The Saudi Gastroenterology Association guidelines for quality indicators in gastrointestinal endoscopic procedures
Gastrointestinal endoscopy is an indispensable tool in the diagnosis and treatment of digestive diseases. However, there is variation in the quality and safety of endoscopy across different regions and facilities. Quality management in this field has historically focused on the individual performance of endoscopists while overlooking the role of the environment in which they practice. Many reports highlight a range of situations resulting in adverse patient experiences and outcomes during or after endoscopic procedures. Therefore, professional organizations, such as the American Society for Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE), have initiated quality improvement projects to create more comprehensive quality standards and optimize patient safety. These indicators included mostly process measures, and there was limited evidence that they improved health outcomes. It was also difficult to establish benchmarks due to the lack of information technology (IT) infrastructure for gathering real-world data. Since then, American and European gastrointestinal endoscopy societies have published extensive databases of quality benchmarks and quality measures. The most extensive data repository was created by the GI Quality Improvement Consortium (GIQuIC). Some endoscopy quality indicators are applicable to all endoscopic procedures, while others are specific, including: esophagogastroduodenoscopy (EGD), colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS) and capsule endoscopy (CE). These could further be classified based on timing before the procedure, intra-procedural and after the procedure. It is also important to view quality indicators in terms of structural measures to evaluate the features of the healthcare environment (e.g., maintenance of endoscopes), process measures that focus on the performance of endoscopic procedures, and outcome measures that analyze the results of endoscopic services performed. With the current advancements in the diagnostic and therapeutic realm of endoscopic procedures in Saudi Arabia, there arises a need to address and define high-quality endoscopy practices. The Saudi Gastroenterology Association has taken the initiative to present the latest evidence-based measures to improve the quality and reduce the variation in endoscopic care provided to our patients in Saudi Arabia. 

