ERCP: a review of technical competency and workload in a small unit☆,☆☆,★

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Abstract

Background: ERCP is increasingly performed not only in large referral centers but also in smaller units. We sought to analyze the success rates of selective cannulation and intervention using the cumulative sum method and to document the workload in a small unit. Methods: Indications, results, and interventions performed by one endoscopist were recorded for all patients undergoing ERCP at Dunedin Hospital. Selective cannulation and successful intervention were used as outcome measures and, using the cumulative sum method, compared to a target value of 90%. Results: Over an 8-year period, 532 ERCPs were performed. Overall 91% and 81% of selective cannulation and interventions respectively, were successful. The cumulative sum method plot shows that satisfactory outcomes for selective cannulation were obtained after some 100 to 120 procedures and after some 120 interventions. ERCP was normal in 171 (32%) patients, stones were found in 169 (32%), and strictures in 81 (15%) patients. Conclusions: The cumulative sum method is a valuable tool to compare individual performance with a nominated target value and to ensure that an acceptable outcome is achieved and maintained. These results show that small units can develop and maintain expertise in ERCP if procedures are performed regularly.(Gastrointest Endosc 1997;46:48-52)

Section snippets

Materials and methods

Dunedin Hospital is a tertiary referral center and teaching hospital with close links to the University of Otago's Medical School. The Gastroenterology Unit provides the only specialist gastroenterologist and ERCP service for an overall population of about 250,000 spread over a fairly large area. Patients from outside Dunedin may have to travel up to 3 hours to Dunedin; the next major center is some 350 km away.

All the ERCPs done in this unit during an 8-year period from May 1986 to April 1994

Results

During the 8-year period 532 ERCPs were performed. Subjects included 237 women and 295 men with a mean age of 61 years (range 17 to 97 years). The number of procedures performed has steadily increased over this period (Fig. 3).

. The total number of ERCPs and the number of interventions performed in each 12-month period are shown from May 86 to April 94.

The proportion of normal examinations remained fairly constant between 25% and 40%. Two hundred sixty-five patients (49.5%) required an

Discussion

The main focus of this study—which includes all ERCPs performed consecutively in one unit by a single endoscopist over 8 years—was to review technical competency in ERCP using the cumulative sum method comparing actual performance to a predetermined standard. A review of an individual endoscopist's performance on its own would be of limited value unless comparison was made to other endoscopists or more objectively to a standard.

The cusum9 is a valuable and easy-to-use tool to assess and monitor

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    • Cited by (0)

    ☆

    From the Departments of Medicine and Preventive and Social Medicine, University of Otago Medical School, Dunedin, New Zealand.

    ☆☆

    Reprint requests: Martin M.T. Schlup, MD, Medicine, University of Otago Medical School, PO Box 913, Dunedin, New Zealand.

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    Copyright © 1997 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.