Welcome back everyone. I hope you've made it. Let's really build off the lessons that we learned, you know, with this morning, and that we discussed as a move to break really looking at quality at the patient and the unit level. So to start off our next set of lectures, we welcome back Dr. Jason Dominance, who will speak on optimizing bowel preparation in your endoscopy unit. Jason. Thank you, Rahul. Good to be back with you all. Hope you had a nice break. I have no disclosures relevant to this talk we're going to talk about barriers to adequate bowel preparation, talk about how to optimize the prep and I'm going to emphasize the importance of split dose and same day and then we're going to talk a little, little bit about some bowel prep scoring options. So it always is a bad day when you start off colonoscopy like this, we want to avoid this at all costs. And when I talk about bowel prep, I'm not just talking about the medication, I'm talking about the timing of the medication dietary changes, any medication considerations like adjustment of insulin doses, and the mental and physical preparation for the patient Some patients, you know, will advise to put Vaseline around the anus to reduce irritation, and the logistics, such as, you know, having an escort who to call with questions. If any of these steps in the process break down and the patient can show up with a poor prep, and that is bad for everyone it leads to need to repeat the procedure additional inconvenience for the patient costs, etc. When you have an inadequate bowel prep, it prolongs the procedure time, it decreases equal intubation rates leads to repeat procedures as I just mentioned, the risks and the costs and it's a bad experience for the patients and the providers alike. And it does lead to reduce detection of adenomas. This is an old study that showed that the adenoma detection and lesion detection rates are considerably lower when the prep is inadequate. So what are the risk factors for a poor bowel preparation. Well there's quite a few older patients, male patients higher BMI inpatients polypharmacy so taking multiple medications, especially things like tricyclic antidepressants and narcotics presence of diabetes, certain neurologic conditions like stroke And you would think that people who have had a prior colon resection might be easier to prep but the converse is true. So prior gastric resections and colonic resections lead to decrease gut motility that can lead to a poor prep. It's important to do a good job educating the patients about the steps in the bowel prep. And there's a number of ways to do that there's educational booklets or videos, people outsource this to companies that can help remind patients how to do the prep. People have used texting apps and smartphone apps and robocalls to help get patients through the prep. And all of these have some, some benefit, and you should figure out with your practice what's practical and what's effective for you. So we have a number of different options for the purgative, the medications laxatives. There's isosmotic full volume preps like four liters of co light or go lightly. There's isosmotic low volume preps like two liter peg electrolyte solutions like movie prep for example. There's hyper osmotic low volume preps like soup prep or popic clenpic suit tab and asthma prep. And then there are over the counter products like magsitrate or Mira lax and sports drinks. It can help, especially with patients who've had trouble in the past with a bowel prep to think about personalizing the regimen if they say they had a lot of nausea with their pal prep in the past. You can prescribe antibiotics up front. If they say that the taste is a big issue for them then there's different options as shown here on the slide that may be may help them with that with a lot of the large volume perhaps they have flavor packets that can be added, although personally my, my experience personal experience with that is that the flavor pack made it worse than just the prep alone. You can if volume is the issue, especially people who have had prior gastric surgery for example you can do the very low volume preps, like planning booze is one liter or movie prep is two liters, and make sure to split dose we're going to emphasize that point over and over again. And many people don't think about same day perhaps I'll have a couple of slides about this issue but for somebody who works at night who doesn't want to take time off from work the day before to prep. You can do the same day prep for afternoon cases. Now, for some special populations advanced age you want to avoid sodium phosphate for post bariatric surgery, as I mentioned, go with the low volume and give people a little more time to take the prep because they only have a 10 cc gastric pouch you're not gonna be able to drink large volumes at a time for renal insufficiencies roses and heart failure. The isosmotic electrolyte lavage solutions are preferred, you want to avoid sodium phosphate and mag citrate. Now, these are some examples of spinal cord injury and cystic fibrosis preps, my VA has a spinal cord injury unit, and we have a three day prep a little different than the one shown here. We do check labs along the way. In, in