Utilization of quality improvement methods to standardize inpatient bowel clean-outs

Background: Functional constipation is a common digestive complaint that can be complicated by fecal impaction necessitating inpatient admission for bowel clean out. Optimal inpatient management for a bowel clean out is unknown, which can lead to wide practice variation among providers. Our institution utilized a quality improvement (QI) initiative to standardize inpatient management of fecal impaction. Methods: A standardized approach to inpatient management for fecal impaction was created based on divisional consensus. A care index (CI), defined by the completion of 4 diagnostic and therapeutic interventions felt integral to effective implementation of the division's standardized management algorithm for fecal impaction was created. The CI was considered completed if a patient received, within 24 hours of admission, (1) medical or manual disimpaction, (2) naso-gastric (NG) tube placement, (3), NuLYTELY initiation and (4) abdominal radiography, if not previously obtained within the prior 7 days. The QI initiative was implemented in January 2020. All admissions to the general gastroenterology service with a primary diagnosis of fecal impaction were reviewed and completion of each CI variable was recorded. Length of stay (LOS) and CI completion were tracked. PDSA cycles included provider education, implementation of an admission order set, nursing education, admission order set revisions and reminder e-mails to the inpatient provider team. Baseline data were obtained from admissions to the general gastroenterology service with a primary diagnosis of fecal impaction between January 1, 2019 and December 31, 2019 and were compared to data collected following initiation of the QI effort between January 1, 2020 and December 31, 2020. Results: Baseline data demonstrated 29 of 118 patients (24.6%) completed all variables of the CI. Following implementation of the QI initiative, 41 of 59 patients (69.5%) completed the CI. The most common reason for an incomplete CI was failure to place an NG tube and initiate NuLYTELY within 24 hours of admission (48% of CI misses), followed by failure to initiate NuLYTELY within 24 hours of admission despite the presence of NG tube (24% of CI misses). Most common reasons for failure to place an NG tube within 24 hours of admission included: patient discharge following enemas or manual disimpaction (27%), failed placement attempts (20%) and physician decision (20%). Median length of stay (LOS) among patients meeting the CI was 51.3 hours compared to a median LOS of 53.8 hours among patients not meeting the CI (p=0.31). Further LOS analysis is ongoing. Conclusion: Through quality improvement methodology, we standardized inpatient care for fecal impaction as evidenced by improved adherence to our fecal impaction management CI. There was no significant difference in LOS among patients meeting the CI and those failing to meet the CI, which may in part be explained by a lower inpatient census due to the COVID-19 pandemic.