Journal List > Korean J Gastroenterol > v.71(5) > 1094738

Min, Cha, Cho, Kim, Yoon, Im, Jung, Moon, Kim, and Jeen: Revision of Quality Indicators for the Endoscopy Quality Improvement Program of the National Cancer Screening Program in Korea

Abstract

Gastroscopy and colonoscopy are widely used for the early diagnosis of stomach and colorectal cancer. The present revision in-tegrates recent data regarding previous quality indicators and novel indicators suggested for gastroscopy and colonoscopy procedures for the National Cancer Screening Program in Korea. The new indicators, developed by the Quality Improvement Committee of the Korean Society for Gastrointestinal Endoscopy, vary in the level of supporting evidence, and most are based solely on expert opinion. Updated indicators validated by clinical research were prioritized, but were chosen by expert consensus when such studies were absent. The resultant quality indicators were graded according to the levels of consensus and recommendations. The updated indicators will provide a relevant guideline for high-quality endoscopy. The future direction of quality indicator development should include relevant outcome measures and an evidencebased approach to support proposed performance targets.

References

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Table 1.
Levels of Agreement and Recommendation
Definition
Level of agreement
 A: Strongly agree with the statement and quality indicators
 B: Agree with the statement and quality indicators
 C: Uncertain of the statement and quality indicators
 D: Disagree with the statement and quality indicators
 E: Strongly disagree with the statement and quality indicators
Level of recommendation
 Strong: Recommendation likely to apply to most National Cancer Screening Program endoscopy settings.
 Intermediate: Recommendation, best action may differ according to particular circumstances or patients in National Cancer Screening Program endoscopy settings
 Weak: Recommendation, alternative approaches likely to be better under some circumstances in National Cancer Screening Program endoscopy settings
Table 2.
Final Statements and Their Level of Agreement for Esophagogastroduodenoscopy and Colonoscopy in the National Cancer Screening Program: Workforce, Process, Facilities and Equipment, and Outcome
  Statements
Workforce An experienced endoscopist with sufficient training in EGD should perform EGD. (EGD)
 [Level of agreement: strongly agree 95.2%, agree 4.8%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
An experienced endoscopist with sufficient training in colonoscopy should perform colonoscopy. (CS)
 [Level of agreement: strongly agree 96.0%, agree 4.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
An endoscopist who performs endoscopies is required to receive continuous endoscopy education. (EGD/CS)
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Endoscopy nursing staff is required to receive training for endoscopy quality improvement. (EGD/CS)
 [Level of agreement: strongly agree 91.3%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 81.8%, intermediate 18.2%, weak 0%]
Process Clinicians should verify the overall condition of the patient before EGD. (EGD)
 [Level of agreement: strongly agree 95.8%, agree 4.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Clinicians should verify the fasting state, general health status, previous medical history, current medication history including anti-platelets or anticoagulants (antithrombotics), and quality of bowel preparation before colonoscopy. (CS)
 [Level of agreement: strongly agree 95.7%, agree 4.4%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Clinicians should provide bowel preparation education to examinees before colonoscopy. (CS)
 [Level of agreement: strongly agree 95.7%, agree 4.4%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Clinicians should provide a sufficient explanation of the procedure and obtain informed consent before colonoscopy. (CS)
 [Level of agreement: strongly agree 95.8%, agree 4.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
All of the standard imaging sites of EGD should be clearly photographed and stored as image records. (EGD)
 [Level of agreement: strongly agree 91.3%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
All of the standard imaging sites of colonoscopy should be clearly photographed and stored as image records. (CS)
 [Level of agreement: strongly agree 91.3%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 81.8%, intermediate 18.2%, weak 0%]
Average withdrawal time in negative-result colonoscopies should be measured and should not be ≥ 6 min. (CS)
 [Level of agreement: strongly agree 70.8%, agree 29.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 72.7%, intermediate 27.3%, weak 0%]
After EGD, the clinician should instruct the examinee as to the post-procedure precautions and how to obtain exam results. (EGD)
 [Level of agreement: strongly agree 91.3%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 81.8%, intermediate 18.2%, weak 0%]
After colonoscopy, the clinician should instruct the examinee as to the post-procedure precautions and how to obtain exam results. (CS)
 [Level of agreement: strongly agree 95.8%, agree 4.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
The tissue sample obtained during endoscopy should be managed properly according to specific protocols. (EGD/CS)
 [Level of agreement: strongly agree 91.7%, agree 8.3%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Facilities and equipment The endoscopy unit should be an independent facility from the outpatient clinic. (EGD/CS)
 [Level of agreement: strongly agree 92.3%, agree 3.9%, uncertain 3.9%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 77.3%, intermediate 22.7%, weak 0%]
Clinicians should be prepared for complications and emergency situations during endoscopy. (EGD/CS)
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Outcome Endoscopy reports should be recorded with high accuracy. (EGD/CS)
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Pathologic findings identified during endoscopy should be precisely described. (EGD/CS)
 [Level of agreement: strongly agree 95.8%, agree 4.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 95.5%, intermediate 4.5%, weak 0%]
Helicobacter pylori infection should be assessed in patients diagnosed with peptic ulcers. (EGD)
 [Level of agreement: strongly agree 78.3%, agree 21.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 63.6%, intermediate 36.4%, weak 0%]
Bowel preparation should be adequate for a thorough colonoscopy. (CS)
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]

