Standardizing Inpatient Bowel Preparation Orders Improves Colonoscopy Outcomes and Reduces Provider Frustration

Abstract

The quality of bowel preparation for inpatient colonoscopies is frequently poor. Many factors may account for this, including system-level issues such as varying and non-standardized methods of prep administration by covering providers. Quality improvement (QI) interventions focused on regimenting this process might impact both inpatient bowel prep quality and related healthcare outcomes. Therefore, we utilized Six Sigma principles in order to characterize the problem of inadequate inpatient preps, reduce resource utilization, and improve provider satisfaction. Formal Define, Measure, Analyze, Improve, Control (DMAIC) methodology was employed. A process map was created to define the problem through stakeholder interviews and process observation (Figure 1). A root-cause analysis was performed to identify factors contributing to poor inpatient bowel preps, which included frequent variability in ordering practices, patient intolerance, and limited guidance for assessing pre-procedure prep quality that led to missed opportunities for obtaining optimal colon preparation. These findings motivated the creation of a standardized electronic health record (EHR)-based orderset. Baseline and post-intervention data were collected as a run chart from February 2017 through June 2018, including patient demographics, procedure indication and timing relative to presentation, Boston Bowel Preparation Score (BPPS), and prep quality impact on diagnostic yield. To evaluate the knowledge, attitudes, and ease of preparing patients for colonoscopy, a survey was distributed to ordering internal medicine residents before and after the intervention. A total of 264 inpatient colonoscopies were evaluated, including 198 procedures pre- and 66 post-intervention. The proportion of procedures in which the prep quality interfered with making a diagnosis dropped from 10% to 6% (Figure 2). However, the intervention demonstrated no significant effect on the median BPPS or the number of cases delayed due to prep quality. After the intervention, providers reporting any instances of incorrect prep instructions decreased from 33% to 28%, and any frustration with the ordering process decreased from 77% to 39%. Our QI intervention reduced the number of cases in which the prep quality affected the ability to make a diagnosis. We did not achieve significant improvement in overall prep quality or reduce procedural delays, likely due to the low incidence of these outcomes at baseline. Nonetheless, our low cost and standardized colonoscopy prep EHR orderset provides “just-in-time” guidance that dramatically improved provider satisfaction, which may justify broader use of such tools.View Large Image Figure ViewerDownload Hi-res image Download (PPT)