Optimizing bowel prep for inpatient colonoscopy:
a proactive, outpatient inspired approach.
Katie Farah, MD, MMM, CPE, FASGE
Associate Professor of Medicine
Drexel University College of Medicine
Philadelphia, Pennsylvania
Colorectal cancer is the second most common cause of cancer death in the United States, and projections suggest approximately 108,860 new cases of colon cancer and 49,990 new cases of rectal cancer will be diagnosed in 2026.1,2 The quality of bowel preparation is crucial for high performance during colonoscopy. Inadequate preparation can affect the adenoma detection rate and result in repeat colonoscopic evaluations, unnecessary costs, and suboptimal patient experiences, which can lead to future noncompliance with colon cancer screening.
In the United States, colonoscopy performed in the inpatient hospital setting is associated with substantially higher costs than that performed in ambulatory or outpatient settings. While exact costs vary by institution, region, and clinical context, published estimates and hospital charge data suggest that inpatient colonoscopy commonly incurs costs in the range of several thousand dollars, often exceeding $2,500 to $7,500 per procedure when including facility fees and associated inpatient services.3-5 These costs are further amplified when procedures are delayed or repeated due to inadequate bowel preparation, contributing to increased healthcare utilization and overall inpatient expenditures.
Inadequate bowel prep, which is responsible for up to one-third of all incomplete colonoscopies,6-7 is a potentially preventable source of low-value care. Achieving adequate bowel preparation is challenging but critical to achieve a high-quality colonoscopy in both outpatient and inpatient settings.
The implementation of risk stratification models is essential for identifying patients at high risk for inadequate bowel preparation, and targeted bowel preparation optimization strategies cannot be overemphasized. Tactics such as enhanced patient education, split-dose or extended regimens, and standardized inpatient preparation protocols may improve procedural efficiency, reduce avoidable repeat procedures, and optimize healthcare resource utilization.8-11
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Addressing Barriers to Improve Inpatient Bowel Preparation
In 2022, my co-investigators and I evaluated barriers to achieving adequate colonoscopy prep and implemented changes to improve the quality of an inpatient bowel regimen at our tertiary care center. This included the creation of a new order set and a nursing-driven protocol in the electronic health record (EHR).12
Our team conducted an observational prospective study over a 4-month period to improve bowel preparation, incorporating an assessment tool to allow nurses to better document bowel prep in the institution’s EHR. The tool, the Nursing Bowel Preparation Assessment Tool (NBPAT), first described by Johnson et al in 2015, was developed to minimize repeat colonoscopies and better predict successful bowel preparation.13 The tool has sub scores for stool consistency, color, and sediment presence, and it automatically calculates a total score of 0 to 5.13
A high score on the NBPAT (4 or 5) is highly predictive of adequate bowel prep at the time of colonoscopy, whereas low scores (1 or 2) and potentially intermediate scores (3) indicate that additional prep may be needed to minimize the risk for an inadequate prep.13
For our study, we evaluated all patients 18 years of age and older who underwent an inpatient colonoscopy, excluding patients with suspected gastrointestinal obstruction and those receiving preparation via a nasogastric (NG) tube at baseline. Polyethylene glycol with electrolyte (PEG-3350) was the 4-liter GI lavage prep used at our medical facilities for bowel cleansing before colonoscopy, with proven safety in a wide range of patients, including those with diabetes, hypertension, cardiac or renal issues, and electrolyte imbalances. Additional prep was given at the discretion of GI fellows.
Adequate colonoscopy prep at the time of colonoscopy was defined as an intact Boston Bowel Preparation Scale (BBPS) score of at least 6, a segmental BBPS score of at least 2, and prep quality described as “good,” “excellent,” or “adequate”; all other prep descriptions (<6) were considered inadequate.13-14
We conducted a retrospective cost-based analysis to evaluate inpatient colonoscopies repeated due to incomplete bowel preparation. Data collected for the 6-month retrospective analysis included patient medical record number (MRN), date of birth, and gender; exam dates; indication; number of colonoscopy procedures aborted and the reason; prep quality determined from the data points in the End writer reporting system; whether follow-up colonoscopy was performed or recommended; recommendation for follow-up inpatient or outpatient procedure and timing; and costs associated with hospital stay and colonoscopy.