General metrics This section describes the general quality measures for the three stages of endoscopy, which can be classified into the following three metrics illustrated in . Pre-procedural metrics Most pre-procedural quality measures can be applied to all types of invasive endoscopic procedures. The pre-procedural period begins with a valid indication, initial testing and planning of the procedure including the appropriate type of sedation to be used during the procedure. The details of procedures and preparations in a written format should be handed over to the patient ahead of time prior to procedure appointment. During the pre-procedural period, healthcare practitioners’ should interview and test patients to detect potential risk factors, such as cardiopulmonary, hepatic, renal, or other comorbid conditions. Patients with significant systematic diseases should have appropriate work up and consultation with the appropriate service(s) prior to the day of procedure. A clear indication for the procedure should be identified, where the quality improvement goal is to minimize the number of procedures without appropriate indications. Furthermore, informed consent from patients for each endoscopic procedure is ideally obtained and signed by the patient or his/her guardian in the ward or the clinic before attending the endoscopy unit. Consent should include a discussion of the sedation plan and risks associated with sedation, indication for the procedure, description of the procedure, likely benefits, common adverse events, and alternatives to the procedure (if any). The endoscopist should give an opportunity to the patient to understand the procedure and ask questions. If sedation for the procedure is provided by an anesthesiologist, then a separate consent obtained by that provider may be appropriate. Prior to starting any endoscopic procedure, checking the vital signs as well as glucometer in diabetic patients is important, and any abnormality should be corrected to avoid any unexpected complications during or after the procedure. The procedure can be started once the correct patient is identified and the timeout is completed. This stage ends with the administration of anesthesia/sedation or insertion of the endoscope. Other quality measures at this stage include provision of prophylactic antibiotics in invasive procedures. According to most of the guidelines, antibiotic prophylaxis is no longer recommended for the prevention of infective endocarditis in patients with cardiac risk factors who undergo diagnostic or therapeutic endoscopy. summarizes the indication for antibiotic prophylaxis in endoscopic procedures. The choice of the antibiotic and its duration depends on the procedure performed and the most likely organism(s) to cause bacteremia. A review of all medications including antiplatelets, anticoagulants, antidiabetics and antiepileptics should be performed at the preprocedural stage. Management of all these medications must be formulated and documented before the procedure. Another parameter is to indicate the American Society of Anesthesiology (ASA) score shown in . This is to ensure that the patient is stable and fit for the procedure, as well as to consider anesthesia consultation and the preparation of appropriate recovery such as intensive care unit, if deemed necessary. Mallampati score is a visual assessment of the distance from the tongue base to the roof of the mouth, that is used to predict the ease of endotracheal intubation. The Modified Mallampati Score has shown to be a useful clinical tool in the assessment of EGD tolerance in non-sedated patients. Poor oropharynx visualization should prompt consideration for sedation with the support of anesthesia. Pre-procedural laboratory investigations should be ordered selectively based on medical history, physical examination and procedural risk factors. Supplements such as pamphlets or videos in advance might enhance patient understanding of the procedure. Summary of recommended quality indicators for endoscopic procedures Pre-Procedure Endoscopy procedures should be performed by a competent endoscopist or trainee under direct supervision by a qualified mentor. Endoscopy should be performed for a clear indication and to be documented. Consent should be obtained and documented to include the indication, sedation plan and its associated risks, description of the procedure, likely benefits, risks, and if any alternatives. A separate consent should be obtained by the provider if sedation will be provided by an anesthesia. Pre-procedure history and focused physical examination should be performed and documented. Risk assessment for sedation-related adverse events (e.g. using ASA score) should be performed and documented. Prophylactic antibiotics should be administered when indicated. Management of antithrombotic and anticoagulant therapy is formulated and documented before the procedure. A clear plan regarding holding and resuming them should be recorded and communicated to the patient and to consider consultation with the appropriate services such as hematology or cardiology, if needed. Intra-procedural metrics This period starts with the administration of sedation/anesthesia or insertion of the endoscope and ends with its removal. It is necessary to closely monitor blood pressure, pulse and oxygen saturation every 5 minutes during the procedure. The routine uses of supplemental oxygen (2 liters/minute) during upper and lower GI endoscopic procedures to prevent desaturation has been shown to reduce desaturation episodes during the procedure (12.4% versus 70.8% for control group, P <.00001). Another important quality metric is to keep track of the doses of sedation drugs and reversal agents. Photo-documentation of major pathologies and important anatomic landmarks is recommended. All endoscopic procedures should be performed by a competent and privileged endoscopist or a trainee under direct supervision. Time tracking from insertion of the scope to the withdrawal is important to monitor safety and quality of the procedure. Post-procedural metrics The post-procedural stage is of vital importance because there is a risk of delayed adverse events. This should include; monitoring the patient recovery, completion of the procedure report , giving the patient written instructions that describe the symptoms and signs of potential complications, follow-up process, antibiotic prescriptions—if indicated—and resuming certain medications such as anticoagulants and antiplatelet drugs. Monitoring for delayed complications associated with endoscopic procedures must be considered by encouraging patients to report worrisome symptoms and educate the patient to contact the endoscopist or report to emergency room in case of unusual symptoms that suggest delayed complications such as gastrointestinal hemorrhage or post-ERCP pancreatitis. The endoscopy unit should have a written policy regarding criteria the patient must meet before discharge from the unit and patients should also be provided with written discharge instructions that include diet and activity restrictions, an explanation of biopsy results, information about follow-up appointments, and any medication changes. If there is no plan to follow up the patient, it is important for the endoscopist to arrange for pathology follow-up and document it in the patient file. In addition, endoscopists should communicate with the referring healthcare provider when deemed necessary. Healthcare institutions should monitor the work of endoscopists and identify sub-optimal performance associated with adverse events (such as perforation, bleeding, infections, pancreatitis, and sedation-associated adverse events such as hypotension, hypoxia, and the need for the reversal of sedation or aborting the procedure). Furthermore, mortality and morbidity meetings should be held on a regular basis to increase departmental awareness, increase data collection, and possibly innovate further quality metrics. Procedure-specific metrics Upper endoscopy Upper endoscopy (EGD) is typically initiated to assess and manage many conditions such as dyspepsia, dysphagia, gastroesophageal reflux, peptic ulcer disease, upper gastrointestinal hemorrhage and to confirm diagnosis of Celiac disease. Furthermore, there is a wide range of indications that involve a lot of different disease-specific measures. Despite the fact that all these measures help to improve the quality of endoscopy procedures, they are still not mandatory in many endoscopy units. There are many proposed quality metrics for endoscopy. In 2015, the ASGE and ACG proposed one of the most comprehensive lists of quality metrics for upper endoscopy. This list has been expanded to include up to 45 process measures that were specific to upper endoscopy. The ESGE and the United European Gastroenterology (UEG) on the other hand, suggested six key performance measures for upper endoscopy, listed in . The general quality metric for EGD is the complete examination of the esophagus, stomach including retroflexion, and duodenum, with proper documentation of all observations . According to ESGE, endoscopist should take photographs for the landmarks as highlighted in and Tables and . In case of presence of gastric mucosal abnormalities such as erythema, erosions, ulcerations, or nodularity, it is recommended to test for Helicobacter pylori (H. pylori) after taking multiple biopsies from different parts of the stomach for histology, rapid urease test, PCR, and/or culture. If the endoscopist notices gastrointestinal bleeding, they should identify its location and source. If the bleeding comes from an ulcer, the endoscopist should avoid using epinephrine injection alone. It is better to combine epinephrine injection with electro-coagulation or clipping. Other EGD quality metrics focus on the best practices for different types of adverse conditions, such as an upper gastrointestinal bleeding. EGD-specific quality indicators also include guidelines for achieving hemostasis and using different treatment modalities, such as variceal ligation, coagulation, or clipping. At the post-procedural stage, there are EGD-specific quality indicators that include, measuring the frequency in which the endoscopists recommended proton-pump inhibitor (PPI) therapy after dilation for peptic esophageal strictures, prescription of H2 antagonists or PPI medications for patients with duodenal or gastric ulcers, documentation of H. pylori testing and recording adverse events. Colonoscopy Compared with other endoscopic procedures, the quality metrics for colonoscopy are the most advanced and well-studied. An essential metric is bowel preparation quality, as appropriate bowel preparation reduces the probability of missed lesions and the risk of interval colorectal cancers and avoids repeated procedures. Other fundamental metrics include photographic documentation of all lesions and landmarks including cecal intubation, detection rate of adenomas in average-risk individuals, and measuring withdrawal time [ and Tables and ]. Multiple studies found that the most important quality indicators for colonoscopy include withdrawal time, cecal intubation rate, and adenoma detection rate (ADR). The ADR is one of the most widespread general indicators in gastrointestinal endoscopy. A lot of data has been gathered about this indicator, and it is directly linked with two essential outcome measures: the incidence and mortality from colorectal cancer. The role of retroflexed view examination after forward view examination versus two forward examinations, in decreasing adenoma miss rates, is yet to be confirmed by further studies. Bowel preparation can be measured using a valid and reliable method such as the Boston Bowel Preparation Scale for the three colonic segments shown in  or Ottawa Bowel Preparation Scale. Furthermore, all patients undergoing colonoscopy for the evaluation of chronic diarrhea should have biopsy specimens obtained. The optimal number and location of biopsies is not established, but ≥8 are recommended. Inclusion of samples from the proximal colon improves the sensitivity for microscopic colitis. Moreover, tissue sampling for histopathological examination to assess the activity of ulcerative and Crohn’s colitis and for CMV, if indicated, with immunohistochemistry, colonic tissue culture, or more sensitive molecular techniques such as nucleic acid amplification tests or quantitative PCR are recommended. During surveillance colonoscopy in patients with ulcerative colitis, 4 biopsy specimens for every 10 cm or ≥33 biopsy specimens is recommended. The use of high-definition colonoscopy or chromoendoscopy increase dysplasia detection in ulcerative colitis nearly 3-4 fold compared with white-light colonoscopy. Finally, there are post-procedural quality measures for colonoscopy that include incidence of post-polypectomy bleeding and perforation, and timing of surveillance colonoscopy after detection of colonic polyps (5-10 year intervals for individuals with 1-2 small tubular adenomas, and 3-year intervals for patients with 3 or more adenomas, if polyp size is more than 10 mm or has villous component on histopathology). Endoscopic retrograde cholangiopancreatography (ERCP) There are many indications to perform ERCP; however, diagnostic ERCP should be avoided if possible, as ERCP is considered among the highest risk and the most challenging of endoscopic procedures. The most important ERCP-specific quality measures for the pre-procedural stage pertain to the indication for ERCP procedure and obtaining informed consent. ERCP should be performed with a clear indication to justify if any complications happen. The informed consent should include all potential adverse outcomes including perforation, infection, pancreatitis, cardiopulmonary events, hemorrhage, and allergic reaction. Other quality indicators deal with the administration of antibiotics as indicated, endoscopists’ training/credentials, and recording of the annual number of ERCP procedures. Post-ERCP pancreatitis is among the most common endoscopic complications with an overall incidence ranging between 3.5 to 9.7%. There are several factors related to ERCP which may contribute to the risk of acute pancreatitis, and all efforts should be made to reduce the risk of post-ERCP pancreatitis and associated adverse events such as multi-organ failure. Pharmacologic prophylaxis with a rectally administered nonsteroidal anti-inflammatory drug (NSAID) such as indomethacin suppository 100 mg or diclofenac suppository 100 mg immediately before ERCP is recommended, to lower the risk of post-ERCP pancreatitis. ESGE recommends routine rectal administration of diclofenac or indomethacin immediately before ERCP in all patients without contraindications to NSAID. When NSAIDs are contraindicated, intravenous fluids can be considered. Two meta-analyses support the role of fluid therapy for PEP prophylaxis; however, caution should be exercised in patients with significant fluid overload. In a recent multicenter, open-label randomized controlled trial, aggressive periprocedural hydration did not reduce the incidence of post-ERCP pancreatitis in patients with moderate to high risk, who routinely received prophylactic rectal NSAID. At the intra-procedural stage, endoscopists should adhere to quality metrics that include documentation of the frequency of deep cannulation of specific ducts and the time and radiation doses of fluoroscopy. Other indicator measures that measure the frequency of extracting common bile duct stones and stent placement for biliary obstruction should be implemented. The post-procedural stage quality indicators include completion of detailed report, early recognition, management, and documentation of acute adverse events such as perforation and significant hemorrhage after sphincteroplasty or sphincterotomy, incidence of post-ERCP pancreatitis, and contacts with patients after two weeks to identify and record delayed adverse events. Endoscopic ultrasound (EUS) Endoscopic ultrasound plays a key role in the diagnosis of gastrointestinal cancers and lesions. The main quality metric of endoscopic ultrasound requires healthcare professionals to document the images of all significant lesions. Furthermore, endoscopists are required to stage cancers using American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) TNM staging system. All identified solid or cystic lesions such as subepithelial or pancreatic should be properly documented and measured along with evaluation for vascular involvement, lymphadenopathy, and distant metastases. The endoscopists should document wall layers that include subepithelial masses. The quality guidelines for endoscopic ultrasound also include the use of cytology and biopsy procedures. In the setting of esophageal cancer staging, visualization of the celiac axis and left lobe of the liver (to rule out metastatic disease) should be documented. The 7 th AJCC staging system re-defines celiac LNs as regional LNs and removes the M1a and M1b classifications. ASGE suggests antibiotics before EUS-FNA of mediastinal and pancreatic/peri-pancreatic cystic lesions and advises against administration of prophylactic antibiotics before diagnostic EUS or EUS-FNA of solid lesions. Antibiotics to cover gram negative organisms such as fluoroquinolone or 3 rd generation cephalosporins administered before the procedure and continued for 3 to 5 days post-procedure to reduce the risk of bacteremia. When performing EUS-FNA, the type and size of the needle used and number of passes should be documented in the procedure report. On-site cytology assessment can be performed to assess sample adequacy. Adequate sample is defined by the presence of cells and/or tissue from the representative lesion to be achieved in ≥85% of cases. At the post-procedural stage, endoscopists should measure the incidence of adverse events after EUS procedure including FNA such as bleeding, infection, and perforation. Summary of recommended quality indicators for endoscopic procedures Intra-Procedure Photodocumentation of important anatomic landmarks and pathology should be performed. During endoscopic procedures, continuous monitoring of oxygen saturation with pulse oximetry and pulse rate/ blood pressure should be recorded every 5 minutes. Doses and routes of administration of all medications including reversal agents used during the procedure should be documented. Any event that requires premature termination of the procedure should be documented. Capsule Endoscopy (CE) Capsule endoscopy provides a non-invasive investigation in patients with mainly lower gastrointestinal tract symptoms. CE is accepted as a modality in patients with overt and occult small-bowel bleeding, Crohn’s disease, evaluation of refractory celiac disease, surveillance of polyposis syndromes and evaluation of suspected small-bowel tumors. However, CE requires longer times (30-60 minutes) for the reading and reporting of findings. CE can also miss certain lesions due to their subtle nature as well as due to reporter experience and fatigue. The main quality metric of CE focuses on video quality itself through the use of subjective video assessments by human observers, and on appropriate video analysis by healthcare professionals through appropriately trained and experienced reporters. For preprocedural metrics, the healthcare provider should be aware about the absolute contraindications such as luminal stenosis, unless surgery is planned and known, or suspected luminal perforation/obstruction. The relative contraindications include swallowing disorders, pregnancy, and implantable cardiac devices as advised by the manufacturer; however, ESGE no longer deems these devices a contraindication to CE. All patients undergoing CE should be evaluated for risk factors for capsule retention, including Crohn’s disease, history of small-bowel obstruction or previous resection, previous abdominal or pelvic radiotherapy, chronic use of a high-dose (NSAID), and known stricture or mass. If any of these conditions are present or the patient has symptoms concerning for obstruction, results from a patency capsule test, a CT or MR enterography procedure, or a combination of these procedures should be obtained before standard capsule administration. In patients with swallowing disorders or for patients at risk of gastric retention, endoscopic placement of the CE into the small intestine can overcome the risks associated with these conditions. Furthermore, adequate bowel preparation is needed for appropriate visualization of the mucosa that consists of a low residue diet, two days prior to the procedure, with a clear liquid diet starting after lunch the day prior to the procedure and an overnight fast. The addition of a purgative such as 2-4 liters of polyethylene glycol during the day prior to the procedure and the use of antifoaming agent such as simethicone 300 mg, 20 minutes before swallowing the capsule improve the diagnostic yield of capsule endoscopy. However, some studies showed that, liquid diet during the day prior to administration of the endoscopic capsule, together with overnight fasting, is a sufficient preparation to achieve a good level of cleanliness of the small bowel. The use of prokinetic such as metoclopramide 10 mg administered orally 15 min before swallowing the capsule, enhance gastric and intestinal transit time and improve the percentage of complete study. With the new generation of capsules whose batteries last longer, the extended transit time represents a lesser problem; however, prokinetics could still offer advantages in diabetic patients and in those patients with prolonged intestinal transit time e.g., patients confined to the bed. Intra-procedural quality guidelines include ensuring that the sensing pads or belt is properly secured to the patient at all times. At the post-procedural stage, patients should be educated on ensuring that the capsule has spontaneously passed, as capsule retention can occur in 1.2-4.6% of cases, depending on the underlying indication for CE. Capsule retention occurs when the capsule does not spontaneously pass within two weeks since ingestion of the device. Abdominal radiography at 2 weeks should be requested if the capsule has not been observed to pass. If capsule retention occurs, endoscopic or surgical intervention to retrieve the capsule should be considered. Furthermore, the patient should be informed to avoid magnetic resonance imaging until the capsule is egested. When CE is performed, photo-documentation and description of lesions of interest and certain anatomic landmarks are the standard protocol. The first duodenal and first cecal images enable calculation of the small bowel transit time. Patients should be instructed to avoid undergoing MRI until the capsule has been expelled, to avoid risk of capsule migration leading to bowel injury and interfering with imaging quality. In order to have an adequate view of the small bowel mucosa and to avoid incomplete examinations, it is recommended that each endoscopy unit develop its own protocol to review the indications/contraindications of the procedure, explain the pre-procedural dietary and medication instructions, to follow up the results of the preparation and modify the bowel preparation protocol if required. Summary of recommended quality indicators for endoscopic procedures Post-Procedure Documentation is required that the patient has met the discharge criteria before discharge from the endoscopy unit. Written instructions should be provided to the patient before discharge that include: dietary restrictions, resumption or change in medications, prescription of new medications, return to activities such as driving, and contact information should an adverse event or question arise. When biopsy is obtained, a clear plan for follow up of pathology results should be documented. Every endoscopic procedure should have a detailed report completed in a timely manner. The results of the endoscopic procedure and followup recommendations must be communicated to the referring provider or primary care physician, and this communication should be documented. Report Cards, benchmarking, and other methods Besides following the established quality guidelines, endoscopists are expected to gather their performance data and generate procedure reports. These reports should include information about the indication, diagnosis, duration, sedation, anatomical extent, complexity grade, ASA grade, and immediate adverse outcomes. Some data can be challenging to collect such as endoscopist-specific patient satisfaction and delayed adverse outcomes. These can be collected through the help of hospital administration and call centers. All data should be uploaded to appropriate resources that will then generate an internal report card with the summary of the endoscopists’ performance and compare it with the performance of other peers. In general, endoscopy quality improvement may take many different forms, such as setting quality assurance standards, using key performance indicators, auditing and helping endoscopists to achieve higher performance standards, improving endoscopy training, enhancing patient experience, and managing endoscopy services and units. The British Society of Gastroenterology (BSG), for example, has taken a comprehensive approach to quality improvement by initiating the Endoscopy Quality Improvement Program. This program includes different forms of quality improvement for upper gastrointestinal endoscopy, lower gastrointestinal endoscopy, ERCP, small bowel endoscopy, and endoscopic ultrasound. Similarly, the Korean government has initiated the National Endoscopy Quality Improvement Program, including a comprehensive list of structural, process, and outcome quality metrics. One of the greatest challenges for endoscopic quality improvement projects is to prioritize the most important quality indicators. As explained by Cohen and Pike, there are too many quality metrics that make healthcare professionals overburdened and confused. In their study of endoscopic quality indicators, Day et al . identified five priority measures that should be adopted by endoscopy units, that include a defined leadership structure in the unit, regular education and training programs, recording and monitoring of both individual and unit-level endoscopy quality indicators, sharing of procedure reports, and proper maintenance and tracking of each endoscope. Future metrics Patient Reported Outcomes Measures (PROMs) and Patient Reported Experience Measures (PREMs) can provide valuable information for improvement in quality of care. A prospective study assessed data from 2808 ERCP procedures. Patient questionnaires were returned for approximately 50% of cases. These PROMs identified female sex and longer procedure times to be predictors of increased procedure related pain. This demonstrates the importance of the use of PROMs/PREMs as a quality metric. Moreover, a meta-narrative review identified 3688 abstracts in search for patient derived and validated endoscopy specific experience measures, none were found. Endoscopy specific PROM questionnaires need to be set in place, analyzed and monitored to improve quality in endoscopy. Another important consideration for the future is the role of artificial intelligence (AI) in medicine, which has been exponentially growing in recent years. Using advanced deep learning technology, endoscopists will be able to provide a more accurate diagnosis. This technology is said to be able to automatically detect and classify endoscopic lesions. However, obtaining high-quality images is a defining prerequisite for AI in endoscopy. AI in endoscopy using convolutional neural network has shown promising results in detecting gastrointestinal pathologies and will likely play a major role in diagnostic imaging in the near future . 

