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558 The Nursing Bowel Preparation Assessment Tool (NBPAT) Is Highly Predictive of Inpatient Bowel Preparation Adequacy: a Prospective Pilot Study
Abstracts
558 The Nursing Bowel Preparation Assessment Tool (NBPAT) Is Highly Predictive of Inpatient Bowel Preparation Adequacy: a Prospective Pilot Study Elyse R. Johnston*, Rajesh N. Keswani, Rachel Cyrus, Lindsay Werth, David Grande, Rena Yadlapati Northwestern University, Chicago, IL Introduction: Inpatient colonoscopy preparations (preps) are frequently inadequate, resulting in aborted and repeat procedures, and associated increases in length of stay and costs. Assessment of bowel prep adequacy prior to inpatient colonoscopy has traditionally been subjective, relying on patient and/or nurse recall. We developed the nursing bowel prep assessment tool (NBPAT), an electronic structured nursing assessment tool to predict bowel prep adequacy. The aims of this study are to describe the development of the NBPAT and its accuracy in predicting bowel prep adequacy. Methods: Design/Setting: This was an observational prospective study at a single tertiary care teaching institution over 4 months of adult patients undergoing bowel prep for an inpatient colonoscopy. The NBPAT was designed and incorporated into an electronic colonoscopy order set. The NBPAT documents sub-scores for stool consistency, color, and sediment presence and automatically summates a total NBPAT score of 0 to 5 (Figure 1). Unit nurses completed the NBPAT the morning of the planned procedure. According to the NBPAT score, additional prep was given at the discretion of the trainee. Definitions: Adequate colonoscopy prep at time of colonoscopy was defined as an intact Boston Bowel Prep Scale (BBPS) score R 6, segmental BBPS R 2 or prep quality described as “good”, “excellent” or “adequate”; all other prep descriptions were considered inadequate. Results: Nursing compliance with utilizing and completing the NBPAT was 66.9% (95/142). NBPAT score was 5 in 40.0%, 4 in 30.5%, 3 in 18.9%, 2 in 7.4%, and 1 in 3.2% of patients. An NBPAT score of 4 or 5 had a 93.9% positive predictive value (PPV) for adequate colonoscopy prep; an NBPAT of 3 to 5 had a PPV of 90.8%. When no additional prep was given, 30% of patients with an NBPAT score of 3 had inadequate preps compared to 6.1% with a score of 4 or 5 (pZ0.04). Patients with NBPAT scores of 1 to 3 had lower rates of inadequate prep when additional prep was administered compared to cases where colonoscopy was performed without additional prep (15.4% vs 50.0%, pZ0.07). All four patients with an NBPAT score of 2 who did not receive additional prep had an inadequate prep at time of colonoscopy (Figure 2). Discussion: Utilizing the NBPAT is feasible and a high score (4 or 5) is highly predictive of adequate bowel prep at time of colonoscopy. Patients with low scores (1 or 2), and potentially those with intermediate scores (3), require additional prep to minimize the risk of an inadequate prep during colonoscopy. Given its ease of use, institutions should consider implementing this tool to reduce the risk of inadequate bowel preps.
Figure 2. Flow diagram of patients undergoing inpatient colonoscopy according to NBPAT score
559 Recognition and Resolution of Duodenoscope Associated MultiDrug Resistant Bacterial Transmission Christopher Baliga*2, Andrew S. Ross1, Michael Gluck1 1 Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA; 2 Virginia Mason Medical Center, Seattle, WA
Figure 1. Nursing Bowel Preparation Assessment Tool (NBPAT) incorporated into the electronic health record
AB154 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Background: Duodenoscopes have been implicated in the transmission of multidrug resistant bacteria (MDRB). Our medical center has been voluntarily submitting cultures since 2010 to a state reference laboratory surveying for the emergence of MDRB in hospitals. We were informed In November 2013 that a cluster of patients treated at our institution had a unique hyper-AmpC-E. Coli, with the preponderance of those patients having had one or more ERCPs. Methods: Chart reviews were undertaken to identify demographics, co-morbidities, procedures performed, and clinical outcomes. The entire endoscope reprocessing procedure was extensively investigated. Significant procedure modifications were undertaken. Results: Thirty patients were identified: 17 had underlying malignant biliary obstructions, 13 had benign biliary obstruction either from complicated pancreatitis or structuring biliary disease. The median number of ERCPs was 2 (range 1 to 13), and all but one had a stent. Eleven patients died during the study period, 6 with pancreatic cancer and 5 of progressive underlying disease. Root-cause analysis demonstrated that scope reprocessing was at or exceeded manufacturer’s recommendations, that the endoscope reprocessing room did not harbor MDRBs, and only duodenoscopes were contaminated with MDRBs. Systematic analysis suggested that the elevator and its channel appeared to be the safe harbor for bacteria. Multiple resolutions were considered: 1)gas sterilization with ethylene oxide, a process that was rejected due to reports that bacteria can survive the process and that ethylene oxide is considered a carcinogen; 2) protein or bioburden assays that quantify scope cleanliness, rejected as those results did not correlate well with scope culture results. Therefore, a unique program was adopted, the “penalty box”, to ensure that only culturenegative duodenoscopes were used. The program was instituted on January 22, 2014. Since that time, 1194 cultures have been collected from duodenoscopes, demonstrating 168 (14%) harboring bacteria, but only 25 growing pathogenic bacteria. No contaminated scopes were utilized on patients, even if only skin contaminants were identified. Since initiation of the “penalty box”, no MDRB have been introduced into any patient undergoing an ERCP. Conclusions: Despite meticulous
