Establishing a quality indicator format for endoscopic ultrasound

Table 1 Endoscopic ultrasound quality indicators

Pre-EUS indicators

Indications for procedure

Detailed description of the patient by the referring physician

Patient completed procedural preparation of minimum 6 h NPO

Antibiotics per protocol were given in the need to perform FNA of pancreatic cysts

Listing of sedatives administered prior to and during EUS

Patient signed agreement of informed consent for EUS and/or if consented for research study

Intra-procedural indicators

A detailed description of the methods used to visualize routinely evaluated EUS organs. If there is any suspicion of organ pathology, the respective organ parenchyma should be described:

Suspected pancreatic lesions should include a parenchymal description including the body, head, tail, and duct

Common bile ducts and gallbladder contents should be detailed and a description of the biliary tree for sludge, stones, or other findings

If found, prominent lymph nodes should be described in detail as well as the kidneys and left liver lobe for the presence or absence of lesions

The celiac axis should be described for general arterial structure along with the aorta and superior mesenteric artery as well as the presence or absence of identifiable lymph nodes

Description of abnormal/pathological results:

Description of any tumor by the tumor, node, and metastasis system

Accurate detailing of the lesions and its surroundings in accordance with layers visualized by EUS

Degree of tumor penetration into organ mucosa and surrounding structures

Detailing the presence of lymph nodes when suspicious for malignancy and when performing FNA

Intra-procedural issues

Presence or absence of any mechanical problems or difficulties including past abdominal surgeries or ascites

Patient awakened/uncooperative during the procedure

Details of the number of FNAs performed with respective number of passes into each suspected lesion including:

Number of passes

Needle size

Number of needles

Impressions of aspirate (bloody, mucinous, color, etc.)

Cytology and/or histological examination

In-room tentative diagnosis

Post-procedural indicators

Summary of medical diagnoses

Examination findings, even if not relevant to the reason for EUS referral, should be listed

Physician recommendations shall be listed with respect to examination findings including instructions for the patient

Instructions for how patients will receive the results and for referring physician

After EUS, the incidence of adverse events should be listed, including pancreatitis, bleeding, and/or infections and the need for hospitalization

The above table is the standardized table of endoscopic ultrasound (EUS) quality indicators. This includes an itemized list for documentation prior to, during, and after performing EUS. FNA: Fine needle aspiration.

Table 2 Indications for endoscopic ultrasound referral

Reason for EUS referral	Percent of cases
Suspected choledocholithiasis	31%
Pancreatic tumor suspicion	17%
Pathologic finding of imaging	16%
Suspicion of esophageal of stomach Tumor	12%
Pancreatic cyst	8%
Pancreatitis	3%
Obstructive Jaundice	3%
Other	19%

The above table displays the various main reasons for endoscopic ultrasound (EUS) referral. Although most commonly due to gallstone of pancreatic pathology, one can observe that EUS may be used to diagnose and to stage other areas in the gastrointestinal tract and surrounding areas.

Table 3 Endoscopic ultrasound pre-procedural, tumor-associated, post-endoscopic ultrasound quality indicators

Quality indicators	Percent
	documented
EUS pre-procedural1
Listed indications for procedure	97%
Detailed patient description from the referring phycisian	82%
Received minimum six hour fast	8%
Given antibiotics per protocol prior to FNA of pancreatic cyst	40%
Listing of anesthesia administered prior to starting EUS	94%
Patient signed agreement of informed consent	61%
EUS findings consistent with or highly suspicious for tumor2
Description by the TNM system	5%
Tumor description (or suspected)	78%
Description of degree of tissue invasion	65%
Presence or absence of lymph nodes	46%
Reports malignant or suspicious lesions	48.50%
Post-EUS3
Summary of medical diagnoses	81.90%
Examination findings, even if not relevant to the reason for EUS referral, should be listed	37.20%
Treatment recommendations with respect to examination findings	79.80%
Advice given to patients after performing EUS	52.10%
Incidence of adverse events, including pancreatitis, bleeding, and/or infections and the need for hospitalization	0%

¹The above chart lists the percent of endoscopic ultrasound (EUS) reports in which pre-procedural quality indicators were documented. Indications and anesthesia were most frequently listed, while pre-procedural preparation, administration of antibiotics prior to fine needle aspiration of pancreatic cysts, and signing informed consent were less often listed in reports;

²This chart demonstrates the adherence to EUS quality indicators for lesions consistent with or suspected to be of malignant etiologies. Although tumors and depth of invasion were commonly described, the tumor, node, and metastasis system was seldom used;

³This table lists the physician adherence to post-procedural EUS quality indicators. Diagnoses, procedural findings relevant to reason for referral and treatment recommendations were most often documented whereas findings inconsistent with the reason for referral, post-procedural patient advice, and listing adverse events were far less often emphasized. FNA: Fine needle aspiration; TNM: Tumor, node, and metastasis.