This section describes the general quality measures for the three stages of endoscopy, which can be classified into the following three metrics illustrated in . Pre-procedural metrics Most pre-procedural quality measures can be applied to all types of invasive endoscopic procedures. The pre-procedural period begins with a valid indication, initial testing and planning of the procedure including the appropriate type of sedation to be used during the procedure. The details of procedures and preparations in a written format should be handed over to the patient ahead of time prior to procedure appointment. During the pre-procedural period, healthcare practitioners’ should interview and test patients to detect potential risk factors, such as cardiopulmonary, hepatic, renal, or other comorbid conditions. Patients with significant systematic diseases should have appropriate work up and consultation with the appropriate service(s) prior to the day of procedure. A clear indication for the procedure should be identified, where the quality improvement goal is to minimize the number of procedures without appropriate indications. Furthermore, informed consent from patients for each endoscopic procedure is ideally obtained and signed by the patient or his/her guardian in the ward or the clinic before attending the endoscopy unit. Consent should include a discussion of the sedation plan and risks associated with sedation, indication for the procedure, description of the procedure, likely benefits, common adverse events, and alternatives to the procedure (if any). The endoscopist should give an opportunity to the patient to understand the procedure and ask questions. If sedation for the procedure is provided by an anesthesiologist, then a separate consent obtained by that provider may be appropriate. Prior to starting any endoscopic procedure, checking the vital signs as well as glucometer in diabetic patients is important, and any abnormality should be corrected to avoid any unexpected complications during or after the procedure. The procedure can be started once the correct patient is identified and the timeout is completed. This stage ends with the administration of anesthesia/sedation or insertion of the endoscope. Other quality measures at this stage include provision of prophylactic antibiotics in invasive procedures. According to most of the guidelines, antibiotic prophylaxis is no longer recommended for the prevention of infective endocarditis in patients with cardiac risk factors who undergo diagnostic or therapeutic endoscopy. summarizes the indication for antibiotic prophylaxis in endoscopic procedures. The choice of the antibiotic and its duration depends on the procedure performed and the most likely organism(s) to cause bacteremia. A review of all medications including antiplatelets, anticoagulants, antidiabetics and antiepileptics should be performed at the preprocedural stage. Management of all these medications must be formulated and documented before the procedure. Another parameter is to indicate the American Society of Anesthesiology (ASA) score shown in . This is to ensure that the patient is stable and fit for the procedure, as well as to consider anesthesia consultation and the preparation of appropriate recovery such as intensive care unit, if deemed necessary. Mallampati score is a visual assessment of the distance from the tongue base to the roof of the mouth, that is used to predict the ease of endotracheal intubation. The Modified Mallampati Score has shown to be a useful clinical tool in the assessment of EGD tolerance in non-sedated patients. Poor oropharynx visualization should prompt consideration for sedation with the support of anesthesia. Pre-procedural laboratory investigations should be ordered selectively based on medical history, physical examination and procedural risk factors. Supplements such as pamphlets or videos in advance might enhance patient understanding of the procedure. Summary of recommended quality indicators for endoscopic procedures Pre-Procedure Endoscopy procedures should be performed by a competent endoscopist or trainee under direct supervision by a qualified mentor. Endoscopy should be performed for a clear indication and to be documented. Consent should be obtained and documented to include the indication, sedation plan and its associated risks, description of the procedure, likely benefits, risks, and if any alternatives. A separate consent should be obtained by the provider if sedation will be provided by an anesthesia. Pre-procedure history and focused physical examination should be performed and documented. Risk assessment for sedation-related adverse events (e.g. using ASA score) should be performed and documented. Prophylactic antibiotics should be administered when indicated. Management of antithrombotic and anticoagulant therapy is formulated and documented before the procedure. A clear plan regarding holding and resuming them should be recorded and communicated to the patient and to consider consultation with the appropriate services such as hematology or cardiology, if needed. Intra-procedural metrics This period starts with the administration of sedation/anesthesia or insertion of the endoscope and ends with its removal. It is necessary to closely monitor blood pressure, pulse and oxygen saturation every 5 minutes during the procedure. The routine uses of supplemental oxygen (2 liters/minute) during upper and lower GI endoscopic procedures to prevent desaturation has been shown to reduce desaturation episodes during the procedure (12.4% versus 70.8% for control group, P <.00001). Another important quality metric is to keep track of the doses of sedation drugs and reversal agents. Photo-documentation of major pathologies and important anatomic landmarks is recommended. All endoscopic procedures should be performed by a competent and privileged endoscopist or a trainee under direct supervision. Time tracking from insertion of the scope to the withdrawal is important to monitor safety and quality of the procedure. Post-procedural metrics The post-procedural stage is of vital importance because there is a risk of delayed adverse events. This should include; monitoring the patient recovery, completion of the procedure report , giving the patient written instructions that describe the symptoms and signs of potential complications, follow-up process, antibiotic prescriptions—if indicated—and resuming certain medications such as anticoagulants and antiplatelet drugs. Monitoring for delayed complications associated with endoscopic procedures must be considered by encouraging patients to report worrisome symptoms and educate the patient to contact the endoscopist or report to emergency room in case of unusual symptoms that suggest delayed complications such as gastrointestinal hemorrhage or post-ERCP pancreatitis. The endoscopy unit should have a written policy regarding criteria the patient must meet before discharge from the unit and patients should also be provided with written discharge instructions that include diet and activity restrictions, an explanation of biopsy results, information about follow-up appointments, and any medication changes. If there is no plan to follow up the patient, it is important for the endoscopist to arrange for pathology follow-up and document it in the patient file. In addition, endoscopists should communicate with the referring healthcare provider when deemed necessary. Healthcare institutions should monitor the work of endoscopists and identify sub-optimal performance associated with adverse events (such as perforation, bleeding, infections, pancreatitis, and sedation-associated adverse events such as hypotension, hypoxia, and the need for the reversal of sedation or aborting the procedure). Furthermore, mortality and morbidity meetings should be held on a regular basis to increase departmental awareness, increase data collection, and possibly innovate further quality metrics. 

