QUALITY ASSURANCE IN ENDOSCOPY

The colonoscopist needs to judge whether he/she is competent to remove a lesion and whether it is safe to remove the lesion in this setting. On the basis of good practice it is recommended that if there is doubt, the lesion must be appropriately documented and the patient referred elsewhere to have the lesion removed

Thus, when considering where endoscopic screening services are to be located, the commissioner should be aware of how often a patient may need to be referred elsewhere. If it is expected that referral somewhere else will be a frequent occurrence (perhaps >1% of patients) then it is better to consider locating the service elsewhere, i.e. where the competence of the available endoscopists would permit less referral. 

To help in the planning of location of endoscopic services for screening, the following five levels of competency are proposed. 

Level 0: The operator does not remove any lesions, referring on all patients with any detected lesions. The operator will be able to biopsy lesions, and pathological material may inform the decision to refer. Basic level of competency for diagnostic FS but not recommended for screening FS. 

 Level 1: Removing lesions <10 mm in diameter at FS. Rationale: larger lesions will indicate a need for colonoscopy and can be removed when the colonoscopy is performed. Tissue is required from smaller lesions to decide whether colonoscopy is necessary. Thus any person performing FS screening should have this level of competency. 

 Level 2: Removing polypoid and sessile lesions <25 mm providing there is good access. All colonoscopists should have this level of competency. 

 Level 3: Removing smaller flat lesions (<20 mm) that are suitable for endoscopic therapy, larger sessile and polypoid lesions, and smaller lesions with more difficult access. Some flat lesions <20 mm with poor access might be unsuitable for this level. Any person doing colonoscopy for positive FOBT in a screening programme should have this level of competency. 

 Level 4: Removing large flat lesions or other challenging polypoid lesions that might also be treated with surgery. This is the type of lesion that would not be removed at the first colonoscopy because of time constraints, if applicable, or because the surgical option needs to be discussed with the patient. If the patient chooses to have endoscopic therapy, then he/she should be referred to a level 4 competent endoscopist. This level of competency would be expected of only a small number of regionally based colonoscopists. 

In the context of colorectal screening and diagnosis in Europe, units only providing Level 0 competencies are not recommended, because unnecessary endoscopic procedures would be required to remove small lesions which could have been removed during the initial FS. Furthermore, unnecessary colonoscopies may be encouraged in the absence of histopathological evaluation of small lesions left in place during the initial FS.