Successful applicants to the ASGE Endoscopy Unit Recognition Program submit a summary of a recently conducted quality improvement (QI) project as part of the application process. The QI project in the spotlight this month looks at the polypectomy technique and the risk of postpolypectomy bleeding or colon perforation.
The purpose of the quality study was to monitor and track polypectomies if performed with cold snare, cold forceps or hot snare. The study was performed to track all polypectomies performed at the center and identify the technique used if a postpolypectomy bleed or colon perforation occurred. New published data demonstrate that “cold snare resection of polyps proves to have a more complete polyp resection as well as decreasing the risk of post polypectomy bleeding.” It has also been stated that “cold snare polypectomy reduces the chance of perforation as it is almost impossible to cut through the muscularis propria with a cold snare.” Incomplete resection of polyps may result in postpolypectomy cancers. Cold forceps are associated with a high rate of incomplete resection, even for diminutive polyps.
The center collected the data by tracking polypectomies performed during colonoscopies, using a tracking tool developed specifically for this study. It was the responsibility of the procedure/circulating nurses to utilize the tracking form for the documentation of the method and the number of polyps removed during the procedure. The center tracks and reports any/all postpolypectomy bleeds as well as perforations; this information would be documented for the study on the tracking form as well as a QI reporting form.
The study was to determine the rates of occurrences of postpolypectomy bleeds and colon perforations as well as complete polyp resection with each polypectomy removal technique. The study was to also determine the number of tubular adenomatous polyps versus sessile serrated polyps removed by cold snare versus cold forceps. The information/data for the type of polyp and technique used for polypectomy will be abstracted from [endowriter] and GIQuIC. The study was to begin in March; however, because of the COVID-19 pandemic, the center was closed due to the guidance of the government. The facility reopened in May with a soft opening to ensure continued safety for all staff and patients. Data collected for the study began in August 2020 through the end of January 2021.
The study revealed that from August 2020 to January 2021 there were 3,376 colonoscopies performed with a total of 1,162 polypectomies. The breakdown revealed that polypectomy methods were cold snare (n=556), hot snare (n=318) and cold forceps (n=288). The study showed that the most-performed technique for polypectomy was cold snare. The results of this study reflect that performing polypectomy by cold snare had less risk of postpolypectomy bleeds or colon perforation during the time the study was in progress. It was noted that on three occasions, hemostasis clips were placed after a hot snare polypectomy as a preventative to decrease the risk for postpolypectomy bleeding:
- The percentage of polyps <10 mm removed with cold snare and cold forceps was 17%. Polyps <10 mm removed via hot snare was 44%.
- The percentage of tubular adenomatous polyps removed via cold snare was 16% and cold forceps removal was 35%.
- Removal of tubular adenomatous polyps with cold snare was 35% and serrated polyp removal via forceps was 18%.
The study revealed no postpolypectomy bleeds or colon perforations occurred during the study. A higher percentage of polyps were removed via the cold snare technique. One unexpected finding during the study was an increase in polyps not retrieved during cold snare polypectomy. Some pathology reports identified vegetable material obtained or no tissue at all in formalin containers. It was determined that this would make a good study for 2021 to determine issues/techniques or a need for more education for the staff in verifying that they obtained tissue and used proper techniques.
The results were presented to the Quality Committee on January 28, 2021. The committee confirmed the need to create a study for 2022 for collecting and sending the correct tissue for pathology. The results and new study for 2021 will be presented to the MEC Committee in April when the center holds its quarterly meeting. The results of this study will be presented to the Governing Board at the Biannual Meeting in July 2021. The [center] staff will be presented with the results of the study at the April staff meeting.
We hope sharing this project summary will be useful to you and your practice. Learn more about gaining honoree status in the ASGE Endoscopy Unit Recognition Program. EURP honoree units may use the ASGE Quality Star logo in the promotion of their units, receive premium educational content bimonthly via an exclusive e-newsletter The Huddle and enjoy a range of additional benefits. Questions should be directed to eurp@asge.org.