From the 2018 HVPAA National Conference
Alexandra Strauss (Johns Hopkins University), Janet Yoder (Johns Hopkins University), Candice Zabko (Johns Hopkins University), Jennifer Yeh (Johns Hopkins University), Neysa Ernst (Johns Hopkins University), Erinne Briley (Johns Hopkins University), Ravi Nehra (Johns Hopkins University), Haitham Algrain (Johns Hopkins University), Anne-Marie Lennon (Johns Hopkins University), Christopher Fain (Johns Hopkins University)
The ability of a colonoscopy to diagnose and treat is reliant on a good bowel preparation (BP). Most inpatient BPs are rated fair or poor. Poor BP results in increased procedures, length of stay, and costs. Unique considerations for hospitalized patients are at the patient, provider, and system level.
Our hospital has high variation in bowel preparations. We aim to improve outcomes by using health systems engineering to evaluate pitfalls and standardize the process. From January 2018 to July 2018, the percentage of inpatient colonoscopies performed at Johns Hopkins Hospital achieving adequate bowel preparation will improve by 25%. An adequate bowel preparation will be defined as a Boston Bowel Preparation Score (BBPS) of greater than or equal to 6 with all segments greater than or equal to 2.
We performed a literature review. We performed a retrospective chart review to define our current state. We identified key stakeholders to address the problem and formed a multi-disciplinary team which included: residents, fellows, attendings, department leadership, floor and endoscopy nurses, anesthesiology, and pharmacy. We performed a tracer and created a process map and Ishikawa diagram. We utilized plan-do-study-act cycles to implement various standardization to different parts of the process. We collected data on process and outcome measures and analyzed using run charts.
Based on our literature review, we found the key components of a bowel preparation include the type of bowel cleanser, logistics of administration, and timing of procedure. Four liters of polyethylene glycol (PEG) is the recommended medication in the inpatient setting. Split dose preparation is the recommended administration and includes drinking half the medication the day prior and half the day of procedure. Timing of procedure has been shown to have better results if scheduled in the morning. On review of our practices, we were inconsistently recommending and performing these methods.
Through iterations of our PDSA cycles, we made several changes. We had our gastroenterology teams utilize an orderset and a note template to provide clear instructions for primary teams and nursing for bowel preparation. The instructions included only using Golytely 4 liters in split dose and included troubleshooting information for nausea and poor palatability. We also switched from enemas or suppositories in the morning if not clear to more PEG. We changed our endoscopy scheduling policy to scheduling all colonoscopies in the morning.
We created a patient packet that explained the importance of a good bowel preparation with color pictures and frequently asked questions. This packet was distributed to patients and reviewed with their nurse. We provided fellow education about the BBPS.
Data is being collected in the form of run charts that will demonstrate the number of patients with adequate bowel preparations and number of cancelled/rescheduled cases. More results will be available at time of presentation.
Standardization of bowel preparation for colonoscopy requires a multi-disciplinary effort due to the involvement of several providers and areas of the hospital. By addressing problems at patient, provider, and system levels, bowel preparation scores can be improved in the inpatient setting.
Implications for the Patient
Our clinical care pathway reduced variability in the BP process. We optimized care by streamlining BP administration and assessment of readiness for colonoscopy. Information technology innovations utilized were order sets, nursing flow charts, and electronic pictures. Patient safety improved by decreasing risk of repeat procedures, excessive anesthesia, and prolonged BPs.