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Journal of Pediatric Gastroenterology & Nutrition:
NASPGN Position Paper

Requirements for Training to Ensure Competence of Endoscopists Performing Invasive Procedures in Children

Hassall, Eric; Training and Education Committee of the North American Society for Pediatric Gastroenterology and Nutrition (NASPGN), the Ad Hoc Pediatric Committee of American Society for Gastrointestinal Endoscopy (ASGE), and t

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This position paper is accompanied by a letter. Please see: Keeffe EB, Van Dam J: Training in endoscopic procedures. J Pediatr Gastroenterol Nutr 1997;24:366.

Received December 21, 1995; accepted December 28, 1995.

Address correspondence and reprint requests to Dr. E. Hassall at the Division of Pediatric Gastroenterology, B.C. Children's Hospital/University of British Columbia, 4480 Oak Street, Vancouver, B.C. V6H 3V4, Canada.

When endoscopic procedures are performed in children by physicians with the requisite cognitive and technical abilities, safe, rapid, and definitive diagnosis may be made and/or treatment instituted. In contrast, the inappropriate or inexpert use of endoscopy may lead directly or indirectly to poor or unsafe patient outcomes. Clearly, there is a need for guidelines for endoscopic procedures to optimize the safety, quality, and appropriate use of endoscopic procedures in children. In recognition of these issues, the American Society for Gastrointestinal Endoscopy (ASGE) has for many years specified standards for training and credentialing for endoscopists performing procedures in adults.

The purpose of this document is to provide guidelines for minimum standards of competence in gastrointestinal endoscopy in children. Trainees in pediatric gastroenterology should have met these guidelines by the end of their training, and those attending pediatric gastroenterologists who perform procedures should possess these minimum standards for the purposes of hospital credentialing. The following principles are pertinent to the guidelines that follow.

1. It is recognized that not all attending pediatric gastroenterologists perform or are expert in endoscopic procedures. Therefore, in any given pediatric unit in which endoscopic procedures are performed in children, a suitably qualified and experienced Endoscopy Training Director is responsible for endoscopy training.

2. The essential clinical cognitive skills of a pediatric gastroenterologist are a prerequisite to certification of competence with pediatric endoscopic procedures.

3. Overall competence with endoscopic procedures is comprised of technical, diagnostic, and therapeutic competence. These terms are defined below. It is recognized that purely technical competence usually precedes diagnostic competence, the latter requiring an integration of an extensive knowledge base in pediatric gastroenterology together with precise endoscopic visual skills.

4. In this document, the terms “endoscopy” and “invasive procedures” include endoscopic and nonendoscopic procedures. Specifically included are esophageal dilatation and percutaneous liver biopsy, because these are procedures with potentially significant risk to patients.

5. For the purpose of this document, the terms “pediatrics” or “children” refer to newborns, children, and adolescents up to the age of 16 years.

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ENDOSCOPY TRAINING IN PEDIATRICS

Defining Competence

1. Technical competence is defined as

A. Knowing the indications and contraindications for the procedure in children.

B. Understanding the principles of and knowing how to safely administer sedation.

C. Demonstrating technical and troubleshooting knowledge of the equipment.

D. Mastery of the mechanical performance of procedures in children.

E. Knowledge of equipment appropriate to children of different ages, sizes, and diagnoses.

F. Appreciating the risks of complications, including avoidance, diagnosis, and treatment as they pertain to children.

2. Diagnostic competence is defined as the ability to accurately recognize the vast majority of the lesions seen, and the clinical relevance of a lesion in a given patient.

3. Therapeutic competence is defined as the ability to recognize whether a particular therapeutic procedure is indicated in a given patient, and the ability to safely and successfully perform that procedure in the majority of children.

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Objectives of Training

Training in pediatric GI endoscopy should be designed to ensure competence. As such, the endoscopist should be able to

1. recommend the procedure based on consultation findings and consideration of indications, contraindications, and diagnostic/therapeutic alternatives.

2. perform procedures safely and successfully in a timely fashion.

3. correctly interpret the vast majority of findings.

4. integrate findings into the patient management plans.

5. understand risk factors, recognize and manage complications.

6. recognize personal and procedural limits and know when to request help.

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Training Institutions

1. Training in pediatric GI endoscopy should be limited to those institutions with certified subspecialists in pediatric gastroenterology, pediatric surgery, radiology, and pathology, with exposure of trainees to those disciplines.

