Service implications of implementing guidance for oral bowel cleansing agents in colonoscopy

Abstract

Introduction:Bowel preparation has led to serious adverse events. Consequently, regulatory and advisory bodies have issued guidance, including a risk stratification of patients, aiming to minimise this risk. Aims: To determine the impact of the new guidance on our current practice of Picolax used in colonoscopy with regard to patient stratification, compliance and service implementation. Methods: Patients listed for day case colonoscopy during October 2009 were audited using data from the hospital and endoscopy databases. A follow-up, structured patient telephone interview evaluated side effects, the assessment process and patient experience. Results: Of the participating 112 patients, 97.4% were clinically reviewed before colonoscopy, 98.3% received written instructions and 70% verbal instructions. None had their preparation dispensed by a regulated professional. Although 62% of patients were retrospectively identified as 'at risk' (elderly, with congestive cardiac failure, cirrhosis or chronic kidney disease or on angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics or non-steroidal anti-inflammatory drugs), none were identified before their procedure. Significant events (postural hypotension, collapse, dizziness, palpitations, faint) were seen in 4.4%, all of whom could potentially be identified as 'at risk' using a stratification of low estimated glomerular filtration rate with relevant co-morbidity (congestive cardiac failure or cirrhosis). Conclusions: Given the difficulties with compliance and the high prevalence of 'at risk' patients, the implementation will be challenging and require significant service redesign.

Improved clinical outcomes and efficacy with a nurse-led colonoscopy surveillance service

“…Others have included: (1) collaboration with our renal doctors and pharmacy to change the bowel preparation protocol from exclusively use of picolax as an oral bowel cleansing agent for both flexible sigmoidoscopy and colonoscopy to a phosphate enema for the former and a polyethylene glycol-based preparation for colonoscopy5; (2) changing our method of referral to an electronic system with pathways, protocols, safety checks and bowel preparation prescription built in; (3) changing our administrative processes to include further safety checks before administration of the bowel preparation. The introduction of our new nurse practitioner-led surveillance service has been an integral part of compliance with the new surveillance category and intervals guidelines,1 2 and also has allowed compliance with the NPSA and BSG consensus guidelines for the safe use of oral bowel cleansing agents 3 4.…”

Preassessment Interview Improves the Efficacy and Safety of Bowel Preparation for Colonoscopy

“…The consensus guidelines recommend a clinical evaluation, measurement of serum eGFR, and a review for the above medications and comorbidities. Based on these parameters, a recent study suggested that up to 64% of patients could be defined as “at risk” of adverse events from bowel preparation [3]. …”