Improving Barrett's Diagnosis and Surveillance Service at a District General Hospital in the United Kingdom

Introduction: Barrett's oesophagus is a well identified precursor for oesophageal adenocarcinoma, with the risk of malignant transformation being 0.5% annually. It is therefore crucial that diagnosis and surveillance standards meet national guidelines. This audit was carried out to assess if our District General Hospital was meeting the standards set by the British Society of Gastroenterology with regards to Barrett's diagnosis and surveillance. Method(s): Data was collected looking at 143 OGDs carried out for Barrett's diagnosis and surveillance at a District General Hospital in the United Kingdom from 01/01/2018 to 30/06/2018. The OGD reports were compared against recommended national standards set by the British Society of Gastroenterology. A proforma was created and was put into use from August 2020. It was utilized by all endoscopists when carrying out OGDs for Barrett's diagnosis and surveillance. The proforma was added to the end of the hospital's standard endoscopy report. Following the intervention and use of the proforma, the second cycle of the audit was carried out looking at 58 OGDs completed between 05/08/2020-27/02/2021 to see if they met the standards set out by the British Society of Gastroenterology. The Barrett's surveillance service and the volume of OGDs carried out following the introduction of the proforma was affected by the Covid-19 pandemic. Result(s): The first cycle of the audit found that only 34% of OGDs had a Prague classification documented correctly. 0% of OGDs had the correct biopsy protocol followed and 12.6% of endoscopies did not have any biopsies taken. 26% of patients had no follow up or surveillance endoscopy interval documented or organised. Following the intervention, it was found that 96% of endoscopies now had a Prague classification documented, an increase of 62%. There was a 65% increase in correct biopsy technique being followed and 100% of OGD reports now had surveillance interval documented if deemed appropriate. Conclusion(s): The audit clearly displays that following our intervention there was a significant improvement in the quality of Barrett's diagnostic and surveillance endoscopies, when compared to national guidelines. Given its potential for malignant transformation, correct surveillance is exceptionally important to improve patient care and reduce mortality. The introduction of a proforma drastically improved the standard of the service provided at our District General Hospital and is one that can be transferable to other hospitals.

The 'Tic'king Bleeder: A Rare Case of Bleeding Dieulafoy's Lesion in a Jejunal Diverticulum

Introduction: Dieulafoy lesion (DL) is a relatively rare and arguably under-recognized condition, accounting for 1-2% of acute GI bleeding. Most bleeding DLs occur in the stomach, followed by the small intestine, with less than 1% occurring in the jejunum. Bleeding DL on a jejunal diverticulum is even more rare, with a handful cases described in the literature. Here we present a rare case of a bleeding DL in a jejunal diverticulum with its endoscopic management. Case Description/Methods: A 65-year-old female with history of COVID-19 infection one month prior to presentation treated with steroids and therapeutic anticoagulation presented to the ED after having multiple episodes of coffee-ground emesis and two episodes of syncope at home. Last dose of Apixaban was 12 hours prior to admission. Physical exam revealed BP of 90/60 on Norepinephrine infusion, HR of 96, abdominal exam was soft and nontender, DRE revealed melena. Hemoglobin/hematocrit was significantly decreased at 3.6/12.8. Patient was appropriately resuscitated with blood products and fluids, and she was scheduled for an EGD. Initial EGD did not identify a clear source of her bleeding, and she was scheduled for colonoscopy. Colonoscopy with deep cannulation of the terminal ileum up to 40cm revealed significant amounts of fresh blood all throughout the colon and terminal ileum. Decision was made for push enteroscopy, which revealed a jejunal diverticulum containing a Dieulafoy lesion with an overlying clot (Image A). The lesion was first injected with epinephrine at 2 sites followed by a clot removal overlying the lesion using 13-0 circular snare. A clear stigma of recent bleeding was noticed from the lesion after clot removal (Image B), after which 2 metallic clips were placed over the lesion to achieve hemostasis (Image C). The patient had no further episodes of bleeding and was follow up in clinic eventually, recovering well. Discussion(s): Because of the life-threatening nature of Dieulafoy lesions, identification is of paramount importance for treatment purposes. Jejunal DLs are a rare entity but should be considered in cases with negative bidirectional endoscopies. In our case, push enteroscopy helped identify the bleeding lesion. DL in a diverticulum can pose a challenge to the endoscopist due to difficulty of access to the lesion. Epinephrine injection followed by mechanical clipping showed a positive outcome in our case which can be considered while approaching bleeding DLs in a diverticulum. (Figure Presented).

Training Experience and Outcomes of the First Cohort of the ASGE Diagnostic EUS Training Program

Introduction: Despite the expanding role and need for endoscopic ultrasound, training opportunities for established endoscopists in the USA are limited. ASGE launched a novel competency-based program to address this training need in 2019. It includes an online learning modules, live webinars, a hands-on weekend course, a summative knowledge exam, followed by a customizable preceptorship with an EUS expert. Aim(s): To describe the training experience of a sample from the first cohort of the ASGE Diagnostic EUS training program. Method(s): A total of 26 applicants were chosen for the first cohort of the training program in 2019. We describe the experience of 3 endoscopists (ST at the Swedish Digestive Health Institute, Seattle, WA;BM at the Borland Groover Clinic, Jacksonville, FL and JH at Guthrie, Sayre, PA) who completed their hands-on training. Their case volumes were 160 (4 mentors), 185 (2 mentors) and 185 (3 mentors) respectively over a total of 12 weeks each. While 1 trainee (JH) was able to get trained at the same institute where he was employed, the other 2 (ST, JH) had to seek training in another state due to lack of preceptorship sites within their states of employment. One center tracked TEESAT scores (The EUS and ERCP Skills Assessment Tool) for every 5 procedures for their trainee (ST), and he was noted achieved a global score of 4 by the 150 th procedure. Result(s): All 3 trainees have been credentialed for EUS privileges at their respective institutes, and are performing EUS independently. Conclusion(s): The ASGE EUS diagnostic training program was able to fulfil the training needs of motivated established clinicians in full time practice. The main challenges encountered were identifying willing institutes and expert EUS preceptors, and institutional administrative barriers. COVID restrictions were a unique hurdle to the timely completion of preceptorship. This program's success in the future depends on buy in from EUS experts in the community and their respective institutions.

