Infection rates after colonoscopy, endoscopy at US specialty centers are far higher than expected

The rates of infection following colonoscopies and upper-GI endoscopies performed at U.S. outpatient specialty centers are far higher than previously believed, according to a Johns Hopkins study published online this month in the journal Gut. Johns Hopkins researcher Susan Hutfless led a team that plumbed medical data from the year 2014 and determined that patients who underwent one of the common procedures at facilities known as ambulatory surgery centers (ASCs) were at greater-than-expected risk of bacterial infections, including E. coli and Klebsiella. "Though patients are routinely told that common endoscopic procedures are safe," says Hutfless, "we found that post-endoscopic infections are more common than we thought, and that they vary widely from one ASC facility to another." Each year in the United States, there are more than 15 million colonoscopies and 7 million upper-GI endoscopies, known as esophagogastroduodenoscopies, or EGDs. Both colonoscopies and EGDs are performed with an endoscope, a reusable optical instrument that allows an endoscopist access to a patient's gastrointestinal tract. They can be used to screen for disease or to perform a number of procedures, such as polyp removal, without the need for invasive surgery. Using an all-payer claims database, Hutfless and her team examined data from six states—California, Florida, Georgia, Nebraska, New York and Vermont—to track infection-related emergency room visits and unplanned inpatient admissions within seven and 30 days after a colonoscopy or EGD. Hutfless says that post-endoscopic infection rates were previously believed to be in the neighborhood of one in a million. This research, the first to explore data on ASCs and postprocedure infection, revealed that the rate of infection seven or fewer days after the procedure was slightly higher than 1 in 1,000 for screening colonoscopies and about 1.6 per 1,000 for nonscreening colonoscopies. Rates for EGDs within that time were more than 3 per 1,000. Patients who'd been hospitalized before undergoing one of the procedures were at even greater risk of infection. Almost 45 in 1,000 patients who'd been hospitalized within 30 days prior to a screening colonoscopy visited a hospital with an infection within a month. Within those same parameters, the rate of infection-related hospitalization for EGDs was more than 59 patients per 1,000. Though the nation's first ASC was established more than 40 years ago, the facilities gained popularity over the last 20 years as more convenient, less expensive alternatives to hospital care for outpatient surgeries and other procedures. The team found evidence that, among the ASC postprocedure infections, the rates were slightly higher for diagnostic procedures, as opposed to screening procedures. ASCs with the highest volume of procedures had the lowest rates of post-endoscopic infections. According to the Ambulatory Surgery Center Association, in 2017, 64 percent of ASCs were owned by physicians, while 28 percent were affiliated with hospitals or health systems. Hutfless points out that, since many ASCs lack an electronic medical record system connected to hospital emergency departments, those ASCs are unlikely to learn of their patients' infections. "If they don't know their patients are developing these serious infections, they're not motivated to improve their infection control," she says. While the overwhelming majority of ASCs follow strict infection-control guidelines, says Hutfless, she and her team found infection rates at some ASCs more than 100 times higher than expected. Advances in endoscopy and colonoscopy have revolutionized gastroenterology and the treatment and prevention of gastric diseases, says Hutfless. But she and her co-authors agree that patients should be aware of infection risk associated with all endoscopic procedures.

Head Games: VR Measures Link Between Endoscopy Performance and Physician Stress

When we use the words “tense up” or “freeze” to describe physical reactions to stress, we may be on the right track in describing how physicians respond to stress while performing complex procedures.

For doctors dealing with life-threatening emergencies during endoscopy, the management of stress is crucial, but poorly understood. Using virtual reality, my team studied how stress affects how trainees perform during gastrointestinal procedures, as well as the relationship between specific body movements and procedure performance. We’re pleased to be presenting our results during the 2018 Digestive Disease Week. 

In the first study, we placed motion sensors on the hands, forearms and foreheads of trainees performing endoscopy on a virtual reality simulator and examined how performance related to reported levels of stress (“Use of Wearable Sensors to Assess Stress Response in Endoscopy Training,” abstract 765). As trainees experienced more stress, they decreased the velocity and acceleration of their arm and hand movements, suggesting less motion and decreased range of movement. Understanding the changes caused by stress is an important first step to help trainees better cope with emergency situations, both early and late in their careers. 

This new field of inquiry is part of a growing emphasis on physician self-awareness. Currently, little data exist on how individual factors, such as stress response, impact quality of care and patient outcomes. We hope future research may identify how to better manage and reduce stress during endoscopy—potentially improving doctor education and patient outcomes.

More investigations are needed to determine if there is a definitive connection between stress and negative or positive outcomes. Experienced physicians may respond differently to stress compared to inexperienced trainees. 

In a separate analysis of data from the trainees’ time on the simulators, we examined how body motion impacts procedure performance, and we determined that head motion could be used to assess trainees’ motor skills ("Use of Wearable Sensors to Assess Biomechanical Learning Patterns in Endoscopy Training," abstract 764).

We found that head motion correlated with performance outcomes and provided a valid measure of procedural competence. Head motion decreased as doctors advanced in their training and completed more procedures. Excess head motion in trainees suggested they may be looking away from the video monitor to check hand or endoscope position too frequently. This loss of visual focus on the monitor may contribute to prolonged task-completion times and may be related to diminished competence with the equipment.

Additional studies may help us identify an objective set of motion variables to define trainee competence in endoscopy allowing us to create personalized training curricula using this technology. Our current training model relies upon expert mentorship and lacks standardized biomechanical assessment and feedback. Motion sensors could help us develop a driver’s test for endoscopy during which trainees complete a set of tasks with defined motion performance thresholds. In the future, such an educational program could help identify individuals best suited for training in advanced procedures or provide specific feedback to individuals in need of remedial education.

New ASGE Guidelines on Sedation and Anesthesia Differ From ASA's Over Capnography Use

The American Society for Gastrointestinal Endoscopy (ASGE) has released updated guidelines on the use of sedation and anesthesia during GI endoscopic procedures.

There are similarities to the guidelines of the American Society of Anesthesiologists (ASA), particularly when it comes to timing of sedation. However, the new ASGE guidelines offer a different approach for capnography during endoscopic procedures under moderate sedation.

Although previously there was no universal practice standard, both the ASGE and ASA are in agreement that patients should fast for a minimum of two hours after ingestion of clear liquids and six hours after ingestion of light meals before sedation can be administered. The new guidelines note it is typical to use the ASA physical status classification system to risk-stratify patients for sedation prior to a procedure, and emphasizes the importance of carefully classifying patients in order to accurately understand their risk for adverse events during GI procedures.

Based on data from the Clinical Outcomes Research Initiative database, increasing ASA physical status has been linked to increasing risk for unplanned cardiopulmonary events during endoscopy. 

The new guidelines recommend the use of pulse oximetry during all sedated endoscopic surgeries. Additionally, blood pressure, oxygen saturation and heart rate should be monitored routinely, and clinical observation for changes in cardiopulmonary status during all endoscopic procedures using sedation should be done. 

In contrast to the ASA, the ASGE maintains that the use of capnography to monitor patients during endoscopic procedures using moderate sedation has not yielded improvements in patient safety. Despite this, capnography was recommended in procedures using deep sedation.

The ASGE guidelines suggest that capnography monitoring be considered in complex endoscopic procedures, for patients with multiple medical comorbidities, or for those at risk for airway compromise. Anesthesia providers should administer sedation in these cases.

Among the recommendations for minimal to moderate sedation, the document notes that benzodiazepines and opioids are safe for use in low-risk upper endoscopy and colonoscopy patients.