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

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.

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.

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.

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 epidermal growth factor receptor with relevant co-morbidity (congestive cardiac failure or cirrhosis).

Given the difficulties with compliance and the high prevalence of 'at risk' patients, the implementation will be challenging and require significant service redesign.