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558 The Nursing Bowel Preparation Assessment Tool (NBPAT) Is Highly Predictive of Inpatient Bowel Preparation Adequacy: a Prospective Pilot Study Elyse R. Johnston*, Rajesh N. Keswani, Rachel Cyrus, Lindsay Werth, David Grande, Rena Yadlapati Northwestern University, Chicago, IL Introduction: Inpatient colonoscopy preparations (preps) are frequently inadequate, resulting in aborted and repeat procedures, and associated increases in length of stay and costs. Assessment of bowel prep adequacy prior to inpatient colonoscopy has traditionally been subjective, relying on patient and/or nurse recall. We developed the nursing bowel prep assessment tool (NBPAT), an electronic structured nursing assessment tool to predict bowel prep adequacy. The aims of this study are to describe the development of the NBPAT and its accuracy in predicting bowel prep adequacy. Methods: Design/Setting: This was an observational prospective study at a single tertiary care teaching institution over 4 months of adult patients undergoing bowel prep for an inpatient colonoscopy. The NBPAT was designed and incorporated into an electronic colonoscopy order set. The NBPAT documents sub-scores for stool consistency, color, and sediment presence and automatically summates a total NBPAT score of 0 to 5 (Figure 1). Unit nurses completed the NBPAT the morning of the planned procedure. According to the NBPAT score, additional prep was given at the discretion of the trainee. Definitions: Adequate colonoscopy prep at time of colonoscopy was defined as an intact Boston Bowel Prep Scale (BBPS) score R 6, segmental BBPS R 2 or prep quality described as “good”, “excellent” or “adequate”; all other prep descriptions were considered inadequate. Results: Nursing compliance with utilizing and completing the NBPAT was 66.9% (95/142). NBPAT score was 5 in 40.0%, 4 in 30.5%, 3 in 18.9%, 2 in 7.4%, and 1 in 3.2% of patients. An NBPAT score of 4 or 5 had a 93.9% positive predictive value (PPV) for adequate colonoscopy prep; an NBPAT of 3 to 5 had a PPV of 90.8%. When no additional prep was given, 30% of patients with an NBPAT score of 3 had inadequate preps compared to 6.1% with a score of 4 or 5 (pZ0.04). Patients with NBPAT scores of 1 to 3 had lower rates of inadequate prep when additional prep was administered compared to cases where colonoscopy was performed without additional prep (15.4% vs 50.0%, pZ0.07). All four patients with an NBPAT score of 2 who did not receive additional prep had an inadequate prep at time of colonoscopy (Figure 2). Discussion: Utilizing the NBPAT is feasible and a high score (4 or 5) is highly predictive of adequate bowel prep at time of colonoscopy. Patients with low scores (1 or 2), and potentially those with intermediate scores (3), require additional prep to minimize the risk of an inadequate prep during colonoscopy. Given its ease of use, institutions should consider implementing this tool to reduce the risk of inadequate bowel preps.
Figure 2. Flow diagram of patients undergoing inpatient colonoscopy according to NBPAT score
559 Recognition and Resolution of Duodenoscope Associated MultiDrug Resistant Bacterial Transmission Christopher Baliga*2, Andrew S. Ross1, Michael Gluck1 1 Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA; 2 Virginia Mason Medical Center, Seattle, WA
Figure 1. Nursing Bowel Preparation Assessment Tool (NBPAT) incorporated into the electronic health record
AB154 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Background: Duodenoscopes have been implicated in the transmission of multidrug resistant bacteria (MDRB). Our medical center has been voluntarily submitting cultures since 2010 to a state reference laboratory surveying for the emergence of MDRB in hospitals. We were informed In November 2013 that a cluster of patients treated at our institution had a unique hyper-AmpC-E. Coli, with the preponderance of those patients having had one or more ERCPs. Methods: Chart reviews were undertaken to identify demographics, co-morbidities, procedures performed, and clinical outcomes. The entire endoscope reprocessing procedure was extensively investigated. Significant procedure modifications were undertaken. Results: Thirty patients were identified: 17 had underlying malignant biliary obstructions, 13 had benign biliary obstruction either from complicated pancreatitis or structuring biliary disease. The median number of ERCPs was 2 (range 1 to 13), and all but one had a stent. Eleven patients died during the study period, 6 with pancreatic cancer and 5 of progressive underlying disease. Root-cause analysis demonstrated that scope reprocessing was at or exceeded manufacturer’s recommendations, that the endoscope reprocessing room did not harbor MDRBs, and only duodenoscopes were contaminated with MDRBs. Systematic analysis suggested that the elevator and its channel appeared to be the safe harbor for bacteria. Multiple resolutions were considered: 1)gas sterilization with ethylene oxide, a process that was rejected due to reports that bacteria can survive the process and that ethylene oxide is considered a carcinogen; 2) protein or bioburden assays that quantify scope cleanliness, rejected as those results did not correlate well with scope culture results. Therefore, a unique program was adopted, the “penalty box”, to ensure that only culturenegative duodenoscopes were used. The program was instituted on January 22, 2014. Since that time, 1194 cultures have been collected from duodenoscopes, demonstrating 168 (14%) harboring bacteria, but only 25 growing pathogenic bacteria. No contaminated scopes were utilized on patients, even if only skin contaminants were identified. Since initiation of the “penalty box”, no MDRB have been introduced into any patient undergoing an ERCP. Conclusions: Despite meticulous
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