Non-technical skills in the management of endoscopic adverse events

Introduction

Adverse events can occur with any interventional procedures (1). Gastroenterologists are expected to face at least one significant adverse event during their career (2). Colonoscopies are the most commonly performed endoscopic procedure, with a serious adverse event rate estimated to be <1% across large healthcare systems (1,3,4). Specifically during gastroenterology (GI) fellowship training, it has been estimated that a trainee who performs about 500 colonoscopies has a 1:2 to 1:3 odds of experiencing colonic perforation (5). While gastroenterologists have been trained to identify adverse events and the technical aspects of treating them, less emphasis has been placed on the non-technical aspects of preventing and managing endoscopy-related adverse events (2,6).

Non-technical skills embody the cognitive and social skills that are critical to high-quality care and safety outcomes (7). While initially implemented as a framework for pilots, this concept has expanded into the medical field, including GI, called endoscopic non-technical skills (ENTS) (7,8). Commonly cited domains of ENTS include communication, teamwork, situational awareness, leadership, judgment/decision making, and professionalism (8-10). Deficiencies in ENTS are a frequent driver of endoscopy patient safety incidents (11,12). Thus, it is crucial to understand and practice these skills to deliver the best care to patients.

The aim of this review is to explore the different ENTS and how they apply to the prevention or management of endoscopy-related adverse events. Further, this review will also discuss resources and strategies to augment ENTS.

Non-technical skills in GI endoscopy

Communication

Communication is a key non-technical skill that spans both patient-endoscopist communication, as well as team communication. Patient-endoscopist communication starts before the procedure with informed consent, where the procedure is discussed along with risks, benefits, alternatives for the procedure, and any questions or concerns are addressed. A patient-centered (“reasonable patient”) approach to informed consent, where the endoscopist discloses all relevant information to the patient in order to make the most informed decision, is preferred and the most common (6,13). This is in contrast to the physician-centered (“reasonable physician”) approach, where the endoscopist decides the amount of information the patient needs to know. This style can be paternalistic and thus has fallen out of favor (6,13). While there is no evidence-based recommendation on the duration of this conversation, the American Society for Gastrointestinal Endoscopy (ASGE) guidelines recommend that there is appropriate time allocated to ensure this conversation is unrushed, thorough, and allows time for the patient to digest the information and ask questions (14). Additionally, these conversations should be tailored to the patient not only with regards to individual risk assessment for adverse events, but also being conscious of potential characteristics that may affect patient understanding of the risks and benefits of the procedure (e.g. health literacy level, language or cultural barriers, or comorbidities such as cognitive impairment). If desired by the patient, it can be helpful to have family members present for the conversation as well. The American College of Gastroenterology (ACG)/ASGE guidelines on quality indicators for all GI endoscopic procedures recommend that informed consent should always be documented prior to the start of a procedure (15).

The pre-procedural period is also an essential time for physician-patient rapport building. This foundation becomes especially important in the setting of disclosing an endoscopy-related adverse event. When this occurs, the endoscopist should promptly report the adverse event to the patient and possibly their support people. Open, patient-centered language should be used throughout the conversation. There are different frameworks to help guide these difficult conversations, with the common themes of finding a quiet location for the conversation, apologizing, and demonstrating honesty and empathy throughout the conversation (6,16,17).

Effective communication is also required among the endoscopy team. As the leader, the endoscopist should strive to create a safe environment of openness and empowerment for all team members to feel comfortable raising any questions or concerns to promote patient-centered care (18,19). Prior to the procedure, practice robust team communication by discussing the expected procedure with the team. This helps set the team and procedure up for success by having any necessary equipment and ensures all team members feel comfortable with their roles in the procedure. During the procedure, standardized and closed-loop communication is ideal. This is especially important in the setting of an endoscopy-related adverse event, given communication difficulties have been cited as a major system factor leading to errors (20). In the surgical literature, team communication failures were the leading system factor in 24% of surgical error cases that led to patient injury (21). While similar data is currently limited in endoscopy, one study showed that communication challenges contributed to 41% of claims against gastroenterologists after an endoscopic perforation and were associated with a 3.31-fold odds of indemnity payment (22). However, larger data on this is not available and hence it should be interpreted with caution.

Teamwork

Teamwork is another essential ENTS, particularly surrounding endoscopic procedures, given the dynamic nature of the endoscopy team. Endoscopy technicians, nurses, and the anesthesia team frequently rotate with different endoscopists based on scheduling and procedural needs, which requires a recalibration to new team interactions. Additionally, teamwork may extend outside of the endoscopy suite with discussion with colleagues in interventional radiology, oncology, surgery, internal medicine, and other consultants to decide on the best procedural plan of action for the patient.