EGD, esophagogastroduodenoscopy; CS, colonoscopy.

Table 3.
Final Statements and Their Level of Agreement for Esophagogastroduodenoscopy and Colonoscopy in the National Cancer Screening Program: Reprocessing and Sedation
  Statements
Reprocessing Endoscopy reprocessing and disinfection guidelines approved by the Endoscopy Professional Association should be available in each endoscopy unit. (EGD/CS)
 [Level of agreement: strongly agree 94.1%, agree 5.9%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
Endoscopic reprocessing procedures should be performed as directed by established protocols and guidelines. (EGD/CS)
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Endoscopic accessories that pass through the mucosa, such as biopsy forceps or incision instruments, must be sterilized. (EGD/CS)
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Personnel performing endoscopic reprocessing and disinfection should wear personal protective equipment. (EGD/CS)
 [Level of agreement: strongly agree 72.7%, agree 22.7%, uncertain 4.6%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 54.6%, intermediate 45.4%, weak 0%]
Endoscopic reprocessing equipment and storage methods should be appropriate as directed by guidelines. (EGD/CS)
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Endoscopists and reprocessing workers should complete endoscopic reprocessing education programs approved by the Endoscopy Professional Association. (EGD/CS)
 [Level of agreement: strongly agree 95.0%, agree 5.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Sedation Pre-sedation history, risk assessment, and sedation-specific informed consent should be obtained for sedative endoscopy. (EGD/CS)
 [Level of agreement: strongly agree 100%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
During sedative endoscopy, the patient's vital signs should be monitored and documented. (EGD/CS)
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Patients should be monitored with discharge assessment scales after sedative endoscopy. (EGD/CS)
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]

EGD, esophagogastroduodenoscopy; CS, colonoscopy.

