ERCP Quality assurance: A model for continuous monitoring

Introduction: Among the various GI procedures, ERCP along with its therapeutic modalities carries the highest risk of complications. The procedure also requires a high degree of endoscopic skill. It is important that this be performed for proper indications and by or under supervision of highly skilled professionals in order to minimize risks. To achieve this goal we developed a model for continuous monitoring to be used purely for educational purposes. Methods: Beginning in January 1992 criteria were established based on historical standards, including appropriate indications, ability to cannulate papilla and the ducts of interest, and complication rates. A computer database was then established for prospective entry of data. This data was analyzed , initially every 6 months for 3 periods, then at yearly intervals. The discrepancies and deviations from established standards were discussed among the staff which included GI fellows in a busy training program. The data was also presented to institution-wide quality assurance committee. Results: Between January 1992 and June 1996 a total of 633 ERCP procedures were performed. In the first review 21% of procedures were considered not indicated. This figure dropped to an average of 4% in subsequent reviews and finally to 1%. At each review indications were revised to reflect continuous evolution in therapeutic endoscopy. Rate of cannulation of duct of interest rose from initial 70% to final 92% reflecting continuous improvements in skill. Overall complications both minor and major, fluctuated both up and down between 6-14%, reinforcing need for continuous monitoring. Conclusions: Continuous monitoring of high risk procedures is a useful educational technique. We developed such a model for ERCP and have applied it continuously since 1992. This, we believe, has resulted in a steady improvement in quality of care. Such a model can be developed in other areas carrying appreciable risks.