We also conducted a prospective analysis consisting of 4 phases over a 15-month period, with the following data collected during each phase:
Demographic data: date, MRN, age, and gender
Clinical data: indication for colonoscopy
Prep data: ingested PEG-3350 (mL), reason if unable to finish prep (eg, severe nausea, vomiting, abdominal pain, or bloating), whether an NG tube was tried, stool clearance
Procedure data: BBPS score, adequacy of bowel prep (defined as BBPS score =6), rate of abortion of colonoscopy due to poor prep
Post-procedure data: length of stay, total cost of hospital care
A 4-Phase Prospective Analysis
In phase 1, the team collected data before implementation of the intervention to establish the baseline adequacy of bowel preparation for inpatients and the percentage of colonoscopies with inadequate preparations resulting in next-day repeat procedures. No hard stops were built into the EHR at baseline. Investigators educated nurses, fellows, faculty, and patients about the protocol for prep intake (Table 1).12 During this phase, nursing compliance using and completing the NBPAT was 67%.
Table 1. Inpatient Bowel Preparation ProtocolEPIC order for split dosing colonoscopy bowel prep (initially for inpatient colonoscopies only).GI (where applicable) to place the orders only. Order for 4,000 mL once should be omitted from network.Type in “PEG-3350” (linked order for 2 orders of 2,000 mL pops up as 2 separate orders [4-L split dose]).Standard regimenOrder for morning procedure (9 PM to noon):
First dose given at 6 PM the night before
Second dose given at 12 AM to be finished by 5 AM
Order for afternoon procedure (noon or later):
First dose given at 6 PM the night before
Second dose given at 3 AM, to be finished by 8 AM
Diet: Clear liquid
Orders based on: First 2 h (8:00 AM-10:00 AM) endoscopies; colonoscopies start at 10:00 AM.High-risk patients (history of bad/inadequate prep, opiates, BMI=45, diabetes, cirrhosis, chronic constipation, Parkinson’s disease, dementia, CVA)2 days of clear liquid; first dose at evaluation; second dose 4 hours later OR 10 oz magnesium citrate (contraindicated in renal insufficiency and CHF); first dose at 5 AM; second dose at 9 AM; nurses will document I/O.Prep intoleranceFirst dose given at 6 PM; if patient can’t drink by 8 PM due to nausea, give antiemetic; if patient cannot tolerate or drank less than 50% by 10 PM, insert NG tube for rapid preps; push 500 mL every 60 min. If NG refused, patient continues to drink; if intolerant to second dose, give antiemetic or NG tube.Assessment of bowel after prep completeMorning procedure I/O at 5 AM; afternoon procedure I/O at 8 AM. Patient ready for procedure if stool is yellow and clear, resembling urine; patient not ready for procedure if stool is dark, murky, brown, dark/light orange, or semi-clear. If not ready, proceed to salvage preparation.Salvage prepAdditional purgative given after I/O assessment. Give additional rapid prep (2 L) over 3 hours.CHF, congestive heart failure; CVA, cerebrovascular accident; I/O, input/output; NG, nasogastric.
Based on reference 12.
During phase 2, we implemented an enhancement of prep assessment for consistency, color, and sediment. In addition, we created a targeted order set in the EHR, with hard stops for nursing and physicians. These hard stops triggered action items so providers would intervene if a patient could not tolerate bowel preparation. GI fellows were educated about the EHR order set for split-dose bowel preparation (recommended by the American Society for Gastrointestinal Endoscopy),15 evaluation of prep adequacy on the morning of the procedure using the NBPAT, and same-day additional prep administration for patients with inadequate stool output. Examples of action items included order sets accounting for nausea, vomiting, placement of an NG tube, and salvage prep therapy after the GI fellow assessed the patient on the morning of the procedure. At this point, nursing compliance with using and completing the NBPAT was 100%.
Phase 3 involved the addition of hard stops for the presence or absence of frank blood and required documentation of prep completion. Nurse workflow for assessment of prep intake was streamlined.
In phase 4, the team conducted a retrospective review of 221 inpatient colonoscopies over a 7-month period to establish baseline colonoscopy prep adequacy and the frequency of repeat procedures in a tertiary care hospital and prospectively collected data for 7 months after the interventions. Barriers were identified for further intervention. On the morning of the procedure, the GI lab status board was updated (Figure 1).12 The red indication resulted in cancellation of the colonoscopy due to either prep refusal or solid stool output (NBPAT score 0). The yellow indication prompted same-day intervention with salvage prep and postponement of the colonoscopy to the afternoon (NBPAT score 1-2), and the green indication signaled procedure readiness (NBPAT score 3-5).
Figure 1. GI procedure status board for bowel preparation adequacy.
Based on reference 12.