Table 4.
Final Quality Indicators and Their Level of Agreement for Esophagogastroduodenoscopy and Colonoscopy in the National Cancer Screening Program: Workforce, Process, Facilities and Equipment, and Outcome
Quality indicators
Workforce Is the EGD for the NCSP performed by specialists with at least one year of supervised endoscopy training or endoscopists with experience of at least 500 or more EGD procedures? (EGD)
 □ Specialists with at least one year of supervised endoscopy training □ Endoscopist with experience of at least 500 or more EGDs
 □ Endoscopist without one year of supervised endoscopy training or experience of less than 500 EGDs
 [Level of agreement: strongly agree 61.9%, agree 38.1%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 77.3%, intermediate 22.7%, weak 0%]
Is the colonoscopy of the NCSP performed by a specialist with at least one year of supervised colonoscopy training in more than 150 cases or an endoscopist with experience of at least 300 or more successful colonoscopies? (CS)
 □ Specialist with one year of supervised colonoscopy training with over 150 cases
 □ Endoscopist with experience of 300 or more successful colonoscopies
 □ Endoscopist without one year of supervised endoscopy training or experience of less than 300 successful colonoscopies
 [Level of agreement: strongly agree 66.7%, agree 33.3%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 77.3%, intermediate 22.7%, weak 0%]
Did the endoscopist perform at least 300 EGDs during the 3-year ‘National Endoscopy Quality Improvement Program'? (EGD)
 □ Yes □ No
 [Level of agreement: strongly agree 13.6%, agree 50.0%, uncertain 36.4%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 59.1%, intermediate 31.8%, weak 9.1%]
Did the endoscopist perform at least 150 colonoscopies during the 3-year ‘National Endoscopy Quality Improvement Program'? (CS)
 □ Yes □ No
 [Level of agreement: strongly agree 37.5%, agree 54.2%, uncertain 4.2%, disagree 4.2%, strongly disagree 0%]
 [Level of recommendation: strong 54.6%, intermediate 40.9%, weak 4.5%]
Did the endoscopist the complete at least 12 hours of endoscopy-related education courses during the 3-year ‘National Endoscopy Quality Improvement Program'? (EGD/CS)
 □ Yes □ No
How many hours of endoscopy-related education courses did the endoscopist attend over the past 3 years? (EGD/CS) () Hours
 [Level of agreement: strongly agree 36.7%, agree 33.3%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 81.8%, intermediate 18.2%, weak 0%]
How often did endoscopic nursing staff participate in training for endoscopy quality improvement over the past 3 years? (EGD/CS)
 □ More than 3 times □ More than 1 time □ None
 [Level of agreement: strongly agree 66.7%, agree 33.3%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 54.6%, intermediate 40.9%, weak 4.5%]
Process Does the clinician verify the fasting state, general health status, past medical history, and medication history including anti-platelets or anticoagulants (antithrombotics) using a preprocedure checklist before endoscopy? (EGD/CS)
 □ Yes □ No
 [Level of agreement: strongly agree 96.0%, agree 4.0%, uncertain 36.4%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Does the clinician educate examinees on bowel preparation and provide colonoscopy information before examination? (CS)
 □ Yes □ No
 [Level of agreement: strongly agree 54.6%, agree 31.8%, uncertain 9.1%, disagree 4.6%, strongly disagree 0%]
 [Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
Does the endoscopist obtain written informed consent for the risks and benefits associated with colonoscopy? (CS)
 □ Yes □ No
 [Level of agreement: strongly agree 91.3%, agree 8.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
Does the endoscopist photograph and record at least 8 clear standard EGD images? (EGD)
 □ Excellent □ Fair □ Poor
 [Level of agreement: strongly agree 73.9%, agree 21.7%, uncertain 4.4%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
Does the endoscopist photograph and record at least 8 clear standard colonoscopy images including the maximal insertion site (e.g., the cecum)? (CS)
 □ Excellent □ Fair □ Poor
 [Level of agreement: strongly agree 77.3%, agree 22.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
Does the endoscopist maintain an average withdrawal time of ≥ 6 min in negative-result colonoscopies in order to inspect the colon mucosa sufficiently? (CS)
 □ Yes □ No
 [Level of agreement: strongly agree 87.5%, agree 12.5%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 77.3%, intermediate 22.7%, weak 0%]
Does the clinician instruct the examinee as to the precautions and how to check the results after EGD? (EGD)
 □ Yes □ No
 [Level of agreement: strongly agree 85.7%, agree 14.3%, uncertain 4.4%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 81.8%, intermediate 18.9%, weak 0%]
Does the clinician instruct the examinee as to the post-procedure precautions and how to obtain examination results after colonoscopy? (CS)
 □ Yes □ No
 [Level of agreement: strongly agree 91.7%, agree 8.3%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 81.8%, intermediate 18.9%, weak 0%]
Does the clinician label the tissue sample obtained during endoscopy? (EGD/CS)
 □ Yes □ No
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Facilities and equipment Is the endoscopy unit separate from the outpatient clinic? (EGD/CS)
 □ Excellent □ Fair □ Poor
 [Level of agreement: strongly agree 92.3%, agree 3.9%, uncertain 3.9%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
Are endoscopic treatment devices (① injection catheter, ② hemoclips) and resuscitation equipment available for the management of adverse events during endoscopy? (EGD/CS)
 □ Yes □ No
 [Level of agreement: strongly agree 84.0%, agree 16.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Outcome Does the EGD report include all of the following items? (EGD)
 1) date of examination
 2) patient information: name, sex and age
 3) name of endoscopist
 4) medications
 5) diagnosis
 6) findings
 7) biopsy details
 8) complications, if any.
 [Level of agreement: strongly agree 95.8%, agree 4.2%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 95.5%, intermediate 4.5%, weak 0%]
Does the colonoscopy report include all of the following items? (CS)
 1) date of examination
 2) patient information: name, sex, and age
 3) name of endoscopist
 4) medications
 5) diagnosis
 6) findings
 7) biopsy details
 8) quality of bowel preparation (or maximum insertion site)
 9) cecal intubation
 10) withdrawal time
 11) complications, if any.
 [Level of agreement: strongly agree 66.7%, agree 25.0%, uncertain 8.3%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 77.3%, intermediate 18.2%, weak 4.5%]
When a pathologic finding is observed, how well are the location, size, and shape of the lesion documented? (EGD/CS)
 □ Excellent □ Fair □ Poor
 [Level of agreement: strongly agree 87.5%, agree 12.5%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 95.6%, intermediate 4.4%, weak 0%]
Do you test the H. pylori infection status of patients diagnosed with peptic ulcers? (EGD)
 □ Yes □ No
Does the endoscopist test for H. pylori infection status of patients diagnosed with peptic ulcers? (EGD)
 □ Yes □ No
 [Level of agreement: strongly agree 66.7%, agree 20.8%, uncertain 12.5%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 63.6%, intermediate 36.4%, weak 0%]
Is the proportion of patients who achieved adequate bowel preparation higher than 85%?
 □ Yes □ No
 [Level of agreement: strongly agree 41.7%, agree 54.2%, uncertain 4.2%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 40.9%, intermediate 59.1%, weak 0%]

