Is colonoscopy quality impacted by source of referral?
Ghanem Alsalem, Khairul Nawawi, Senthil Kumar, Eoin Slattery
Department of Gastroenterology, University Hospital Galway, Ireland
The performance of colonoscopy on in-hospital patients can be fraught with frustration. Not only do these patients have multi-organ system failure and take multiple medications, they also tend to have poor preparation and mobility status. Effectiveness of colonoscopy ultimately depends on the quality of the examination.
To assess the effectiveness of inpatient colonoscopy and to identify reasons for poor performance. Using a priori reasoning that colonoscopy preparations would be poor, we also aimed to assess the feasibility of performing requested inpatient colonoscopy as an outpatient.
We recruited consecutive patients undergoing inpatient colonoscopy in a tertiary referral hospital. Basic demographics, indication for procedure, quality of preparation, and validated quality markers of endoscopy were collected. Inpatient colonoscopy requests were triaged by the gastroenterology team.
99 patients underwent inpatient colonoscopy (May 2015 - December 2015). The mean age of patients was 68 years (53% male). Anaemia was the most common indication for colonoscopy (n=43), followed by change of bowel habit (n=19), an abnormal radiology finding (12). Physician assessment of preparation was deemed excellent/good in 15 patients, satisfactory in 47 patients and poor or inadequate in the remainder (n=37). Colonoscopy was incomplete in 18% of patients, majority related to poor prep (78%, n=14). Polyp detection rate in patients with adequate bowel prep was 45% (28/62), and in inadequate bowel prep was 24% (9/37). The commonest reason necessitating request of an inpatient procedure surrounded travel difficulties and problems with tolerating prep due to social exclusion (75%).
Inpatient colonoscopies at our institution failed to reach minimum quality standards with caecal intubation rates of only 82%. Inadequate bowel preparation was the single biggest reason for this. The reasons for this can likely be explained by: inadequate knowledge surrounding standard cleansing regimes by referring physicians, inadequate toilet facilities in ward areas based on Victorian-era ward structure, difficulties re: timing of prep and subsequent scheduling of procedure. A greater effort to avoid inpatient colonoscopy should be made where possible, given the logistic difficulties and potential risk of inadequate colonoscopy in this ill cohort of patients.