most patients although we've done some studies looking at that and don't see much changes, which is very reassuring. Let's go with our first poll question for this topic. Which of the following is the most common type of prep used in your practice. Which of the following is the most common type of prep used in your practice. Are you using the full volume perhaps a low volume perhaps that are isosmotic are using the hyper osmotic low volume or over the counter products. Oh, quite a quite a spread. Okay, it's, it's fairly even distribution between the large volume and low volume and over the counter. Very interesting. Thanks everyone. Mouse control back there we go. Okay, so if you want to learn more about the different perhaps some of the, the composition, the cost, etc. It's, there's a nice document from the ASG John Saltzman and colleagues published a few years ago and the PM ID is referenced there I've got it listed in a different way on a later slide with the, it's published in GA, and I believe it's available on the website without necessarily having a subscription. You can correct me if I'm wrong. Now the runway time the time between your last dose of prep and the start of the colonoscopy is really important. You want to be careful to make sure that patients are getting the prep, not too far ahead of when you plan to start your procedure. The more of a delay between the last dose of prep and the start of the procedure means worse quality colonoscopy prep lower scores in this. The scoring system are better and you can see when the time between the last dose and the procedure itself is eight hours you have a better score. Then what's more than eight hours and actually the guidelines recommend even shorter than that. You want it to be in the three to five hour range or three to four hour range ideally. So let's go to our next poll question, how often is split dosing using your practice is it use less than 10% of colonoscopies 10 to 33 34 to 66 67 to 90 or greater than 90% of your procedures. Greater than 90% for 65% of you and yeah this is great so for those of you who are not routinely using split dose prep. I hope that the next few slides are going to convince you to change your practice. I'd love to hear from you reasons why you're not changing your practice if you think there's some reason why you shouldn't use split dose prep. Split dose has become the standard of care, the guidelines are universal in recommending split dose prep. Not to say that there's never an indication for not doing split dose, and you know those of you who aren't using it if you're using same day, then that's great we'll talk about that in a moment. But split dose preps have been demonstrated to be superior for any type of prep, I should say, compared to to using it the day prior same day it's okay we'll talk about that. Typically, about half of the prep is taken the evening prior, and then the second dose starts between four and six hours before the colonoscopy, you want to complete the last dose at least two hours before the procedure because of NPO requirements. There was a meta analysis that showed that split dose is superior to peg full dose peg, the day prior in terms of the quality of colon cleansing. Also patients prefer, they're less likely to discontinue the prep, they're more willing to repeat the same prep, and they have less nausea, so patients prefer split dose. If you look at adenoma detection rates, you see here there's a 26% increase in the risk, you know, the odds of basically finding adenomas when you use a split dose prep compared to day prior. When you compare low volume to high volume split dose, there's no difference between the two. So it's fine to use split dose low volume, and you know it's equal equally effective to split dose high volume. So why don't people use split dose preps? I suspect some of the reasons here may be why some of you who answer you're not using it are not doing. You may be worried that patients don't want to get up early in the morning to take the second dose. If you're doing an 8am case, and you need them to finish by 6am, and then get on the road and drive to your practice, you know they're going to be getting up at two or three in the morning. Well, when surveyed, 85% of survey participants were willing to get up in the middle of the night to take that second dose, and 78% actually complied. So some did not comply, that's always a concern. But you could always schedule them later in the day if they don't want to get up at two in the morning, they don't have to be first dates. Some people are worried about having the need to have a bowel movement while driving into your practice. I understand that, I definitely get that. When they actually study it, it turns out the rate of patients having an issue where they feel like they have to go to the toilet while they're driving into the practice is no different between those who took a split dose and those who took a night prior dose. There's concern among some people that split dose is an issue for the NPR requirements, particularly some anesthesiologists raise this issue. If you look at the anesthesia guidelines, the minimum fasting for a clear liquid is two hours, and that's what we're talking