EGD, esophagogastroduodenoscopy; CS, colonoscopy; NCSP, National Cancer Screening Program.

Table 5.
Final Quality Indicators and Their Level of Agreement for Esophagogastroduodenoscopy and Colonoscopy in National Cancer Screening Program: Reprocessing and Sedation
  Quality indicators
Reprocessing Does the Endoscopy unit have ‘Endoscopy reprocessing and disinfection protocols' approved by the Endoscopy Professional Association? (EGD/CS)
 □ Yes □ No
 [Level of agreement: strongly agree 95.2%, agree 4.8%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
Are the endoscopic reprocessing procedures performed properly as directed by specific protocols? (EGD/CS)
 □ Excellent □ Fair □ Poor
 [Level of agreement: strongly agree 95.7%, agree 4.4%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Are high-level disinfectants used during endoscopy reprocessing? (EGD/CS)
 □ Yes □ No
 [Level of agreement: strongly agree 100%, agree 0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 95.5%, intermediate 4.5%, weak 0%]
Do reprocessing personnel follow the disinfectant procedures during endoscopy reprocessing? (EGD/CS)
 □ Check both the disinfectant instructions and protocols regarding disinfectant management
 □ Check only disinfectant instructions
 □ Check only procedures of disinfectant management
 [Level of agreement: strongly agree 90.5%, agree 9.5%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 86.4%, intermediate 13.6%, weak 0%]
Are the endoscopic accessories that pass through the mucosa, such as biopsy forceps or incision instruments, disposable or sterilized for reuse in the case of reusable products? (EGD/CS)
 □ Yes □ No
 [Level of agreement: strongly agree 90.5%, agree 9.5%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 100%, intermediate 0%, weak 0%]
Do reprocessing personnel wear personal protective equipment? (EGD/CS)
 □ Yes □ No
 [Level of agreement: strongly agree 80.0%, agree 20.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 50.0%, intermediate 50.0%, weak 0%]
Is there an appropriate reprocessing area separate from the endoscopy examination room? (EGD/CS)
 □ Excellent □ Fair □ Poor
Is there an appropriate reprocessing room separate from the endoscopy unit? (EGD/CS)
 □ Excellent □ Fair □ Poor
 [Level of agreement: strongly agree 90.0%, agree 10.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 72.3%, intermediate 22.7%, weak 0%]
Are endoscopes kept in a dedicated endoscope storage cabinet where the tip of endoscope does not touch the bottom surface of the storage cabinet? (EGD/CS)
 □ Excellent □ Fair □ Poor
[Level of agreement: strongly agree 85.0%, agree 15.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Do endoscopists and reprocessing personnel complete endoscopic reprocessing education programs approved by the Endoscopy Professional Association? (EGD/CS)
 □ Excellent □ Fair □ Poor
 [Level of agreement: strongly agree 83.3%, agree 16.7%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Sedation Does the clinician document the pre-sedation history and risk assessment and obtain sedation-specific informed consent separately?
 □ Excellent □ Fair □ Poor
 [Level of agreement: strongly agree 95.0%, agree 5.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
[Level of recommendation: strong 95.5%, intermediate 4.5%, weak 0%]
Does the clinician monitor and record patient status (oxygen saturation, blood pressure, pulse rate), type and dose of sedatives, and adverse events during sedative endoscopy? (EGD/CS)
 □ Yes □ No
 [Level of agreement: strongly agree 89.5%, agree 10.5%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 90.9%, intermediate 9.1%, weak 0%]
Does the clinician monitor patients using a standardized discharge scoring system after sedative endoscopy? (EGD/ CS)
 □ Yes □ No
 [Level of agreement: strongly agree 95.0%, agree 5.0%, uncertain 0%, disagree 0%, strongly disagree 0%]
 [Level of recommendation: strong 83.4%, intermediate 13.6%, weak 0%]

EGD, esophagogastroduodenoscopy; CS, colonoscopy.

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