Tu1079

A Picture is Worth a Thousand Words, but…: Quality Improvement inColonoscopy Report WritingSyeda Hossain, Jerome Giovinazzo, Jediah J. Sim, Colleen C. Gillespie, Michael A. Poles,Elizabeth H. Weinshel

Background: Since the advent of computerized note writing software, little has been doneto study the quality of endoscopic reporting. We observed tremendous variability in thequality of the reports at our endoscopy lab. GI training programs must provide formaltraining in both the performance of procedures as well as in documentation of the findings.A well-crafted procedure report must include the indications, procedural details, findingsand recommendations that are crucial to effective communication and quality patient care.We sought a method to assess the quality of our endoscopic reports as well as a process toimprove the documentation in our GI lab. Methods: We reviewed a representative sampleof colonoscopy reports written at a VA medical center by fellows (signed by a supervisingattending) and developed a list of shortcomings in documentation. We developed a 1 hourdidactic session for our GI fellows from these observations and the known ASGE guidelinesfor colonoscopy note writing. In parallel, an assessment tool was developed to objectivelyevaluate a colonoscopy report. A sample of reports prior to and after the didactic interventionwas evaluated for each participating fellow by 2 reviewers (blinded to patient/author identity).The rating form contained elements that were determined to be crucial for effectivelycommunicating the indications for, quality of, results of and recommendations regarding acolonoscopy, each of which were rated on a 3-point scale: not documented, partly, or fullydocumented. Quality of documentation in notes prior to the didactic session (67 reportsfor 7 fellows, 6-12 notes each) was compared (using Chi-square statistics) with notes afterthe session (69 reports, 7 fellows, 4-15 reports each) to evaluate the impact of the educationalintervention. Results: The samples of patients were similar across the pre- and post-educa-tional session time periods (96%male VA population; mean age=64, SD=11; 95% outpatient).While the global quality of documentation in all assessed areas did not significantly differin “pre” and “post” samples, there were significant differences favoring the intervention inseveral key areas directly related to the goals of the educational session. Only 11% of thepre reports fully explained the indication for the colonoscopy compared with 51% of thepost reports (Chi Sq=24.01, p<.001). Furthermore38% of pre reports were rated as fullyexplaining when and why a repeat colonoscopy was indicated compared with 65% of postreports (Chi Sq=9.53, p=.002). Conclusions: Training programs will need to train fellowsnot only in procedural skills but appropriate documentation of clinical and proceduralencounters. Programs will need an assessment tool to evaluate reports and a targeted interven-tion to improve procedure documentation.

Tu1080

Improving Handover of Care in Gastroenterology to Enhance Patient Safety: AModel for EducationMorris Gordon

Background In 2003, the Accreditation Council for Graduate Medical Education added apolicy calling for reduced permitted duty hours for doctors in the USA, mirroring similarchanges across the globe. While the aim of these changes is to enhance patient safety, theyhave resulted in an exponential increase in shift handover in acute specialities such asGastroenterology, which also poses risks. Despite extensive published literature discussingmainly system based strategies to improve handover, there is little evidence of extensiveimprovement. Malter et al (1) published their experiences introducing an educational inter-vention into fellowship training, with perceived trainee improvement in handover skillsobserved. A recently published systematic review of education to improve handover (2)synthesised an evidence based framework for patient safety training that is applicable to allareas of practise. This framework targets human factor and non-technical skills. This wasused to design a short, low cost intervention to improve handover, which was recentlyintroduced locally. Its design and effectiveness will be reported. Method The handoverteaching session designed will be presented, including a short video. During this pilot,trainees were assessed on their patient safety attitudes pre and post intervention using thepreviously validated APSQ-II survey, as well as on their perceived handover skills and finallytheir views on the session. Results The teaching was delivered over 2 hours in a single roomwith one facilitator to 14 junior doctors and medical students. Patient safety attitudesimproved significantly post intervention (Mean score pre 134, post 142, p=0.026). 100%of participants reported that after the session they were more capable at spotting sourcesof error and challenging colleagues who handover poorly. Likert ratings for the content,relevance, interactivity and enjoyment of the session were positive (Mean ratings 9/10 forall areas). Conclusions Using our patient safety education framework, handover educationcan be designed for use within fellowship training and is well received by trainees. Suchtraining significantly improves patient safety attitudes and perceived handover skills. Gastro-enterologists involved in education should consider employing our evidence based frameworkto guide local design of handover improvement interventions. 1) Malter L, Weinshel E.Improving hand-off communication: A gastroenterology fellowship performance improve-ment project. Am J Gastroenterol 2010;105:490-2. 2)Gordon M, Findely R. Educationalin tervent ions to improve handover of care : A systemat ic review. Med Educ2011:45:1081-1089