about here. Split dose, you should finish it no less than two hours before the start of the procedure. In my book, all the preps we're talking about are clear liquids. Some anesthesiologists will say that these solutions are toxic if they get in the lungs, they're hyperosmotic, they could cause lung injury. There are case reports where people have had lung injury from bowel prep. All the case reports I've seen have been in people who were like children who were non-compliant with bowel prep and typically neurologically devastated children or neurologically devastated adults where an NG tube was put in and the prep was forced through an NG tube at rates that may be concerning for causing aspiration events. When you look at a study here by Huffman et al at the bottom of the slide, they looked at how much liquid was in the stomach when you scope somebody. They did EGD after bowel prep and sucked out all the fluid that was in the stomach. And note that the split dose prep had 20 mils of fluid in the stomach, which was the same as the amount of fluid in the stomach from night prior. Liquids like bowel prep empty from the stomach very rapidly. The fluid that they're finding may not even be the bowel prep, it may be just gastric secretions. So it's very low volume. There should not be this concern, but I know some anesthesiologists do express this concern and they may put up barriers to using split dose. Now I mentioned same day bowel preps. If you're doing an afternoon case, you can have the patient drink the bowel prep at six in the morning. This is superior to day prior prep and it's comparable to split dose prep in various studies. Patients are less likely to lose sleep or have bloating compared to the evening prior or split dose preps. And there obviously is less interference with their work if they just have to prep on the day of their procedure. I have my afternoon colonoscopy scheduled in October and this is what I'm planning to do. When you compare same day prep versus split dose prep, you see there is no difference. So same day prep works very well at getting the colon clean for that colonoscopy. How about dietary restriction? You know, I've always been in the camp of giving people a clear liquid diet for the day before. But I'm changing my ways because the literature is showing that allowing a low residue diet for breakfast and lunch, and in some cases even dinner, yielded no difference in prep quality compared to clear liquids. So patients, you know, one of the things they hate most about going through colonoscopy, and typically the bowel prep is the worst part of a colonoscopy, right? Making people stop eating for the day before the procedure is one of the things patients complain about most. If you allow them to eat a low residue diet, then they will find the experience of having a colonoscopy less difficult. The U.S. Multisociety Task Force says that if you're using a split dose prep, you can allow a low residue diet or full liquids up until the evening prior to the colonoscopy. I've given you some examples of what is not part of a low residue diet and what is at the bottom of the slide. Patients are more willing to repeat a colonoscopy if they are allowed to eat the day before. So you allow pasta or rice, like white rice, not whole rice, not whole grain pasta. You allow fish and milk and meat, eggs, cheese, etc. You do not allow fiber, seeds, nuts, fruits, etc. So which of the following best describes the dietary instructions in your practice on the day prior? Are you only allowing clear liquids? Are you allowing full liquids, low residue, or you have no dietary restrictions? Clear liquids only is the winner here, and 16% during low residue, and a few with full liquids. So that's very interesting. You know, I've been slow to change on this, but I think the literature suggests that low residue is okay, and we should think about how that's going to make the experience better for our patients. You might try that as a quality improvement project. You might have better patient satisfaction. So here is the meta-analysis I mentioned. This was published in GIE three years ago, showing that low residue diet was no different than clear liquid. In fact, maybe a slight, slight trend toward benefit of low residue. If people are more willing to complete the diet, then that's going to make, sorry, complete the prep, that's going to get you a better prep overall. Don't forget, you've got water jets on your scope that can help clean the walls of the colon. I do a lot of washing, as I said earlier. Now, measuring bowel prep quality is one of those quality metrics. It's not a priority indicator, as we discussed on my last talk, but it is important. You want to see at least 85% of outpatient exams are adequate, and for EURP, which you heard a little bit about before, the target is 90% or better. You assess bowel prep quality only after you've done all the washing, all right? The quality of the prep, when you put the scope in, is important if you're trying to compare bowel prep A to bowel prep B. But if you want to see if your exam was adequate or not, you're reporting after you've done all the cleaning. And again, it should be at least 85% of, you know, on a per-physician basis. Adequate means that you're willing to recommend the surveillance recommendations from the guidelines that we talked about earlier today. If you don't reach the 85% benchmark, then you should do that PDSA or the Six Sigma approach to do a quality improvement initiative. And I strongly recommend you use the Boston Bowel Prep Scale. The Iran Chick Scale is also acceptable. We're going to talk about that here in a second. Now, for those of you who don't know the Boston Bowel Prep Scale, it is the best validated quality metric we have, or bowel prep score we have. It's a score of 0 to 3. 