Pre-clinical testing of single use flexible bronchoscopes: clinician preference based on physical characteristics and level of experience

Single use flexible bronchoscopes (SUFBs) have come to the forefront in the COVID-19 pandemic to minimise risk of infectious transmission as well as carry out bedside procedures for critically unwell patients. Multiple companies have released SUFBs with varying technical metrics. We hypothesised that clinician bronchoscope preference varies depending on physical characteristics and level of experience. 39 participants including physicians, surgeons and anaesthetists with a range of expertise from first time endoscopists to consultants took part in a trial of all available SUFBs (The Surgical Company (TSC) Broncoflex©, Boston Scientific©, Ambu©, Vathin©, Pentax© prototype scope). Likert scales were used to evaluate scope parameters including ergonomics, comfort and ease of procedures. Participant parameters were collected including height, gender and hand size. TSC Broncoflex © was the preferred scope overall with ratings of 82% for ergonomics and 83% for usage. Female participants preferred Pentax (p=0.04);male participants preferred TSC (p=0.04). Participants with small or medium glove size preferred Pentax (p=0.02) while those with large glove size ranked Vathin and TSC highest. Doctors with >10 years experience preferred Pentax (p=0.04). Gender, hand size and previous experience influenced scope preference. These factors should be considered in future scope development.

ENDOSCOPY SITUATION AND GASTROENTEROLOGICAL MEDICAL CARE IN BHUTAN

Since October 2019, I worked for 2 years as an endoscopist at Jigme Dorji Wangchuck National Referral Hospital, located at Thimphu, Bhutan. Though this period overlapped the COVID-19 pandemic, I was involved in approximately 4, 000 cases of upper gastrointestinal (GI) endoscopy, 350 cases of colonoscopy, and 140 cases of ERCP. In Bhutan, the infection rate of Helicobacter pylori is higher than 70%, and even among young adults the rate is alarming. Gastric cancer is a malignant disease with the highest mortality and is mostly detected in advanced stages. Therefore, a national flagship project that takes aim at the eradication of H. pylori and early detection of gastric cancer has been recently created. Endoscopic health examinations named Endoscopy Camp are being conducted every weekend. In this article, we showed how upper GI endoscopy, colonoscopy, and ERCP is developing in Bhutan, which still lacks sufficient medical resources. We hope more Japanese endoscopists take an active interest in developing countries' medical care. Copyright © 2022 Japan Gastroenterological Endoscopy Society. All rights reserved.

THE IMPACT OF CENTRAL COORDINATION ON ENDOSCOPY EFFICIENCY

Background: The impacts of the COVID-19 pandemic have been far reaching and have necessitated many changes to healthcare delivery. At the QEII Health Sciences Center physical space limitations for patient check-in and recovery have restricted outpatient endoscopy to 3 of 4 available endoscopy suites. On June 1, 2020 a new system of central endoscopy triage and coordination for the Division of Digestive Care and Endoscopy (DC&E) was implemented in an effort to increase efficiency and maintain patient access to endoscopy. The components of the RESET (Re-introduce Endoscopy Safely and EfficienTly) Plan included a) a new endoscopy coordinator role to manage a common endoscopy waitlist, endoscopist schedules, and booking clerks, b) a modified triage system to improve waitlist consistency, c) a common endoscopy waitlist with patients booked in the next available appointment regardless of endoscopist, d) discontinuation of fixed endoscopy slots for endoscopists, and e) appointment scheduling no sooner than 4-weeks in advance to minimize no-shows and last-minute cancellations. Aims: The aim of this study is to evaluate the impact of the RESET Plan on the efficiency of DC&E endoscopy. Methods: A retrospective pre- and post-implementation study evaluating the volume and efficiency of outpatient endoscopy before and after implementation of the RESET Plan. The Pre-RESET period included all procedures performed from June 1, 2019 to October 31, 2019. The Post-RESET period included all procedures performed from June 1, 2020 to October 31, 2020. A separate endoscopy suite and triage system is used for endoscopic retrograde cholangiopancreatography (ERCP) and these cases were excluded. Early effectiveness outcomes were reported including a comparison of the number of endoscopic procedures per week and per list, pre- and post- implementation. Data analysis was primarily descriptive with data expressed as frequencies, means (SD), and proportions (%). Exploratory group comparisons were performed using independent-samples T-Test. Results: During the 5-month Pre-RESET period, 2203 endoscopic procedures were performed. During the Post-RESET period a total of 1920 procedures were performed. Due to pandemic restrictions, there was a 29% decrease in available endoscopy lists from 2019 to 2020. There was a 24% increase in the number procedures performed per endoscopy list, from 6.4 to 8.0 (p=0.004, 95% CI 0.52- 2.53), pre- and post-RESET. Conclusions: While the COVID-19 pandemic has disrupted healthcare delivery, it has also provided an opportunity to implement health system structure and process changes. The RESET Plan resulted in significant gains in efficiency which largely offset losses in endoscopy throughput imposed by COVID-19 pandemic restrictions. Future research will determine what patient and health system factors most significantly impact system efficiency as well as the cost-effectiveness of the RESET Plan.