Most pre-procedural quality measures can be applied to all types of invasive endoscopic procedures. The pre-procedural period begins with a valid indication, initial testing and planning of the procedure including the appropriate type of sedation to be used during the procedure. The details of procedures and preparations in a written format should be handed over to the patient ahead of time prior to procedure appointment. During the pre-procedural period, healthcare practitioners’ should interview and test patients to detect potential risk factors, such as cardiopulmonary, hepatic, renal, or other comorbid conditions. Patients with significant systematic diseases should have appropriate work up and consultation with the appropriate service(s) prior to the day of procedure. A clear indication for the procedure should be identified, where the quality improvement goal is to minimize the number of procedures without appropriate indications. Furthermore, informed consent from patients for each endoscopic procedure is ideally obtained and signed by the patient or his/her guardian in the ward or the clinic before attending the endoscopy unit. Consent should include a discussion of the sedation plan and risks associated with sedation, indication for the procedure, description of the procedure, likely benefits, common adverse events, and alternatives to the procedure (if any). The endoscopist should give an opportunity to the patient to understand the procedure and ask questions. If sedation for the procedure is provided by an anesthesiologist, then a separate consent obtained by that provider may be appropriate. Prior to starting any endoscopic procedure, checking the vital signs as well as glucometer in diabetic patients is important, and any abnormality should be corrected to avoid any unexpected complications during or after the procedure. The procedure can be started once the correct patient is identified and the timeout is completed. This stage ends with the administration of anesthesia/sedation or insertion of the endoscope. Other quality measures at this stage include provision of prophylactic antibiotics in invasive procedures. According to most of the guidelines, antibiotic prophylaxis is no longer recommended for the prevention of infective endocarditis in patients with cardiac risk factors who undergo diagnostic or therapeutic endoscopy. summarizes the indication for antibiotic prophylaxis in endoscopic procedures. The choice of the antibiotic and its duration depends on the procedure performed and the most likely organism(s) to cause bacteremia. A review of all medications including antiplatelets, anticoagulants, antidiabetics and antiepileptics should be performed at the preprocedural stage. Management of all these medications must be formulated and documented before the procedure. Another parameter is to indicate the American Society of Anesthesiology (ASA) score shown in . This is to ensure that the patient is stable and fit for the procedure, as well as to consider anesthesia consultation and the preparation of appropriate recovery such as intensive care unit, if deemed necessary. Mallampati score is a visual assessment of the distance from the tongue base to the roof of the mouth, that is used to predict the ease of endotracheal intubation. The Modified Mallampati Score has shown to be a useful clinical tool in the assessment of EGD tolerance in non-sedated patients. Poor oropharynx visualization should prompt consideration for sedation with the support of anesthesia. Pre-procedural laboratory investigations should be ordered selectively based on medical history, physical examination and procedural risk factors. Supplements such as pamphlets or videos in advance might enhance patient understanding of the procedure. Summary of recommended quality indicators for endoscopic procedures Pre-Procedure Endoscopy procedures should be performed by a competent endoscopist or trainee under direct supervision by a qualified mentor. Endoscopy should be performed for a clear indication and to be documented. Consent should be obtained and documented to include the indication, sedation plan and its associated risks, description of the procedure, likely benefits, risks, and if any alternatives. A separate consent should be obtained by the provider if sedation will be provided by an anesthesia. Pre-procedure history and focused physical examination should be performed and documented. Risk assessment for sedation-related adverse events (e.g. using ASA score) should be performed and documented. Prophylactic antibiotics should be administered when indicated. Management of antithrombotic and anticoagulant therapy is formulated and documented before the procedure. A clear plan regarding holding and resuming them should be recorded and communicated to the patient and to consider consultation with the appropriate services such as hematology or cardiology, if needed. 

