diabetic colon preparation for gi procedure ann hayes bsn, rn, cgrn marti buffum dnsc, rn, pmhcns-bc...
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Diabetic Colon Preparation Diabetic Colon Preparation for GI Procedurefor GI Procedure
Ann Hayes BSN, RN, CGRNAnn Hayes BSN, RN, CGRNMarti Buffum DNSc, Marti Buffum DNSc, RN, PMHCNS-BCRN, PMHCNS-BC
Joyce Hughes MS, RN, CGRNJoyce Hughes MS, RN, CGRN
Veterans Affairs Medical CenterVeterans Affairs Medical CenterSan FranciscoSan Francisco
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BackgroundBackground
Colon cancer second leading cause death Colon cancer second leading cause death from a cancer in North Americafrom a cancer in North America
150,000 colon cancer diagnosed per year150,000 colon cancer diagnosed per year
Totally preventableTotally preventable
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ColonoscopyColonoscopy
Increasingly used for screeningIncreasingly used for screening
Adequate bowel prep significant for GI Adequate bowel prep significant for GI units and patientsunits and patients
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Clinical ProblemClinical Problem
Inadequate colon preparation means Inadequate colon preparation means repeat procedurerepeat procedure
Colonoscopy has potential risksColonoscopy has potential risks Bleeding and perforationBleeding and perforation Sedation complications:Sedation complications:
• Cardiac Cardiac • respiratoryrespiratory
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Required bowel cleansingRequired bowel cleansing
Day prior to procedureDay prior to procedure
Wide variety of colon prepsWide variety of colon preps
Patients often complain about prepPatients often complain about prep
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Preventing repeat procedurePreventing repeat procedure
Decreases availability of colon screeningDecreases availability of colon screening
Maximizes patient safetyMaximizes patient safety
Ensures organizational efficiencyEnsures organizational efficiency
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Clinical Problem in GI unitClinical Problem in GI unit
1997 Survey of 64 patients colonoscopy 1997 Survey of 64 patients colonoscopy prepspreps
19% had good preps19% had good preps
81% poor prep means repeat exam81% poor prep means repeat exam
GI nursing staff began QI project to GI nursing staff began QI project to improve patient care by improving colon improve patient care by improving colon prepspreps
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Nursing Interventions to Improve Nursing Interventions to Improve Colon PrepsColon Preps
Improve patient educationImprove patient education
Phone call week prior to procedurePhone call week prior to procedure
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2001 Survey2001 Survey
50 colon preps = 79% good to excellent50 colon preps = 79% good to excellent
But diabetic colon preps = only 63% goodBut diabetic colon preps = only 63% good
New finding!!New finding!!
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Prep SurveyPrep Survey
Suggests diabetic patients having more Suggests diabetic patients having more difficulty attaining adequate colon prepdifficulty attaining adequate colon prep
Needs to improve / change the way Needs to improve / change the way diabetic patients are preppeddiabetic patients are prepped
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Are diabetics different?Are diabetics different?
Need to do a literature reviewNeed to do a literature review
Found no colon prep studies with diabeticFound no colon prep studies with diabetic
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Literature review Literature review
Nakahara et al., (2002) Nakahara et al., (2002) Gastroparesis: slow emptying of stomachGastroparesis: slow emptying of stomach
Well known in medicineWell known in medicine
Causes nausea and often vomitingCauses nausea and often vomiting
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Literature Literature
Taylor & Schubert (2001) diabetic patients Taylor & Schubert (2001) diabetic patients prepped significantly less effective prepprepped significantly less effective prep
Using PEG solution for colonoscopyUsing PEG solution for colonoscopy
17 of 45 diabetic patients had inadequate 17 of 45 diabetic patients had inadequate colon prepcolon prep
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LiteratureLiterature
Fincher et al (1999) : preps for Fincher et al (1999) : preps for sigmoidoscopy less likely to be adequatesigmoidoscopy less likely to be adequate
Study of 299 Study of 299
Regardless of which 3 preps used, Regardless of which 3 preps used, diabetics less likely to have adequate prepdiabetics less likely to have adequate prep
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Literature reviewLiterature review
Study by Maleki et al., (1998): significantly Study by Maleki et al., (1998): significantly slower colonic transit timesslower colonic transit times
Ascending and transverse colon slowerAscending and transverse colon slower
Study by Celik et al., (2001)Study by Celik et al., (2001)
Constipation a problem for 2/3 diabeticsConstipation a problem for 2/3 diabetics
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Special Needs of DiabeticSpecial Needs of Diabetic
Approach to colon prep in diabetic patients Approach to colon prep in diabetic patients needs to be different needs to be different
Need to change standard prep usedNeed to change standard prep used
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PEG SolutionPEG Solution
