Table 3 Potential problems and solutions at patient, nurse, physician and system level for the bowel preparation process for inpatient colonoscopy
Level | Potential problems | Potential solutions |
|---|---|---|
Patient | Poor palatability | Switch to Polyethylene glycol-electrolyte solution with flavor packets of 4 flavors attached to bottle and no sulfur taste |
Chill bowel preparation | ||
Mix with flavor powders or non-red juice | ||
Unable to drink fast enough due to volume or nausea (assuming obstruction not suspected) or altered mental status (i.e. delirium or dementia) | Anti-emetics | |
Nasogastric Tube | ||
Not following instructions | Patient education handout | |
Family involvement | ||
Inpatient status ± underlying risk factors for poor bowel preparation | Consider 6-L bowel preparation | |
Consider 2-day bowel preparation | ||
Flushes bowel movement before nurse evaluating | Nursing places toilet hat when close to ready | |
Nursing | Floor nurse protocol cannot require bedside checks more frequently than every 4 h | Encourage family to help |
Recruit medical assistant participation | ||
Use of technology for reminders | ||
Unclear importance of bowel preparation and instructions highly variable | Standardize instructions | |
Nursing education sessions | ||
Endoscopy and floor nurses discuss day prior to procedure | ||
Original nurse communication with instructions acknowledged by day shift nurse and not viewed by night shift nurse | Instructions in medication order so viewable when administering | |
Orderset with timed instructions | ||
Variable reporting of readiness for procedure | Nursing education and picture of readiness on patient education | |
Toilet hat | ||
Endoscopy and floor nurses discuss morning of procedure | ||
Physician | Preparation recommended by gastroenterology highly variable leading to confusion | Create protocol for standardization |
Instructions from gastroenterology not clear and/or written in notes | Electronic note templates for easy use in gastroenterology notes | |
Due to nature of complex inpatient consult service, decision-to-scope communicated late (i.e., after 6 pm) to primary team | Set mutually agreed upon expectation for early communication by gastroenterology with a set latest time (i.e., 4 pm) | |
Ordering suppositories and enemas as “rescue” in the morning leads to false sense patient is clear when right side of colon is not | Using more bowel preparation instead of suppositories and enemas | |
Conversion to 2-day preparation | ||
Boston Bowel Preparation Score not properly documented. This could be knowledge gap or due to busy inpatient consult service while scoping. Procedure notes written at end of day leading to memory and bias | Scoring education | |
Document score in Brief-Op note immediately post-procedure for reference later when writing procedure note | ||
Primary team orders differently than gastroenterology recommendations | Primary team education | |
Orderset | ||
System | Amount of bowel preparation consumed not documented | Fellow or nurse go to bedside to document amount drank |
Educate nursing day prior to document in medical record | ||
Lag time between order and administration | Stock bowel preparation in pyxis on specific floors | |
Long chain of communication: GI, primary team, day nurse, night nurse | Set protocol for communication expectations, note templates, ordersets | |
Dietary keeps flavor mix packs and nursing unable to get after certain hour | Stock flavor packs on floor or use Polyethylene glycol-electrolyte solution with flavor packets of 4 flavors attached to bottle |