A Proactive Approach to Successful Inpatient Colonoscopy Preparation

Introduction: Bowel preparations are often not adequate in the hospital setting due to lack of nursing documentation, lack of follow through to achieve bowel prep efficacy by the prescriber, and patient risk factors. Methods: We performed a baseline analysis of current state inpatient bowel prep adequacy. We collaborated with our EPIC team for development of a new EPIC order set for split dose preps, and a nursing workflow to assess for bowel cleanliness following prep intake (Figure 1a). The EPIC order set included timing for AM/PM colonoscopies, options for high risk patients who would need salvage prep, and built-in nursing orders for patients unable to tolerate prep. We provided hard stops for nursing documentation to ensure that all information was recorded regarding amount of prep consumed. GI fellows did a 7 AM check on day of procedure to ensure prep completion. Bowel prep assessment measured consistency, color and sediment of stool to identify readiness for colonoscopy to the GI lab by indicating green for readiness and red if not ready. In-service education was provided to GI Fellows and nursing on utilization of the EPIC order set. Training was provided for nurse educators and staff. Adequate administration of prep was reviewed with pharmacy. Results: Pre-intervention data showed 106 (48.0%) inadequate inpatient bowel preps with 18.6% colonoscopies needing repeat procedures during same hospitalization. This resulted in a 41 day increase in length of stay (LOS) over the 7 month period. Post-intervention data showed 51 (30.4%) inadequate preps resulting in a 17.6% reduction from baseline (p=0.0005). Only 2.4% colonoscopies were repeated during the same hospitalization with only a 4 day increase in LOS. This was a 16.2% (p=0.0001) reduction from baseline. Cost savings estimated at $56,869. The addition of salvage prep after same day 7 AM evaluation by GI fellows provided the greatest impact in bowel prep adequacy. Conclusion: Inpatient colonoscopies are often repeated due to poor bowel prep due to several factors including patient tolerability, lack of documentation of intake, and lack of follow-up by clinician to ensure completion of prep intake. Repeat colonoscopy due to poor prep leads to increased LOS, cost, and decreased patient satisfaction. We propose the above interventions which describe a proactive, not reactive, approach to optimizing bowel prep efficacy and LOS, decreasing cost, and improving patient satisfaction.Figure 1.: Split Dose Bowel Preparation Order SetTable 1.: Bowel Preparation Results: Pre- and Post- Intervention