Polyethylene glycol-based isotonic salt Polyethylene glycol-based isotonic salt solutionsolution
Davis et, al 1980Davis et, al 1980
Safest and most commonly usedSafest and most commonly used
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Sodium Phosphate SolutionSodium Phosphate Solution
Low volume, strong laxativeLow volume, strong laxative
Associated with dangerous fluid & Associated with dangerous fluid & electrolyte shiftselectrolyte shifts
FDA issued a warningFDA issued a warning
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Magnesium Citrate (Mg)Magnesium Citrate (Mg)
Study by Berkelhammer 2002 showed Mg Study by Berkelhammer 2002 showed Mg citrate milder, low volume laxativecitrate milder, low volume laxative
Minimizes electrolyte imbalance, Minimizes electrolyte imbalance, dehydration & aphthous ulcersdehydration & aphthous ulcers Sodium phosphate solution = 5.5% ulcersSodium phosphate solution = 5.5% ulcers Mg = 1% ulcersMg = 1% ulcers Significant finding: p< 0.01Significant finding: p< 0.01
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Mg CitrateMg Citrate
Aphthous ulcers lead to diagnosis Aphthous ulcers lead to diagnosis confusionconfusion
Could be: IBD, ischemic colitis or infectionCould be: IBD, ischemic colitis or infection
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Mg CitrateMg Citrate
Available over the counter & low costAvailable over the counter & low cost
Minimal fluid and electrolyte shiftMinimal fluid and electrolyte shift
Fewer incident aphthous ulcersFewer incident aphthous ulcers
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Mg Citrate & ElectrolytesMg Citrate & Electrolytes
Sharma et, al 2001 study showed:Sharma et, al 2001 study showed:
No significant shifts in BP, pulse and No significant shifts in BP, pulse and electrolyteselectrolytes
Mg citrate safe & effective for colon cleansingMg citrate safe & effective for colon cleansing
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Usual Reaction to failed Usual Reaction to failed colon prepcolon prep
Repeat colonoscopyRepeat colonoscopy
Double PEG = 8 litersDouble PEG = 8 liters
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Double Prep ProblemDouble Prep Problem
Diabetics have slow gastric emptyingDiabetics have slow gastric emptying
Would have difficult consuming large volumesWould have difficult consuming large volumes
Possible vomiting and non adherencePossible vomiting and non adherence
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Constipation ProblemConstipation Problem
Large percentage of diabetic are Large percentage of diabetic are constipatedconstipated
Need to correct this prior to starting colon Need to correct this prior to starting colon prepprep
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Decision ProcessDecision Process
Conferred with Dr McQuaid, Chief GIDCConferred with Dr McQuaid, Chief GIDC
Tried new prep on small group with good Tried new prep on small group with good successsuccess
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Standard Colon PrepStandard Colon Prep
Clear liquids day prior to colonoscopyClear liquids day prior to colonoscopy
Late afternoon:Late afternoon: 10 oz Mg citrate10 oz Mg citrate 4 liters PEG4 liters PEG
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New Diabetic Colon PrepNew Diabetic Colon Prep
All patients have clear liquid diet day priorAll patients have clear liquid diet day prior
Diabetics: two days prior to exam 10oz. Diabetics: two days prior to exam 10oz. Mg citrateMg citrate
All patients: day before test, 10oz Mg All patients: day before test, 10oz Mg citrate and 4 liters PEGcitrate and 4 liters PEG
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Research QuestionResearch Question
Will new colon prep two 10oz Mg citrate Will new colon prep two 10oz Mg citrate (1 day apart) & 4 liters PEG solution (1 day apart) & 4 liters PEG solution improve diabetic prep over original prep improve diabetic prep over original prep 10oz Mg citrate and 4 liters PEG solution?10oz Mg citrate and 4 liters PEG solution?
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MethodMethod
Design: Experimental designDesign: Experimental design
Randomized controlled trialRandomized controlled trial
Double blinded: physician-nurse team and Double blinded: physician-nurse team and patientpatient
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Conducted at GIDCConducted at GIDC
University-affiliated VA Medical CenterUniversity-affiliated VA Medical Center
IRB approval form University of California IRB approval form University of California and VA Research Committee and VA Research Committee
200 subjects200 subjects
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ProcedureProcedure
ConsentConsent
Randomization: random table of numbersRandomization: random table of numbers
Blinded procedure staffBlinded procedure staff
Patient drinks one of two preps: Patient drinks one of two preps: experimental or standard experimental or standard
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InstrumentsInstruments
Demographic InformationDemographic Information AgeAge SexSex Use of narcoticsUse of narcotics Years of being diabeticYears of being diabetic Signs of peripheral or retinal neuropathySigns of peripheral or retinal neuropathy Serum creatinineSerum creatinine
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InstrumentsInstruments
Patient QuestionnairePatient Questionnaire Which prep consumed?Which prep consumed? How much was consumed?How much was consumed? How long it took to consume ?How long it took to consume ?
