518 Optimizing Inpatient Colonoscopy Preparation: A QI Project

Abstract

INTRODUCTION: Hospitalization is an independent risk factor of poor bowel preparation and it has a lower procedure completion rate as compared to outpatients. Ineffective inpatient colonoscopy preparation may lead to delayed or canceled procedures which subject the patient to additional bowel preparation and sedation. Subsequently it results in patient inconvenience, increased cardio-pulmonary complications, longer hospital stays, and increased hospital cost. METHODS: Defining the problem: Chart review of the inpatient colonoscopies performed between May and July 2017 revealed that 4 liters-single dose polyethylene glycol–electrolyte lavage solution [PEG-ELS] was used in more than 90% of the inpatient colonoscopies. The percentage of colonoscopies with a rating of fair or poor was 36%. On average, 15% of patients failed inpatient bowel preparation. Aim of the project: To reduce the percentage of failed inpatient colonoscopies to less than 10% by May 2018 and to reduce the percentage of inpatients colonoscopies with an inadequate bowel preparation by 5% by May 2019. Interventions: 1) Fellows education on the evidence based split-dose regimen. 2) Bowel prep quality deemed adequate if cecal intubation was successful and prep was satisfactory to identify the targeted lesions. 3) Nothing by mouth orders to be started at 4 am or later instead of traditional after midnight orders. 4) Notify MD orders if the patient has any problem with the bowel prep to enhance communication with nurses. 5) As needed orders for nasogastric tube placement for administration of the prep. 6) An order set was implemented in Epic to facilitate the process and make it uniform. RESULTS: After the first PDSA cycle (Sep 2017-May 2018), we were able to reduce the percentage of failed inpatient colonoscopies from an average of 15% to less than 5% and we reduced the percentage of inadequate bowel prep by 4% (Goal of 5%). In the second PDSA cycle (May 2018-May 2019), we maintained the percentage of failed inpatient bowel preparation under 10% (4.2-7.5%) and reduced the percentage of inadequate bowel prep 17% from the baseline. CONCLUSION: Implementing a split-dose regimen of 4 liter PEG-ELS for all inpatient colonoscopies, improving communication between nurses and ordering physicians, and executing a standard order set for bowel prep orders and instructions are successful strategies in optimizing inpatient bowel preparation. The reliability of the bowel preparation quality scales needs to be validated for use in inpatient colonoscopies.