Background A perceived increase in the use of biliary stents during endoscopic retrograde cholangiopancreatography (ERCP) was observed by our nursing team leader and brought to the attention of the Director of Endoscopy. Purpose To assess a) biliary stent utilization during ERCP, b) the adherence for stent placement based on published guidelines, and c) the associated cost. Method A chart review of all consecutive patients that underwent ERCP for one year (January 2020 to 2021) at the University of Alberta Hospital (UAH) was performed. The need for biliary stent placement was assessed independently by two blinded reviewers and compared with published guidelines. Costs were calculated using Alberta Health Services fee codes. Result(s) A total of 598 patients (316 F) with mean age of 60±19 years (range 3-99 years) underwent 842 ERCPs. Clinical indications for the initial ERCP were common bile duct (CBD) stones (376, 63%), malignant stricture (84, 14%), benign stricture (49, 8%), bile leak (27, 5%), stent removal (15, 3%), and others (47, 8%). Of the 244 patients that had a follow-up ERCP, the most common indications were stent removal (126, 52%), stent replacement (61, 25%), stent placement (28, 11%), and stone extraction (8, 3%). A total of 296 biliary stents were inserted, of which 223 stents (114 plastic, 109 metal) were inserted during the first ERCP (223/598, 37%) and 73 stents (43 plastic, 30 metal) during follow-up ERCP (73/244, 30%). Of the 296 stents, 79 (27%) were inserted for indications not in accordance with published guidelines (63/223 initial ERCP, and 16/73 follow-up ERCP, kappa=0.62). Most of these were placed in CBD stone cases (61/63 initial ERCP, 6/16 follow-up ERCP). In the subgroup of 376 patients with CBD stones, 61 (16%) underwent stent placement not in accordance with published guidelines. The added cost of such stent insertions and follow-up ERCPs for stent removal was $130,000. Conclusion(s) Stent insertion not in accordance with published guidelines was identified in some patients with CBD stones presenting for ERCP. To reduce unnecessary follow-up procedures and healthcare resource utilization, ERCP stent insertion education based on published guidelines, as well as regular practice audit and feedback are required. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared
Background A retrospective chart audit was performed to review biliary stent utilization from January 2020 to 2021 at the University of Alberta Hospital (UAH). Inappropriate stent usage was identified in 16% of patients with common bile duct (CBD) stones presenting for endoscopic retrograde cholangiopancreatography (ERCP). To improve this clinical practice, a quality improvement (QI) initiative was developed and completed. Purpose To reduce the number of inappropriately inserted biliary stents in patients with CBD stones. Method The results of the chart audit (pre-intervention) were shared with the ERCP group. The QI intervention was to align biliary stent insertion in accordance with published guidelines. A chart audit (post-intervention) was then performed on all ERCPs from July, 2021 to June, 2022. The indication for biliary stent insertion was assessed independently by two blinded reviewers. Result(s) A total of 661 patients (337 F) with mean age of 59±19 years (range 12-98 years) underwent 885 ERCPs during this post-intervention period. Of the 661 patients, 384 (58%) were referred for CBD stones. A total of 192 biliary stents (105 plastic, 85 metal) were placed during the first ERCP (192/661, 29%), as compared to the pre-intervention year (223/598, 37%, p=ns). However, only 13/192 stents (7%) were placed not in accordance with published guidelines (kappa=0.53), compared with 63/223 (28%) in the pre-intervention year (p<0.0001). This accounts for a 75% reduction in overall unnecessary stent placement. This reduction was mainly seen in the CBD stone subgroup, where there was an 88% reduction in inappropriate biliary stent placement compared to the pre-intervention year (8/384, 2% vs. 61/376, 16%, p<0.0001). Image Conclusion(s) Education to align practice in accordance with published guidelines has demonstrated a significant improvement in biliary stent insertion during ERCP in patients with CBD stones. This has resulted in significantly fewer inappropriate stent placements, a reduction in unnecessary follow-up ERCPs, and an overall saving of healthcare resources. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared
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