Interventions Yielded Benefits
At baseline, 106 of 221 patients (48%) had inadequate prep, with 41 patients (19%) requiring repeat inpatient colonoscopy during the same hospitalization. After the first intervention, 78 of 215 inpatients (36%) had inadequate prep. Split-dose bowel prep was ordered in both groups, but it was unclear whether the patients followed the regimen correctly. Documentation of prep intake was poor, and partial documentation occurred in 21 patients (10%). After the second intervention, 51 patients (30%) had inadequate preps.
Assessment of Protocol in New Community Hospital
The third intervention did not result in a significant difference in bowel prep adequacy at our tertiary care hospital. However, in light of the overall improvement observed, we implemented this revised protocol with all 3 interventions to evaluate its efficacy upon opening a new community hospital.12
With the newly built platform in the EHR available at the community hospital’s opening, we found that 22 of 85 inpatient colonoscopies (26%) had an inadequate prep over an 11-month period. Possible reasons for improved bowel prep adequacy at our new community hospital include the presence of a consistent advanced practice provider in the division of gastroenterology who was well trained in the new EHR protocol and had more time for early-morning patient evaluation. In addition, structured nursing training at initial hospital orientation as well as proactive education likely contributed to better process and protocol adherence.
Cost analysis was performed for each patient who had more than 1 inpatient procedure due to inadequate prep. The average cost was estimated to be approximately $1,537 per repeat procedure, which included the colonoscopy, anesthesia, and a 1-day increase in length of hospital stay. With the decrease in repeat inpatient colonoscopies due to inadequate prep during the same hospitalization, the cost savings at our tertiary care hospital was estimated to be $46,110 over the 15-month duration from these simple interventions alone. Assuming roughly half of inpatient colonoscopies would have been inadequate before order set implementation and standardization at the new hospital, the cost savings for the new hospital over an 11-month period was estimated at $29,203 after 26% of the preps proved to be inadequate (Figure 2).12
Figure 2. Cost savings after implementing protocol to improve inpatient bowel preparation.
Based on reference 12.
Protocol Decreases Inadequate Prep, With Downstream Benefits
Our evaluation showed it is possible to achieve a significant reduction in inadequate bowel prep for colonoscopy by educating providers on the split-dose prep order set, early morning bowel prep assessment, and proactive same-day “salvage” prep. We revised our current bowel prep order set but found that even though the prep was ordered as a split dose, documentation of intake times and tolerability initially was lacking. Therefore, we implemented an additional intervention to identify high-risk patients and give additional prep as needed.
Often, patients do not tolerate the preparation and experience significant side effects such as nausea and vomiting. With the implementation of a simple order set in the EHR for PEG-3350 split dosing as well as education for nurses and patients, we increased compliance and tolerability of bowel preparation, decreased healthcare resource utilization, and, therefore, improved the quality of care and patient experience.
Other studies have examined the utility of an electronic order set designed for inpatient split-dose bowel preparation in decreasing length of stay, improving BBPS scores, and reducing the need for repeat colonoscopy. In 2020, Cotter et al performed a prospective study and designed an electronic order set for 248 inpatients undergoing colonoscopy with split-dose bowel preparation and the use of medical, pharmacy, nursing, and patient advocacy teams for education and “prep checks.”16 As-needed antiemetics, prokinetics, NG tube insertion, and additional preparation were given when appropriate. BBPS scores improved by 0.78 points and length of stay decreased by 0.8 days in the intervention group.
Liu et al performed a single-center randomized controlled study to investigate the effect of education of ward nurses on bowel preparation quality in inpatients undergoing colonoscopy; 191 patients with and without nurse education were compared, and the investigators found that the proportion of colonoscopies with adequate bowel preparation was 13.8% higher in the education group than in the control group.17 They concluded ward nurse education improved bowel preparation quality and reduced adverse event rates in inpatients undergoing colonoscopy.17
Predictors of Inadequate Bowel Preparation
In 2025, the US Multi-Society Task Force (USMSTF) on Colorectal Cancer published an update to the 2014 recommendations for optimizing bowel preparation adequacy.18 The USMSTF has made recommendations on several questions related to outpatients at low risk for inadequate bowel preparation before, during, and after colonoscopy.18 Tables 2 through 4 review the recommendations for each of these phases and their application to the inpatient setting and suggest potential areas for improvement and future study.12,18
Table 2. Recommendations for Patients at Low Risk for Inadequate Bowel Preparation Prior to ColonoscopyIssueUSMSTF recommendationInpatient approach and considerationsPatient navigators and electronic adjuncts (automated texting programs) to help prepare patients for colonoscopyIndividuals undergoing colonoscopy should receive both verbal and written education instructions for all components of colonoscopy prep.