To start on a strong note and promote cohesion among the various team members, the endoscopist should set expectations and roles for each team member prior to the procedure. A clear understanding of each team member’s abilities and experience, and a strong rapport among the team (e.g., nurse-physician dynamics) can help improve team functioning and collaboration. In the setting of an endoscopic adverse event, team debriefs are helpful to promote reflection on the events that occurred, how to mitigate them in the future, and even improve non-technical skill performance (23,24).

While there are studies evaluating the efficacy of teamwork in other healthcare settings such as the intensive care unit, operating room, and inpatient medicine rounding, studies are currently lacking specifically evaluating teamwork in the endoscopy suite. However, Ravindran et al. developed a preliminary behavior marker system to help support training for endoscopy teamwork, which requires further validation and evaluation (10).

Situational awareness

Flin et al. describe situational awareness as “knowing what is going on around you” (25). The need for situational awareness begins prior to the procedure as the endoscopist reviews the patient’s relevant medical history that may affect the difficulty of the procedure (e.g., inadequate bowel preparation, use of anticoagulants, prior history of difficult sedation). Review of these factors affects the informed consent and preparation for the procedure in terms of equipment and sedation plan, thus prompting the need for collective situational awareness with the entire endoscopy team prior to the procedure. This can be accomplished with a pre-endoscopy safety checklist.

In surgery, introduction of pre-surgical checklists have been found to improve patient morbidity and mortality (26). This prompted similar research within GI with pre-endoscopy safety checklists. Overall, studies have shown success with developing and implementing a checklist, but the direct impact on patient safety outcomes is currently less clear (27-29). However, pre-endoscopy safety checklists appear to improve non-technical skills, including situational awareness, communication, and teamwork (30,31).

Situational awareness is then practiced throughout the procedure, requiring ongoing monitoring of the patient condition and the environment to be on high alert to any changes in the environment or early signs of adverse events (25,32).

Decision making and judgment

Decision making is the “process of making a judgment or choosing an option, sometimes called a course of action, to meet the needs of a given situation” (25). Decision making in endoscopy begins prior to the procedure with personalization of the procedure in terms of equipment and endoscopic plan based on the patient’s status and comorbidities (19). After an endoscopic adverse event occurs, apt decision making is critical and requires consideration of the options, weighing the risks and, prior to making a decision and then reviewing the outcome (8,25). This may include recognizing one’s own limits and being flexible in changing plans as needed. This also includes discussion with endoscopy team members and other peer endoscopists to determine best course of action. For example, if a perforation occurs during a colonoscopy, the endoscopist may weigh attempting endoscopic closure versus surgical consultation based on factors such as the size and location of the perforation. After the procedure, the endoscopist should document the rationale for certain interventions to demonstrate their decision making and plans for the next steps (19).

Leadership

Effective leadership has been the focus of non-technical skill research across many disciplines, such as aviation, business, and manufacturing, and has been shown to improve safety performance (33). The importance of this non-technical skill extends into healthcare as well. If decision making and judgment encompasses the endoscopist’s internal cognitive processing, leadership reflects the execution of the decisions through team coordination and effective communication. While difficult to definitively study the efficacy of leadership with a randomized controlled trial (RCT), a systematic review of 18 healthcare-related studies concluded that effective leadership promotes a high-quality work environment that prioritizes a safe patient environment, which ultimately will lead to positive patient outcomes (34). Within GI, the endoscopist typically serves as the leader during an endoscopic procedure. Thus, it is the responsibility of the endoscopist to set the tone of a safe, supportive working environment.

In the setting of an adverse event during endoscopy, the endoscopist needs to remain calm and take initiative as the leader of the team (32). To achieve better control of a difficult situation, the leader needs to have a clear vision of what their goal of the situation is through effective decision making and then develop the most effective strategy to achieve it, as suggested by Valori et al. with the “Strategic”, “Organizational”, and “Operational” zones to effective leadership (35). From the prior example of discovering a perforation during colonoscopy, the endoscopist decides to attempt endoscopic closure of the defect. For this goal to come to fruition, the endoscopist employs an organizational strategy to have a nurse call an experienced nearby colleague as well as obtain the appropriate equipment to perform defect closure. After the procedure, the endoscopist can demonstrate strong leadership by taking ownership of the patient outcome and resolving any lingering conflicts (19).

Professionalism

Professionalism in healthcare has been defined as “the code of conduct for promoting the best interest of our patients” (6). It requires the “habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection” (36). Given this broad definition, professionalism is infused throughout many aspects of endoscopy and the management of endoscopic adverse events, including the informed consent process, communication after an adverse event, legal issues surrounding endoscopic adverse events, and how to cope as an individual, trainee, and team after an adverse event (6,37).