Tu1081

Prospective Evaluation of Psychological Impact of Outpatient Clinics onGastroenterology TraineesGavin C. Harewood, Karl X. Clancy, Stephen Patchett, Frank Murray

Introduction: Efforts to enhance efficiency of gastroenterology (GI) practice frequently resultin an increased workload on physicians. It remains unknown what impact the workload ofa busy GI clinic practice has on the psychological wellbeing of GI trainees. This studyprospectively assessed the impact of a busy outpatient practice on anxiety and depression

S-741 AGA Abstracts

levels among GI trainees. Methods: A modified version of the Hospital Anxiety and Depres-sion Scale (HADS) instrument was prospectively administered to five GI fellows of similarexperience level prior to / half-way through / at completion of GI outpatient clinics overthe course of four weeks. The questionnaire comprised 3 questions assessing anxiety (max-imum score, 9) and 3 questions assessing depression (maximum score, 9) for a maximumscore of 18. The number of patients seen in consultation by each fellow per clinic wasalso recorded. In this practice model, each fellow sees patients without intermission untilcompletion of the clinic (approximately 14 patients per fellow). Outpatients are randomlyassigned to ensure each doctor sees similar proportions of patients with each level ofcomplexity of illness. Results: In total, 379 outpatients were seen by five GI fellows. Thefigures illustrate pre-, mid-, post-clinic anxiety, depression scores with mean number ofpatients/clinic for each fellow. There was a significant increase in mean depression score(0.8 [pre-clinic] vs 1.9 [post-clinic], p=0.03) and a smaller increase in anxiety (1.9 [pre-clinic] vs 2.3 [post-clinic], p=0.4) over the course of the clinic. The least efficient fellows(those seeing fewest patients) had higher baseline depression/anxiety scores and also demon-strated the largest increases in depression, 1.9 to 4.1 (p = 0.001) vs 0 to 0.25 (p = 0.2)and anxiety, 3.0 to 4.3 (p = 0.08) vs 1.0 to 0.9 (p = 0.8) over the course of the clinic.Conclusion:Working in an outpatient clinic appears to exert a negative toll on the psycholo-gical wellbeing of GI fellows. The most pronounced impact is seen among trainees withhigher baseline depression/anxiety levels who appear to function less effectively (take longerto see patients), i.e. happier doctors are more productive. Psychological evaluation of traineesmay be helpful in identifying those clinical activities which trigger depression/anxiety;tailoring clinical activities to minimize depression/anxiety may enhance overall wellbeingand clinical productivity among trainees.

Tu1082

Gastroenterology Training in a Resource Limited Setting - Zambia, SouthernAfricaAkwi W. Asombang, Eleanor Turner-Moss, Anil B. Seetharam, Paul Kelly