COLONOSCOPY WAITING LIST VALIDATION ACHIEVES TWO-THIRDS REDUCTION OF NUMBERS AWAITING POST-POLYPECTOMY SURVEILLANCE

Introduction Waiting lists in Northern Ireland are the worst in the UK, representing a growing problem and one exacerbated by the Covid-19 pandemic. Those currently awaiting diagnostic services in NI total 147,543 including 31,313 endoscopy investigations (60% of which are waiting >26 weeks). By applying recent BSG/ACPGBI/PHE Guidelines for post-polypectomy surveillance, this study aimed to reduce the numbers of those awaiting planned colonoscopy within our Trust. The Guidelines suggest patients with polyps and high-risk findings should receive a one-off surveillance colonoscopy at 3 years, compared to previous 1-year interval advice. Patients who previously required follow up endoscopy at 5 years may be safely discharged with invitation to screening if no high risk features. Methods Validation of the waiting list was undertaken by consultants and nurse endoscopists with reference made to the current Guidelines. Patient records were reviewed using the Unisoft GI Reporting Tool v14.40.10 and the NI Electronic Care Record. Those relevant to polyp surveillance were identified (n=2001). Each request was categorised to either 'Remove', 'Proceed' or 'Defer'. Outcomes were recorded in an Excel spreadsheet. Patients were informed by letter of any change to their management plan, reasons for removal from the waiting list and given advice on seeking new referral if further symptoms developed. Participation in the Bowel Cancer Screening Programme (BCSP) was encouraged. The NHS England 2021-22 National Tariff for colonoscopy with biopsy (£548) was referenced in calculation of potential cost savings. Results A total of 5403 requests were on the endoscopy waiting list. 84 patients were deceased and were removed from the list. 1964 related to polyp surveillance and 37 to polyp site check. Following validation of 2001 tests, 1286 (64%) were categorised as 'Remove', 588 (29%) 'Proceed' and 127 (6%) 'Defer'. Reasons for removal included no high-risk features, age over 75 or life expectancy less than 10 years. Potential cost savings following removal of 1286 requests totalled £704,728.00. Conclusion Validation of the waiting list, considering updated or incorrect adherence to the current surveillance guidelines, achieved almost two thirds reduction. If applied nationally, this may greatly reduce the burden of outstanding endoscopy procedures and improve access to these services. Current guidelines state that patients >10 years younger than the BCSP who have polyps without high-risk features should be considered for colonoscopy at 5 or 10 years. In Northern Ireland, the BCSP lower age limit is 60 years. If this were reduced in line with England's 50 years, this may further reduce some surveillance burden allowing suitable patients to be invited to the Screening pathway rather than repeat endoscopy.

EDINBURGH DYSPHAGIA SCORE SAFELY PRIORITISES ENDOSCOPY IN A NURSE LED TELEPHONE TRIAGE CLINIC

Introduction As part of the COVID recovery strategy, the GI unit in North Sector of GGC set up a telephone clinic manned by experienced endoscopy nurse specialists to triage urgency of dysphagia investigation by undertaking symptom assessment and utilising the Edinburgh Dysphagia Score (EDS). Patients with high EDS were vetted to (the highest) Category 1 (of 4) priority, and patients with low EDS were investigated at Category 2. The outcomes for all patients referred with dysphagia over a 6 month period commencing January 2021 were audited to determine the safety and clinical value of maintaining this approach in the longer term. Methods Information on all patients referred to the service was prospectively collected using a shared MS Teams Excel spreadsheet. We collected information on the EDS at interview, the decision to investigate and the designated priority of the investigation. Electronic cases records were then interrogated to ascertain the outcome of investigations. Statistical comparison of the frequency of diagnoses made at endoscopy was undertaken using the CHI square test. Results 296 patients were assessed via 40 nurse dysphagia triage clinics during this period, with 266 undergoing endoscopy. Only 14/296 (6.4%) patients avoided endoscopy solely on account nurse assessment and reassurance. Relative diagnostic frequency is detailed in table 1. 144 (48.6%) were triaged to Category 1 endoscopy and 122 (41.2%) to category 2 endoscopy. Oesophageal cancer was diagnosed in 9/128 (7%) patients with EDS ≥ 3.5 and only 1/106 with EDS < 3.5 (p<0.05). For all other diagnoses there was no significant difference in frequency between those with high or low EDS. 59% of all patients had no new gastroesophageal diagnosis made. New diagnosis of Barrett's oesophagus was uncommon, being found in 2.6%. Conclusions Routine use of the Edinburgh Dysphagia score can safely and effectively prioritise dysphagia investigation. While this can be delivered via a telephone triage clinic run by experienced nurse endoscopists, such an approach rarely avoids endoscopy and with the return of capacity the nurses may be better utilised delivering endoscopy sessions rather than triage clinics. Alternative means of utilising the EDS need urgently considered, such as embedding the calculation of the EDS directly into the GP referral process to allow prioritisation at time of vetting. This will be the next focus of our service.

