The Importance of High-Quality ERCP Services
Endoscopic Retrograde Cholangiopancreatography (ERCP) is one of the most complex and high-risk procedures routinely performed by gastroenterologists. As a fully therapeutic intervention, ERCP requires a comprehensive approach focused on patient safety, a dedicated multidisciplinary team, specialized facilities, and robust clinical governance.
Over the past decade, there have been numerous changes to ERCP practice, yet significant variation in service delivery remains across the UK. In response, the British Society of Gastroenterology (BSG) commissioned an ERCP quality improvement project (EQIP) to establish a clear set of standards for delivering a high-quality and safe ERCP service.
This comprehensive document, developed through national surveys, stakeholder interviews, and consensus-building, outlines 70 key statements covering the entire patient journey – from referral and booking to discharge and follow-up. It provides a detailed template for ERCP service delivery that should now be implemented by all providers to benchmark their services and drive continuous quality improvement.
The Patient Journey: Ensuring Appropriate Referrals and Timely Procedures
Establishing a dedicated ERCP policy is essential to reduce variation in clinical practice and provide clarity on administrative processes and common scenarios. All ERCP units should have a written policy covering areas such as referral vetting, preprocedural assessment, patient consent, safety checklists, complication management, and systems for tracking stent removals.
Referral pathways play a critical role, as incomplete or illegible requests can lead to delays and errors. ERCP units should use standardized electronic request forms that include a minimum dataset to determine procedure appropriateness. Where electronic forms are not immediately possible, paper forms should be legible, complete, and have typed patient demographics.
Appropriate vetting of referrals by an ERCP consultant is essential to avoid unnecessary procedures. Final responsibility for vetting decisions must lie with a nominated ERCP consultant, even if the process is delegated. Particular attention should be paid to identifying patients where ERCP may be avoided, such as when bile duct stones have already passed.
Tracking systems for patients requiring repeat procedures or stent removals are crucial to prevent complications from blocked or buried stents. Units must have a reliable means of monitoring these planned procedures, with an escalation policy if delays occur.
Ensuring Informed Consent and Minimizing Risks
Despite the often urgent nature of ERCP, units must adhere to robust consent processes as outlined in BSG guidance. All outpatients should have the opportunity to discuss the procedure and its risks in advance, either face-to-face or over the phone, with a member of the ERCP team. Inpatients should receive a preprocedural visit from the ERCP team.
The consent form should be signed in a private setting, not in a shared space. ERCP-trained nurses can contribute to the consent process, but final confirmation of consent must be by an ERCP endoscopist.
Careful preprocedural preparation is critical, including reviewing imaging, checking medications and comorbidities, ensuring adequate hydration, and notifying any required support specialties. Specialist radiological input should be available to review imaging where needed.
To enhance safety, ERCP lists should begin with a full team briefing, followed by a minimum of a sign-in and time-out procedure. When stents are to be used, there should be an additional time-out to verify the correct stent. Debriefs at the end of lists should focus on good practice and adverse events.
Fostering a Positive Team Culture and Environment
The ERCP environment can be challenging, with the potential for fatigue and stress. Lists should be booked to avoid late finishes, with breaks provided and access to support staff. A focus on teamwork, communication, and a just, learning culture should be cultivated to promote patient safety and staff wellbeing.
Complication prevention and early recognition are essential. Units should have clear policies on managing ERCP-related complications, and a culture of early escalation and review should be encouraged through team training.
Adequate postprocedural monitoring and recovery are crucial. Patients should be recovered in a suitable environment, staffed by nurses trained in recognizing ERCP-related adverse events. The minimum recommended recovery period is 4 hours, although 2 hours may be sufficient for selected low-risk patients.
The Role of Nursing and Clinical Governance
ERCP nursing is a highly specialized skill, and units must ensure their nurses receive appropriate training, competency assessment, and ongoing support. Each unit should have a list of nurses competent to lead ERCP lists, and a named lead ERCP nurse responsible for training, equipment, and governance.
ERCP services must have robust clinical governance arrangements, including regular morbidity and mortality reviews, quality audits, and a designated medical governance lead. All units should monitor individual and unit-level ERCP volumes, aiming for a minimum of 100 procedures per endoscopist and 200 per unit annually.
Optimizing Facilities and Equipment
ERCP procedures require dedicated fluoroscopy rooms with sufficient space for the endoscopy, radiology, and anesthetic teams. Equipment must be appropriately sized and configured to minimize musculoskeletal strain on staff. Radiation safety measures, including dosimetry and mandatory safety training, should be in place.
Adequate duodenoscope availability and reprocessing capacity are essential to support a full ERCP list without delays. Staff must be trained in the use of all ERCP equipment, especially less frequently used items.
Developing Regional ERCP Networks
The BSG recommends that ERCP services should work collaboratively within regional networks, following a hub-and-spoke model. Each network should develop agreed pathways for preprocedural, procedural, and postprocedural care, as well as regular multidisciplinary team meetings to discuss complex cases.
Networks should also establish mechanisms to enable cross-unit working of medical and nursing staff, optimize capacity utilization, and ensure timely access to specialist interventions like biliary drainage.
Conclusion
This comprehensive service specification outlines the key components of a high-quality and safe ERCP service, with the patient’s perspective at the forefront. By implementing these consensus-derived standards, ERCP providers can improve service delivery, enhance patient outcomes, and drive continuous quality improvement. The adoption of these principles should now be a priority for all units offering ERCP in the UK.
