An Automated Inpatient Split-dose Bowel Preparation System Improves Colonoscopy Quality and Reduces Repeat Procedures

Abstract

Background/goals: Inpatient colonoscopy preparations are often inadequate, compromising patient safety and procedure quality, while resulting in greater hospital costs. The aims of this study were to: (1) design and implement an electronic inpatient split-dose bowel preparation order set; (2) assess the intervention's impact upon preparation adequacy, repeated colonoscopies, hospital days, and costs.

Study: We conducted a single center prospective pragmatic quasiexperimental study of hospitalized adults undergoing colonoscopy. The experimental intervention was designed using DMAIC (define, measure, analyze, improve, and control) methodology. Prospective data collected over 12 months were compared with data from a historical preintervention cohort. The primary outcome was bowel preparation quality and secondary outcomes included number of repeated procedures, hospital days, and costs.

Results: On the basis of a Delphi method and DMAIC process, we created an electronic inpatient bowel preparation order set inclusive of a split-dose bowel preparation algorithm, automated orders for rescue medications, and nursing bowel preparation checks. The analysis data set included 969 patients, 445 (46%) in the postintervention group. The adequacy of bowel preparation significantly increased following intervention (86% vs. 43%; P<0.01) and proportion of repeated procedures decreased (2.0% vs. 4.6%; P=0.03). Mean hospital days from bowel preparation initiation to discharge decreased from 8.0 to 6.9 days (P=0.02). The intervention resulted in an estimated 1-year cost-savings of $46,076 based on a reduction in excess hospital days associated with repeated and delayed procedures.

Conclusions: Our interdisciplinary initiative targeting inpatient colonoscopy preparations significantly improved quality and reduced repeat procedures, and hospital days. Other institutions should consider utilizing this framework to improve inpatient colonoscopy value.

Figure 1. Standardized Bowel Preparation Algorithm

The study team developed this bowel preparation algorithm via a two-round Delphi method with eight gastroenterology attendings. The new algorithm incorporates a split-dose bowel preparation to start at 6PM the evening prior to scheduled procedure. If at the 10PM nursing check the preparation is well tolerated and effective, the next step is to administer the second portion of the split-dose preparation at 3AM. If, however, at the 10PM nursing check the patient is not tolerating the preparation or the preparation is ineffective, nurses are advised to additionally administer antiemetics (Ondansetron) and rescue purgatives as appropriate (Bisacodyl, Magnesium Citrate [not to be used if CrCl < 30 mL/min], and/or tap water enemas). During the second nursing check at 5AM nurse documents the prepped stool characteristics on the electronic nursing bowel preparation assessment tool (NBPAT). This documentation is immediately available on the electronic health record. The gastroenterology fellow checks the NBPAT documentation in the morning to gauge pre-procedural preparation adequacy and proceeds accordingly.

Figure 2. The Nursing Bowel Preparation Assessment Tool (NBPAT)

Prepared stool is scored based on three sub-groups: consistency (solid=0, semi-solid=1, liquid=2), color (brown=0, orange/dark yellow=1, clear/light yellow=2), sediment (present=0, not present=1). A total bowel preparation score out of 5, with 5 being most optimal, is automatically summated. This tool is documented and available to the healthcare team immediately via the electronic health record. Image embedded in the figure borrowed with permission from Dr. Brennan Spiegel.

Figure 3. The Electronic Colonoscopy Order Set

Improvement interventions incorporated into a single electronic colonoscopy order set and include automated nursing instructions on split-dose bowel preparation administration, preparation checks, and use of rescue agents as needed.