OUTCOMES OF A CONSULTANT DELIVERED VS SPECIALIST REGISTRAR LED OOH ENDOSCOPY SERVICE FOR SUSPECTED AUGIB

Introduction Acute upper gastrointestinal bleeding (AUGIB) has an incidence between 84-172 per 100,000 people per year resulting in 50-70000 hospital admissions every year. Out -of-hours (OOH) endoscopy rotas for AUGIB are typically delivered by Consultant Gastroenterologists. Prior to the COVID-19 pandemic, the AUGIB OOH service was Specialty Registrar (SpR) led at Leeds Teaching Hospitals, and was felt to provide invaluable exposure and experience for SpRs in the endoscopic management of patients presenting with AUGIB. Following the start of the COVID pandemic, and subsequent redeployment of SpRs, the AUGIB OOH service has been a Consultant delivered one. The aim of this retrospective study was to compare the safety and efficacy of a SpR led OOH AUGIB service (2016 database) with a Consultant delivered service (2020-21 database) at the same trust. Methods We included adult patients (>16 years), presenting to LTHT between March and September 2016 with suspected AUGIB having an endoscopy procedure performed on a SpR led OOH rota and compared this with patients presenting with suspected AUGIB between September 2020 and March 2021 during which period the service was entirely consultant delivered. Baseline clinical, laboratory, admission Glasgow- Blatchford Score, demographic data, grade of endoscopist, place of endoscopy, findings of endoscopy and treatments applied were recorded. Primary outcome was 30-day mortality secondary to GI bleeding. Secondary outcomes included time to endoscopy and rebleed rate Results 177 patients from the 2016 database (62% male, median age 67, range 18-97) and 100 patients from the 2020-21 database (60% male, median age 63, range 18-96) were included in the study. 97.2% patients (2016) vs 93% (2020-21) had a GBS score ≥7. 30-day GI bleed related mortality was 2.89% (2016) vs 3% (2020-21) (p value 0.93). The median time to endoscopy was 16.3 hours (2016) vs 17.2 hours (2020-21). 8.9% (2016) vs 7% (2020-21) experienced a rebleed. Conclusions This study has shown that a Registrar led OOH AUGIB service has comparable outcomes to a Consultant delivered rota in important outcomes such as time to endoscopy and 30-day mortality. Where service configuration allows, a registrar led rota can aid in improving the standard of SpR training whilst also freeing up Consultants to undertake increased elective work and reduce the backlog created by the COVID-19 pandemic.

THE NATIONAL CENSUS OF UK ENDOSCOPY SERVICES 2021

Introduction The Joint Advisory Group (JAG) on Gastrointestinal (GI) Endoscopy biennial census provides an insight into the provision of UK endoscopy services. We report on the 2021 census which was conducted to understand the impact of COVID-19 and ongoing pressures on endoscopy services. Methods The census was disseminated to all JAG-registered services in April 2021 using an online survey platform. Prior to analysis, any missing data from services was sought as part of a second step verification process. Data were analysed across the domains of endoscopic activity, waiting time targets, workforce, COVID-19, safety, GI bleeding, anaesthetic support, equipment and decontamination. Outcome variables from each section of the census were analysed against independent variables derived from service-specific core demographic data (JAG accreditation status, sector and region) using a variety of statistical methods. Results Overall, 321 services completed the census, with information pertaining to 393 individual units (response rate 79.2%). In 2020, just over 1.5 million endoscopic procedures were performed across all services. In the first 3 months of 2021, 66% of services met urgent cancer waits, 38.7% met routine waits and 33.9% met surveillance waits (Figure 1). Workforce redeployment was the predominant reason cited for not meeting targets. There were significant regional differences in the proportion of patients waiting 6 or more weeks (p = 0.001). During the pandemic, 64.8% of NHS services had staff redeployed and there was a mean sickness rate of 8.5% with no clear variation across sectors or regionally. Endoscopic activity was outsourced to the private sector in 21.6% of services. Services were, on average, at 79.3% activity compared to 2 years ago. JAG accredited services are more likely to meet urgent cancer waits, with a lower proportion of patients waiting 6 weeks or more (p = 0.03). Clinical endoscopists, who make up 11% of the endoscopist workforce, have a significantly greater number of annual planned sessions per individual than consultant colleagues, who make up 75% of the workforce. Over 10% of services stated that equipment shortage interferes with service delivery. Conclusions Services are adapting to continued pressure and there are signs of a focussed response to demand during a time of ongoing uncertainty. These findings will inform ongoing guidance from JAG and relevant stakeholders.

TRANS-NASAL OESOPHAGOGASTRODUODENOSCOPY (OGD): CHALLENGING THE STATUS QUO - A DISTRICT GENERAL HOSPITAL CASE SERIES

Introduction Oesophagogastroduodenoscopy (OGD) is commonly performed and trans-oral OGD is a very safe procedure. However, it requires nursing support, patient sedation, a dedicated endoscopy suite, and is disliked by patients. The national census by the Joint Advisory Group on Gastrointestinal Endoscopy reported 860,000 OGDs were performed across the UK in a calendar year. of these, only 26,685 were trans-nasal despite having a similarly low risk profile and being preferred by patients. We compared comfort score, sedation, and safety to show trans-nasal OGD is a feasible alternative to trans-oral OGD reducing nursing burden, avoiding endoscopy suites, and reducing procedure length. Methods A single centre retrospective analysis was performed comparing all OGDs performed by a single endoscopist at Whipps Cross and Mile End Hospitals between 01/06/2021 and 24/11/2021. Demographic data, route of entry, indication, comfort score (scale of 0-3), sedation agent and dose, and any complications were recorded for each procedure. The data sets were compared using paired t-test for statistical significance. Results There was 110 OGDs performed (table 1);73 transoral (66%) and 37 trans-nasal (34%). of those trans-nasal OGD 18 (49%) were completed seated. The trans-nasal route had mean comfort score of 0.29 compared with 0.85 for trans-oral route (p = 0.001). There was no statistical difference in xylocaine application with either route. The mean dose of both fentanyl and midazolam was statistically higher in the trans-oral route compared with trans-nasal (p = 0.0001). There were only two complications reported in the cases reviewed. Conclusions Trans-nasal OGD caused significantly less discomfort than trans-oral OGD and required significantly less sedation, and almost half of patients undergoing trans-nasal OGD were able to tolerate the procedure in a seated position. This has advantages for patient safety, as the risk of aspiration is greatly reduced, but is also much less resource intensive. Given the current pressure on endoscopy services nationwide, amplified by COVID-19, trans-nasal endoscopy is safe, less resource intensive, and can be performed outside of a dedicated endoscopy suite. This may be a useful tool in alleviating waiting list pressure and should be discussed with patients and service leads.