This period starts with the administration of sedation/anesthesia or insertion of the endoscope and ends with its removal. It is necessary to closely monitor blood pressure, pulse and oxygen saturation every 5 minutes during the procedure. The routine uses of supplemental oxygen (2 liters/minute) during upper and lower GI endoscopic procedures to prevent desaturation has been shown to reduce desaturation episodes during the procedure (12.4% versus 70.8% for control group, P <.00001). Another important quality metric is to keep track of the doses of sedation drugs and reversal agents. Photo-documentation of major pathologies and important anatomic landmarks is recommended. All endoscopic procedures should be performed by a competent and privileged endoscopist or a trainee under direct supervision. Time tracking from insertion of the scope to the withdrawal is important to monitor safety and quality of the procedure. 

The post-procedural stage is of vital importance because there is a risk of delayed adverse events. This should include; monitoring the patient recovery, completion of the procedure report , giving the patient written instructions that describe the symptoms and signs of potential complications, follow-up process, antibiotic prescriptions—if indicated—and resuming certain medications such as anticoagulants and antiplatelet drugs. Monitoring for delayed complications associated with endoscopic procedures must be considered by encouraging patients to report worrisome symptoms and educate the patient to contact the endoscopist or report to emergency room in case of unusual symptoms that suggest delayed complications such as gastrointestinal hemorrhage or post-ERCP pancreatitis. The endoscopy unit should have a written policy regarding criteria the patient must meet before discharge from the unit and patients should also be provided with written discharge instructions that include diet and activity restrictions, an explanation of biopsy results, information about follow-up appointments, and any medication changes. If there is no plan to follow up the patient, it is important for the endoscopist to arrange for pathology follow-up and document it in the patient file. In addition, endoscopists should communicate with the referring healthcare provider when deemed necessary. Healthcare institutions should monitor the work of endoscopists and identify sub-optimal performance associated with adverse events (such as perforation, bleeding, infections, pancreatitis, and sedation-associated adverse events such as hypotension, hypoxia, and the need for the reversal of sedation or aborting the procedure). Furthermore, mortality and morbidity meetings should be held on a regular basis to increase departmental awareness, increase data collection, and possibly innovate further quality metrics. 

