CLINICAL INFORMATION

Clinicians were asked to provide information on the investigations and physiological measurements made before the procedure. Unfortunately, documentation of patient’s
pre-procedural investigations was limited and there are no obvious reasons as to why this section was so poorly completed.

From the limited data, 71 patients were shocked, as defined by a tachycardia (pulse rate greater than or equal to 100 bpm) and hypotension (systolic blood pressure less than or equal to 90 mmHg). In addition, three had both a bradycardia (pulse rate less than or equal to 50 bpm) and hypotension. Were all appropriate efforts made to improve the patients’ condition before the procedures were carried out?

Data concerning the patient’s weight were returned in only 24% (429/1,818) of cases
(Table 10).

The widespread failure to record patients’ weight is surprising. The patient’s weight is
helpful when judging the doses of sedation for endoscopic procedures especially in those who are frail and sick. The weight is also an important marker of nutritional status but the proportion of patients weighed was lowest for the group of patients undergoing a PEG procedure. In nearly all cases it was possible to move the patient to another location prior
to their endoscopic procedure so there can be few excuses for failing to weigh patients.

Advisors found that in many cases the correct investigations had not been carried out before procedures; for example, advisors judged that patients scheduled for ERCP should have their bilirubin level and clotting status checked before the procedure. In 93% (221/237) of patients the bilirubin level was available. However, in 80% (189/237) of ERCP patients there was no record of a clotting study having been performed. When appropriate investigations were performed, abnormal results were disregarded.