A patient-centered framework for health systems engineering in gastroenterology: improving inpatient colonoscopy bowel preparation

Alexandra T Strauss,Gayane Yenokyan,Janet Yoder,Ravi Nehra,Jennifer Yeh,Diego A Martinez,Kathy Bull-Henry,Ellen Stein,Candice Zabko,Christopher Fain,Tara Feller,Lawrence C H Hsu,Haitham Al-Grain

doi:10.1186/s12876-021-01661-4

Abstract

BackgroundInpatient colonoscopy bowel preparation (ICBP) is frequently inadequate and can lead to adverse events, delayed or repeated procedures, and negative patient outcomes. Guidelines to overcome the complex factors in this setting are not well established. Our aims were to use health systems engineering principles to comprehensively evaluate the ICBP process, create an ICBP protocol, increase adequate ICBP, and decrease length of stay. Our goal was to provide adaptable tools for other institutions and procedural specialties.MethodsPatients admitted to our tertiary care academic hospital that underwent inpatient colonoscopy between July 3, 2017 to June 8, 2018 were included. Our multi-disciplinary team created a protocol employing health systems engineering techniques (i.e., process mapping, cause-effect diagrams, and plan-do-study-act cycles). We collected demographic and colonoscopy data. Our outcome measures were adequate preparation and length of stay. We compared pre-intervention (120 ICBP) vs. post-intervention (129 ICBP) outcomes using generalized linear regression models. Our new ICBP protocol included: split-dose 6-L polyethylene glycol-electrolyte solution, a gastroenterology electronic note template, and an education plan for patients, nurses, and physicians.ResultsThe percent of adequate ICBPs significantly increased with the intervention from 61% pre-intervention to 74% post-intervention (adjusted odds ratio of 1.87, p value = 0.023). The median length of stay decreased by approximately 25%, from 4 days pre-intervention to 3 days post-intervention (p value = 0.11).ConclusionsBy addressing issues at patient, provider, and system levels with health systems engineering principles, we addressed patient safety and quality of care provided by improving rates of adequate ICBP.

Highlights

Inpatient colonoscopy bowel preparation (ICBP) is frequently inadequate and can lead to adverse events, delayed or repeated procedures, and negative patient outcomes
Effective colonoscopy is dependent on adequate bowel preparation by consuming a bowel cleansing medication prior to the procedure to allow for visualization of the colonic mucosa
The process started with the initial decision to scope made by the GI team which were comprised of fellows and attendings and were the same mix of experience levels throughout our entire study

Summary

Introduction

Inpatient colonoscopy bowel preparation (ICBP) is frequently inadequate and can lead to adverse events, delayed or repeated procedures, and negative patient outcomes. A. Strauss et al BMC Gastroenterol (2021) 21:89 common problem is when hospitalized patients undergo bowel preparation for an inpatient colonoscopy, they frequently have an aborted procedure because the bowel preparation has failed (i.e., solid stool). Strauss et al BMC Gastroenterol (2021) 21:89 common problem is when hospitalized patients undergo bowel preparation for an inpatient colonoscopy, they frequently have an aborted procedure because the bowel preparation has failed (i.e., solid stool) This results in repeat bowel preparation, repeat or delayed procedures, compromised patient experience, and inefficient use of resources in the endoscopy unit. Hospitalized patients have additional risk factors that impact inpatient colonoscopy bowel preparations (ICBP). The consequences of an inadequate ICBP include repeat procedures, increased length of stay (LOS) [2], and increased costs [3, 12]

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