Consenting patients for endoscopic retrograde cholangiopancreatography: results of a survey of 182 UK endoscopists and 2059 of their patients.

OBJECTIVES: To describe the endoscopic retrograde cholangiopancreatography (ERCP) consent process. METHOD: A prospective, multicentre study of ERCP, supplemented by questionnaires administered to participating endoscopists and their patients. RESULTS: A total 165 of 182 (91%) endoscopists completed a questionnaire describing personal practice with 140 of 165 (85%) routinely providing written information to patients; 120 of 165 (73%) routinely acquiring verbal consent on the day of ERCP; 23 of 165 (14%) delegating acquisition of consent to another team member and 59 of 165 (36%) usually/always describing alternative treatments to patients. Types of complication disclosed (and percentage of incidence quoted) varied significantly. A total of 2059 of 4561 (45%) patients completed the questionnaire following their first recorded procedure, at a mean of 11 days post-ERCP. Most (1968/2059; 96%) patients were satisfied with the explanation provided; they understood why ERCP was recommended (1935/2059; 94%) and recalled being informed of complications (1745/2059; 85%). Regression analysis of first-ever (nonurgent) ERCP suggested that patients were more likely to recall being informed of risk (odds ratio; 95% confidence interval) if they were younger (1.04 per 5-year decrease, 1.02-1.05), had an American Society of Anesthesiology score of less than 3 (2.0; 1.18-3.4); or had verbally consented more than 1 week in advance of ERCP (2.41, 1.02-5.71, when compared with those who consented on the day of ERCP). After ERCP 964 of 2059 (47%) patients were warned of specific symptoms that could arise. CONCLUSION: The ERCP consent process could be improved by consistent disclosure of risk, acquisition of verbal consent well in advance of the procedure, provision of information after ERCP and increased attention to older and more sick patients.

Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice.

OBJECTIVE: To examine endoscopic retrograde cholangio-pancreatography (ERCP) services and training in the UK. DESIGN: Prospective multicentre survey. SETTING: Five regions of England. PARTICIPANTS: Hospitals with an ERCP unit. OUTCOME MEASURES: Adherence to published guidelines, technical success rates, complications and mortality. RESULTS: Organisation questionnaires were returned by 76 of 81 (94%) units. Personal questionnaires were returned by 190 of 213 (89%) ERCP endoscopists and 74 of 91 (81%) ERCP trainees, of whom 45 (61%) reported participation in <50 ERCPs per annum. In all, 66 of 81 (81%) units collected prospective data on 5264 ERCPs, over a mean period of 195 days. Oximetry was used by all units, blood pressure monitoring by 47 of 66 (71%) and ECG monitoring by 37 of 66 (56%) units; 1484 of 4521 (33%) patients were given >5 mg of midalozam. Prothrombin time was recorded in 4539 of 5264 (86%) procedures. Antibiotics were given in 1021 of 1412 (72%) cases, where indicated. Patients' American Society of Anesthesiology (ASA) scores were 3-5 in 670 of 5264 (12.7%) ERCPs, and 4932 of 5264 (94%) ERCPs were scheduled with therapeutic intent. In total, 140 of 182 (77%) trained endoscopists demonstrated a cannulation rate >/=80%. The recorded cannulation rate among senior trainees (with an experience of >200 ERCPs) was 222/338 (66%). Completion of intended treatment was done in 3707 of 5264 (70.4%) ERCPs; 268 of 5264 (5.1%) procedures resulted in a complication. Procedure-related mortality was 21/5264 (0.4%). Mortality correlated with ASA score. CONCLUSION: Most ERCPs in the UK are performed on low-risk patients with therapeutic intent. Complication rates compare favourably with those reported internationally. However, quality suffers because there are too many trainees in too many low-volume ERCP centres.

Hepatitis C: tackling the silent epidemic.

Chronic hepatitis C virus infection is responsible for a significant and growing burden on NHS services. It is one of the commonest causes of liver cirrhosis and hepatocellular carcinoma, and the leading indication for liver transplantation. Major advances have been made in treatment, which can eradicate the virus in more than 50% of patients and reduce complications, but progress is hampered by inadequate detection and access to treatment.