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We applaud Verma and Chilton1 for publishing their survey on diathermy use for polypectomy which provides evidence of variation in UK practice. On behalf of Joint Advisory Group on Gastrointestinal Endoscopy (JAG),2 the UK quality assurance body for endoscopy, we wish to share our proposals of future workstreams pertinent to diathermy.
Patient safety should be at the forefront of endoscopy practice. Diathermy is a modality which, if delivered inappropriately, has the potential for serious harm. It is recognised that both efficacy and safety of polypectomy vary between endoscopists.3 4 Although such heterogeneity may be explained by individual approaches to polypectomy,5 insights specific to diathermy are now elucidated in this survey. The accruing evidence supports the need for greater standardisation of training in polypectomy and diathermy to safeguard patients.
Nationally, competence in polypectomy is evaluated using direct observation of polypectomy skills (DOPyS) assessments and is a prerequisite for JAG certification for lower gastrointestinal (GI) endoscopy and bowel cancer screening accreditation.6 DOPyS assess two diathermy-specific competencies: knowledge of settings and its application, with candidates required to: ‘demonstrate the application of the appropriate degree of diathermy with no evidence of contralateral burns or cutting through too quickly causing bleeding’. However, the interpretation of this is subjective and at the discretion of the trainer/assessor. Endoscopy certification is undergoing curriculum-wide reforms; JAG is commissioning evidence-based reviews to ensure that competence-assessment tools and certification pathways remain fit for purpose and that certified practitioners can practice safely and effectively. The topic of diathermy remains firmly on the agenda.
Standardised training interventions targeted at trainees (mandatory Basic Skills Courses) and trainers (Train-the-Trainer and upskilling courses) have underpinned the transformation in colonoscopy quality between successive national colonoscopy audits.7 8 As the majority of survey respondents were independent endoscopists,1 the practice variations and knowledge gaps identified may affect the quality of polypectomy training to subsequent generations of trainees. At present, specific polypectomy training courses are not mandated for trainees or for the upskilling of trainers. Within the training pipeline, e-learning modules are being developed for certifiable procedures. While diathermy theory is covered in colonoscopy Basic Skills Courses, reinforcing this learning through diathermy-specific e-learning may support a better understanding of risk, settings and quality standards. Diathermy training may also be delivered via polypectomy simulation,9 enabling assessment and development of trainees’ and trainers’ skills in a protected environment.
Finally, quality improvement revolves around performance monitoring, benchmarking and intervention. Improving Safety and Reducing Error in Endoscopy (ISREE) is a 5-year JAG initiative aimed at improving safety in high-risk practice such as diathermy and will align with endoscopy training workstreams and the National Endoscopy Database (NED). Diathermy and polypectomy have been proposed for inclusion in future iterations of NED, which will require endoscopy reporting systems nationwide to standardise data collection of relevant data fields. This can provide robust UK data on diathermy practice, stratifiable by polyp characteristic, which may permit correlation with patient outcomes and inform future standards relevant to polypectomy. A decade following improvements in diagnostic colonoscopy, it is hoped that these combined measures will facilitate similar improvements in the quality and safety of polypectomy nationally.
Contributors KS: drafted the initial manuscript. AM, PD, GVS and ST-G: refined the content, ensured the integrity of the document in relation to JAG’s views and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests All authors are affiliated with the Joint Advisory Group on Gastrointestinal Endoscopy (JAG). KS and PD are members of the JAG and National Endoscopy Database committee, AM is leading the national review of colonoscopy and polypectomy certification, GVS is chair of the JAG quality Assurance of training working group and ST-G is the chair of JAG.
Provenance and peer review Not commissioned; externally peer reviewed.
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