Taking an Old Standard to New Places: Split-Dose Preps Improve Bowel Cleanse in the Inpatient Setting

Abstract

Introduction: Split-dose bowel prep is standard of care for outpatient colonoscopy as it improves bowel cleansing and adenoma detection. However, split-dose bowel prep has not been widely adopted in the inpatient setting. This may be due to the paucity of data evaluating split-dose prep in hospitalized patients. Here, we aimed to assess the efficacy and feasibility of split-dose bowel preps among inpatients after implementation of a split prep order set in the EHR. The impact of this study is to validate or refute, whether current guidelines translate to the inpatient setting to help change current practice in hospitalized patients. Methods: We performed an interrupted time series study at an academic medical center evaluating the feasibility and efficacy of split-dose bowel preps on Boston Bowel Preparation Scale (BBPS) scores for inpatient colonoscopies. An order set was created in the EHR to facilitate ordering of split dosing. To mirror standard outpatient practices, the order set allowed nurses to administer the standard laxative (228g of polyethylene glycol in 4L of water) in two, divided doses, each given over 2 hours. Timing of each dose was determined by the ordering provider, based on the time of the procedure. Endoscopy nurses measured and recorded the BBPS score in the EHR for each patient as part of standard care. For the pre- (9/2016-8/2017) and post-split prep order set (9/2017-4/2018) periods, we compared BBPS scores, adequate bowel cleanse (BBPS ≥6) rates, and proportion of procedures that used split prep. We used multivariable regression to adjust for confounding factors. Results: Our study included 1185 and 718 hospitalized patients in the pre and post-split prep order set groups, respectively (Table 1). Implementation of the order set did not significantly increase the proportion of colonoscopies that employed split prep (pre 20.3% v. post 23.7%; p=.09). Howerever, split-dosing did increase the odds for adequate cleansing (non-split 76.7% v. split 84.4%; aOR 1.59 [1.28-2.14]). Table 2 presents results from the multivariable regression on adequate bowel cleansing conducted among the full cohort. Conclusion: Our study demonstrates that standard outpatient practice of split prep dosing is feasible in the inpatient setting and leads to improved bowel cleanse. However, implementation of a split prep order set in the EHR did not significantly increase its use. Further research is needed to best determine how to improve uptake of split-prep dosing among hospitalized patients.1086_A Figure 1 No Caption available.1086_B Figure 2 No Caption available.