(strong recommendation, high-quality evidence)Telephonic/virtual navigation, electronic messaging and instructional video content via the patient’s in-room television may be a potential area of improvement .Patient diet before colonoscopy Limit dietary modifications to the day before the colonoscopy for ambulatory patients at low risk for inadequate prep. Dietary modifications should include the use of low-residue and low-fiber foods or full liquids for the early and midday meals on the day before the colonoscopy when using a split-dose regimen.
(strong recommendation, high-quality evidence)Optimal protocol for healthy inpatients who are not at high risk for having inadequate bowel prep is not clear. There may be a role for a full-liquid or even low-residue diet in the absence of other risk factors.Specific bowel prepNo single bowel prep purgative is recommended over others for ambulatory patients at low risk for inadequate prep.
(strong recommendation, high-quality evidence)
However, selection should balance patient comorbidities, safety, and cost. Consideration should be given to the patient’s medical history, medications, and adequacy of prior colon preps.
(strong recommendation, moderate-quality evidence)Inpatients likely require heightened considerations of comorbidities, safety, prior medical history, medications, and adequacy of prior prep. Hyperosmolar purgatives should be avoided in patients with renal insufficiency and cardiac conditions, who would otherwise be at risk for fluid shifts. Most inpatient facilities offer an iso-osmotic and isotonic agent, safe in this population, as a first-line purgative.Splitting dosesSplit-dose administration of bowel prep purgatives for all patients, regardless of high- or low-volume prep.
(strong recommendation, high-quality evidence)The same likely would hold true for the inpatient population.Same-day prep vs split-dose regimenA same-day regimen is an acceptable alternative to split dosing for individuals undergoing an afternoon colonoscopy.
(strong recommendation, high-quality evidence)
A same-day regimen is inferior to split dosing for those undergoing a morning colonoscopy.
(weak recommendation, low-quality evidence)In our study, salvage prep had to be administered to the patient on the same day if the early-morning specimen was turbid, but this was only after the initial split-dose prep had been administered. It is unclear if same-day preps in inpatients pose an increased risk for bowel prep inadequacy, or if it is more feasible to proceed with day-prior prep, early-morning check, and, if needed, additional prep for an afternoon procedure.Optimal timing for starting bowel purgativeIndividuals using a split-dose regimen for colonoscopy prep should begin consuming the second portion 4 to 6 hours before the time of colonoscopy and complete it at least 2 hours before the procedure starts.
(strong recommendation, moderate-quality evidence)This model was used in our inpatient study for optimal timing of bowel prep. These settings are more likely to have challenges (eg, delays in prep due to other tests), so following the recommended timing may be challenging.Adjuncts to improve prep adequacyData strongly supporting the timing and dosage of oral simethicone are lacking. If the endoscopist chooses to use oral simethicone as an adjunct for bowel prep, a dose of 320 mg may be used.
(weak recommendation, moderate-quality evidence)
Routine use of non-simethicone adjuncts for bowel prep is not recommended.
(weak recommendation, low-quality evidence)
Further studies are needed.In our study, simethicone was not given orally. Although variability exists in practice with respect to oral simethicone as an adjunct, it occasionally is recommended, but cost, patient inconvenience, and access may pose a challenge.Based on references 12 and 18.
USMSTF, U.S. Multi-Society Task Force
Table 3. Recommendations for Patients at Low Risk For Inadequate Bowel Preparation During ColonoscopyIssueUSMSTF recommendationInpatient inpatient approach and considerationsCancelling when patients report poor adherence to prepWhen a patient reports incomplete adherence to the bowel prep regimen or suggests their bowel prep may not be adequate, insertion of the colonoscope to the sigmoid colon should be performed to confirm inadequacy before aborting the procedure.
(weak recommendation, low-quality evidence)
If a colonoscopy is being aborted because of inadequate bowel prep quality, the endoscopist should photograph the segment(s) of colon that resulted in abortion of the procedure.In our study, although a rare occurrence, if the appearance of the stool did not meet criteria during early morning rounds, the prep was continued to the next hospital day. If the prep was less than adequate during any colonoscopy, the physician aborted the procedure. Although photographs were sometimes lacking, this is an appropriate approach in the inpatient setting.Assessing and describing bowel cleanliness in the endoscopy reportBowel prep quality should be assessed after all washing and suctioning have been completed, using reliably understood descriptors that communicate the adequacy of the prep.
