Effect of acuity level and patient characteristics on bowel preparation quality: a retrospective cohort study of inpatient colonoscopies

BMC Gastroenterology (2023) 23:126 Kabir et al. BMC Gastroenterology https://doi.org/10.1186/s12876-023-02751-1 Open Access RESEARCH ARTICLE Effect of acuity level and patient characteristics on bowel preparation quality: a retrospective cohort study of inpatient colonoscopies Christopher Kabir1* , Mariani Salazar Leon1, Cindy Ndiaye1 and Michael Flicker1 Abstract Background and aims Colonoscopy is the primary method to detect mucosal abnormalities in the colon, rectum, and terminal ileum. Inadequate bowel preparation is a common problem and can impede successful visualization during colonoscopy. Although studies identified hospitalization as a predictor of inadequate bowel preparation, acuity of care vary greatly within this patient population. The current study aims to examine the effect of patient characteristics and care level predictors on inadequate bowel preparation quality within the inpatient setting. Methods This retrospective study was conducted in a single urban level 1 trauma medical center and included adult patients undergoing diagnostic colonoscopy while admitted in the hospital from January 1, 2015 to June 30, 2020. We examined the level of inpatient care between the General Medical Floor (GMF), Intensive Care Units (ICU) and Telemetry Unit (TU) and assessed this association with bowel preparation quality, adjusting for known and unknown predictors. Results Of 538 patients undergoing colonoscopy, 47.4% were admitted into TU, 43.7% into GMF and 8.9% into ICU. For the entire sample, 72.7% of patients achieved good or excellent preparation and quality of bowel preparation differed by care level (P = 0.01). Patients from the critical care units were less likely to achieve adequate bowel preparation when compared to GMF (Odds Ratio [OR] 0.36; 95% Confidence Interval [CI] 0.17,0.77), after adjusting for patient characteristics, medications, physical status, and preparation regimen. No significant difference in Bowel Preparation Quality (BPQ) was identified between patients from GMF and TU (OR 0.96; 95%CI 0.61, 1.52). Furthermore, adequate BPQ was associated with withdrawal time and cecal intubation, but not higher adenoma detection rates. Conclusions Results suggest the ICU setting is an independent predictor for inadequate bowel preparation and patients with prior opioid and laxative use may be more likely to have inadequate bowel preparation in the hospital. Future interventions should prioritize preprocedural clinician meetings for critical care unit patients, including a more detailed readiness assessment and thorough medication history. Keywords Preoperative care (MeSH), Colonoscopies (MeSH), Hospitalization (MeSH), Bowel preparation quality *Correspondence: Christopher Kabir 1 Advocate Illinois Masonic Medical Center, Advocate Aurora Research Institute, Advocate Aurora Health, Center for Education, 836 W Wellington Ave, #2025 Chicago, IL 60657, USA Introduction Colonoscopies are the gold standard for diagnosing colorectal cancer, the second most common cause of cancer death in the United States of America. Colorectal cancer, while currently declining in ages 65 years © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kabir et al. BMC Gastroenterology (2023) 23:126 and older, is increasing in incidence among younger Americans [1]. In response, the U.S. Multi-Society Task Force on Colorectal Cancer revised its age recommendations to begin colorectal cancer screening five years earlier, from 50 to 45 years of age, and reaffirmed the importance of early diagnosis, including prompt assessment of symptoms such as blood loss or anemia [2]. Diagnostic efficacy, however, is dependent upon Bowel Preparation Quality (BPQ), which is often categorized as Inadequate Bowel Preparation (IBP) or Adequate Bowel Preparation (ABP). It is well established that ABP is difficult to achieve in hospitalized patients and inpatient status is consistently reported as a strong independent predictor of IBP. Research shows that 67% (60–75%) of hospitalized patients attain ABP prior to colonoscopy, and ABP remains up to two times more likely (OR [Odds Ratio] 2.02; 95%CI [Confidence Interval] 1.88, 2.16) among outpatients when compared to inpatients [3–6]. Lower ABP rates among hospitalized patients have negative consequences for the patient and may result in reduced diagnostic yield, increased hospital costs, and prolonged length of stay [7, 8]. Bowel preparation quality has been studied in many healthcare settings, identifying a variety of clinical and patient predictors of IBP, including: older age [4, 5, 7, 9, 10], male gender [4–6, 9, 11], medications such as tricyclic antidepressants or opiates [5, 6, 8], constipation [5, 6, 12], afternoon procedure times [6, 8, 9, 13], prolonged hospitalization before colonoscopy [12], preprocedural physical fitness [8, 12], type of bowel preparation regimen [3, 12, 14], and significant comorbidities such as diabetes mellitus [5, 11, 12]. Despite robust evidence that outpatients achieve higher quality of bowel preparation when compared to inpatients, no study has investigated patient disposition within a hospital as an opportunity to identify modifiable factors and settingbased interventions to improve BPQ. A clear understanding of patient and care level variables within the hospital can identify patients who may benefit from enhanced pre-colonoscopy readiness assessments or different bowel preparation protocols. The aim of this study was to investigate the association between the quality of bowel preparation and predictors stratified by acuity level of inpatient care between the General Medical Floor (GMF), Telemetry Unit (TU), and Intensive Care Units (ICU). We hypothesized that ICU patients had worse quality of bowel preparation. Secondary objectives were to evaluate adequate bowel preparation related to quality metrics, colonoscopic findings, length of stay prior to colonoscopy, and time of colonoscopy. 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