Methods to improve ENTS

Traditionally, trainees have acquired both technical and non-technical skills through the apprenticeship model, where they are learning from a senior endoscopist. However, over the years, there has been concern about this model and its implication on patient safety and the operations of the endoscopy suite, especially for trainees early on in their endoscopic practice (11,38,39). Thus, there has been an emphasis on using simulation-based training to improve endoscopic skills. While systematic reviews and meta-analysis have not yet supported that simulation-based training is superior and should replace the conventional apprenticeship model, it can be useful as an adjunctive learning method, and may even shorten the learning curve to endoscopic competency (40,41). Further, simulation-based training is a requirement of the Accreditation Council for Graduate Medical Education for GI fellowships in the United States (42).

Studies evaluating the utility of simulation-based training for the development of ENTS can be separated into two categories: endoscopist-focused and endoscopy team-focused studies. In one of the first studies to show that simulation-based training can effectively improve ENTS, Grover et al. validated a comprehensive curriculum that included both technical and non-technical skills for 33 novice endoscopists (43). The curriculum utilized multimodal learning techniques included didactic lectures and virtual reality simulation-based training, and ultimately evaluated performance on two colonoscopies using the Joint Advisory Group Observation of Procedural Skills (JAG DOPS) scale. Compared to the control group, whom only had the virtual reality-based training and a list of objectives, the intervention group performed better in the clinical environment as measured by JAG DOPS, which was felt to be in part due to improved knowledge and non-technical skills derived from the time dedicated to learning about patient experience and safety, as well as approaches to troubleshooting.

Multiple studies have evaluated the outcome of a team-focused interventions to improve non-technical skills, which is especially impactful given successful endoscopic practice relies on a well-functioning team. In a pre-post intervention study, Matharoo et al. sought to determine if non-technical skills training for bowel cancer screening (BCS) endoscopy teams improved patient safety knowledge and attitudes (44). Twenty-three participants, including endoscopists, endoscopy nurses, and administrative staff, underwent a single day training including didactic sessions, interactive discussions, group exercise, and analysis of endoscopy videos. They ultimately found improved knowledge on patient safety and some, but not all, safety attitudes on how this knowledge may influence their attitudes on error management. The authors attributed this to self-selection bias in that the attendees who wanted to attend already were interested in and practiced good safety attitude. Another single-center RCT by Walsh et al. evaluated the impact of a non-technical skills comprehensive curriculum compared to a control curriculum for novice endoscopists (9). Similar to Grover et al., they found improved clinical performance on the first two clinical colonoscopies, as measured by JAG DOPS (9,43). In all, both endoscopist- and team-focused interventions have been helpful in improving ENTS and potentially clinical skills and patient outcomes.

ENTS applicability outside of endoscopic adverse events

While ENTS are critical in the management of endoscopic adverse events, the same core skills can be useful in urgent endoscopic settings such as acute GI bleeding, food impactions, and foreign body retrievals. In the setting of acute upper GI bleeding, communication with the patient and the team may include proactive discussion of what the endoscopist may expect to find and contingency planning if they are not able to find or control the bleeding (e.g., advanced imaging, interventional radiology consultation). When performing the upper endoscopy, situational awareness is key throughout the procedure to stay alert to any signs of decompensation. If active arterial bleeding is noted from a gastric ulcer with an exposed vessel, the endoscopist must use thoughtful decision making to decide what the best method to control the bleeding is (e.g., hemostatic clips, over-the-scope clips, bipolar cauterization, hemostatic spray, epinephrine injection). Effective leadership would help put the decision to use dual therapy with epinephrine injection and then an over-the-scope clip into action by communicating with the team what the next steps will be, and which tools will be needed. After hemostasis is achieved and the procedure ends, the team can debrief how the procedure went and areas for improvement.

Conclusions

ENTS include cognitive and social skills key to endoscopic practice including communication, teamwork, situational awareness, leadership, judgment/decision making, and professionalism. Deficiencies in ENTS are frequently implicated in endoscopy-related adverse events. Thus, the recognition and improvement of ENTS are critical to high-quality patient care and the management of endoscopic adverse events. While early studies are encouraging that ENTS training helps improve knowledge and clinical outcomes, the literature regarding ENTS is currently limited.

Future studies should seek to validate a standardized assessment tool specific for ENTS. Different studies have aimed to create an assessment tool, although some have also incorporated technical skills and/or have not yet been validated (10,45-49). This tool could then be used in larger, multicenter RCTs, which are needed to demonstrate generalizability and long-term efficacy at both the endoscopy team and patient levels. Finally, the outcomes of these studies could help to inform how to best incorporate ENTS curricula into GI fellowship training and endoscopic practice.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-50/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-25-50/coif). M.B. serves as a consultant for Boston Scientific, Cook Medical, and Steris. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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