Upper endoscopy Upper endoscopy (EGD) is typically initiated to assess and manage many conditions such as dyspepsia, dysphagia, gastroesophageal reflux, peptic ulcer disease, upper gastrointestinal hemorrhage and to confirm diagnosis of Celiac disease. Furthermore, there is a wide range of indications that involve a lot of different disease-specific measures. Despite the fact that all these measures help to improve the quality of endoscopy procedures, they are still not mandatory in many endoscopy units. There are many proposed quality metrics for endoscopy. In 2015, the ASGE and ACG proposed one of the most comprehensive lists of quality metrics for upper endoscopy. This list has been expanded to include up to 45 process measures that were specific to upper endoscopy. The ESGE and the United European Gastroenterology (UEG) on the other hand, suggested six key performance measures for upper endoscopy, listed in . The general quality metric for EGD is the complete examination of the esophagus, stomach including retroflexion, and duodenum, with proper documentation of all observations . According to ESGE, endoscopist should take photographs for the landmarks as highlighted in and Tables and . In case of presence of gastric mucosal abnormalities such as erythema, erosions, ulcerations, or nodularity, it is recommended to test for Helicobacter pylori (H. pylori) after taking multiple biopsies from different parts of the stomach for histology, rapid urease test, PCR, and/or culture. If the endoscopist notices gastrointestinal bleeding, they should identify its location and source. If the bleeding comes from an ulcer, the endoscopist should avoid using epinephrine injection alone. It is better to combine epinephrine injection with electro-coagulation or clipping. Other EGD quality metrics focus on the best practices for different types of adverse conditions, such as an upper gastrointestinal bleeding. EGD-specific quality indicators also include guidelines for achieving hemostasis and using different treatment modalities, such as variceal ligation, coagulation, or clipping. At the post-procedural stage, there are EGD-specific quality indicators that include, measuring the frequency in which the endoscopists recommended proton-pump inhibitor (PPI) therapy after dilation for peptic esophageal strictures, prescription of H2 antagonists or PPI medications for patients with duodenal or gastric ulcers, documentation of H. pylori testing and recording adverse events. Colonoscopy Compared with other endoscopic procedures, the quality metrics for colonoscopy are the most advanced and well-studied. An essential metric is bowel preparation quality, as appropriate bowel preparation reduces the probability of missed lesions and the risk of interval colorectal cancers and avoids repeated procedures. Other fundamental metrics include photographic documentation of all lesions and landmarks including cecal intubation, detection rate of adenomas in average-risk individuals, and measuring withdrawal time [ and Tables and ]. Multiple studies found that the most important quality indicators for colonoscopy include withdrawal time, cecal intubation rate, and adenoma detection rate (ADR). The ADR is one of the most widespread general indicators in gastrointestinal endoscopy. A lot of data has been gathered about this indicator, and it is directly linked with two essential outcome measures: the incidence and mortality from colorectal cancer. The role of retroflexed view examination after forward view examination versus two forward examinations, in decreasing adenoma miss rates, is yet to be confirmed by further studies. Bowel preparation can be measured using a valid and reliable method such as the Boston Bowel Preparation Scale for the three colonic segments shown in  or Ottawa Bowel Preparation Scale. Furthermore, all patients undergoing colonoscopy for the evaluation of chronic diarrhea should have biopsy specimens obtained. The optimal number and location of biopsies is not established, but ≥8 are recommended. Inclusion of samples from the proximal colon improves the sensitivity for microscopic colitis. Moreover, tissue sampling for histopathological examination to assess the activity of ulcerative and Crohn’s colitis and for CMV, if indicated, with immunohistochemistry, colonic tissue culture, or more sensitive molecular techniques such as nucleic acid amplification tests or quantitative PCR are recommended. During surveillance colonoscopy in patients with ulcerative colitis, 4 biopsy specimens for every 10 cm or ≥33 biopsy specimens is recommended. The use of high-definition colonoscopy or chromoendoscopy increase dysplasia detection in ulcerative colitis nearly 3-4 fold compared with white-light colonoscopy. Finally, there are post-procedural quality measures for colonoscopy that include incidence of post-polypectomy bleeding and perforation, and timing of surveillance colonoscopy after detection of colonic polyps (5-10 year intervals for individuals with 1-2 small tubular adenomas, and 3-year intervals for patients with 3 or more adenomas, if polyp size is more than 10 mm or has villous component on histopathology). Endoscopic retrograde cholangiopancreatography (ERCP) There are many indications to perform ERCP; however, diagnostic ERCP should be avoided if possible, as ERCP is considered among the highest risk and the most challenging of endoscopic procedures. The most important ERCP-specific quality measures for the pre-procedural stage pertain to the indication for ERCP procedure and obtaining informed consent. ERCP should be performed with a clear indication to justify if any complications happen. The informed consent should include all potential adverse outcomes including perforation, infection, pancreatitis, cardiopulmonary events, hemorrhage, and allergic reaction. Other quality indicators deal with the administration of antibiotics as indicated, endoscopists’ training/credentials, and recording of the annual number of ERCP procedures. Post-ERCP pancreatitis is among the most common endoscopic complications with an overall incidence ranging between 3.5 to 9.7%. There are several factors related to ERCP which may contribute to the risk of acute pancreatitis, and all efforts should be made to reduce the risk of post-ERCP pancreatitis and associated adverse events such as multi-organ failure. Pharmacologic prophylaxis with a rectally administered nonsteroidal anti-inflammatory drug (NSAID) such as indomethacin suppository 100 mg or diclofenac suppository 100 mg immediately before ERCP is recommended, to lower the risk of post-ERCP pancreatitis. ESGE recommends routine rectal administration of diclofenac or indomethacin immediately before ERCP in all patients without contraindications to NSAID. When NSAIDs are contraindicated, intravenous fluids can be considered. Two meta-analyses support the role of fluid therapy for PEP prophylaxis; however, caution should be exercised in patients with significant fluid overload. In a recent multicenter, open-label randomized controlled trial, aggressive periprocedural hydration did not reduce the incidence of post-ERCP pancreatitis in patients with moderate to high risk, who routinely received prophylactic rectal NSAID. At the intra-procedural stage, endoscopists should adhere to quality metrics that include documentation of the frequency of deep cannulation of specific ducts and the time and radiation doses of fluoroscopy. Other indicator measures that measure the frequency of extracting common bile duct stones and stent placement for biliary obstruction should be implemented. The post-procedural stage quality indicators include completion of detailed report, early recognition, management, and documentation of acute adverse events such as perforation and significant hemorrhage after sphincteroplasty or sphincterotomy, incidence of post-ERCP pancreatitis, and contacts with patients after two weeks to identify and record delayed adverse events. Endoscopic ultrasound (EUS) Endoscopic ultrasound plays a key role in the diagnosis of gastrointestinal cancers and lesions. The main quality metric of endoscopic ultrasound requires healthcare professionals to document the images of all significant lesions. Furthermore, endoscopists are required to stage cancers using American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) TNM staging system. All identified solid or cystic lesions such as subepithelial or pancreatic should be properly documented and measured along with evaluation for vascular involvement, lymphadenopathy, and distant metastases. The endoscopists should document wall layers that include subepithelial masses. The quality guidelines for endoscopic ultrasound also include the use of cytology and biopsy procedures. In the setting of esophageal cancer staging, visualization of the celiac axis and left lobe of the liver (to rule out metastatic disease) should be documented. The 7 th AJCC staging system re-defines celiac LNs as regional LNs and removes the M1a and M1b classifications. ASGE suggests antibiotics before EUS-FNA of mediastinal and pancreatic/peri-pancreatic cystic lesions and advises against administration of prophylactic antibiotics before diagnostic EUS or EUS-FNA of solid lesions. Antibiotics to cover gram negative organisms such as fluoroquinolone or 3 rd generation cephalosporins administered before the procedure and continued for 3 to 5 days post-procedure to reduce the risk of bacteremia. When performing EUS-FNA, the type and size of the needle used and number of passes should be documented in the procedure report. On-site cytology assessment can be performed to assess sample adequacy. Adequate sample is defined by the presence of cells and/or tissue from the representative lesion to be achieved in ≥85% of cases. At the post-procedural stage, endoscopists should measure the incidence of adverse events after EUS procedure including FNA such as bleeding, infection, and perforation. Summary of recommended quality indicators for endoscopic procedures Intra-Procedure Photodocumentation of important anatomic landmarks and pathology should be performed. During endoscopic procedures, continuous monitoring of oxygen saturation with pulse oximetry and pulse rate/ blood pressure should be recorded every 5 minutes. Doses and routes of administration of all medications including reversal agents used during the procedure should be documented. Any event that requires premature termination of the procedure should be documented. Capsule Endoscopy (CE) Capsule endoscopy provides a non-invasive investigation in patients with mainly lower gastrointestinal tract symptoms. CE is accepted as a modality in patients with overt and occult small-bowel bleeding, Crohn’s disease, evaluation of refractory celiac disease, surveillance of polyposis syndromes and evaluation of suspected small-bowel tumors. However, CE requires longer times (30-60 minutes) for the reading and reporting of findings. CE can also miss certain lesions due to their subtle nature as well as due to reporter experience and fatigue. The main quality metric of CE focuses on video quality itself through the use of subjective video assessments by human observers, and on appropriate video analysis by healthcare professionals through appropriately trained and experienced reporters. For preprocedural metrics, the healthcare provider should be aware about the absolute contraindications such as luminal stenosis, unless surgery is planned and known, or suspected luminal perforation/obstruction. The relative contraindications include swallowing disorders, pregnancy, and implantable cardiac devices as advised by the manufacturer; however, ESGE no longer deems these devices a contraindication to CE. All patients undergoing CE should be evaluated for risk factors for capsule retention, including Crohn’s disease, history of small-bowel obstruction or previous resection, previous abdominal or pelvic radiotherapy, chronic use of a high-dose (NSAID), and known stricture or mass. If any of these conditions are present or the patient has symptoms concerning for obstruction, results from a patency capsule test, a CT or MR enterography procedure, or a combination of these procedures should be obtained before standard capsule administration. In patients with swallowing disorders or for patients at risk of gastric retention, endoscopic placement of the CE into the small intestine can overcome the risks associated with these conditions. Furthermore, adequate bowel preparation is needed for appropriate visualization of the mucosa that consists of a low residue diet, two days prior to the procedure, with a clear liquid diet starting after lunch the day prior to the procedure and an overnight fast. The addition of a purgative such as 2-4 liters of polyethylene glycol during the day prior to the procedure and the use of antifoaming agent such as simethicone 300 mg, 20 minutes before swallowing the capsule improve the diagnostic yield of capsule endoscopy. However, some studies showed that, liquid diet during the day prior to administration of the endoscopic capsule, together with overnight fasting, is a sufficient preparation to achieve a good level of cleanliness of the small bowel. The use of prokinetic such as metoclopramide 10 mg administered orally 15 min before swallowing the capsule, enhance gastric and intestinal transit time and improve the percentage of complete study. With the new generation of capsules whose batteries last longer, the extended transit time represents a lesser problem; however, prokinetics could still offer advantages in diabetic patients and in those patients with prolonged intestinal transit time e.g., patients confined to the bed. Intra-procedural quality guidelines include ensuring that the sensing pads or belt is properly secured to the patient at all times. At the post-procedural stage, patients should be educated on ensuring that the capsule has spontaneously passed, as capsule retention can occur in 1.2-4.6% of cases, depending on the underlying indication for CE. Capsule retention occurs when the capsule does not spontaneously pass within two weeks since ingestion of the device. Abdominal radiography at 2 weeks should be requested if the capsule has not been observed to pass. If capsule retention occurs, endoscopic or surgical intervention to retrieve the capsule should be considered. Furthermore, the patient should be informed to avoid magnetic resonance imaging until the capsule is egested. When CE is performed, photo-documentation and description of lesions of interest and certain anatomic landmarks are the standard protocol. The first duodenal and first cecal images enable calculation of the small bowel transit time. Patients should be instructed to avoid undergoing MRI until the capsule has been expelled, to avoid risk of capsule migration leading to bowel injury and interfering with imaging quality. In order to have an adequate view of the small bowel mucosa and to avoid incomplete examinations, it is recommended that each endoscopy unit develop its own protocol to review the indications/contraindications of the procedure, explain the pre-procedural dietary and medication instructions, to follow up the results of the preparation and modify the bowel preparation protocol if required. Summary of recommended quality indicators for endoscopic procedures Post-Procedure Documentation is required that the patient has met the discharge criteria before discharge from the endoscopy unit. Written instructions should be provided to the patient before discharge that include: dietary restrictions, resumption or change in medications, prescription of new medications, return to activities such as driving, and contact information should an adverse event or question arise. When biopsy is obtained, a clear plan for follow up of pathology results should be documented. Every endoscopic procedure should have a detailed report completed in a timely manner. The results of the endoscopic procedure and followup recommendations must be communicated to the referring provider or primary care physician, and this communication should be documented. 