AN EVALUATION OF THE NATIONAL CLINICAL ENDOSCOPIST TRAINING PROGRAMME IN WALES

Introduction Increased demand for endoscopy has created a need to increase the number of Clinical Endoscopists (CEs) contributing to service delivery. From April 2019 CEs were recruited to an accelerated programme of blended training interventions (Core teaching;Masters level modules;Simulation;JAG courses;online lesion recognition (SLATE) courses;Training lists;and Online Tutorials) - providing a pathway from novice to JAG certification within 12 months for Upper GI endoscopy, and 2 years for Colonoscopy. Methods We conducted quantitative and qualitative evaluation mapped to a logic model of the impact and effectiveness of two CE cohorts using triangulated evidence sources - literature review;workplace observation, surveys and interviews with trainees;interviews with stakeholders - trainers and mentors;discussions with course leaders;Data from the Cognitive Load Inventory for Colonoscopy (CLIC) survey;and Programme outcome data. Results Of ten trainees evaluated, one resigned (lack of local support). COVID adversely affected time taken to complete training - six completed all elements of training in time (3 JAG Certified, 3 in process of certification);three still in training were all redeployed. All trainees and trainers agreed the programme supports the development of technical skills required for the CE role. Endoscopic non-technical skills (ENTS) were highlighted as important - lesion recognition, decision-making, report writing & patient management - and take time to develop. All trainees reported positive impact on them personally, their career prospects and on their Units. They enjoyed peer learning and developed new skills in negotiating with colleagues and advocating for patients. Prior experience in an endoscopy unit correlated with better progress through the course and older trainees reported less extrinsic cognitive load. A dedicated trainer was critical to success, supported rapid progression and resolved training issues more effectively. Lack of training lists was the biggest barrier to progression. Academic supervision and support was valued. Trainers felt selection of the 'right' trainee was critical and wanted greater involvement in the selection process. A number of areas for programme improvement have been identified - recruitment process, trainer involvement in induction, programme manual, training agreements, developing independent prescribing competency. Conclusions The blended CE training pathway supports the acquisition of technical skills and ENTS from novice to JAG Certification. Qualitative review has highlighted several areas where the programme can be improved.

CHALLENGES AND LESSONS FROM AN EVALUATION OF THE NATIONAL CLINICAL ENDOSCOPIST TRAINING PROGRAMME IN WALES

Introduction There is a UK-wide need to increase the number of Clinical Endoscopists (CEs). From April 2019 CEs were recruited to an accelerated programme of training (small group teaching, Masters level modules;simulation;JAG courses;training lists;and on-line courses & tutorial groups) - to achieve JAG accreditation. Methods We conducted quantitative & qualitative evaluation mapped to a logic model (1) of the impact of the training. We combined evidence from literature review, observation, surveys and interviews with trainees, trainers & mentors;discussion with course leaders;data from the Cognitive Load Inventory for Colonoscopy (CLIC) survey (2) and review of programme outcome data. Results Ten trainees in two cohorts were evaluated - six completed all elements of training, three are still in training (redeployed due to COVID). Thematic analysis highlighted eight areas: technical skills, non-technical skills, the programme, academic elements, training units, trainers, personal qualities, and career development. All trainees reported acquiring technical skills enabling them to undertake procedures safely. Trainees reported significant highs and lows. Older trainees and those with experience of working in endoscopy units reported less cognitive load. Non-technical skills took longer but leading the team or writing reports with support from tutors were helpful in overcoming anxieties. Trainees valued the structure the programme provided - structured handbooks and parallel training for independent prescribing would have added value. Good clinical and senior nurse support correlated with good progression. Trainees described barriers of professional jealousy, no identified trainer or training list, or lack of senior support. COVID-19 was a factor. Trainers identified the resilience, resourcefulness and negotiating as key skills and felt they could identify applicants most likely to succeed. Trainees were motivated to take on the role but needed help and support if training had not gone well. Conclusion The journey taken by CEs to acquire the skills required for advanced practice roles tests a wide range of knowledge, motor, and professional skills. Developing the crucial critical thinking and cognitive skills must develop alongside mental resilience, and requires support from course tutors, optimally designed course elements, access to training lists and supportive local teams.

Is nasojejunal feeding as effective as we think? An evaluation of nasojejunal feeding in the Intensive Care Unit

Early enteral feeding is important in maintaining the integrity of the gastrointestinal tract mucosal barrier and associated with less bacterial translocation and decreased stimulation of the systemic inflammatory response and subsequent improved outcomes in intensive care (ICU) patients. Enteral feeding by nasogastric (NG) tubes is the preferred route of nutritional support for most ICU patients. However, ICU patients with delayed gastric emptying and poor intestinal motility may not tolerate gastric feeding and may therefore benefit from post-pyloric feeding via nasojejunal (NJ) tubes1. We reviewed the effectiveness of 35 NJ tube placement in 24 patients on ICU between January and March 2021. The M:F ratio was 4:1, median age 69 years (30–80 years) and 54% of patients were non-White British. 10 patients (42%) had diabetes and 54% had COVID-19 as part of their admitting diagnoses. The median BMI was 25 (range 20 – 32.3) and none of the patients were identified as high risk for refeeding syndrome at the time of NJ tube insertion. Nutritional information was unavailable on 5 patients. Of the remaining 19 patients, 26% of patients (n=5) were commenced on parenteral nutrition (PN) within 48 hours of NJ insertion. Only 1 patient was able to meet their nutritional requirements enterally via NJ tube at 5 days;a further 2 patients had their nutritional requirements met with supplemental PN. In 8 of 22 referrals the indication for NJ tube insertion was because an NG tube could not be passed. The evaluation revealed discrepancies in adherence to protocols for high gastric residual volumes and prokinetic use. Documentation surrounding decision making, requesting and inserting an NJ tube was poor and probably reflects the complexity of the patients, involvement of multiple clinical teams, and various documentation modalities (i.e., verbal, written and different electronic systems). There was clinical dispute regarding the indication for NJ tube insertion in 23% of cases (documented in 3 of 13 referrals for NJ tube insertion). Where documentation was available 43% of patients (n=10) had an NJ tube placed on the day of request;the median time from request to insertion was 1 day (range 0-10). 5 patients had more than one NJ tube inserted (median 3;range 2–5). There was variation in experience and expertise of the endoscopists placing the NJ tubes. NJ tube feeding is considered to be less expensive and have less complications than PN2. However, our evaluation has revealed a range of issues relating to both the insertion and use of NJ tubes in an ICU setting. The true resource ‘cost’ of NJ tube insertion is probably underestimated in the literature and the complications of PN probably overestimated in the context of modern ICU and nutrition support team clinical practices. We suspect that our clinical experience is not unique and that more research is needed in this area. We are using this work to educate clinical teams, standardise documentation, provide better support and supervision for endoscopists, and raise awareness of the benefit and need for supplemental PN where nutritional requirements are not consistently reached enterally. 1 Schröder S, Hülst S V, Claussen M et al. Postpyloric feeding tubes for surgical intensive care patients. Anaesthetist 2011;60 (3): 214-20. 2 Lochs H, Dejong C, Hammarqvist F et al. ESPEN Guidelines on enteral nutrition: Gastroenterology. Clin Nutr 2006;25(20: 260-74.

