Colonoscopy Bowel Preparation Quality Improvement for Decompensated Cirrhosis Patients Undergoing Evaluation for Liver Transplantation

Abstract

Introduction: Inadequate colonoscopy bowel preparations (BP) are reported in up to 25% of cases, and can necessitate early repeat of colonoscopy and increased health care cost. Recent data suggests that patients with decompensated cirrhosis may be at high risk for inadequate BP. We aimed to reduce our rate of poor BP in decompensated cirrhotic via a quality improvement initiative targeting patient education on proper bowel purge administration during outpatient liver transplantation (LT) evaluation. Methods: Our study had three phases: (1) baseline retrospective chart review, and (2) educational intervention, (3) prospective chart review. Phase 1 was completed by performing retrospective chart review of all patients undergoing LT evaluation at our facility in 2014. Phase 2 then implemented a 6-minute colonoscopy and BP patient education video during the initiation LT evaluation visit for all patients with scheduled colonoscopy, along with staff education on this intervention. All patients received split-prep GoLYTELY® or MoviPrep® bowel purges. Phase 3 then allowed for chart review of colonoscopy procedure documents to collect qualitative statements on BP adequacy recorded by the performing endoscopist. If bowel preparations were reported poor or fair with the need of an immediate repeat endoscopy, we documented that as an inadequate bowel preparation. The primary endpoint was to demonstrate an improvement in the rate of adequate BP after the educational intervention. Results: 454 patients (Mean age: 59 years; 60% males) underwent LT evaluation at our center in 2014, and of these 287 patients underwent screening colonoscopies with 57/287 (19.8%) having poor BP (Phase 1). 106 patients underwent outpatient LT evaluation after Phase 2 initiation of which 26 had colonoscopies. 9 of these 26 (34.6%) patients had poor BP (Phase 3). Conclusion: After a patient education intervention on bowel purge administration for decompensated cirrhotics undergoing outpatient LT evaluation, rates of inadequate BP failed to improve. Further study is needed to determine if education on proper bowel prep administration is the primary barrier to improved BP in decompensated cirrhotics, or if other factors play a larger role.