Key components of an ERCP unit SOP
| Booking policies | Day-case procedures (avoiding overnight admission) Transfers |
| Waiting list management | Demand vs capacity monitoring Anaesthetic supported cases Repeat procedures Stent removals |
| Pre-assessment policy | Medical comorbidities Drugs Relevant blood tests Fitness for DS/GA (as required) |
| Referral policy to local and/or regional MDT | Preprocedure cases for discussion Complications Repeats |
| Vetting for appropriateness | Person(s) responsible Process for review and documentation |
| Consent for ERCP | Inpatients, outpatients, transfers Preprocedure information provision Patients that lack capacity |
| Safer surgical checklists | Team briefing Sign-in/time-out Implant time-outs Debrief |
| Nursing | Training and competencies Room numbers Recovery and discharge policy |
| Clinical pathways | Prophylaxis against post-ERCP pancreatitis Common bile duct stones Suspected malignant biliary obstruction (distal and proximal) (Reference to published clinical guidelines) Management of adverse events—access to surgery and interventional radiology |
| Clinical governance | Audit policy—data collection processes KPI monitoring Complication tracking Readmissions Duty of Candour policy Mortality review process |
| Ionising radiation | Monitoring/dosimeters Training Personal protective equipment |
| Stent insertion | Decision regarding permanent versus temporary Removal request and tracking |
DS/GA, deep sedation or general anaesthetic; ERCP, Endoscopic Retrograde Cholangiopancreatography; KPI, key performance indicator; MDT, multidisciplinary team; SOP, standard operating policy.