**8.2 Quality measurement**

10 Gastrointestinal Endoscopy

rate varies among countries and even among centres of the same country. The use of sedation improves the tolerance and acceptance of gastrointestinal endoscopy (Bell 2004) but increases the cost of the procedure and is responsible for about 50% of the GI endoscopy

Sedation for gastrointestinal endoscopy may induce central respiratory depression and/or airway obstruction. Early diagnosis and treatment of these complications is mandatory and

Current recommendations for monitoring include patient responsiveness, blood pressure, respiratory rate and oxygen saturation. Oxygen saturation is a critical vital sign, but there can be a significant delay between inadequate ventilation and desaturation. Supplemental oxygen can dangerously increase this disconnect. Thus one must monitor adequacy of

Appropriate supervision and training is critical for developing skills necessary to perform conscious sedation. There is uniform agreement in the literature and all relevant societal guidelines agree that specific training is needed for both endoscopic procedure and any sedation associated with the procedure (America Society of Anaesthesiologists 2002, ASGE

There are no published studies on the use of sedation in most African countries including Nigeria. This is partly because there are no guidelines in place to regulate the use of sedation in gastrointestinal endoscopy. Similarly the rate and type of sedation employed by endoscopists in these countries is not known. However, it is tempting to assume that endoscopists in developing countries either undersedate their patients or avoid sedation all together in order to avoid the attendant increase in cost and increase in complications.This is because the endoscopists do not have any special training in the use of sedatives and the centres where they work do not always have the basic facilities to monitor patients adequately during the procedures. One consequence of this situation is that patients who find the procedure seriously unpleasant because they were not sedated may not only refuse future examination but spread concern to others. A meta-analysis showed sedation to achieve better patient cooperation and satisfaction and willingness to have it repeated.

The development of quality assurance is a major task of the Health authorities in liaison with experts issued from the respective medical societies. It also applies to the hospital environment as well as to practitioners who have to be submitted to certification, after the report from expert visitors. Accreditation of gastroenterologists and certification of hospitals

In Nigeria, the postgraduate medical colleges (West African College of Physicians/Surgeons and the National Postgraduate Medical College) undertake periodic accreditation visits to

are done periodically to ensure that standards do not go below prescribed levels.

ventilation by direct observation, auscultation and/or end-tidal CO2 monitoring.

complication rates (Lazzaroni et al 2005).

**7.1 Monitoring** 

**7.2 Training for sedation** 

2008, Cohen et al 2007).

(McQuaid et al 2008).

**8. Quality assurance** 

**8.1 Accreditation and certification** 

**7.3 Situation in developing countries** 

this can only be accomplished by patient monitoring.

There are inherent difficulties of measuring quality in gastrointestinal endoscopic procedures. This is particularly so because complications are rare. Because mortality is negligible, rates do not vary greatly among physicians. Also there is a lack of surrogate measurable outcome measures in GI endoscopy. Measuring the process is the alternative but, again, there has not been any significant progress in process measurement.

Quality measurement is even more problematic in developing countries because of a general lack of baseline. There are no guidelines in place that reflect the peculiar economic realities in these countries.