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InstrumentsInstruments
Colon cleansing scaleColon cleansing scale Used by GI staff since 1998Used by GI staff since 1998 Adams et al., (1994)Adams et al., (1994) Scale of 1 to 5Scale of 1 to 5
• 1 = very clear of feces1 = very clear of feces• 5 = solid stool, aborted procedure5 = solid stool, aborted procedure• Colon rated at cecum, consensus between nurse Colon rated at cecum, consensus between nurse
and endoscopist and endoscopist
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Inclusion Criteria Inclusion Criteria
Outpatient colonoscopyOutpatient colonoscopy DiabeticDiabetic English speakingEnglish speaking
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Exclusion CriteriaExclusion Criteria
DementiaDementia PsychosisPsychosis Prior colon surgeryPrior colon surgery
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ProceduresProcedures
Recruitment: all diabetic outpatients being Recruitment: all diabetic outpatients being scheduled for colonoscopyscheduled for colonoscopy
Consented patientsConsented patients
Select randomizedSelect randomized envelope (table of envelope (table of random numbers)random numbers)
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ProcedureProcedure
Give prep and instructions: standard or Give prep and instructions: standard or experimentalexperimental
All patients received verbal and written All patients received verbal and written instructions from GI RNinstructions from GI RN
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ProceduresProcedures Continued Continued
Day of procedure: admitting nurse Day of procedure: admitting nurse completes demographics completes demographics
MD and patient (blinded):MD and patient (blinded):
completed colon prep evaluation during completed colon prep evaluation during colonoscopycolonoscopy
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Study Results: DemographicsStudy Results: Demographics
Mean age 62 yearsMean age 62 years Men 187; women 8Men 187; women 8 IDDM = 53; NIDDM = 143IDDM = 53; NIDDM = 143
Demographics not significantly different Demographics not significantly different between the two groupsbetween the two groups
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Study ResultsStudy Results
Good colon prep:Good colon prep: Diabetic (experimental) prep = 70% Standard Diabetic (experimental) prep = 70% Standard
prep = 54%prep = 54% Chi-square = 5.14Chi-square = 5.14 P = 0.02P = 0.02
Diabetic patients who used Diabetic prep had Diabetic patients who used Diabetic prep had significantly cleaner colonsignificantly cleaner colon
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69.7%
53.5%
40
50
60
70
80
Diabetic Prep
Standard Prep
Chi-square = 5.14, p=0.02
Percent of Patients for Whom Colon was Easily Visualized
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Percent of Patients Who Drank 4 Liters of PEG as Directed
91.4% 91.2%
50
60
70
80
90
100
Diabetic Prep
Standard Prep
p=.96, NS
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ConclusionConclusion
Diabetic patients having a colonoscopy will Diabetic patients having a colonoscopy will get better colon cleansing if given 10 oz get better colon cleansing if given 10 oz Mg citrate two days prior to procedure Mg citrate two days prior to procedure then 10 oz Mg citrate and 4 liters PEG the then 10 oz Mg citrate and 4 liters PEG the day prior to procedureday prior to procedure
Other GI procedure units could confidently Other GI procedure units could confidently implement this prep for diabetic patientsimplement this prep for diabetic patients
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Practice ChangePractice Change
Diabetic prep routinely for all diabetic Diabetic prep routinely for all diabetic patients scheduled for colonoscopypatients scheduled for colonoscopy
Expanding the use of this prep to patients Expanding the use of this prep to patients with constipation and those who had with constipation and those who had inadequately cleans colon on past inadequately cleans colon on past colonoscopy colonoscopy
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Diabetes Serious & Common Diabetes Serious & Common Problem in USProblem in US
2008: 8% (24 million)2008: 8% (24 million)
2010 increase to 15%2010 increase to 15%
Veterans 20% in 2000Veterans 20% in 2000
Most are 60 years and olderMost are 60 years and older
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Safety of Mg CitrateSafety of Mg Citrate
There were no adverse events in studyThere were no adverse events in study No clinical evidence of:No clinical evidence of:
• HypovolemiaHypovolemia Electrolyte imbalanceElectrolyte imbalance
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Patient tolerance to Mg CitratePatient tolerance to Mg Citrate
No patient in study voiced complaintNo patient in study voiced complaint
Flavor toleratedFlavor tolerated ComfortComfort
Significant fewer repeat colonoscopySignificant fewer repeat colonoscopy
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Limitations of StudyLimitations of Study
Small number of women in studySmall number of women in study
Question concerning constipation not Question concerning constipation not effectiveeffective
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Strengths of StudyStrengths of Study
Large sample sizeLarge sample size
Experimental designExperimental design
Double blindDouble blind
Hence finding are generalizable Hence finding are generalizable
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Goal is Clean ColonGoal is Clean Colon
When prepping patient consider:When prepping patient consider: Bowel habitsBowel habits Medical conditionsMedical conditions Difficulty swallowingDifficulty swallowing Lack of mobilityLack of mobility
Above may warrant change is colon prepAbove may warrant change is colon prep
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Nursing ResearchNursing Research
Effects the nursing cultureEffects the nursing culture
Nurse involved in research are likely to: Nurse involved in research are likely to: Develop innovationsDevelop innovations Find best practices to improve patient careFind best practices to improve patient care