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Developing a day case ‘treat and transfer’ ERCP service under GA

Dr Deepak Joshi on behalf of the Endoscopy Department, King’s College Hospital NHS Foundation Trust, London

Authors and Institution

Dr Deepak Joshi  – Consultant Hepatologist & ERCP
Dr Brian Prater –  Consultant Anaesthetist
Lysetta Harding – Endoscopy Matron
Dr Phil Harrison – Consultant Hepatologist & ERCP
Dr John Devlin – Consultant Hepatologist & ERCP
Dr David Reffitt – Consultant Hepatologist & ERCP
Dr John Hunt – Consultant Hepatologist & ERCP
Mr Amyn Haji – Endoscopy lead

Endoscopy Department, King’s College Hospital NHS Foundation Trust, London

Challenges

Over the last decade, general anaesthetic (GA) has been increasingly used for advanced endoscopic procedures in particular ERCP. The availability of ERCP under general anaesthetic  (GA) is limited in our region due to financial costs and the unsuitability to perform ERCP within the ERCP room.  However, ERCP at King’s College Hospital (KCH) has been performed under GA since 2008 and we have the availability of 9 dedicated GA lists within the endoscopy department. Previously, waiting for an inpatient transfer for a GA to KCH led to significant delays. We, therefore, wanted to improve the patient experience and support our referring Trusts by developing a day case treat and transfer ERCP under GA service.

How we managed the challenges

A clear pathway was devised in conjunction with the King’s anaesthetic department detailing the minimal information required for the patient to undergo a GA at KCH. We also developed a referral email address allowing referrers to contact the KCH ERCP team. A ‘traffic light system’ was developed which detailed the patient journey and signposted referrers (see attached article). An anaesthetic review in the referring Trust is mandatory and in particular, assessing for the patient for suitability for GA but also for transfer to and from KCH with a trained nurse. A multi-disciplinary approach was important in the design of this service with key insight and support from the KCH endoscopy nursing team.

Evaluation and Outcomes

In April 2015, the day case treat and transfer ERCP service under GA was developed and introduced for surrounding Trusts. Since its introduction, we have performed over 120 cases. We published our initial experience in Frontline Gastroenterology, 2018 Oct 9(4); 317-322. We demonstrated that the service was safe and feasible from an anaesthetic and endoscopic perspective. We did not expect to have a 100% endoscopic completion rate but more importantly there were no anaesthetic related issues. Feedback from our referrers has been positive and this has been echoed by patients who had previously had a failed ERCP due to intolerance of sedation. This service is now well established and helps support the need for ERCP in South London and the Kent area.

Learning Points

This service can be replicated across other HPB/ERCP networks. We have already shared our experience with other large HPB centres across London and the UK. Our protocols have been shared highlighting the ease of delivering this service within one’s ERCP network. Our 3 main learning points which had led to the successful implantation of this service were: 1) the rapid review of the anaesthetic assessment performed at the referring Trust by the KCH anaesthetic team; (2) a clear and concise line of communication between the referring teams and the endoscopic department at KCH; (3) the availability and input of the KCH endoscopy nursing staff. The service is simple to implement and will help improve patient flow and the patient experience whilst maintaining patient safety. Trusts that cannot support GA ERCP can therefore liaise within their networks with larger centres to develop this service.

More information:

  1. El-Sherif et al. Day case ‘treat and transfer ERCP service under GA. Frontline Gastroenterology, 2018 Oct 9(4); 317-322.
  2. Joshi et al. Experience of propofol sedation in a UK ERCP practice: lessons for service  provision. Frontline gastroenterology 2015; 6; 32-7.