Standardizing Diagnosis and Management of Functional Constipation at an Academic Tertiary Pediatric Emergency Department

From the 2021 HVPAA National Conference

Denise Young (Rainbow Babies and Children’s Hospital), Alexandra Houck, Nikita Habermehl, Sarah Margolius, Senthilkumar Sankararaman

Background

Constipation is a common pediatric disorder, with a mean prevalence of 14% of children worldwide. Although it can be managed in an outpatient setting, constipation is a frequently encountered diagnosis in the emergency department (ED). The diagnosis can often be made based on careful history and physical examination alone. However, studies have shown there is significant variability in the diagnosis and management of constipation in the ED, including frequent ordering of laboratory studies, urinalysis, and imaging.

Objective

To evaluate the effectiveness of a standardized clinical care guideline on diagnosis and management of functional constipation at an academic tertiary pediatric emergency department in reducing use of abdominal radiograph for diagnostic workup, and decreasing variability in medications prescribed at discharge.

Methods

For our baseline data, we performed a retrospective chart review of patients diagnosed with constipation in our pediatric ED between January 1, 2019 and March 31, 2019. Data collected included demographics, chief complaint, diagnostic workup, and medications prescribed at discharge. Following analysis of baseline data, an interdisciplinary team consisting of a pediatric resident, two pediatric emergency medicine fellows, one pediatric gastroenterology fellow, and a pediatric gastroenterology attending, developed a clinical care guideline (CCG) for diagnosis and management of constipation in the pediatric ED. The CCG was implemented on January 4, 2021. Education and reminder emails were also provided for faculty and housestaff for one month following implementation. Post-intervention data was collected from January 4, 2021 to March 15, 2021.

Results

We excluded patients who initially presented with signs and symptoms of a systemic illness or diagnosis other than constipation, and patients who were currently followed by pediatric gastroenterology for constipation. There were a total of 67 patients in our baseline data, and 19 patients in our post-intervention data (Table 1). The most common chief complaint was abdominal pain for both groups. In the pre-CCG group, 22.3% of patients had documentation of a history of constipation. Sixty-four percent of patients had a 1-view abdominal radiograph and 20.9% of patients had a urinalysis performed as part of the diagnostic work-up of constipation. After implementation of the CCG, 78.9% of patients had documentation of diagnostic criteria for constipation, and the overall use of abdominal radiograph decreased to 42.1%. Thirty-one percent of patients in the post-CCG group had a urinalysis done. Post-CCG, 94.7% of patients were prescribed laxatives, all of which were polyethylene glycol. None of the patients in the post-CCG cohort re-presented to the ED or had an admission for constipation within 4 weeks of their initial presentation.

Conclusions

Through the implementation of a CCG, we increased the median documentation of a constipation history using the Rome IV criteria from 21% to 80%, and decreased utilization of abdominal radiograph from a median of 64% to 50%. There was no change in ordering of urinalysis. We will go through additional PDSA cycles to further improve our process and decrease use of imaging and urinalysis to our goal of 20% reduction from baseline.

Clinical Implications

Constipation is a commonly encountered diagnosis in the pediatric ED that can often be made without reliance on laboratory studies, urinalysis, or abdominal radiograph. We demonstrated that the diagnosis and management of constipation in the ED can be standardized using a clinical care guideline, leading to a decrease in utilization of resources, and an increase in providing high-value care.

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