BACKGROUND: The burden of digestive disease continues to increase across the Africancontinent, yet formal training in Gastroenterology is lacking. Zambia, a country with apopulation of 13 million, is primarily served by the University Teaching Hospital (1600adult and 300 pediatric beds). Gastroenterological specialty consultation is provided by oneadult and one pediatric gastroenterologist, two endoscopists and two trainees. AIM: Giventhe disparity in supply of formally trained gastroenterologists, we sought to evaluate theneed and efficacy of a structured gastroenterology didactic session in expanding awarenessand understanding of digestive disorders. METHODS: A four-day symposium was developedwith didactic sessions (day 1,2) and practical endoscopy (day 3,4). Open enrollment forundergraduate, residents, and attending physicians was allowed. Didactic sessions includedcase presentations highlighting pathophysiology and management. Three gastroenterologistsfrom the UK led lectures and supervised workshops. Practical endoscopy focused on dia-gnostic and therapeutic procedures and their application to diagnosis and treatment ofailments of the GI tract. Pre and post-workshop questionnaires were distributed to particip-ants during didactic sessions. A pre-workshop questionnaire gauged expectations and identi-fied objectives to be met at the symposium. Post-workshop questionnaires were administeredin an attempt assess efficacy of each session. Participants graded sessions from 1 (poor) to5 (excellent) on quality of case presentations, knowledge, clarity and mode of presentation.We assessed if time allotted to each topic was sufficient, value of session, impact on practiceand interest in future symposiums. RESULTS: There were 46 attendees on day 1: 41%undergraduates, 41% residents, 11% consultants and 4% unspecified. Day 2 had 24 particip-ants: 17% undergraduates, 71% residents, 9% consultants, 4% unspecified. Primary pre-workshop symposium expectation was to gain knowledge in: general gastroenterology(55.5%), practical endoscopy (13.8%), pediatric GI (5%), epidemiology of GI disordersspecific to Zambia (6%), and interaction with international speakers (6%). The post sympo-sium questionnaire was answered by 19 participants, of whom 95% felt specific aims weremet; all would attend future conferences and recommend to others. CONCLUSION: In

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sthe first formal Gastroenterology meeting in Zambia sponsored by the British Society ofGastroenterology participants expressed interest in improving knowledge base of gastroenter-ology. This objective was met by a structured 4 day symposium focusing on case basedpresentations and introduction to endoscopy. The beneficial effect of a structured symposiumin developing countries warrants further attention as a mechanism to improve diseaseawareness in areas where resources are limited.

Tu1083

Making the Grade - a Report Card for Endoscopic DocumentationSyeda Hossain, Jerome Giovinazzo, Jediah J. Sim, Michael A. Poles, Colleen C. Gillespie,Elizabeth H. Weinshel

Background: A well-crafted endoscopic procedure report must include the indications,procedural details, findings and recommendations crucial to effective communication andquality patient care. We sought a method to assess the quality of our endoscopic reports.Methods: A comprehensive rating form to assess reports was derived from the literature,guidelines, and review of a pilot sample of reports. The rating form included sections forindications (urgency, purpose and review of prior reports); safety (review of medications,allergies, anesthesia, patient identification); procedure details (anatomic extent, limitations,complications, patient tolerance, quality of preparation and views); technical aspects (scopedescription, time to endpoint, withdrawal time, difficulty); images; findings; recommenda-tions (need/timing of repeat colonoscopy, alterations of medications, and diet) and consist-ency with guidelines based on findings. A GI fellow and a medical resident used the formto independently rate the quality of 66 reports (6-12 reports per 7 fellows). Agreementamong raters (inter-rater reliability) was established using kappa estimates. Results: Reportscame from a sample representative of VA patients (n=66; average age 64, SD=11; 94% male).Inter-rater reliability varied across assessment items. The raters did not agree on whetherthe urgency, acuity, anesthesia plan, limitations to the examination, complications and dietrecommendations were fully documented. However, strong agreement (Kappas > .60) existedin areas of indication, anatomic extent, time to withdraw, images, polyps, recommendationsregarding when to repeat colonoscopy, scheduling of follow-up visit, and adherence ofrecommendations with guidelines. Endoscopic documentation that had the highest level ofconcordance and suggest that the quality of documentation was sufficient in such areas asanatomic extent (95%) and full description of polyps (87%) but needed improvement inothers (68% documented the purpose but of these only 16% explained the purpose; only18% noted time to withdraw; and 25% noted scheduling of follow-up visit). Image inclusionand labeling varied by image (68% included an IC valve image but only 13% the cecalstrap). 65% of reports included an explanation for recommendations regarding repeat colon-oscopy but only 35%were rated as matching guidelines. Conclusions: Quality of colonoscopyreports can be rated with our easy-to-use assessment form; however, further research isneeded to determine how to improve inter-rater reliability in some areas. Fellows appearto provide adequate documentation in many critical areas (indications, safety, procedureand technical details) but often fail to justify the purpose of the colonoscopy and may needtraining so that their recommendations are more guideline-based.

