S1246 The Development of an Evidence-Based Management Algorithm for Iatrogenic Endoscopic Perforations and Its Impact on Physician Knowledge: A Quality Improvement Project

Abstract

INTRODUCTION: Iatrogenic endoscopic perforations can lead to serious complications and death. If identified immediately, perforations can be closed endoscopically with a 90% success rate. Knowledge of acute management of iatrogenic perforations may decrease the associated morbidity and mortality. Therefore, the objectives of this study were to: (1) develop an evidence-based acute iatrogenic endoscopic perforation (AIEP) management algorithm that is available for quick reference in the GI lab; and (2) to study its impact on physicians’ knowledge. METHODS: AIEP management algorithm was created using the most current recommendations by ASGE/ESGE and additional input from advanced endoscopists, nurses, and anesthesiologists was obtained in an open discussion forum. Figure 1 shows the final AIEP management algorithm. We assessed change in physician knowledge using a pre-post study design. To accomplish this, we created a 10-item questionnaire (Figure 2) that assessed physicians' knowledge on the appropriate identification and treatment of an acute iatrogenic perforation. The questionnaire was filled out before (pre-test) and after (post-test) GI physicians and fellows read a standardized one-page educational material based on the aforementioned perforation algorithm. RESULTS: 29 subjects (8 fellows and 21 practicing gastroenterologists) participated in the assessments. Overall pre-test and post-test accuracies were 75% and 95% (P < 0.01), respectively. On pre-test, the biggest gaps in knowledge were seen in questions 3 and 4 (most sensitive imaging test to diagnose perforations and most common site of perforation during routine colonoscopy) among the fellows, and question 7 (TTS clips for max 10mm perforation closures) for the GI physicians. The fellows' pre-test and post-test accuracies were 67.5% and 96% (P < 0.01), and the practicing gastroenterologists' pre-test and post-test accuracies were 78% and 95% (P < 0.01) (Figure 3), respectively. CONCLUSION: Using standardized methodology and a multidisciplinary approach, an AIEP management algorithm was created in an effort to improve patient care and alleviate physician stress. Additionally, we showed that a brief one-page educational material can significantly improve physician knowledge on the appropriate identification and treatment of perforations. Future studies are required to evaluate if maintaining such algorithms as quick reference guides in the endoscopy suite can improve outcomes of patients in the event of an AIEP.Figure 1.: Ten question pre- and post-training assessment for acute iatrogenic endoscopic perforations, a quality improvement study in the GI lab.Figure 2.: Management algorithm for acute iatrogenic endoscopic perforations.Figure 3.: Panel A and B show the pre- and post-test accuracies per question for fellows and practicing gastroenterologists, respectively.