Upper endoscopy (EGD) is typically initiated to assess and manage many conditions such as dyspepsia, dysphagia, gastroesophageal reflux, peptic ulcer disease, upper gastrointestinal hemorrhage and to confirm diagnosis of Celiac disease. Furthermore, there is a wide range of indications that involve a lot of different disease-specific measures. Despite the fact that all these measures help to improve the quality of endoscopy procedures, they are still not mandatory in many endoscopy units. There are many proposed quality metrics for endoscopy. In 2015, the ASGE and ACG proposed one of the most comprehensive lists of quality metrics for upper endoscopy. This list has been expanded to include up to 45 process measures that were specific to upper endoscopy. The ESGE and the United European Gastroenterology (UEG) on the other hand, suggested six key performance measures for upper endoscopy, listed in . The general quality metric for EGD is the complete examination of the esophagus, stomach including retroflexion, and duodenum, with proper documentation of all observations . According to ESGE, endoscopist should take photographs for the landmarks as highlighted in and Tables and . In case of presence of gastric mucosal abnormalities such as erythema, erosions, ulcerations, or nodularity, it is recommended to test for Helicobacter pylori (H. pylori) after taking multiple biopsies from different parts of the stomach for histology, rapid urease test, PCR, and/or culture. If the endoscopist notices gastrointestinal bleeding, they should identify its location and source. If the bleeding comes from an ulcer, the endoscopist should avoid using epinephrine injection alone. It is better to combine epinephrine injection with electro-coagulation or clipping. Other EGD quality metrics focus on the best practices for different types of adverse conditions, such as an upper gastrointestinal bleeding. EGD-specific quality indicators also include guidelines for achieving hemostasis and using different treatment modalities, such as variceal ligation, coagulation, or clipping. At the post-procedural stage, there are EGD-specific quality indicators that include, measuring the frequency in which the endoscopists recommended proton-pump inhibitor (PPI) therapy after dilation for peptic esophageal strictures, prescription of H2 antagonists or PPI medications for patients with duodenal or gastric ulcers, documentation of H. pylori testing and recording adverse events. 

Compared with other endoscopic procedures, the quality metrics for colonoscopy are the most advanced and well-studied. An essential metric is bowel preparation quality, as appropriate bowel preparation reduces the probability of missed lesions and the risk of interval colorectal cancers and avoids repeated procedures. Other fundamental metrics include photographic documentation of all lesions and landmarks including cecal intubation, detection rate of adenomas in average-risk individuals, and measuring withdrawal time [ and Tables and ]. Multiple studies found that the most important quality indicators for colonoscopy include withdrawal time, cecal intubation rate, and adenoma detection rate (ADR). The ADR is one of the most widespread general indicators in gastrointestinal endoscopy. A lot of data has been gathered about this indicator, and it is directly linked with two essential outcome measures: the incidence and mortality from colorectal cancer. The role of retroflexed view examination after forward view examination versus two forward examinations, in decreasing adenoma miss rates, is yet to be confirmed by further studies. Bowel preparation can be measured using a valid and reliable method such as the Boston Bowel Preparation Scale for the three colonic segments shown in  or Ottawa Bowel Preparation Scale. Furthermore, all patients undergoing colonoscopy for the evaluation of chronic diarrhea should have biopsy specimens obtained. The optimal number and location of biopsies is not established, but ≥8 are recommended. Inclusion of samples from the proximal colon improves the sensitivity for microscopic colitis. Moreover, tissue sampling for histopathological examination to assess the activity of ulcerative and Crohn’s colitis and for CMV, if indicated, with immunohistochemistry, colonic tissue culture, or more sensitive molecular techniques such as nucleic acid amplification tests or quantitative PCR are recommended. During surveillance colonoscopy in patients with ulcerative colitis, 4 biopsy specimens for every 10 cm or ≥33 biopsy specimens is recommended. The use of high-definition colonoscopy or chromoendoscopy increase dysplasia detection in ulcerative colitis nearly 3-4 fold compared with white-light colonoscopy. Finally, there are post-procedural quality measures for colonoscopy that include incidence of post-polypectomy bleeding and perforation, and timing of surveillance colonoscopy after detection of colonic polyps (5-10 year intervals for individuals with 1-2 small tubular adenomas, and 3-year intervals for patients with 3 or more adenomas, if polyp size is more than 10 mm or has villous component on histopathology). 

There are many indications to perform ERCP; however, diagnostic ERCP should be avoided if possible, as ERCP is considered among the highest risk and the most challenging of endoscopic procedures. The most important ERCP-specific quality measures for the pre-procedural stage pertain to the indication for ERCP procedure and obtaining informed consent. ERCP should be performed with a clear indication to justify if any complications happen. The informed consent should include all potential adverse outcomes including perforation, infection, pancreatitis, cardiopulmonary events, hemorrhage, and allergic reaction. Other quality indicators deal with the administration of antibiotics as indicated, endoscopists’ training/credentials, and recording of the annual number of ERCP procedures. Post-ERCP pancreatitis is among the most common endoscopic complications with an overall incidence ranging between 3.5 to 9.7%. There are several factors related to ERCP which may contribute to the risk of acute pancreatitis, and all efforts should be made to reduce the risk of post-ERCP pancreatitis and associated adverse events such as multi-organ failure. Pharmacologic prophylaxis with a rectally administered nonsteroidal anti-inflammatory drug (NSAID) such as indomethacin suppository 100 mg or diclofenac suppository 100 mg immediately before ERCP is recommended, to lower the risk of post-ERCP pancreatitis. ESGE recommends routine rectal administration of diclofenac or indomethacin immediately before ERCP in all patients without contraindications to NSAID. When NSAIDs are contraindicated, intravenous fluids can be considered. Two meta-analyses support the role of fluid therapy for PEP prophylaxis; however, caution should be exercised in patients with significant fluid overload. In a recent multicenter, open-label randomized controlled trial, aggressive periprocedural hydration did not reduce the incidence of post-ERCP pancreatitis in patients with moderate to high risk, who routinely received prophylactic rectal NSAID. At the intra-procedural stage, endoscopists should adhere to quality metrics that include documentation of the frequency of deep cannulation of specific ducts and the time and radiation doses of fluoroscopy. Other indicator measures that measure the frequency of extracting common bile duct stones and stent placement for biliary obstruction should be implemented. The post-procedural stage quality indicators include completion of detailed report, early recognition, management, and documentation of acute adverse events such as perforation and significant hemorrhage after sphincteroplasty or sphincterotomy, incidence of post-ERCP pancreatitis, and contacts with patients after two weeks to identify and record delayed adverse events. 

Endoscopic ultrasound plays a key role in the diagnosis of gastrointestinal cancers and lesions. The main quality metric of endoscopic ultrasound requires healthcare professionals to document the images of all significant lesions. Furthermore, endoscopists are required to stage cancers using American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) TNM staging system. All identified solid or cystic lesions such as subepithelial or pancreatic should be properly documented and measured along with evaluation for vascular involvement, lymphadenopathy, and distant metastases. The endoscopists should document wall layers that include subepithelial masses. The quality guidelines for endoscopic ultrasound also include the use of cytology and biopsy procedures. In the setting of esophageal cancer staging, visualization of the celiac axis and left lobe of the liver (to rule out metastatic disease) should be documented. The 7 th AJCC staging system re-defines celiac LNs as regional LNs and removes the M1a and M1b classifications. ASGE suggests antibiotics before EUS-FNA of mediastinal and pancreatic/peri-pancreatic cystic lesions and advises against administration of prophylactic antibiotics before diagnostic EUS or EUS-FNA of solid lesions. Antibiotics to cover gram negative organisms such as fluoroquinolone or 3 rd generation cephalosporins administered before the procedure and continued for 3 to 5 days post-procedure to reduce the risk of bacteremia. When performing EUS-FNA, the type and size of the needle used and number of passes should be documented in the procedure report. On-site cytology assessment can be performed to assess sample adequacy. Adequate sample is defined by the presence of cells and/or tissue from the representative lesion to be achieved in ≥85% of cases. At the post-procedural stage, endoscopists should measure the incidence of adverse events after EUS procedure including FNA such as bleeding, infection, and perforation. Summary of recommended quality indicators for endoscopic procedures Intra-Procedure Photodocumentation of important anatomic landmarks and pathology should be performed. During endoscopic procedures, continuous monitoring of oxygen saturation with pulse oximetry and pulse rate/ blood pressure should be recorded every 5 minutes. Doses and routes of administration of all medications including reversal agents used during the procedure should be documented. Any event that requires premature termination of the procedure should be documented. 