BIAS AND ENDOSCOPY TURNOVER TIME IN A TERTIARY REFERRAL ACADEMIC CENTER ENDOSCOPY UNIT

Introduction: Room turnover time (TOT) is a measurement of endoscopy unit efficiency and delays in procedures lead to wasted health care expenditures. Several factors have been identified to influence turnover time including communication, staffing, case complexity, and specific surgeon. Previous research has indicated stereotypes about perceptions of physicians based on their gender or experience. For instance, women in surgical subspecialties endure gender discrimination from conscious and unconscious bias, that produce obstacles to career development and lead to burnout. It is unclear if these biases affect work flow in an endoscopy unit. Here, we sought to evaluate if endoscopists gender or academic experience affected their endoscopy room turnover time. Methods: We evaluated 2,917 inpatient and outpatient endoscopic procedures performed at our large academic tertiary care center between July 2019 and July 2021. TOT was calculated by taking the difference between a prior patient “out of room time” and the next patient “in room time”. TOT was averaged for each endoscopist and T-tests were used to evaluate for any statistical difference between groups. Academic experience was differentiated by having £5 years or >5 years since completing GI fellowship, or holding a leadership position. Results: The average room TOT was 31:28 minutes amongst 26 different gastroenterology providers. There was no statistically significant difference in TOT by gender (p=0.99), serving in a leadership position (p=0.46), or being >5 years since completing fellowship (p=0.63). TOT was longest for advanced endoscopic procedures (p=0.025). TOT increased and case volume decreased in April and May 2020, following the onset of the COVID-19 pandemic. Conclusion: Neither gender or years of academic experience were associated with differences in endoscopic room TOT. More research is needed in gender or professional bias as related to work flow in medicine. Our other future directions include identification and analysis of other endoscopy efficiency metrics for endoscopy suite quality improvement. References: Day, L.W et al. Quality and Efficiency in Gastrointestinal Endoscopy Units. 2018, Springer International Publishing. p. 587- 601. Stephens EH et al. The Current Status of Women in Surgery: How to Affect the Future. JAMA Surg. 2020 Sep.

EARLY INTESTINAL ULTRASOUND PREDICTS ENDOSCOPIC RESPONSE ON ANTI-INFLAMMATORY TREATMENT AND SHOWS DRUG-SPECIFIC RESPONSE TO BIOLOGICALS AND TOFACITINIB IN ULCERATIVE COLITIS

Introduction Objective evaluation of treatment response is the gold standard in ulcerative colitis (UC). In this setting, intestinal ultrasound (IUS) is a non-invasive alternative to endoscopy. Recent studies showed change in IUS parameters after treatment initiation but studies with an endoscopic reference standard are scarce. The aim of this study was to evaluate early change of IUS parameters and determine cut-off values for endoscopic endpoints in UC patients starting anti-inflammatory treatment. Methods In this longitudinal prospective study consecutive patients with moderate-severe UC (baseline endoscopic Mayo score (EMS)≥2) starting an anti-inflammatory treatment were included. Clinical scores, biochemical parameters and IUS parameters were collected at baseline, after 2 (T1), 6 (T2) and 8-26 weeks (T3) around time of the second sigmoidoscopy/colonoscopy. Bowel wall thickness (BWT), Colour Doppler signal (CDS), haustrations, inflammatory fat and wall layer stratification were measured as previously established1. Endoscopic remission (ER) and mucosal healing (MH) were evaluated in the sigmoid and defined as EMS=0 and EMS≤1, respectively. The ultrasonographist and endoscopist were blinded for the outcomes of endoscopy and IUS, respectively. Results 51 consecutive patients were included (Table 1) of whom 31 underwent a second endoscopy. Two additional patients underwent colectomy and were considered non-responders. 18 patients did not undergo second endoscopy due to the COVID-19 pandemic (n=2), refusal (n=5), loss to follow-up (n=1) or treatment escalation because of clinical deterioration confirmed by IUS and biomarkers before second endoscopy was performed (n=10). BWT was significantly lower from T2 onwards in patients reaching MH (p=0.026) and ER (p=0.002) at T3 (Fig 1). A significant decrease in BWT was already visible at T1 in patients receiving infliximab (median DBWT T0-T1: -26% [-43% - -6%], p=0.001) or tofacitinib (median ∆BWT T0-T1: -33% [-46% - -5%], p=0.001) but not in patients treated with vedolizumab (median ∆BWT T0-T1: -14% [-43% - 5%], p=0.11). Most accurate BWT cut-off values at T3 to determine MH and ER were 3.52 mm (AUROC: 0.95, 95% CI: 0.86-1.00, p<0.0001, sens:91%, spec:91%) and 2.98 mm (AUROC: 0.94, 95% CI: 0.85-1.00, p=0.001, sens:87%, spec:100%), respectively. At T2, BWT per 1 mm increase and CDS were inversely associated with MH (BWT: OR: 0.48 (0.24-0.96, p=0.038);CDS: OR 0.16 (0.03-0.83), p=0.028) and ER (BWT: OR: 0.30 (0.11-0.76), p=0.01). Conclusion BWT and CDS 6 weeks after start of treatment could predict MH and ER. In addition, treatment response at IUS is drug-specific. Furthermore, we have provided accurate BWT cut-off values for endoscopic outcomes. In a point-of-care setting, (early) treatment evaluation with IUS could guide treatment decision in UC in order to optimize treatment response. 1. Bots et al. JCC 2021

