Managing Inpatient Constipation: A Docusate Initiative

Abstract

Introduction: Constipation is a common occurrence in the inpatient setting that mandates initiation of medications as appropriate. Docusate is a commonly used stool softener that decreases surface tension in the intestine and allows increased water entry into stool. Several studies conducted in different patient settings, including geriatric, pain, and general hospital medicine wards, have found inpatient use of docusate to be ineffective. In addition to little therapeutic benefit, docusate requires significant nursing time (45 sec/pill administered) and adds to patient pill burden. The aim of this study was to determine physician understanding of the management of constipation in the inpatient setting and to implement system-wide education initiatives and tools on appropriate therapies in order to reduce unnecessary docusate prescribing. Methods: Baseline data from a large academic inner-city hospital was obtained to determine prescribing habits of docusate. Utilizing the Plan-Do-Study-Act (PDSA) (Figure 1) quality improvement workflow, high-volume prescribers were determined. Interventions including education sessions on alternative therapies, including polyethylene glycol as a preferred laxative, as well as bowel-regimen prescribing guidance in the electronic medical record (EMR) prescribing dashboard were put in place.1108_A Figure 1. PDSA Cycle - Docusate prescribing initiativeResults: Orthopedic, Ob-Gyn, Neurosurgical, Medicine, and Urology services made the majority of docusate prescriptions. Baseline physician survey results from 70 medicine residents, found that 43% of residents reflexively ordered a bowel regimen if patient was elderly (age >65), while 34% of residents reflexively ordered a bowel regimen for all patients. Only 37% would wait to order bowel regimen if the patient had reported constipation. The majority (61%) of bowel regimens ordered included docusate, with 89% of prescriber's belief that docusate was at least some what effective in treatment of inpatient constipation. Following the intervention period, the overall docusate prescribing was reduced from an average of 22.6 orders/day to 17.5 orders/day (22% reduction) (Figure 2), along with a 60% increase (8.4 orders/day to 13.4 orders/day) in polyethylene glycol prescribing over this study period.1108_B Figure 2. Docusate prescribing; Trend throughout intervention periodConclusion: Our data demonstrate that implementation of system-wide educational and EMR prescribing tools can reduce inappropriate docusate prescriptions in the inpatient setting. Further steps will include continued education initiatives and resources for all high volume prescribers.