122 Multidisciplinary Quality Improvement Initiative to Reduce Bowel Complications in Post-Operative Orthopedic Patients

Abstract

INTRODUCTION: Gastrointestinal (GI) complications in patients undergoing orthopedic surgery are common but underreported. Prolonged immobility and the use of post-operative narcotics can increase the risk of GI complications which include: constipation, ileus, bowel obstruction, stercoral colitis, perforation, and death. In 2017 we observed an increase in GI complications among patients undergoing orthopedic surgery at our orthopedic hospital. This prompted a multidisciplinary quality improvement (QI) initiative to reduce GI complications among patients admitted after joint or spine surgery. METHODS: Following a surge of GI complications at our university-affiliated tertiary referral orthopedic satellite hospital in early 2018 we created a multidisciplinary QI program. The first component was a didactic lecture delivered by a GI attending to the orthopedic trainees, attendings, physician extenders, nurses and staff. The 1 hour lecture discussed an effective GI history, exam and reviewed the symptoms and treatment of common GI conditions affecting post-operative patients. The second component was the development of a post-operative constipation and bowel assessment algorithm focused on early identification, escalation and treatment of GI conditions (Figure 1). The third component was a redesign of the electronic medical record post-operative constipation order sets in order to facilitate implementation of the aforementioned bowel algorithm. This new order set changed laxative orders from “as needed” to standing with an option to be held for diarrhea. These QI initiatives were implemented on a rolling basis from 1/31/2018 to 5/31/2018. Cases of ileus, obstruction and perforation were determined based on coding for admitted orthopedic patients. RESULTS: The proportion of patients admitted with each diagnosis was compared from the first quarter (1/1 to 3/31) of 2018 to 2019 corresponding to 6 months after the implementation of all QI components (Figure 2). We achieved a 71% reduction in overall bowel complications (P < 0.05). The greatest reduction was achieved in post-operative ileus by 81% (P < 0.05). Following the QI initiative there was only 1 perforation corresponding to a 50% reduction. CONCLUSION: We created a multidisciplinary QI program that successfully reduced GI complications in patients hospitalized following orthopedic surgery. The greatest impact was in the reduction of post-operative ileus and serious adverse events such as perforation.