2. Each training program must designate an Endoscopy Training Director, who is skilled in the performance of standard procedures (defined in Table 1).

Table 1
Table 1
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3. The Endoscopy Training Director is responsible for

A. ensuring that trainees learn all appropriate technical and cognitive skills from competent teachers.

B. incorporating endoscopic teaching materials, books, atlases, and videotapes into the training program.

C. periodically reviewing and updating training methodology and the quality of training in the GI Procedures Unit.

D. reviewing on a regular basis with the trainee the trainee's procedure log, for the purposes of assessing the trainee's progress and determining when the trainee has attained competence in a specific procedure.

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Procedures

1. For certification of endoscopic competence, a candidate must have satisfactorily completed training in pediatric gastroenterology. The content of that training must meet the syllabus requirements of either the Sub-Board of Pediatric Gastroenterology and Nutrition of the American Board of Pediatrics or the Pediatric Gastroenterology Section of the Royal College of Physicians and Surgeons of Canada.

2. Standard procedures are those in which every pediatric gastroenterologist should possess competence.

A. Certification of competence requires:

I. Performing satisfactorily under direct supervision a minimum number of cases for each procedure, performed personally by each trainee, as in Table 1.

II. Signature of satisfactory completion of the standard procedure log and directly observed level of competence by the Endoscopy Training Director.

B. Certification of competence should be required to obtain hospital privileges to perform endoscopy in children, whatever definition of “child” is used by that hospital.

3. Attaining the requisite numbers. No more than 20% of the procedures in each category (not overall) may be performed in patients >16 years of age. In the case of percutaneous liver biopsy, the minimum of 10 procedures must all be performed in children 16 years or younger.

4. Advanced procedures.

A. Advanced procedures are not required for certification of competence of pediatric GI endoscopists.

B. The category of advanced procedures includes pneumatic dilatation for achalasia, all endoscopic retrograde cholangiopancreatography-related diagnostic and therapeutic techniques, laparoscopy, esophageal stent placement, endoscopic tumor ablation, and techniques of hemostasis other than variceal sclerosis or banding.

C. Pediatric gastroenterologists wanting advanced endoscopy training are encouraged to follow the ASGE program for advanced training.

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ONGOING COMPETENCE

Maintenance of Skills

Skills acquired with a large initial experience may require fewer procedures to maintain skills; however, a minimum number of cases for each major procedure category should be required to maintain privileges.

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Designation of Expert Endoscopist

For attending pediatric gastroenterologists who do not perform procedures on a regular basis, an expert pediatric endoscopist/s should be designated to perform and supervise procedures.

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New Procedures

As endoscopy evolves, new procedures develop for which privileges may be requested. The process for credentialing depends on the background skills and privileges of the applicant and whether the new procedure is a minor or major variant of established techniques. For minor extensions of demonstrated skills, reading or viewing videotapes may be sufficient training. Some new procedures may require formal training or “hands-on” equivalent supervised experience with adequate written documentation. Endoscopic sphincterotomy is an example of an extremely complex and high-risk procedure requiring extensive training and experience. Therefore, privilege granting for endoscopic sphincterotomy requires documented competency.

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RELEVANT READING

ASGE Guidelines on The Standards of Practice of Gastrointestinal Endoscopy

ASGE Statement on Endoscopy Training

ASGE Statement on Methods of Granting Hospital Privileges to Perform Gastrointestinal Endoscopy

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Training and Education Committee of NASPGN

Eric Hassall, M.B.Ch.B. F.R.C.P.(C.). (Chair), Vancouver, B.C.; Susan Orenstein, M.D. Pittsburgh, PA; Phil Rosenthal, M.D., San Francisco, CA; Jim Wright, M.D., Birmingham, AL; Colin Rudolph, M.D. Ph.D., Cincinnati, OH; Richard Schreiber, M.D. F.R.C.P.(C.), Montreal, PQ; Mike Hart, M.D., Atlanta, GA.

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Ad Hoc Pediatric Committee of ASGE

Robert Wyllie, M.D. (Chair), Cleveland, OH; William Treem, M.D., Hartford, CT; William Byrne, M.D., Oakland, CA; Richard Colletti, M.D., Burlington, VT; Marsha Kay, M.D., Cleveland, OH; Eric Hassall, M.B.Ch.B., F.R.C.P.(C.), Vancouver, BC.

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