- Email: [email protected]
Preventing Poor Bowel Preps Before They Become a Problem
198
AGA Section
identified this as an area of improvement because the use of PPI drips at our institution is frequent. The use of PPI drips leads to decreased comfort and mobility of patients, increased costs and usage of resources (pharmacy, nursing, use of an infusion pump, etc). Our goal was to establish a quality-improvement initiative that addressed this issue leading to a scenario where providers could safely “skip the drip.” METHODS: Our quality-improvement initiative was submitted to the hospital’s “Choosing Wisely” challenge. The intervention was mapped to the COST (culture [promoted by faculty at our gastroenterology department]; oversight [tracking usage by pharmacy]; systems change [electronic health record changes to remind clinicians about the indications to use PPI drips], and training [in-person and email education of medicine and emergency department housestaff and hospitalists] Framework. To date, we focus on appropriateness of continuous PPI orders in the 2 months post intervention (July 9, 2015 to August 31, 2015) compared with a 2-month historical control period pre-implementation (July 9, 2014 to August 31, 2014). Time-driven activity-based costing was used to calculate cost savings based on US Department of Labor wages for nursing and pharmacy. RESULTS: The number of PPI drips post-intervention was 53 compared with 60 pre-intervention. Specifically, postendoscopic PPI continuous intravenous therapy was discontinued at a significantly greater rate post-intervention (from 66% to 93%; P ¼ .004). There was a trend in the choice of post-endoscopy PPI, providers were more likely to follow established guidelines (83% vs 95%; P ¼ .09). Using time-driven activity-based costing, we calculated a $277.45 difference in cost per patient day for using continuous PPI infusion vs twice-daily PPI, and a net savings of >$93,000 over 1 year just for this portion of the intervention. CONCLUSIONS: A quality-improvement project for the appropriate use of PPIs in the setting of upper gastrointestinal bleeding resulted in projected substantial savings without affecting medical care. We believe that this is a model that can be easily replicated at other institutions. Further research is needed to assess the long-term impact of continuing this intervention at our institution.
Gastroenterology Vol. 151, No. 1
patient demographic characteristics, medical comorbidities, procedural preparation, and procedural findings. Multivariable models were constructed using logistic regression and the analysis of maximum likelihood ratios to assess statistical associations and risk factors for adequate colon preparation. Institutional Review Board approval was obtained for this study. RESULTS: Five hundred and forty-seven patients were enrolled in our study. Of these, inadequate BP was seen in 20.9% (n ¼ 135) of colonoscopies. Our results found significant differences in bowel prep adequacy with the following medical issues based on multivariate analysis (significant values shown in Table 1): chronic obstructive pulmonary disease (P ¼ .002), diabetes with end-organ damage (P < .001), severe neurological disease (P ¼ .003), use of constipation medications (P ¼ .003), tricyclic antidepressant use (P < .001), clear diet instructions followed (P ¼ .003), if prep was completed (P < .001), and if split-dose prep was used (P < .001 with 82.5% using split dosing). We did not see a significant difference in the adequacy of bowel prep with regard to the following: age, sex, education level, race, cirrhosis, chronic kidney disease, congestive heart failure, inflammatory bowel disease, irritable bowel syndrome, past gastrointestinal surgery, narcotic use, family history of colon cancer, body mass index, inpatient procedures, type of prep used (92.4% used Golytely; Braintree Laboratories, Braintree, MA), previous colonoscopy, diverticula on exam, and diagnostic vs screening exam. CONCLUSIONS: The likelihood of inadequate BP is strongly influenced by medical comorbidities, such as advanced diabetes, chronic obstructive pulmonary disease, neurological disease, and the use of gutslowing medications. We have confirmed the importance of split-dose preparation as well as the use of a clear liquid diet before colonoscopy. A prospective study to develop a scoring system to predict which patient can benefit from an extended BP building on our findings is planned to improve the costeffectiveness of current endoscopic practice. Conflicts of interest The authors disclose no conflicts.
