the decontamination of flexible endoscopes, in particular duodenoscopes:

  • Adherence to manufacturers' instructions at all times is essential.
  • The pre clean procedure should take place at the patient bedside, as described in the instructions from the UK suppliers and BSG guidance.
  • The cover on the raiser bridge mechanism at the distal tip should be removed prior to brushing all areas of the distal tip and cleaning with detergent and replaced on completion of the decontamination process. The brush must be used on all surface areas of the distal tip ensure that all debris is removed.
  • The elevator wire channel should be flushed with detergent during the manual cleaning ensuring the correct size syringe is used. If automated flushing systems are used for this stage of the process, staff should ensure that this channel is included.
  • Staff should ensure that the endoscope washer disinfector has the capability of flushing the elevator wire channel with detergent, disinfectant and rinse water.
  • If stored in a drying cabinet, the elevator wire channel should be flushed with HEPA filtered air along with all the other channels. If this channel is not flushed with air, the endoscope should be used within 3 hours or the endoscope reprocessed before patient use. Not all cabinets have this facility. An EN standard, EN 16442, has now been published for endoscope storage drying cabinets.
  • Routine microbiological surveillance of processed endoscopes is not recommended. However, this may be carried out on advice from the infection prevention and control team if an outbreak is known or suspected.
  • Staff should receive comprehensive training, and a record retained, on all aspects of the decontamination of endoscopes, in particular, duodenoscopes.

Choice Framework for Local Policy and Procedures CFPP 01-06

These documents offer best practice guidance on the management and decontamination of flexible endoscopes. They consist of five documents covering operational management, design and installation, testing methods, validation and verification and policy and management. These are large documents that will be subject to periodic updates and therefore it is recommended that rather than download all or part of the guidance the link is made available on endoscopy desktops. These guidelines are designed to provide information and guidance to those working within endoscopy services in England, please see the link below for relevant guidelines for Scotland, Wales and Northern Ireland.

Audit

Audit is key to understanding and ensuring that the decontamination environment and the processes within it are safe and effective. The MHRA (August 12) talks about the legal implications if there are failures in both understanding and practices in decontamination. The CFPP 0106 reminds us that the Health Act Code of Practice (2006) recommends that healthcare organisations comply with guidance establishing Essential Quality Requirements (EQR) and demonstrate that a plan is in place for progression to Best Practice (BP). There are a number of audit tools available for use within endoscopy to demonstrate compliance with EQR and allow planning to achieve BP. The Infection Prevention society has developed comprehensive audit tools to sit alongside the guidance in CFPP 01-06. These tools are now recommended by the member committees of the Professional Expert Communication Forum (PECF): Decontamination of medical devices as the UK wide audit tool of choice.

Access IPS audit tools here

Access list of member organisations of the Professional Expert Communication Forum (PECF) here

"Transmissible Spongiform Encephalopathy Agents: Safe Working and the Prevention of Infection"

As part of its remit for the whole of the UK the Department of Health ACDP TSE Risk Management Subgroup produces the guidance document Transmissible spongiform encephalopathy agents: safe working and the prevention of infection. The aim of the guidance is the minimisation of the risk of transmission of CJD, and vCJD. This has recently been reviewed by a working party of the subgroup and updated (February 2015) and it is recommended that decontamination teams review the changes to these documents.

Read the entire updated document on the Department of Health's 'Advisory Bodies' website:

MHRA Guidelines

View documentation "Top ten tips" revised 2012 on MHRA website:

DOPS training and assessment tool for manual cleaning processes in endoscopic decontamination

Following collaboration between Olympus, Pentax and Aquilant, the BSG and the Decontamination Professional Expert Communication Forum (DPECF)  are pleased to announce the launch of this DOPS training and assessment tool.

Background

There have been numerous reports on the potential transmission of multi resistant bacteria with particular reference to duodenoscopes and the manual cleaning of these instruments.

There is the potential to transmit infection via any endoscope through poor adherence to manual cleaning processes and to date there has been no single way of assessing and validating these processes. Knowledge and practice varies significantly between departments and indeed individuals and there is a need to have a standardised approach and pathway that can be quality assured and validated to minimise the risk to patients and staff from endoscopically transmitted infection.

Purpose and use

The purpose of this DOPs form is to provide a universal and standarised training and assessment tool for continuity when training in manual cleaning processes. It consists of two parts:

  • PART 1. Manufacturers will deliver the initial specific product training as they currently do, traceable to the product reprocessing instructions and confirming the topics covered in the training from the listed criteria (shaded grey on the DOPS form)
  • PART 2. The employer will then undertake an assessment of competency to undertake manual cleaning of endoscopes as part of the Skills for Health END21 competency and as annual revalidation of practice from the listed criteria on the form, including validation of competency in the topics covered in the manufacturer's training.

Each section/topic should be signed and dated by the individual delivering the training or assessing the competency. This should then form part of annual appraisal and revalidation of practice.

If you have any questions or queries please email Helen.griffiths1@nhs.net or contact your endoscope manufacturer.