Tu1084

Shared Decision Making (SDM) Skills in GI FellowsBrijen Shah, Benjamin Abiri, Sophie Balzora, Michael A. Poles, Sondra Zabar, Colleen C.Gillespie, Elizabeth H. Weinshel, Sita S. Chokhavatia

Background: SDM is a skill where patients, families, and gastroenterologists discuss the prosand cons of a treatment decision. Providers need to employ SDM to navigate the uncertaintyabout colorectal cancer screening and surveillance (CRCS) especially in patients with limitedlife expectancy (LE) and the elderly (over 75). Factors used in SDM for CRCS includeprocedure risk/ benefit, patient preference, and LE. Often, age and co-morbidity trumppatient preference over LE. We used the OSCE (objective structured clinical examination)format to engage fellows in a simulated patient care encounter for polyp surveillance in a74 year old lady who had a 50% 9-year LE. The objective of this educational project wasto assess GI fellows' ability to participate in SDM for CRCS and their application of medicalknowledge to these types of encounters. Methods: A 15-minute OSCE station with a trainedstandardized patient (SP) was developed as part of 4 OSCE stations focused on culturalcompetency. Fellows were asked to discuss the risk/benefit of colonoscopy with the SP, andthe SP was to make her decision based on the discussion about CRCS or defer a decisionuntil a later date. At the end of the session, fellows completed a post test and the SPcompleted a validated behavior-based checklist of 32 items, of which SDM was a subset.Skills were rated on a 3-pt scale for each item (not done, minimally done, well done).Outcomes: 11 GI fellows completed this station. The SP deferred a decision for 64% offellows and made a decision for 18% of fellows at the end of the encounter. Of four itemsused to measure SDM, 9 fellows (82%) performed 50% (2/4) of the skills well. Fellowswere least adept at exploring the SP's beliefs, values, and preferences as they related todecision making (mean 1.55/3). The patient education/counseling skill subset was modestlycorrelated with SDM subset (r2=0.57), while communication and relationship developmenthad a weaker association. Fellows identified SDM criteria accurately on the multiple choiceposttest (92%). Conclusion: SDM is a new skill set combining communication, prognostica-tion, and education that gastroenterologists will need to employ to navigate CRCS decisionsin an aging society. This educational project illustrates that fellows have some skills in SDM,but require specific training on how to educate older patients. We plan to further analyzethe encounters for specific language or data used by fellows which influenced the SP'sdecision and survey participants in 3-4months to test the durability of the exercise. Combinedwith prior geriatric OSCE data about informed consent, we have targets for educationalcurriculum development and skills assessment related to CRCS in older adults.

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Tu1085

Colonoscopy Queue Position Not Associated With Adenoma Detection AmongGI TraineesMichael Y. Chan, Jonathan I. Chang, Elliottt A. Birnstein, Nirali Patel, Linda S. Chan,Loren A. Laine, Michael M. Kline