OBJECTIVE & AIMS: Multiple factors can predispose to poor
Adherence to Clostridium difficile Infection Treatment Guidelines at a Tertiary Care Hospital: A Retrospective Chart Review Christine Granato,1 Xiang Lu,2 Sally Thurston,2 Danielle Marino1 1 Division of Gastroenterology and Hepatology; and 2 Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York
bowel preparation (BP), which impairs adequate mucosal evaluation with colonoscopy and decreases safety of procedure. Despite split-dose BP, there are still a significant number of patients with poor BP. We performed a prospective quality-improvement survey in an attempt to identify patients that would benefit from extended BP (and/ or increased instruction). METHODS: Data were gathered before colonoscopy in our endoscopy suite with use of a quality-improvement survey. Each BP was evaluated and scored by the same gastroenterology fellow with input from the attending endoscopist. Recipients with inadequate preparation, which was defined as a Boston Bowel Preparation Score of 2 in any colonic segment (right, transverse, or left) were compared to patients with adequate preparation statistically with regard to multiple factors, including baseline
BACKGROUND & AIMS: Morbidity secondary to Clostridium difficile infection (CDI) places a burden on the health care system. Updated practice guidelines for CDI have been published by the Infectious Diseases Society of America in 2010, with a supplement published in 2013 by the American College of Gastroenterology on recommendations for diagnosis, management, and prevention of CDI. Both guidelines identify a scoring system to calculate the severity of CDI, with recommended antibiotic choices based on CDI severity. The aim of this study was to evaluate the adherence to guidelines for the management of severe CDI in hospitalized patients at an academic medical center. METHODS: A retrospective chart review on hospitalized patients fulfilling criteria for severe CDI was completed from 2011 to 2014. Inclusion
Conflicts of interest The authors disclose no conflicts.
Preventing Poor Bowel Preps Before They Become a Problem Charles B. Orton, Johnathan Stine, Steven Powell
AGA Section
identified this as an area of improvement because the use of PPI drips at our institution is frequent. The use of PPI drips leads to decreased comfort and mobility of patients, increased costs and usage of resources (pharmacy, nursing, use of an infusion pump, etc). Our goal was to establish a quality-improvement initiative that addressed this issue leading to a scenario where providers could safely “skip the drip.” METHODS: Our quality-improvement initiative was submitted to the hospital’s “Choosing Wisely” challenge. The intervention was mapped to the COST (culture [promoted by faculty at our gastroenterology department]; oversight [tracking usage by pharmacy]; systems change [electronic health record changes to remind clinicians about the indications to use PPI drips], and training [in-person and email education of medicine and emergency department housestaff and hospitalists] Framework. To date, we focus on appropriateness of continuous PPI orders in the 2 months post intervention (July 9, 2015 to August 31, 2015) compared with a 2-month historical control period pre-implementation (July 9, 2014 to August 31, 2014). Time-driven activity-based costing was used to calculate cost savings based on US Department of Labor wages for nursing and pharmacy. RESULTS: The number of PPI drips post-intervention was 53 compared with 60 pre-intervention. Specifically, postendoscopic PPI continuous intravenous therapy was discontinued at a significantly greater rate post-intervention (from 66% to 93%; P ¼ .004). There was a trend in the choice of post-endoscopy PPI, providers were more likely to follow established guidelines (83% vs 95%; P ¼ .09). Using time-driven activity-based costing, we calculated a $277.45 difference in cost per patient day for using continuous PPI infusion vs twice-daily PPI, and a net savings of >$93,000 over 1 year just for this portion of the intervention. CONCLUSIONS: A quality-improvement project for the appropriate use of PPIs in the setting of upper gastrointestinal bleeding resulted in projected substantial savings without affecting medical care. We believe that this is a model that can be easily replicated at other institutions. Further research is needed to assess the long-term impact of continuing this intervention at our institution.
