Editor—In their quality improvement report on improving caecal intubation rates at colonoscopy Ball et al conclude that these improvements were due to three key measures: increasing appointment times, allocating the procedures to the most skilled operators, and improving bowel preparation in frail patients.1 We have several issues related to each of their interventions.
Firstly, colonoscopy appointment times were increased from 20 minutes to 30 minutes. The Royal College of Physicians recommends that consultant gastroenterologists perform a maximum of six colonoscopies per notional half day (3 1/2 hours)2; 30 minutes is therefore slightly less than the suggested minimum time per procedure. Perhaps increasing appointment times even further would have resulted in even better caecal intubation rates. Moreover, an appointment shorter than the recommended lower limit is unlikely to be adequate for training purposes.
Secondly, although it may seem sensible to allocate colonoscopies to the most proficient practitioners, this intervention could also have an impact on the training of junior doctors.
Thirdly, admitting frail patients for bowel preparation may not be a cost effective measure. The authors do not state how many extra admissions this created; however, as 14% of patients attending for colonoscopy are 75 or older,3 frail patients requiring admission may represent a sizeable burden for many hospitals. Computed tomography without bowel preparation is likely to identify gross pathology in such patients and may be a viable alternative. In addition, inpatient bowel preparation is, in our experience, often less effective than that performed at home: we agree with Ball et al that admission to wards with expertise in this area is important.
Finally, colonoscopic technology has improved notably over recent years: carbon dioxide (instead of air) insufflation and variable stiffness colonoscopes are likely to improve patients' comfort and completion rates. Ball et al do not say whether any of their equipment was updated between audit periods.
Competing interests: None declared.
References
- 1.Ball JE, Osbourne J, Jowett S, Pellen M, Welfare MR. Quality improvement programme to achieve acceptable colonoscopy completion rates: prospective before and after study. BMJ 2004;329: 665-7. (18 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Royal College of Physicians of London. Consultant physicians working for patients. 2nd ed. London: RCP, 2001.
- 3.Bowles CJA, Leicester R, Romaya C, Swarbrick E, Williams CB, Epstein O. A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal screening tomorrow? Gut 2004;53: 277-83. [DOI] [PMC free article] [PubMed] [Google Scholar]