DOES USE OF AN ENDOSCOPIC PATIENT FACEMASK REDUCE PARTICLE AEROSOLIZATION DURING UPPER ENDOSCOPIC PROCEDURES? A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

Background: The COVID-19 pandemic has heightened awareness surrounding the danger of aerosolizing procedures which may lead to viral transmission. Most viruses are spread via droplets which are predominantly 5-10 microns (mm) in size and can remain suspended in the environment for extended periods of time. While personal protective equipment may reduce some risk, this prolonged suspension of infectious droplets may still lead to transmission. Furthermore, there is little data describing the risk of aerosolization during upper endoscopic procedures. We sought to characterize particle aerosolization between patients undergoing upper endoscopy with and without an endoscopic patient facemask. Methods: Adult patients scheduled for elective upper endoscopic procedures under monitored anesthesia care at a tertiary care center between August and October 2021 were prospectively enrolled. Patients were randomized to either receive an endoscopic facemask designed with fenestrated openings for endoscope insertion (Procedural Oxygen Mask, Simi Valley, CA) or undergo endoscopy with no mask using nasal cannula oxygen support. Exclusion criteria included requiring endotracheal intubation or medically needing an endoscopic facemask for oxygen delivery. Particle aerosols were measured using a commercially available particle detector (Met One GT-526S, Grants Pass, OR) which measured particles of six different sizes (<0.3mm, 0.3-0.5mm, 0.5-0.7mm, 0.7-1mm, 1-5mm and 5- 10mm). The device was placed at 1 foot from the subject's mouth and equidistant between the endoscopist and the anesthesia staff. Measurements were taken every 5 seconds for analysis. A linear mixed effects model was used to analyze the difference in particle aerosolization between groups. Results: Out of 57 patients who were randomized, 27 underwent endoscopy with a facemask and 30 underwent endoscopy with no mask. There were no significant differences in age, gender, body mass index, Mallampati score, patient positioning, or American Society of Anesthesiology (ASA) score between the 2 groups. Analysis of 27,724 measurements showed no difference in particle aerosolization of any size particle between the 2 study arms. The predictive model demonstrated a trend of decreasing particles during endoscopy which then increased by the end for all six particle sizes for both groups. Conclusions: Use of a widely available endoscopic patient facemask did not prevent particle aerosolization during upper endoscopic procedures. Interestingly, there was an initial decrease in particle counts during the procedures followed by a subsquent increase which may reflect heightened aerosolization with insertion and removal of the endoscope. Further study is warranted to determine if additional interventions may be useful for preventing particle aerosolization during endoscopy and improving safety for all health care staff. (Table Presented) (Figure Presented)

Use of a specialty endoscopy online platform for continuing medical education for clinical endoscopists during the COVID-19 pandemic.

BACKGROUND: To explore the use of a digestive endoscopy professional online platform by domestic endoscopists and its application effect on endoscopists' continuing medical education, analyse the related problems of continuing medical education using this method, and propose targeted improvement suggestions. METHODS: Based on the "Doctor's Circle" app, a questionnaire was sent to all members who successfully registered on the Hebei Biliary and Pancreatic Endoscopy Diagnosis and Treatment Alliance online platform. The questionnaire was available for 30 days. The questionnaire survey results were collected and counted for a grouping comparison. RESULTS: By the deadline, 703 completed questionnaires had been received. After the registered doctors joined the platform, 469 (66.7%) experienced a significant influence on their own endoscopic operation ability level, and 354 (50.3%) felt a significant improvement in their ability to diagnose biliary- and pancreatic-related diseases. The application effect of the platform on members' continuing medical education was affirmed by the vast majority of registered doctors. The clinical specialty of registered doctors, the length of time they joined the platform, the length of time they participated in the platform activities each time, and whether they played back course videos after the live broadcast of the course on the platform were the main factors affecting the application effect on continuing medical education (P < 0.05). Registered doctors who benefited significantly from the platform used it for 6-12 months, participated in activities for 1-2 hours each time, and often played back course videos. CONCLUSION: The new model of continuing medical education based on an online platform breaks through the constraints of traditional models and meets the individualized needs of every medical worker to improve their comprehension level. At present, the global outbreak of COVID-19 makes this learning mode increasingly popular among medical workers. We should constantly improve the organization of the content and methods of continuing medical education courses, make the online platform better serve the majority of medical workers, and effectively improve the comprehension levels of clinicians.

