A Simple Change Leading to a Dramatic Improvement in Inpatient Bowel Prep

Abstract

Introduction: Adequate bowl prep prior to colonoscopy is essential. At Geisinger, we are attempting to ensure that inpatient bowel prep quality matches our outpatient bowel prep quality. When the endoscopist does the procedure, documentation of their assessment of the bowel prep is qualified as good, adequate, fair, inadequate, poor, or unsatisfactory. Fair- unsatisfactory rankings lead to repeat colonoscopies and repeat prep on the part of the patient leading to both patient/provider dissatisfaction. Review of our last quarterly report (Oct-Dec 2015) at GMC- Danville showed that our inpatient bowel prep quality was significantly worse compared to our outpatient bowel prep quality (49% inpatient colonscopies were given a rating of fair, inadequate, poor, or unsatisfactory compared to 17% in the outpatient setting. Methods: Review of prior inpatient bowel preparation categorizations by the endoscopist for the quarter of Oct-Dec 2015 were reviewed for the inpatients undergoing colonoscopy at GMC- Danville to obtain baseline date on the quality of our inpatient colonoscopy. For the Jan-March 2016 quarter, the GI department instituted a change in how our inpatient bowel preps were ordered. Effective 1-16, the order for the bowel prep began to be placed by the the inpatient GI team instead of the internal medicine team; thus insuring timely and accurate prep ordering. The order consists of a total of 20 mg Bisacodyl at 3 pm the day and Miralax 255 mg at 6 pm the day prior to the colonoscopy with the patient then NPO after midnight for the procedure the next day. Quarterly data for January-March 2016 and then again from April- June 2016 will be reviewed to see if this change in ordering the bowel prep by the GI consult team improves the quality of inpatient bowel prep as assessed by the provider performing the procedure. Results: Review of the first quarterly (January-March 2016) data shows that the simple change of controlling who orders the bowel prep helps improve the quality of inpatient colonoscopy. Twenty-six percent of patients (27/104) were found to have a ranking of inadequate, poor, or unsatisfactory bowel prep leading to re-preparation and repeat colonoscopy in the first quarter of 2016 compared to 49% for the prior quarter (October to December 2015). In April 2016, 37% of patients (18/49) were ranked as having an inadequate, poor, or unsatisfactory bowel prep leading to a repeat colonoscopy. In May 2016, 27% of patients (9/33) were ranked as having an inadequate, poor, or unsatisfactory bowel prep. Conclusion: Conclusions and Recommendations: Based on our review thus far into this project, it appears that the simple change of standardizing the order of the bowel prep with the inpatient GI consult team ordering the prep and using Bisacodyl 20 mg at 3 pm and Miralax at 6 pm as the prep the day prior to colonoscopy has helped improve the quality of our inpatient colonoscopy at Geisinger Medical Center- Danville. Continued review of June 2016 data is being done, in addition to looking into other factors such as the actual timing of arrival of the prep to the floor and when the patient starts the prep as other factors, in addition to if they are on a clear liquid diet strictly the day prior to colonscopy that may be affecting the quality of inpatient prep. Continued follow-up with monthly and quarterly analysis will continue to be done to determine if any other changes need to be made to improve the quality of the inpatient bowel prep.