Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada.
Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudia Arabia.
BMJ Open Gastroenterol. 2024 Aug 21;11(1):e001375. doi: 10.1136/bmjgast-2024-001375.
A retrospective chart audit was performed to review biliary stent utilisation from January 2020 to January 2021. Non-guideline-based stent insertion was identified in 16% of patients with common bile duct (CBD) stones presenting for endoscopic retrograde cholangiopancreatography (ERCP). To improve this knowledge-practice gap, a quality improvement (QI) intervention was devised and trialled.
To synchronise clinical indications for biliary stent insertion in patients with CBD stones in accordance with published guidelines.
Using a QI pre-post study design, chart audits were completed and shared with the ERCP team (n=6). Indication for biliary stent insertion was compared to published guidelines assessed by two reviewers independently ( statistic calculated). The QI intervention included an education session and quarterly practice audits. An interrupted time series with segmented regression was completed.
A total of 661 patients (337 F), mean age 59±19 years (range 12-98 years), underwent 885 ERCPs during this postintervention period. Of 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 with the preintervention year (223/598, 37%, p=0.2). Furthermore, 13/192 stents (7%) were placed not in accordance with published guidelines (=0.53), compared with 63/223 (28%) in the preintervention year (p<0.0001). A 75% reduction in overall avoidable stent placement was achieved with a direct cost avoidance of $C97 500. For the CBD stone subgroup, there was an 88% reduction in avoidable biliary stent placement compared with the preintervention year (8/384, 2% vs 61/375, 16%, p<0.0001).
Education with audit and feedback supported the closing of a knowledge-to-practice gap for biliary stent insertion during ERCP, especially in patients with CBD stones. This has resulted in a notable reduction of avoidable stent placements and additional follow-up ERCPs and an overall saving of healthcare resources.
对 2020 年 1 月至 2021 年 1 月期间的胆道支架使用情况进行了回顾性图表审核。内镜逆行胰胆管造影术（ERCP）时发现，16%的胆总管（CBD）结石患者存在非指南推荐的支架置入。为了缩小这一知识与实践之间的差距，设计并试行一项质量改进（QI）干预措施。
根据已发表的指南，协调 CBD 结石患者胆道支架置入的临床指征。
采用 QI 前后研究设计，对 6 例 ERCP 团队进行图表审核（n=6）。由两名独立评审员评估胆道支架置入指征是否符合已发表的指南（计算统计学）。QI 干预措施包括一次教育会议和季度实践审核。完成了中断时间序列和分段回归分析。
共有 661 例患者（337 例女性，平均年龄 59±19 岁[范围 12-98 岁]）在干预后期间进行了 885 例 ERCP。在 661 例患者中，有 384 例（58%）因 CBD 结石就诊。在首次 ERCP 时共放置了 192 个胆道支架（105 个塑料支架，85 个金属支架）（192/661，29%），而在前一年（223/598，37%，p=0.2）。此外，与前一年相比（13/192，7%），有 13 个支架（13/192，7%）的放置不符合已发表的指南（=0.53）。在 CBD 结石亚组中，与前一年相比（8/384，2%），可避免的胆道支架放置减少了 88%（8/384，2% vs 61/375，16%，p<0.0001）。
教育与审核和反馈相结合，为 ERCP 期间胆道支架置入缩小了知识与实践之间的差距，特别是在 CBD 结石患者中。这导致可避免的支架放置以及额外的后续 ERCP 减少，同时节省了整体医疗资源。