3 is a pristine colon. Again, this is after you've done your washing. A score of 2 is on the upper right-hand corner. You can see a little flex of stool here and there. Now, you could wash those and suction those away, but there's not a lot of stool blocking the view. The score of 1 is in the lower left. You can see you're going to miss polyps under that adherence stool. And the score of 0 is unprepped. You assign a score for the right colon, the transverse colon, and the left colon. So, the score is anywhere from 0 to 9. You can have 0 to 3 in each of the three segments. And what you want to see is a score of at least 2 in each of the three segments. So, the minimum acceptable score is a 6, but it also has to be at least a 2 in each segment. If you had 3, 3, and 0, that's a 6, but you've got a whole segment of the colon that's unprepped. That's unacceptable. That is inadequate. So, this has been well validated. There are studies from Audrey Calderwood, who was at Boston when they helped develop this scale. She's one of the developers of it. They showed that the score correlates nicely with people's recommendations for surveillance. There's a nice study from Clark and Lane showing that when the score is a 2 or 3, the miss rate for adenomas is only 5%. When the score is a 1, there's a 16% miss rate. So, again, you need at least a score of 2 in each segment. It's very easy to learn this. If your doctors aren't doing it, they can learn it in a matter of minutes. And then all of the endoscopic software systems have this available. The Aronchic score is what a lot of people use, right? It's excellent, good, fair, or poor. But there's no validation of this. This has never been validated. If you look at how it's been defined, excellent, good, and fair all mean that greater than 90% of the mucosa was seen. What's different is how much suctioning you need to do. And remember what I said before, the amount of cleaning is not the issue. That's to compare bowel prep A to bowel prep B. But if you're looking at adequacy, it doesn't matter how much cleaning you had to do to get to an adequate exam. So, I'm not a big fan of Aronchic. It's not validated. People use it all the time. What's good enough? Does it have to be excellent or good? Is fair good enough? We can discuss that in the chat or in the Q&A later if people want. And then, if you don't have an adequate prep, you want to rebook them the next day or at least within a year. This is on the U.S. Multisite Task Force recommendations. If possible, the patients are already mostly prepped. So, you want to see if you can give them some additional prep. I'll even do that the same day. If in the morning I have a bad prep and we have available to squeeze them in later that day, we'll give them some prep in the endoscopy unit and re-scope them in the afternoon. If they're willing to wait around, the rides are willing to wait. We'll bring them back the next day, you know, so that they don't have to start from scratch. But you've got to look at why did it fail. Did they eat despite the prep? Did they not take enough volume? Did they take the wrong prep? Was the timing off? Did they take it yesterday and you're doing an afternoon case today? You can look at different adjuncts like the sucotal or magsitrate. If somebody has a history of constipation, we'll give them up to a week of Miralax on a daily basis to help prime the pump, if you will. Often I'll give six liters or two days of clears or a longer low-residue diet beforehand. When given a low-fiber diet for three days, clear liquid diet the day before, bisacotyl and four liters of PEG, it's been reported that you get a 90% adequate prep rate in these difficult situations. Of course, if it's a screening colonoscopy you're doing and somebody said, I did the prep, it didn't work, you know, I don't want to do this again, you've got alternatives. You can either give them FIT or other screening tests. Of course, if it's a surveillance colonoscopy, you're diagnosed like you don't have that option. So finally, take-home points, use split dosing or same-day prep. Consider liberalizing the diet if you're using split dose, so low-residue diet. I want to, you know, encourage you all to have your docs grade the bowel prep for each colonoscopy and monitor the adequacy on a peer-to-peer physician basis. And if it's less than 90%, go down that quality improvement process. And there's a couple of the key references that I encourage you to take a look at. Thank you very much for your time and attention.

bowel preparation

split dosing

same-day preparation

inadequate bowel prep

patient experience

detection of adenomas