ANALYZING AND IMPROVING ENDOSCOPY UNIT EFFICIENCY IN AN ACADEMIC TERTIARY CARE UNIVERSITY HOSPITAL

DDW 2022 Author Disclosures: Armin Parsi: NO financial relationship with a commercial interest ;QiQi Zhou: NO financial relationship with a commercial interest ;G. Nicholas Verne: NO financial relationship with a commercial interest Background: The COVID-19 pandemic required postponement of many elective gastrointestinal (GI) endoscopic procedures. With the pandemic now in control, the number of patients requiring GI endoscopic procedures has steadily increased. This increasing demand combined with a shortage of qualified support staff in the aftermath of the pandemic has made efficiency-improvement in endoscopy centers an increasingly important topic for academic medical centers. Aim: To determine strategies to enhance efficiency in an academic tertiary-care endoscopy unit. The overall goal was to decrease physician down-time and maximize the use of support staff and nurses without adversely impacting the patient or provider experience. Methods: We introduced a new metric, inter-procedure time, defined as the elapsed time between endoscope removal from one patient and endoscope insertion into the next patient, as the metric of choice to measure and track improvements in efficiency. This metric not only accounts for the time spent for room turnover but also other factors that may delay initiation of the subsequent procedure while the patient is already in the endoscopy room. In an ongoing prospective quality-improvement project, we initiated a 3-pronged intervention strategy: 1) employed a “one- endoscopist-two-room” model, 2) improved nonphysician staff utilization by having a nurse rotating between two endoscopy rooms, and 3) instituted clear communication of when a procedure was close to completion in order to begin the room turnover process. Results: The inter-procedure times were prospectively measured for 100 consecutive patients presenting for elective outpatient endoscopy before the intervention and 66 consecutive patients after the intervention. Patient demographics, severity of comorbidities, and the type of endoscopic procedures did not differ between the two groups. Before the intervention, the average inter-procedure time was 36.7±21min while after the intervention the average inter- procedure time decreased to 17±9.7 min(p< 0.001). After the intervention, the number of endoscopic procedures performed per day increased by 32% without any change in the number of endoscopists or support staff. Conclusions: 1. Strategies such as one-endoscopist-two-room model, improving nonphysician staff utilization, and improved communication between providers can significantly enhance efficiency of endoscopy units without increasing costs. 2. Decreasing inter-procedure time is directly associated with increasing endoscopy unit output. Interprocedure time is therefore an appropriate metric for measuring and tracking efficiency in endoscopy units. 3. Further studies are needed to assess sustainability of these improvements in the long term. (No Image Selected)

SIGNIFICANT REDUCTION IN THE DIAGNOSIS OF BARRETT'S ESOPHAGUS (BE) AND RELATED DYSPLASIA DURING THE COVID-19 PANDEMIC: AN ANALYSIS OF THE GIQUIC NATIONAL BENCHMARKING REGISTRY

DDW 2022 Author Disclosures: Sachin Wani: NO financial relationship with a commercial interest ;Jeffrey Williams: NO financial relationship with a commercial interest ;Jennifer Holub: NO financial relationship with a commercial interest ;Audrey Calderwood: YES financial relationship with a commercial interest;Dark Canyon Laboratoties:Advisory Committees or Review Panels ;Jason Dominitz: NO financial relationship with a commercial interest ;Prasad Iyer: YES financial relationship with a commercial interest;Exact Sciences:Consulting;Exact Sciences:Grant/Research Support;Pentax:Grant/Research Support;Pentax:Consulting;Ambu:Consulting;Symple Surgical:Consulting;Medtronic:Consulting ;Nicholas Shaheen: YES financial relationship with a commercial interest;Lucid:Grant/Research Support;Medtronic:Grant/Research Support;Steris:Grant/Research Support;Pentax:Grant/Research Support;CDx Medical:Consulting;Cernostics:Consulting;Interpace Diagnostics:Grant/Research Support;Phathom Pharmaceuticals:Consulting;Exact Sciences:Consulting;Aqua Medical:Consulting;Cook Medical:Consulting Background: The COVID-19 pandemic has disrupted endoscopy practices with significant reductions in procedural capacity creating unprecedented decreases in cancer screening and surveillance services. Using a national registry with matched endoscopy and pathology data, we aimed to assess the impact of the pandemic on the proportion of patients diagnosed with BE and BE-related dysplasia and adherence to established quality indicators in BE. Methods: We analyzed data from the GI Quality Improvement Consortium (GIQuIC) Registry, a national repository of endoscopy data. Procedure data from all EGDs in the registry during the study period, including procedure indication, demographics, endoscopy findings, pathology results and recommendations were assessed from 1/2018 – 5/2021. Three cohorts based on date of EGD performance were created: Pre-pandemic (1/2018-2/2020), Early Pandemic (3/2020-7/2020) and Late-pandemic (8/2020-5/2021). Observed and expected number of BE and dysplasia cases/month were calculated. Adherence to Seattle protocol was assessed by dividing the BE length by number of pathology jars submitted;a ratio of ≤2.0 with rounding down was considered adherent. Adherence to recommended surveillance for non-dysplastic BE (NDBE) was calculated by assessing the proportion recommended to undergo an EGD between 3-5 years. Results: Among 1,619,684 EGDs assessed, 94,081 (5.8%) met inclusion criteria (Table 1). These cases were largely performed by GIs and represented 394 practices and 2666 endoscopists nationwide with geographic distribution within the U.S. as follows: West 24%, Midwest 13%, South 40%, and Northeast 23%. Fewer endoscopies were performed by non-GIs during the early (1.5%) and late pandemic (1.5%) compared to pre-pandemic period (9.3%, p<0.001). The mean BE length was 2.3 (2.5) cm and distribution based on histology was NDBE 87.5%, low-grade dysplasia (LGD) 2.2%, indefinite for dysplasia (IND) 2.9%, high-grade dysplasia (HGD) 1.5%, and unknown 5.8%. Table and Figure highlight the significant reduction in the number of patients diagnosed with BE (47.9% and 24.1%) and BE-related dysplasia (HGD: 38.5% and 25.3%;LGD: 45% and 34%, any dysplasia: 43.9% and 31.3%) per month during the early and late pandemic periods. Over the pandemic, there was no decline in adherence rates to quality indicators in BE with an overall adherence rate to the Seattle protocol and appropriate recommended surveillance interval in NDBE of 83% and 68.4%, respectively. Conclusions: Results of this study demonstrate a significant decline in EGD volume with an associated reduction in the number of patients diagnosed with BE and related dysplasia during the COVID-19 pandemic. The absence of a compensatory increase in diagnoses in the late pandemic period is concerning with likely long-term deleterious downstream effects on esophageal adenocarcinoma morbidity and mortality. [Formula presented] [Formula presented]