Gastroenterology Vol. 151, No. 1
patient demographic characteristics, medical comorbidities, procedural preparation, and procedural findings. Multivariable models were constructed using logistic regression and the analysis of maximum likelihood ratios to assess statistical associations and risk factors for adequate colon preparation. Institutional Review Board approval was obtained for this study. RESULTS: Five hundred and forty-seven patients were enrolled in our study. Of these, inadequate BP was seen in 20.9% (n ¼ 135) of colonoscopies. Our results found significant differences in bowel prep adequacy with the following medical issues based on multivariate analysis (significant values shown in Table 1): chronic obstructive pulmonary disease (P ¼ .002), diabetes with end-organ damage (P < .001), severe neurological disease (P ¼ .003), use of constipation medications (P ¼ .003), tricyclic antidepressant use (P < .001), clear diet instructions followed (P ¼ .003), if prep was completed (P < .001), and if split-dose prep was used (P < .001 with 82.5% using split dosing). We did not see a significant difference in the adequacy of bowel prep with regard to the following: age, sex, education level, race, cirrhosis, chronic kidney disease, congestive heart failure, inflammatory bowel disease, irritable bowel syndrome, past gastrointestinal surgery, narcotic use, family history of colon cancer, body mass index, inpatient procedures, type of prep used (92.4% used Golytely; Braintree Laboratories, Braintree, MA), previous colonoscopy, diverticula on exam, and diagnostic vs screening exam. CONCLUSIONS: The likelihood of inadequate BP is strongly influenced by medical comorbidities, such as advanced diabetes, chronic obstructive pulmonary disease, neurological disease, and the use of gutslowing medications. We have confirmed the importance of split-dose preparation as well as the use of a clear liquid diet before colonoscopy. A prospective study to develop a scoring system to predict which patient can benefit from an extended BP building on our findings is planned to improve the costeffectiveness of current endoscopic practice. Conflicts of interest The authors disclose no conflicts.
OBJECTIVE & AIMS: Multiple factors can predispose to poor
Adherence to Clostridium difficile Infection Treatment Guidelines at a Tertiary Care Hospital: A Retrospective Chart Review Christine Granato,1 Xiang Lu,2 Sally Thurston,2 Danielle Marino1 1 Division of Gastroenterology and Hepatology; and 2 Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York
bowel preparation (BP), which impairs adequate mucosal evaluation with colonoscopy and decreases safety of procedure. Despite split-dose BP, there are still a significant number of patients with poor BP. We performed a prospective quality-improvement survey in an attempt to identify patients that would benefit from extended BP (and/ or increased instruction). METHODS: Data were gathered before colonoscopy in our endoscopy suite with use of a quality-improvement survey. Each BP was evaluated and scored by the same gastroenterology fellow with input from the attending endoscopist. Recipients with inadequate preparation, which was defined as a Boston Bowel Preparation Score of 2 in any colonic segment (right, transverse, or left) were compared to patients with adequate preparation statistically with regard to multiple factors, including baseline
BACKGROUND & AIMS: Morbidity secondary to Clostridium difficile infection (CDI) places a burden on the health care system. Updated practice guidelines for CDI have been published by the Infectious Diseases Society of America in 2010, with a supplement published in 2013 by the American College of Gastroenterology on recommendations for diagnosis, management, and prevention of CDI. Both guidelines identify a scoring system to calculate the severity of CDI, with recommended antibiotic choices based on CDI severity. The aim of this study was to evaluate the adherence to guidelines for the management of severe CDI in hospitalized patients at an academic medical center. METHODS: A retrospective chart review on hospitalized patients fulfilling criteria for severe CDI was completed from 2011 to 2014. Inclusion
Conflicts of interest The authors disclose no conflicts.
Preventing Poor Bowel Preps Before They Become a Problem Charles B. Orton, Johnathan Stine, Steven Powell