Audit of Pre-colonoscopy Bowel-prep Protocol

Introduction

We cannot have good colonoscopy without good preparation (Figures-1a,b,c,). Yet, many clinicians follow arcane protocols for pre-colonoscopy bowel preparation. Engrossed in the minutiae of the tree they overlook the forest. Therefore audit of bowel-prep protocol is important. Clinical audit is one of the stanchions of clinical governance.[1] This ensures that we do what we do, i.e. patient care, even better.[2]

Multi-disciplinary audit

Appendix-1 outlines our bowel-prep protocol. We decided to conduct a multi-disciplinary peer audit involving colo-rectal surgeons, endoscopists and gastroenterologists/colo-proctologists (Figure-2).

Audit-process

Initial part of our audit-process paralleled the steps of evidence-based medicine (EBM) (Figure-3).[3]

Problem identification/evaluation criteria

The following problem-areas required auditing, based on our clinical experience:

1. Cleansing effectiveness: Postponement of colonoscopy, inadequate diagnosis, instrument damage

2. Safety/side effects: Infection, fluid-electrolyte imbalance 3. Patient tolerance: 4. Cost:

e-Literature search

The literature was searched for standard procedure(s)/international guidelines, to identify research-derived evidence reflecting best medical practices, and to select those that were most applicable to us.[3]

We came across protocols from St. Mark’s Hospital[4], University Surgeons[5], UK Nursing Standard[6], American Society for Gastrointestinal Endoscopy (ASGE)[7], and Royal College of Surgeons of Edinburgh (RCSEd)[8].

e-Critical appraisal

The first two[4,5] and third[6] were instructions for patients and nurses, respectively. None of them had research-derived evidence. ASGE described cleansing effectiveness, safety/advantages and cost[7], and RCSEd dealt with patient tolerance[8] (Appendix-2,3); these were most applicable to our audit.

Data collection

All colonoscopies performed during previous year were reviewed and the findings tabulated (Table-1, Appendix-4).

Comparison/shortfall identification

Standards from ASGE[7] were taken for comparing areas (1), (2) and (4); while those from RCSEd[8]

were utilized to compare (3) of our problem-areas. The differences from the standards were considered significant if p<0.05 in any category. Based on the shortfall identified, changes were instituted to match the selected standards.

Change models

We considered two models on which to base the changes to our protocol; the Johari window model (Figures-4a,b)[9], and the Change management theory model, based on Eweles-Simnett’s theoretical formula (Figure-5)[10].

Summary

Our purpose was to integrate critical appraisal with our clinical expertise, evaluate our effectiveness/efficiency, and seek ways to improve them for next time (final two steps of EBM).[3] The overall steps of our audit-process are summarized in Figure-6.

Availability of appropriate agents for bowel-prep is a potential barrier that may require resolution. The audit cycle would need to be repeated after a suitable period.

Reflection–informatics issues

Computerised systems enable accurate and standardised data recording; speedy searching (viz. EMIS GV search/statistics module); SMART (specific, measurable, achievable, reasonable, time-phased) data collection; proper presentation and reflection (‘shop window’ and ‘mirror’); and reporting (viz. TS 6000 Report Wizard). Therefore they are invaluable for clinical audit (viz. PSV Clinical Audit Module).[1,9,11]

Without computerization, data collection from (often incomplete!) records and tabulation was a Herculean task.[9] We therefore learnt some valuable secondary lessons during our audit; the crucial role of informatics/information systems in clinical audit and e-clinical governance;[1,9,11] and, non-use of information systems violated risk management principles that required mitigation.[12]

Reference

1. Simpson L. Chapter 3: Concepts Clinical Governance. In: Simpson L and Robinson P, editors. e-Clinical Governance. Oxford: Radcliffe Medical Press; 2002 [Cited 2005 December 11]. Available from: http://www.prodigy.nhs.uk/training/eClinicalGovernance/chapter3.asp.

2. Robinson P. Chapter 4: Doing what we already do. In: Simpson L and Robinson P, editors. e-Clinical Governance. Oxford: Radcliffe Medical Press; 2002 [Cited 2005 December 11]. Available from: http://www.prodigy.nhs.uk/training/eClinicalGovernance/chapter4.asp.

 

3. Raison H. Chapter 5: Evidence-based medicine. In: Simpson L and Robinson P, editors. e-Clinical Governance. Oxford: Radcliffe Medical Press; 2002 [Cited 2005 December 11]. Available from: http://www.prodigy.nhs.uk/training/eClinicalGovernance/chapter5.asp.

4. Wolfson Unit for Endoscopy [homepage on the Internet]. BOWEL PREPARATION FOR COLONOSCOPY. St. Mark’s Hospital: Wolfson Unit for endoscopy; © 2003 [Cited 2005 December 11]. Available from: http://www.wolfsonendoscopy.org.uk/bowel-preparation-for-colonoscopy.html

5. University Surgeons [homepage on the Internet]. Bowel Preps For Endoscopic Examinations. University Surgeons; [Cited 2005 December 11]. Available from: www.usurg.com/news/BowelPreps.htm.