(strong recommendation, moderate-quality evidence)The protocol recommended by the task force would be appropriate for the inpatient population.Use of irrigation pump to improve bowel prepRoutine use of irrigation pumps to assist with bowel prep during colonoscopy suggested.
(weak recommendation, very low-quality evidence)Routine use of irrigation pumps was not apparent on a consistent basis during our study. It seems reasonable to follow the outpatient recommendations on irrigation pumps for the inpatient population when feasible.Use of simethiconeOccasionally, bubbles in the visual field at the time of colonoscopy significantly affect visualization and, by extension, procedural quality. If simethicone is used in those circumstances, use the lowest possible dilution (0.5 mL simethicone in 99.5 mL water) and administer only through an instrument channel that is routinely brushed during endoscope reprocessing.In our study, simethicone was administered through an instrument channel that was routinely brushed during endoscopic reprocessing. However, the dilution technique and amount of water used was variable.Salvage maneuversSame-day salvage maneuvers are suggested when feasible.
(weak recommendation, moderate-quality evidence)In our proactive approach, we used same-day salvage maneuvers when bowel prep was inadequate during the morning patient check and administered additional purgatives. We did not proceed with colonoscopy if there was evidence of inadequate bowel prep.Based on references 12 and 18.
USMSTF, U.S. Multi-Society Task Force
Table 4. Recommendations for Patients at Low Risk for Inadequate Bowel Preparation After ColonoscopyIssueUSMSTF recommendationInpatient approach and considerationsRoutine measurement of bowel prep adequacy by endoscopist and endoscopy unitRoutine tracking of the rate of adequate bowel preps at the level of individual endoscopists and at the level of the endoscopy unit is recommended.
(strong recommendation, moderate-quality evidence)
Individuals who are ambulatory and at low risk for inadequate bowel prep whose colonoscopies are cancelled for presumed inadequate prep (before colonoscopic insertion) should be included when calculating both endoscopy unit and endoscopist-level bowel prep adequacy rates.It is unclear if it is feasible or beneficial to track the rate of adequate bowel preps at the individual endoscopist and the endoscopy unit level in (diagnostic) inpatient procedures because the higher-risk inpatient population has lower overall prep adequacy rates.Standard minimum bowel prep adequacy rateThe endoscopy unit-level and individual endoscopist-level bowel prep adequacy rate of should be at least 90%.
(strong recommendation, moderate-quality evidence)
When significant variability in bowel prep adequacy is seen between endoscopists in a practice with shared prep processes, assess variability among intraprocedural efforts to augment quality bowel prep and assessment of adequacy.At the time of our original study, routine documentation of bowel prep adequacy using the Boston Bowel Preparation Scale had not been standardized and, therefore, not measured on the outpatient or inpatient patient population. Although most providers had a bowel prep adequacy rate greater than 90%, further evaluation into reasons for lower rates was not performed. It could be useful to perform such evaluations to improve standardization.Management when prep is not salvageableCompletion colonoscopy should be performed within 12 months for screening or surveillance.
(strong recommendation, moderate-quality evidence)
When bowel prep is deemed inadequate and the indication is for alarm symptoms or a positive nonendoscopic colorectal cancer screening test, a colonoscopy with adequate bowel prep should occur as soon as possible, with timing that considers the date of onset of symptoms or the date of the positive noninvasive screening test.In our study, no screening colonoscopies were performed on inpatients. If the prep was inadequate, provisions were made for next day colonoscopy. If alarm symptoms or a positive FIT was the indication and the procedure was not performed the following day, every effort was made to schedule repeat colonoscopy within 4 weeks.Protocol for patients at high risk for poor prepIndividuals at high risk for inadequate bowel prep quality should be managed similarly to individuals with a prior inadequate prep, with modifications made to their regimen.
(strong recommendation, moderate-quality evidence)
The suggested regimen includes split-dose 4 L PEG-ELS + 15 mg bisacodyl the afternoon before the colonoscopy, and a low-residue diet 3 and 2 days before procedure, changing to clear liquid diet the day prior.
(weak recommendation, low-quality evidence)In our study, the split-dose 4 L PEG-ELS was used for all inpatients. However, we did not use bisacodyl as part of our regimen. We also placed every patient on a clear liquid diet the day before the procedure.Based on references 12 and 18.
