Maintaining ercp capacity and high quality key performance quality indicators (Kpis) during the challenge of covid-19 restrictions: What have we learnt?

2021 
Introduction: COVID-19 has negatively impacted on the delivery of endoscopy services worldwide. In the UK, national endoscopy database (NED) indicated activity was dramatically reduced by 80-95%1 during the first wave in 2020, due to redeployment of staff, challenges with personal protective equipment (PPE), room air-change cycle and patients' unwillingness to attend during lockdown restrictions. ERCP is a higher-risk procedure often performed in patients with an urgent indication such as cancer obstruction or gallstone-related biliary sepsis or pancreatitis. We aimed to define the impact of COVID-19 on our ERCP service delivery, clinical outcomes, patient safety and endoscopists' KPIs. Aims & Methods: We examined Nottingham ERCP outcomes during the COVID-19 pandemic in 2020 compared to those before in 2019 at a highvolume HPB endoscopy centre serving a local population of 750,000 and tertiary HPB MDT population of 2.3 million. Technical success, comfort rates and complications according to RCP JAG and ESGE quality standards, including 8- and 30-day readmission rates and deaths were recorded. We also assessed the incidence of Covid-19 infection among the population who underwent ERCP. Results: Pre-pandemic, during 2019, 686 ERCP procedures were performed. Of these, 433 (63.1%) were cases of first ever ERCP. In 2020, 614 ERCPs were performed including 390 (63.5%) cases of first ever ERCP. During the COVID-19 pandemic in 2020, compared to 2019, there was no significant reduction in any of: total number of ERCP procedures (619 vs. 686);virgin ERCP successful cannulation of the intended duct (91.3% vs. 89.6%;p=0.8);complete CBD stone clearance (80% vs. 81%;p=0.9);successful stent placement across extrahepatic stricture (91.9% vs. 97.3%;p=0.6);obtaining stricture cytology (85.6% vs. 84.4%;p=0.9). The sensitivity of biliary cytology for cancer (C5 or C4 with compatible imaging/tumour markers or clinical follow up) was 68% vs. 70%;p=0.6. Patient comfort score was recorded as moderate/severe in 6% of cases in 2019 vs. 7.1% in 2020 (p=0.4). Following ERCP, the number of patients re-admitted within 8- and 30-days was 22 (3.2%) and 37 (5.4%) in 2019, versus 30 (4.9%) and 42 (6.8%) in 2020;p= 0.15 and p= 0.3, respectively. All-cause and procedure-related mortality within 30 days from ERCP was 1.6% and 0.14% in 2019 vs. 1.79% and 0.65% in 2020;p=0.8 and p=0.15, respectively. In total, 25/9500 (0.26%) of all patients undergoing any endoscopy tested positive for COVID-19 within 14 days of endoscopy. However, none tested positive following ERCP. Conclusion: Our provision of clinically urgent ERCP during 2020 and the COVID-19 pandemic did not significantly fall due to combination of senior prioritisation of all referrals, accessing unused operating theatres and reducing training lists. Patients underwent ERCP in a safe environment, keeping comfort levels within accepted limits and post-operative Covid-19 infection levels to zero. The endoscopists' KPIs of successful outcome and adverse events were similar despite the challenges of PPE and staff anxieties or exhaustion.
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