6. Bulmer F. Bowel preparation for rectal and colonic investigation. Nursing Standard 2000; 14(20): 32-5. [Cited 2005 December 11]. Available from: http://www.nursing-standard.co.uk/archives/ns/vol14-20/res.pdf.

7.. American Society for Gastrointestinal Endoscopy [homepage on the Internet]. Colonoscopy preparations. American Society for Gastrointestinal Endoscopy; 2001 May [Cited 2005 December 11]. Available from: http://www.asge.org/nspages/practice/patientcare/colonscopy.cfm.

8. Fasih T, Tabaqchali MA, Varma JS. PATIENTS’ PERCEPTION OF COLONOSCOPY. Royal College of Surgeons of Edinburgh; [Cited 2005 December 11]. Available from: http://www.edu.rcsed.ac.uk/lectures/lt35.htm.

9. Robinson P, Simpson L. Chapter 8: Showing and reflecting: shop windows and mirrors. In: Simpson L and Robinson P, editors. e-Clinical Governance. Oxford: Radcliffe Medical Press; 2002 [Cited 2005 December 11]. Available from: http://www.prodigy.nhs.uk/training/eClinicalGovernance/chapter8.asp.

10. Eweles L, Simnett I, editors. Promoting Health – A Practical Guide. London: Bailliere Tindall/RCN; 1999.

11. Thomas J. Chapter 9: The clinical computer system and e-clinical governance. In: Simpson L and Robinson P, editors. e-Clinical Governance. Oxford: Radcliffe Medical Press; 2002 [Cited 2005 December 11]. Available from: http://www.prodigy.nhs.uk/training/eClinicalGovernance/chapter9.asp.

12. Graham G. Chapter 6: Risk Management. In: Simpson L and Robinson P, editors. e-Clinical Governance. Oxford: Radcliffe Medical Press; 2002 [Cited 2005 December 11]. Available from: http://www.prodigy.nhs.uk/training/eClinicalGovernance/chapter6.asp.

Appendix-1

Pre-colonoscopy bowel preparation protocol, as practiced in one centre

 

      Appendix-2

Summary of preparation agents – ASGE Summary of preparation agents – ASGE Summary of preparation agents – ASGE Summary of preparation agents – ASGE Summary of preparation agents –

ASGE

Agent Volume Safety / Advantages Efficacy(adequate

prep)

Cost

PEG-ELS ColyteGolytely flavored and non-flavored

4 L Produces no significant change in weight, vital signs, serum electrolytes, or complete blood counts. It is relatively safe in electrolyte imbalance, advanced liver disease, poorly compensated CCF, or renal failure.

33%-91%19 $16.98-$18.13 per 4L

93%-100%4,17,18

$16.98-$18.13 per 4L (not sold in 2 L volumes)+ bisacodyl($0.11/tablet)

PEG-ELS ColyteGolytely flavored and non-flavored

2L + bisacodyl ormagnesium citrate

SF-ELS Nulytelyflavored andnon-flavored

4 L 73%-86.5%13,14,19

$19.15

NaP (aqueous) FleetsPhospho-Soda

90 ml Have the potential to alter serum electrolytes and ECF status.

Better tolerated

Greater degree of asymptomatic hyperphosphataemia in children

64%-90%19 $1.16/45ml $2.07/90 ml

80%20 $32.75

NaP (tablet) Visacol

40 tablets

PIEE per-rectal PulsedIrrigation Enhanced Evacuation

5 gal in 25 ml pulses

Short time to achieve colonic cleansing (30 minutes)

Ability to prepare patients who are unable to tolerate oral preparations or unable to ambulate to a commode.

17/18 (94%)21

Approximately $50 per preparation, plus initial cost of Avitar unit (approximately $7000)

Appendix-3

Scoring of Patient’s perception of Full Bowel Preparation - RCSEd Scoring of Patient’s perception of Full Bowel Preparation - RCSEd Scoring of Patient’s perception of Full Bowel Preparation - RCSEd Scoring of Patient’s perception of Full Bowel Preparation - RCSEd Scoring of Patient’s perception of Full Bowel Preparation - RCSEd Scoring of Patient’s perception of Full Bowel Preparation - RCSEd

Tolerance to preparation

Easy 0 Tolerable 1 Slightly difficult 2

Distressing 3 Unbearable 4

Abdominal discomfort

None Mild Moderate Distressing Unbearable

Sleep loss None Mild Moderate Distressing Unbearable

Nausea & Vomiting None Mild Moderate Distressing Unbearable

Accept preparation again

Definitely would

Probably would

Only if necessary

Probably would not

Never again

                             

Acceptance of repeat colonoscopy – RCSEd

 

Appendix-4

Key to abbreviations in data Table-1

 

 

 

 

 

 

 

MSc Health Informatics; RCSEd + Univ of Bath; Unit 7; Dec 2005; Unit Tutor – Louise; Student – Sanjoy Sanyal 1