The Outpatient World
Several risk factors contribute to inadequate bowel preparation quality for outpatient ambulatory patients, with potentially additive effects. These include cirrhosis, Parkinson’s disease, dementia, tricyclic antidepressant use, diabetes, opioid use, and gastroparesis.18 In addition, previous colorectal surgery, lower level of education, BMI greater than 30 kg/m2, hypertension, tobacco use, male sex, age older than 65 years, and constipation have all been implicated as risk factors for inadequate bowel preparation, with odds ratios between 1.1 and 3.4.18 Inpatient status and Medicare and Medicaid insurance were associated with odds ratios of 1.2 to 1.5.18
Borg et al evaluated 1,588 ambulatory colonoscopies and demonstrated a linear increase in the risk for inadequate bowel preparation with an increasing number of risk factors. Consistent with the cumulative effect of multiple risk factors, the presence of 7 risk factors was associated with a 98% likelihood of inadequate bowel preparation.19
The Inpatient World
Hospitalization is a known independent risk factor for poor bowel prep. Reasons for inadequate bowel preparation include the use of a large-volume bowel prep agent that leads to poor patient compliance and an inability to complete prep; communication gaps among physicians, nurses, and patients about the steps involved in completing a bowel prep; and lack of knowledge among patients, providers, and nurses about the importance of bowel prep completion and clinician documentation. Patients often discontinue their bowel prep when they believe it is adequate based on stool appearance or other factors or when they cannot tolerate it any further due to nausea, vomiting, bloating, or other symptoms. In addition, nursing staff reporting tends to be subjective. Documentation of bowel prep intake and stool output is often scant, and procedure cancellations and/or low diagnostic yield due to poor preparation are common.
The presence of predictors of inadequate bowel preparation must be considered when identifying patients who may need additional support or assistance with the preparation process or rescue maneuvers such as additional salvage preparations.15 Medical conditions associated with inadequate bowel preparation include chronic constipation (and/or use of constipating medications), diabetes mellitus, obesity, cirrhosis, Parkinson’s disease, dementia, and stroke. Polypharmacy, prior colon resection, and a prior history of inadequate colonoscopy prep are additional factors associated with poor prep.7,20-23 Special interventions may be needed to increase the likelihood patients with these risk factors follow instructions and successfully complete preparation. In the inpatient setting, patients often have numerous chronic conditions and, at times, are challenged physically and mentally in ways that decrease their likelihood of being able to follow directions without assistance.
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The Task Force additionally mentions that modified bowel preparations may be an option for patients at risk for inadequate bowel prep.18 In our study, we demonstrated that identifying those at higher risk for inadequate prep and making proactive modifications can be advantageous, resulting in a notable decrease in the number of inadequate bowel preparations in the inpatient population.12 To date, predictive models, although published, have not been proven to improve bowel preparation quality, and an efficient method has not been established to identify higher-risk patients during scheduling.24 Artificial intelligence that assists with predictive models likely would add value and identify those who could potentially benefit from alternate preparation therapy.24
Conclusion
Inadequate bowel preparation increases the cost of colonoscopy delivery and not only results in patient inconvenience but also creates additional risk.25 Because it is crucial for cost-effective colonoscopy, adequacy of bowel preparation is recognized as one of the 5 priority indicators for colonoscopy (strength of recommendation, 1C+), with a performance target of at least 90%.25 It is recommended that the colonoscopy report include descriptors of bowel preparation as “excellent,” “adequate,” or “good” or record a BBPS score of at least 2 in all 3 colon segments.5,24
Several studies have demonstrated that inpatient bowel preparation is very challenging compared with prep in the outpatient setting and results in more colonoscopies being cancelled and/or repeated. Richter et al found in their tertiary teaching hospital that 51% of inpatients had a suboptimal bowel preparation.26 In addition, cost data revealed that a repeat colonoscopy resulted in a 60% to 257% increase in patient costs, with an average risk of 138% (direct and indirect costs).26
Implementation of a standardized order set as well as related EHR functionality is of paramount importance in any inpatient hospital facility where colonoscopy is performed. In our evaluation, outcome measures included improved nursing compliance, accountability regarding complete documentation, improved frequency of provider assessment to evaluate for timely tolerability, and identification of high-risk features of poor bowel preparation. These optimization tactics improve the patient experience, increase efficiency, decrease length of stay, and lower costs, resulting in higher-value care. Although significant opportunities for improvement related to preparation in colonoscopy remain, our study demonstrated tremendous efficacy in efforts to improve quality and lower cost. It is of utmost importance to continue to pursue strategies to address bowel preparation inadequacy, as it places a significant cost burden on hospitals at a time when healthcare costs continue to increase.
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