Impact of endoscopic ultrasound quality assessment on improving endoscopic ultrasound reports and procedures

Table 1 Endoscopic ultrasound quality indicators (American Society of Gastrointestinal Endoscopy 2006)

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

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

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

EUS: Endoscopic ultrasonography; NPO: Nil Per Os; FNA: Fine needle aspiration.

Table 2 Endoscopic ultrasonography quality indicator frequencies and comparative statistical analysis

EUS QIs	Rambam 2013-2014 EUS reports % documented (n = 200)	WJGE Lachter et al 2013 (data from 2009), EUS reports % documented (n = 100)	Improvement significance (P value)
Pre-procedural
Indications for procedure	99%	97%	NS
Detailed patient description from referring physician	100%	8%	P < 0.001
Minimum 6 h NPO	100%	40%	P < 0.001
Antibiotics per protocol prior to FNA of pancreatic cysts	99.5%	94%	P = 0.0014
Listing of anesthesia administered prior to and during EUS	100%	61%	P < 0.001
Patient signed agreement of informed consent	100%	61%	P < 0.001
Intra-procedural
Suspected pancreatic lesions should include parenchymal description of body, head, tail, and duct	95%	64%	P < 0.001
CBD and GB contents should be detailed and a description for sludge, stones or other findings	98%	0%	P < 0.001
LN detailed description as well as kidney and left liver lobe for lesions	50%	35%	P = 0.04
Celiac axis described for arterial structure along w/aorta, SMA and LNs	13%	5%	NS
Description by TNM system	100%	95%	NS
Detailing of lesions and surroundings in accordance with layers visualized by EUS	75%	65%	NS
Degree of tumor penetration into organ mucosa and surrounding structures	80%	46%	NS
Detailing presence of LN when suspicious for malignancy and when performing FNA	100%	6%	P < 0.001
Presence or absence of mechanical problems or difficulties including past abdominal surgeries or ascites	100%	2%	P < 0.001
Patient awakened or uncooperative during procedure	78%	-	-
No. of passes (FNA)	67%	-	-
Needle size	99%	-	-
No. of needles	40%	-	-
Impressions of aspirate (bloody, mucinous, color)	100%	-	-
Cytology/histology	100%	-	-
In-room tentative Dx	100%	-	-
Post-procedural
Summary of Dx	95%	37%	P < 0.001
Exam findings, even if not relevant to reason for EUS referral	100%	80%	NS
Physician recommendations with respect to exam findings	99%	52%	P < 0.001
Instructions for how patient will receive results	100%	0%	P < 0.001
Incidence of adverse events should be listed

NS: Not Significant; Dx: Diagnosis; LN: Lymph node; TNM: Tumor node metastasis; EUS: Endoscopic ultrasonography; NPO: Nil Per Os; FNA: Fine needle aspiration; CBD: Common bile duct; GB: Gallbladder; SMA: Superior mesenteric artery.

Table 3 Indications for endoscopic ultrasonography referral

	Rambam 2013-2014 EUS reports	2009 EUS reports
Suspected CBD stone	19%	31%
Pancreatic tumor suspicion	8%	17%
Pathologic findings on imaging	19%	16%
Suspicion of esophageal or stomach tumor	6%	12%
Pancreatic cyst	8%	8%
Pancreatitis	6%	3%
FNA/biopsy	11%	-
Submucosal lesion clarification	4%	-
Screening/followup	5%	-
Other	12%	-

EUS: Endoscopic ultrasonography; FNA: Fine needle aspirations; CBD: Common bile duct.