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pete@merchantmarketinggroup.com (Administrator) Endoscopy Mon, 02 Mar 2009 15:51:51 +0000
ERCP – The Way Forward, A Standards Framework http://www.bsg.org.uk/clinical-guidance/endoscopy/ercp-–-the-way-forward-a-standards-framework.html http://www.bsg.org.uk/clinical-guidance/endoscopy/ercp-–-the-way-forward-a-standards-framework.html Mark Wilkinson, (BSG Endoscopy, working party convenor and chairman) et al.

June 2014

Executive Summary:

To improve the quality and availability of ERCP in the UK, a working party was set up incorporating a number of stakeholders (Appendix 3) to make recommendations to achieve this goal. The attached framework document is the output of that process. It is recognised that not all changes can be achieved immediately, but that these are the standards to be aimed for. Though regulatory frameworks differ among the 4 nations of the UK (and delegates from Scotland, Wales and Ireland were represented on the working party) it is intended that this framework will be applicable to the whole of the UK.

In brief its recommendations are:

  1. ERCP should only be carried out in facilities dedicated to high standards of performance and safety, as measured by key performance indicators.
  2. That there should be a minimum of 75 cases per annum for ERCP endoscopists, and 150 cases minimum per facility, although we should be aiming for a minimum of 100 cases and 200 cases respectively.
  3. That ERCP services should work collaboratively in a regional or hub-and-spoke model, with simple and rapid referral pathways established.
  4. That facilities for urgent or emergency ERCP should be widely available.
  5. That minimum standards for independent practitioners should be based on intention to treat and include a >=85% cannulation rate of virgin papillae, CBD stone clearance for >=75% of those undergoing 1st ever ERCP, and for patients with an extra-hepatic stricture, successful stenting with cytology or histology where appropriate at 1st ERCP in >=80%.
  6. That performance criteria should be monitored by a detailed audit and feedback process via a strengthened JAG/GRS process, and be incorporated into consultant appraisal.
  7. That the organisation and standards for training for ERCP should follow from the above performance criteria.
  8. That newly appointed consultants are mentored to ensure a safe and effective transition from trainee to independent practitioner.
  9. That high quality performance in ERCP service and training should support high quality research.
  10. There should be a national registry of ERCP cases to monitor practice and outcomes which will aid a cycle of continuous improvement and provide research data to plan better care in the future.
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h.ellison@bsg.org.uk (howard) Endoscopy Wed, 11 Jun 2014 09:52:42 +0000
Guidance on the indications for diagnostic upper GI endoscopy, flexible sigmoidoscopy and colonoscopy http://www.bsg.org.uk/clinical-guidance/endoscopy/guidance-on-the-indications-for-diagnostic-upper-gi-endoscopy-flexible-sigmoidoscopy-and-colonoscopy.html http://www.bsg.org.uk/clinical-guidance/endoscopy/guidance-on-the-indications-for-diagnostic-upper-gi-endoscopy-flexible-sigmoidoscopy-and-colonoscopy.html Adam Harris Chair, BSG Clinical Services and Standards Committee (CSSC) - April 2013

In 2011 the Independent Practice Committee of the BSG was asked to provide approved guidance on the indications for diagnostic endoscopy. There was none although it was common practice to 'validate' requests for endoscopy; indeed this is a requirement of the GRS. Following this request it was agreed that a small working group of individuals from CSSC (Adam Harris), Independent Practice Committee (Simon Greenfield), Endoscopy Section (Steve Hughes and Mark Wilkinson) and Surgical Section (Roger Leicester) would produce a draft list of indications for diagnostic upper GI endoscopy, flexible sigmoidoscopy and colonoscopy. The 'evidence-base' for this was unsurprisingly small but wherever possible, the Guidance is supported by published documents from the BSG and NICE.

The first draft was circulated to the members of BSG Endoscopy Section and CSSC. An amended document was sent to William Allum (President, AUGIS) and Rupert Pullen (ACPGBI), Karen Nugent (ACPGBI) and Graham Williams (President, ACPGBI) who took the Guidance to their respective Councils; their helpful comments were addressed to produce the final document. On 22 March 2013 BSG Council approved the tripartite Guidance.

Last, we appreciate fully that this Guidance cannot be fully inclusive and ultimately clinical judgement is required to determine when an endoscopy is required but taking into account these reservations, we hope that you will find this Position Statement useful.

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h.ellison@bsg.org.uk (howard) Endoscopy Thu, 08 May 2014 11:32:50 +0000
Service Provision and Training for Endoscopic Ultrasound in the UK http://www.bsg.org.uk/clinical-guidance/endoscopy/service-provision-and-training-for-endoscopic-ultrasound-in-the-uk.html http://www.bsg.org.uk/clinical-guidance/endoscopy/service-provision-and-training-for-endoscopic-ultrasound-in-the-uk.html J Meenan, K Harris, K Oppong, C McKay, I Penman, N Carroll, S Norton.

