ASGE Guideline Provides Standards for Pediatric Endoscopy

The international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) has issued quality standards and indicators for conducting endoscopic procedures in children in a new guideline developed and endorsed by the American Society for Gastrointestinal Endoscopy (ASGE) and published in Gastrointestinal Endoscopy.

The guideline, which is jointly supported by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), provides consensus- and evidence-based measures that can be used to support continuous quality improvement in endoscopy services for children, regardless of who performs the procedure and where it is performed.

“The PEnQuIN standards are intended to provide a framework for quality assurance and improvement initiatives for endoscopic procedures in children, whereas the indicators are designed to serve as measurable and auditable key performance metrics,” the guideline working group noted.

Developing PEnQuIN Guidelines

The PEnQuIN group included 33 endoscopists from 31 centers in 11 countries in North America and Europe. The members represent multiple geographic regions, practice settings, and practice types, including academic and community, as well as therapeutic and diagnostically focused endoscopists.

The guideline development process was based on the Appraisal of Guidelines, REsearch and Evaluation II (AGREE) framework, and the Population, Intervention, Comparator, Outcome (PICO) approach was used to frame questions relevant to each potential quality standard and its corresponding indicator(s). The quality of evidence was assessed using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach.

The standards and indicators apply to the full process of endoscopy in children, including facilities, procedures, and endoscopists and endoscopists in training. Overall, 49 standards, 47 indicators, and 30 reporting elements were included.

The PEnQuIN working group reached consensus on 27 standards for facilities that support pediatric endoscopy and 10 indicators to identify high-quality endoscopic care in children; 14 standards regarding pediatric endoscopic procedures and 30 indicators to identify high-quality procedures; and 6 standards that all providers who perform pediatric endoscopy should adhere to and 2 standards for endoscopists in training, with 7 corresponding indicators to identify high-quality endoscopists.

The working group set minimum targets for defining high-quality pediatric ileocolonoscopy for an unadjusted cecal intubation rate of at least 90% and an unadjusted terminal ileal intubation rate of at least 85%. A minimum target for the key indicator rate of adequate bowel preparation was set at 80% or higher.

The working group also confirmed that colorectal cancer-related quality indicators such as adenoma detection rate and withdrawal time are not useful for endoscopic procedures in children.

Strong Recommendations to Implement in Clinical Practice

Among the 49 included standards, 4 were classified as “strong” recommendations. In its first strong recommendation, the guideline advises that endoscopy facilities where pediatric procedures are conducted should ensure availability of pediatric-specific monitoring and resuscitation equipment (evidence: moderate). In its second strong recommendation, the guideline states that endoscopy facilities where pediatric procedures are performed should ensure availability of endoscopic equipment that is age, size, and weight appropriate (evidence: very low).

The third strong recommendation states that for a patient and/or caregiver to provide informed consent/assent to undergo an elective endoscopic procedure, the patient and/or caregiver must be advised in a timely fashion regarding all relevant information about the procedure, including its risks, benefits, and alternatives, if any; the patient also should be provided with an opportunity to raise any questions about the procedure with a physician, and the process should be documented (evidence: moderate).

In the fourth strong recommendation, the guideline advises that all endoscopists in training who perform procedures in pediatric patients should be supervised with regular performance monitoring and constructive feedback until they have competence to perform the specified routine and/or emergency pediatric procedures according to appropriate current standards (evidence: very low).

Conditional Recommendations for Endoscopic Care

Among other recommendations for facility-related standards, the guideline advises that endoscopy facilities where pediatric procedures are performed should meet or exceed operating standards defined by the appropriate national or provincial/state regulatory authorities and be accredited to provide pediatric care (evidence: very low). In addition, endoscopy facilities where pediatric procedures are conducted should have an established process for the proper handling, labeling, and processing of tissue and other endoscopically obtained specimens (evidence: very low).

The guideline also advises that patients and/or caregivers should receive appropriate information about the endoscopic procedure before the procedure date (evidence: low). Endoscopy facilities where pediatric procedures are performed are recommended to have the personnel and technical resources required by national and/or provincial/state standards to complete all planned pediatric procedures safely and effectively (evidence: very low).

Among the procedure-related standards, the guideline recommends that pediatric endoscopic procedures be conducted for an appropriate, clearly documented indication, consistent with current evidence-based guidelines, when available (evidence: low) and that appropriate sedation/anesthesia be provided to ensure patient cooperation, comfort, and safety corresponding with best practices and consistent with evidence-based guidelines, when available (evidence: low).

Furthermore, the guideline recommends that bowel preparation for lower endoscopic procedures be of sufficient diagnostic quality to allow for a complete procedure and be measured using a tool with strong validity evidence or, at a minimum, using standardized language with clear definitions (evidence: low). Endoscopic biopsy samples are recommended to be obtained as appropriate for the procedural indication, consistent with current evidence-based guidelines, when available (evidence: low).

In addition, all patients and/or caregivers should be provided at discharge with written information about potential symptoms that may indicate a procedure-related adverse event and instructions on what to do if these symptoms develop (evidence: very low).

For endoscopist-related standards, the guideline recommends that all endoscopists involved, directly or indirectly, in endoscopy service delivery to pediatric patients should be trained and certified as being competent to conduct a specified routine and/or emergency pediatric endoscopic procedures according to appropriate standards (evidence: very low). The guideline also recommends that endoscopists who perform lower endoscopic procedures on pediatric patients should strive to complete an ileocolonoscopy unless the procedure is being performed for an indication that does not require it (evidence: low). Endoscopists who conduct procedures in pediatric patients should regularly review their endoscopic practice and outcome data with the goal of continuous professional development (evidence: very low).

In addition, all endoscopists in training who perform procedures on pediatric patients should be supervised with regular performance monitoring and constructive feedback until they have achieved competence to perform a specified routine and/or emergency pediatric procedures according to appropriate current standards (evidence: very low).

The PEnQuIN working group noted that the current evidence base for associating the standards and indicators with clinical outcomes is limited and that uncertainty about standard levels of performance is significant.

“However, it is our hope that these guidelines lay a foundation for quality improvement efforts for pediatric endoscopy services and endoscopists,” the working group stated. “Moving forward, it will be important to develop central data repositories to enable multicenter longitudinal data collection to determine appropriate minimum and aspirational targets for other PEnQuIN quality indicators against which services and providers can measure their performance.”

The guideline was reviewed and approved by the governing board of the ASGE. The guideline also was reviewed by patient representatives and by other societies, including the Canadian Association of Gastroenterology.

Disclosure: One of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of the author’s disclosures.