Alexandra T Strauss1, Jennifer Yeh2, Diego A Martinez3, Gayane Yenokyan4, Janet Yoder5, Ravi Nehra6, Tara Feller6, Kathy Bull-Henry7, Ellen Stein7, Lawrence C H Hsu8, Haitham Al-Grain9, Candice Zabko5, Christopher Fain7. 1. Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 600 N Wolfe St. Blalock 465, Baltimore, MD, 21205, USA. Astraus6@jhmi.edu. 2. Department of Internal Medicine, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA. 3. Department of Emergency Medicine, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA. 4. Johns Hopkins Biostatistics Center, Johns Hopkins University Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA. 5. Department of Medical Nursing, Johns Hopkins University, 601 N Caroline St, Baltimore, MD, 21287, USA. 6. Department of Pharmacy, Johns Hopkins Hospital, 601 N Caroline St, Baltimore, MD, 21287, USA. 7. Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 600 N Wolfe St. Blalock 465, Baltimore, MD, 21205, USA. 8. Operations Integration, Johns Hopkins Health System, 601 N Caroline St, Baltimore, MD, 21287, USA. 9. Department of Anesthesiology, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA.
Abstract
BACKGROUND: Inpatient colonoscopy bowel preparation (ICBP) is frequently inadequate and can lead to adverse events, delayed or repeated procedures, and negative patient outcomes. Guidelines to overcome the complex factors in this setting are not well established. Our aims were to use health systems engineering principles to comprehensively evaluate the ICBP process, create an ICBP protocol, increase adequate ICBP, and decrease length of stay. Our goal was to provide adaptable tools for other institutions and procedural specialties. METHODS: Patients admitted to our tertiary care academic hospital that underwent inpatient colonoscopy between July 3, 2017 to June 8, 2018 were included. Our multi-disciplinary team created a protocol employing health systems engineering techniques (i.e., process mapping, cause-effect diagrams, and plan-do-study-act cycles). We collected demographic and colonoscopy data. Our outcome measures were adequate preparation and length of stay. We compared pre-intervention (120 ICBP) vs. post-intervention (129 ICBP) outcomes using generalized linear regression models. Our new ICBP protocol included: split-dose 6-L polyethylene glycol-electrolyte solution, a gastroenterology electronic note template, and an education plan for patients, nurses, and physicians. RESULTS: The percent of adequate ICBPs significantly increased with the intervention from 61% pre-intervention to 74% post-intervention (adjusted odds ratio of 1.87, p value = 0.023). The median length of stay decreased by approximately 25%, from 4 days pre-intervention to 3 days post-intervention (p value = 0.11). CONCLUSIONS: By addressing issues at patient, provider, and system levels with health systems engineering principles, we addressed patient safety and quality of care provided by improving rates of adequate ICBP.
BACKGROUND: Inpatient colonoscopy bowel preparation (ICBP) is frequently inadequate and can lead to adverse events, delayed or repeated procedures, and negative patient outcomes. Guidelines to overcome the complex factors in this setting are not well established. Our aims were to use health systems engineering principles to comprehensively evaluate the ICBP process, create an ICBP protocol, increase adequate ICBP, and decrease length of stay. Our goal was to provide adaptable tools for other institutions and procedural specialties. METHODS:Patients admitted to our tertiary care academic hospital that underwent inpatient colonoscopy between July 3, 2017 to June 8, 2018 were included. Our multi-disciplinary team created a protocol employing health systems engineering techniques (i.e., process mapping, cause-effect diagrams, and plan-do-study-act cycles). We collected demographic and colonoscopy data. Our outcome measures were adequate preparation and length of stay. We compared pre-intervention (120 ICBP) vs. post-intervention (129 ICBP) outcomes using generalized linear regression models. Our new ICBP protocol included: split-dose 6-L polyethylene glycol-electrolyte solution, a gastroenterology electronic note template, and an education plan for patients, nurses, and physicians. RESULTS: The percent of adequate ICBPs significantly increased with the intervention from 61% pre-intervention to 74% post-intervention (adjusted odds ratio of 1.87, p value = 0.023). The median length of stay decreased by approximately 25%, from 4 days pre-intervention to 3 days post-intervention (p value = 0.11). CONCLUSIONS: By addressing issues at patient, provider, and system levels with health systems engineering principles, we addressed patient safety and quality of care provided by improving rates of adequate ICBP.
Entities:
Keywords:
Bowel preparation; Colonoscopy; Health systems engineering; Quality improvement
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