Introduction

Endoscopic ultrasound (EUS) is a standard procedure that plays an important role in the management of both malignant and benign disease. The development of EUS services in the UK has been haphazard and training inconsistent. The British Society of Gastroenterology has charged a working group with the task of laying down a national framework for how such services might be commissioned, structured and regulated; with particular attention to defining how endoscopist skills might be acquired, assessed and maintained. This report lays out a map for this process and its future revision.

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j.rother@bsg.org.uk (John Rother) Endoscopy Wed, 26 Oct 2011 10:42:14 +0000
AOMRC Upper Gastrointestinal Bleeding Toolkit (CROMES Project) http://www.bsg.org.uk/clinical-guidance/endoscopy/aomrc-upper-gastrointestinal-bleeding-toolkit-cromes-project.html http://www.bsg.org.uk/clinical-guidance/endoscopy/aomrc-upper-gastrointestinal-bleeding-toolkit-cromes-project.html 'Scope for Improvement: A toolkit for a safer Upper Gastrointestinal Bleeding (UGIB) service'

A BSG led UK-wide audit in 2007 highlighted significant deficiencies and inconsistencies in service provision and care of patients presenting with UGIB. The BSG, under Kel Palmer's stewardship, undertook a piece of research, initiated under the title of Consultant Rota On-call Modelling of Endoscopy Services (CROMES).

The BSG has worked with the Royal College of Physicians, Royal College of Radiologists, National Patient Safety Agency and Royal College of Nursing to develop a toolkit to provide practical support to providers and commissioners to consider changes to their UGIB services to help improve the quality of care and outcomes for patients with UGIB. The Toolkit may be downloaded below from the AOMRC website:

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h.ellison@bsg.org.uk (howard) Endoscopy Thu, 02 Jun 2011 09:44:42 +0000
Guidance for the Use of Propofol Sedation for Adults Undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) http://www.bsg.org.uk/clinical-guidance/endoscopy/guidance-for-the-use-of-propofol-sedation-for-adults-undergoing-endoscopic-retrograde-cholangiopancreatography-ercp.html http://www.bsg.org.uk/clinical-guidance/endoscopy/guidance-for-the-use-of-propofol-sedation-for-adults-undergoing-endoscopic-retrograde-cholangiopancreatography-ercp.html Guidance for the use of propofol sedation for adult patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) and other complex upper GI endoscopic procedures

Royal College of Anaesthetists logo British Society of Gastroenterology logo

April 2011

On behalf of the Joint Royal College of Anaesthetists (RCoA) and British Society of Gastroenterology (BSG) Working Party.

Working Group:

Chair: Andy Tomlinson (RCoA)
Jonathan Green (BSG)
Stuart Cairns (BSG)
David Cressey (RCoA)
Ian Smith (RCoA)
John Peacock (AAGBI)

Introduction

This guidance has been written because increasingly challenging diagnostic and therapeutic endoscopic procedures are being performed in adults and there is a need for more prolonged and satisfactory sedation to be administered; there is increasing evidence that this can be provided safely and appropriately by propofol when administered by those trained in its use. Sedation with propofol should be viewed as a completely separate entity from its use as a general anaesthetic.

These guidelines aim to cover UK practice in the use of propofol for sedation only in adult patients during endoscopic procedures, using ERCP as a specific example, as this group of patients can clearly benefit from the use of this drug administered by an appropriately trained anaesthetist or consultant anaesthetist supervised Physicians Assistant (Anaesthesia), so allowing the endoscopist to concentrate fully on the procedure. It is recognised that there are certain circumstances where general anaesthesia may be more appropriate, but these guidelines will not consider this further.

This guidance is to be added as an appendix to the BSG guideline Safety and Sedation during Endoscopic Procedures.

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h.ellison@bsg.org.uk (howard) Endoscopy Thu, 02 Jun 2011 09:01:37 +0000
National Patient Safety Agency Rapid Response Report http://www.bsg.org.uk/clinical-guidance/endoscopy/national-patient-safety-agency-rapid-response-report.html http://www.bsg.org.uk/clinical-guidance/endoscopy/national-patient-safety-agency-rapid-response-report.html National Patient Safety Agency Rapid Response Report Issued: Reducing risk of overdose with midazolam injection in adults

Some adult patients are being overdosed with midazolam injection when used for conscious sedation. The presentation of high strength midazolam as 5mg/ml (2ml and 10ml ampoules) or 2mg/ml (5ml ampoule) exceeds the dose required for most patients. There is a risk that the entire contents of high strength ampoules are administered to the patient when only a fraction of this dose is required. Doses often exceed that required, are not titrated to the patient’s individual needs, do not take into account concurrent medication (e.g. opioids) and may involve high risk groups for example, the frail or the elderly. There is frequent reliance on injectable flumazenil (antagonist/reversing agent) for reversal of sedation in patients that have been over sedated.

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pete@merchantmarketinggroup.com (Administrator) Endoscopy Sat, 07 Mar 2009 20:22:18 +0000