Introduction: Endoscopist fatiguemay have an impact on the quality of colonoscopy. Recentlyit has been suggested that procedural queue position in the endoscopic work schedule mayimpact polyp detection. However, it remains unclear if this relationship occurs among GItrainees, whose clinical environment differs from other practitioners. Therefore, we soughtto assess the relationship of procedural queue position on cecal intubation rate, polypdetection, and adenoma detection among GI trainees. Methods: We conducted a prospectivestudy on outpatients receiving surveillance or diagnostic colonoscopies at a large countyhospital over a 4-month period. Prior to data collection, we delineated a conceptual modelto specify patient- and procedure-related factors that would predict colonoscopy completion,polyp detection, and adenoma detection. Patient factors included age, gender, ethnicity,BMI, prior surgery, personal/family hx of colorectal cancer or polyp and hx of previouscolonoscopy or flex sig. Procedure factors included indication, bowel preparation qualityand withdrawal time. All procedures were performed with attending supervision by GItrainees who had completed at least 150 colonoscopies prior to participation in the study.The primary outcome was adenoma detection rate (ADR), defined as proportion of colonos-copies with≥1 adenoma detected. Secondary outcomes included polyp detection rate (PDR),defined as proportion of endoscopies with ≥1 polyp seen, total number of adenomas, totalnumber of endoscopically-detected polyps, and cecal intubation rate. Queue position wasassessed as a continuous and dichotomous (queue position <5 or≥5) variable. We performedunivariate analysis (Chi-square tests for dichotomous variables and Poisson regression forcount data) to compare colonoscopy queue position to the primary and secondary outcomes.Results: A total of 221 colonoscopies were performed (mean age±SD: 55±9, 59% male);65% of colonoscopies were performed at a queue position of <5 (range 1 to 11). ADR was32% (mean # of adenomas±SD: 0.42±0.71). No statistically significant differences werefound between queue position <5 or ≥5 for all risk factors. No statistically significantdifferences were found when comparing procedural queue position as a continuous (Table1) or dichotomous (Table 2) variable for all outcome measures. Conclusions: In this prospect-ive study of GI trainees, no association was found between procedural queue position andkey colonoscopy performance variables, including ADR, PDR, and cecal intubation rate.These findings suggest that qualities unique to a training environment, including supervisionfrom an attending and a less rigorous endoscopic work schedule, may help maintain colonos-copy performance. Further research among GI trainees in other institutions should beperformed to validate these findings.

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Tu1086

Teaching Sonography in a Curricular Course During Undergraduate MedicalEducation: A Prospective Pilot StudyHauke Heinzow, Hendrik Friederichs, Philipp Lenz, Karin Hengst, Marschall Bernhard,Jan C. Becker, Dirk Domagk

Objective: As a non-invasive and readily available diagnostic tool, sonography is one of themost important imaging techniques in medicine. Sonography is usually trained duringphysicians' specialist training according to European Federation of Societies for Ultrasoundin Medicine and Biology (EFSUMB) standards. A new curricular practical teaching aims totrain students in their 2nd clinical year in sonography. An explorative pilot study evaluatedthe acceptance of this new teaching method, and compared it to other practical activitiesin medical education at Muenster university. Methods: During 2010 and 2011, 240 medicalstudents in their 2nd clinical year of undergraduate medical education participated in thetraining. Before and after the training, 192 of the students (80 %) completed a questionnairefor self-assessment of technical knowledge, safety of the procedure, and motivation inperforming sonography. In addition, the students were asked about their attitude to a furthercareer in internal medicine, and they evaluated the teaching situation by using the Likertscale between 5 ("strongly agree“) and 1 ("strongly disagree“). To compare this training toother educational activities a standardized online evaluation tool was performed additionally.Results: There was a significant increase in technical knowledge (d=1.635, p<=.001), andsafety (d=1.568, p<=.001) in comparing the pre- vs. post-results of the students' self assess-ment. We did not observe a significant increase in terms of motivation as well as attitudetowards a career in internal medicine. The clinical relevance (mean 3.92) and self-motivation(mean 3.86) of the teaching were evaluated positively. Conclusions: Training sonographyaccording to certified EFSUMB standards was successful. It increased the students' self-assessed technical knowledge as well as their self-assurance to perform the examination.