Capsule endoscopy provides a non-invasive investigation in patients with mainly lower gastrointestinal tract symptoms. CE is accepted as a modality in patients with overt and occult small-bowel bleeding, Crohn’s disease, evaluation of refractory celiac disease, surveillance of polyposis syndromes and evaluation of suspected small-bowel tumors. However, CE requires longer times (30-60 minutes) for the reading and reporting of findings. CE can also miss certain lesions due to their subtle nature as well as due to reporter experience and fatigue. The main quality metric of CE focuses on video quality itself through the use of subjective video assessments by human observers, and on appropriate video analysis by healthcare professionals through appropriately trained and experienced reporters. For preprocedural metrics, the healthcare provider should be aware about the absolute contraindications such as luminal stenosis, unless surgery is planned and known, or suspected luminal perforation/obstruction. The relative contraindications include swallowing disorders, pregnancy, and implantable cardiac devices as advised by the manufacturer; however, ESGE no longer deems these devices a contraindication to CE. All patients undergoing CE should be evaluated for risk factors for capsule retention, including Crohn’s disease, history of small-bowel obstruction or previous resection, previous abdominal or pelvic radiotherapy, chronic use of a high-dose (NSAID), and known stricture or mass. If any of these conditions are present or the patient has symptoms concerning for obstruction, results from a patency capsule test, a CT or MR enterography procedure, or a combination of these procedures should be obtained before standard capsule administration. In patients with swallowing disorders or for patients at risk of gastric retention, endoscopic placement of the CE into the small intestine can overcome the risks associated with these conditions. Furthermore, adequate bowel preparation is needed for appropriate visualization of the mucosa that consists of a low residue diet, two days prior to the procedure, with a clear liquid diet starting after lunch the day prior to the procedure and an overnight fast. The addition of a purgative such as 2-4 liters of polyethylene glycol during the day prior to the procedure and the use of antifoaming agent such as simethicone 300 mg, 20 minutes before swallowing the capsule improve the diagnostic yield of capsule endoscopy. However, some studies showed that, liquid diet during the day prior to administration of the endoscopic capsule, together with overnight fasting, is a sufficient preparation to achieve a good level of cleanliness of the small bowel. The use of prokinetic such as metoclopramide 10 mg administered orally 15 min before swallowing the capsule, enhance gastric and intestinal transit time and improve the percentage of complete study. With the new generation of capsules whose batteries last longer, the extended transit time represents a lesser problem; however, prokinetics could still offer advantages in diabetic patients and in those patients with prolonged intestinal transit time e.g., patients confined to the bed. Intra-procedural quality guidelines include ensuring that the sensing pads or belt is properly secured to the patient at all times. At the post-procedural stage, patients should be educated on ensuring that the capsule has spontaneously passed, as capsule retention can occur in 1.2-4.6% of cases, depending on the underlying indication for CE. Capsule retention occurs when the capsule does not spontaneously pass within two weeks since ingestion of the device. Abdominal radiography at 2 weeks should be requested if the capsule has not been observed to pass. If capsule retention occurs, endoscopic or surgical intervention to retrieve the capsule should be considered. Furthermore, the patient should be informed to avoid magnetic resonance imaging until the capsule is egested. When CE is performed, photo-documentation and description of lesions of interest and certain anatomic landmarks are the standard protocol. The first duodenal and first cecal images enable calculation of the small bowel transit time. Patients should be instructed to avoid undergoing MRI until the capsule has been expelled, to avoid risk of capsule migration leading to bowel injury and interfering with imaging quality. In order to have an adequate view of the small bowel mucosa and to avoid incomplete examinations, it is recommended that each endoscopy unit develop its own protocol to review the indications/contraindications of the procedure, explain the pre-procedural dietary and medication instructions, to follow up the results of the preparation and modify the bowel preparation protocol if required. Summary of recommended quality indicators for endoscopic procedures Post-Procedure Documentation is required that the patient has met the discharge criteria before discharge from the endoscopy unit. Written instructions should be provided to the patient before discharge that include: dietary restrictions, resumption or change in medications, prescription of new medications, return to activities such as driving, and contact information should an adverse event or question arise. When biopsy is obtained, a clear plan for follow up of pathology results should be documented. Every endoscopic procedure should have a detailed report completed in a timely manner. The results of the endoscopic procedure and followup recommendations must be communicated to the referring provider or primary care physician, and this communication should be documented. 

Besides following the established quality guidelines, endoscopists are expected to gather their performance data and generate procedure reports. These reports should include information about the indication, diagnosis, duration, sedation, anatomical extent, complexity grade, ASA grade, and immediate adverse outcomes. Some data can be challenging to collect such as endoscopist-specific patient satisfaction and delayed adverse outcomes. These can be collected through the help of hospital administration and call centers. All data should be uploaded to appropriate resources that will then generate an internal report card with the summary of the endoscopists’ performance and compare it with the performance of other peers. In general, endoscopy quality improvement may take many different forms, such as setting quality assurance standards, using key performance indicators, auditing and helping endoscopists to achieve higher performance standards, improving endoscopy training, enhancing patient experience, and managing endoscopy services and units. The British Society of Gastroenterology (BSG), for example, has taken a comprehensive approach to quality improvement by initiating the Endoscopy Quality Improvement Program. This program includes different forms of quality improvement for upper gastrointestinal endoscopy, lower gastrointestinal endoscopy, ERCP, small bowel endoscopy, and endoscopic ultrasound. Similarly, the Korean government has initiated the National Endoscopy Quality Improvement Program, including a comprehensive list of structural, process, and outcome quality metrics. One of the greatest challenges for endoscopic quality improvement projects is to prioritize the most important quality indicators. As explained by Cohen and Pike, there are too many quality metrics that make healthcare professionals overburdened and confused. In their study of endoscopic quality indicators, Day et al . identified five priority measures that should be adopted by endoscopy units, that include a defined leadership structure in the unit, regular education and training programs, recording and monitoring of both individual and unit-level endoscopy quality indicators, sharing of procedure reports, and proper maintenance and tracking of each endoscope. 

Patient Reported Outcomes Measures (PROMs) and Patient Reported Experience Measures (PREMs) can provide valuable information for improvement in quality of care. A prospective study assessed data from 2808 ERCP procedures. Patient questionnaires were returned for approximately 50% of cases. These PROMs identified female sex and longer procedure times to be predictors of increased procedure related pain. This demonstrates the importance of the use of PROMs/PREMs as a quality metric. Moreover, a meta-narrative review identified 3688 abstracts in search for patient derived and validated endoscopy specific experience measures, none were found. Endoscopy specific PROM questionnaires need to be set in place, analyzed and monitored to improve quality in endoscopy. Another important consideration for the future is the role of artificial intelligence (AI) in medicine, which has been exponentially growing in recent years. Using advanced deep learning technology, endoscopists will be able to provide a more accurate diagnosis. This technology is said to be able to automatically detect and classify endoscopic lesions. However, obtaining high-quality images is a defining prerequisite for AI in endoscopy. AI in endoscopy using convolutional neural network has shown promising results in detecting gastrointestinal pathologies and will likely play a major role in diagnostic imaging in the near future . 

The field of endoscopy has experienced significant advances in quality improvement and implementation of mandatory quality metrics. As shown in this paper, there are both general and specific quality guidelines for all endoscopic procedures, including EGD, colonoscopy, ERCP, endoscopic ultrasound, and capsule endoscopy. Quality indicators can be categorized based on their nature (structural, process, and outcome) and sequence (pre-procedural, intra-procedural, and post-procedural). Many systems of indicators have been proposed by different professional societies and organizations. Therefore, there is currently a need to develop a universal system to avoid overburdening and confusing healthcare professionals with diverse approaches to quality improvement. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. 

Nil. 

There are no conflicts of interest. 

