Abstract
Introduction:
Constipation is a common diagnosis among hospitalized patients. It results in considerable morbidity in elderly patients, healthcare utilization and economic burden. Laxatives are commonly prescribed but poorly monitored due to benign side effect perception.
Aim:
We undertook a review of the quality of laxative prescribing and subsequent monitoring amongst an inpatient cohort. We propose new standards:
- Medication review at least once weekly
- Documented rationale for choice of medication
- Specified timeframe review and outcome documentation.
We reviewed current hospital trust policy of laxative prescribing and produced a new constipation management guideline in response to early audit data.
Method:
Data collected across medical wards in Trafford General Hospital, Manchester. Data was collected on types of laxatives, reason for prescription, date of review, length of course, compliance and effect of laxatives. Two rounds of audit were performed 6 months apart, with an interim intervention of staff education and local introduction of a new constipation management guideline. The guideline consisted of decision algorithm and suggested treatment.
Results:
47 individual prescriptions were audited in round 1 and 72 prescriptions in round 2, this represented 23 and 32 patients respectively. Review of medications within first week of prescription improved from 17% to 83.7% across the two cycles. Documentation of constipation diagnosis improved from 52.2% to 97.2%. There were large percentage improvements in documentation of specified treatment outcomes across all audited fields, despite overall poorer medication compliance among patients in round 2 (56.9% versus 66% in round 1). The average length of laxative use decreased from 18.6 days to 15.3 with overall percentage of patient with constipation resolved increased from 65% in round 1 to 73% in Round 2.
Conclusion: Staff education and implementation of treatment guidelines made a substantial improvement to the medical management of constipation in hospitalized patients.
Comments
Laxatives prescription monitoring for an overlooked problem
Good work, Constipation is a common problem in elderly patients which is commonly overlooked and mismanaged. Outcome of your audit is encouraging. I only suggest that we should involve the primary care as many patients should have been commenced on laxatives in the community and a few admissions could have been avoided.
Indeed, Treatment of this overlooked problem can definitely help us avoid few admissions.
Thank you for your suggestion, putting a plan in place with the primary care involved would definitely be the next step moving. I will forward your kind suggestion to the team and our consultant overlooking this project and hopefully in the coming months we should put a plan in place
Laxatives prescription monitoring for an overlooked problem
Excellent work. Will be sharing within a health economy . A problem badly managed and delegated as non exciting even before telemedicine and even when guidelines produced no follow up as you have done
Thank you for your kind words.
The problem in secondary care is that when dealing with sepsis, Heart failure and other such grave conditions, Constipation and other chronic conditions unfortunately takes a back seat. Our main aim at the moment is continuous staff education regarding this matter, until it becomes a second nature to the team involved to optimize laxatives. From proper documentation of bowel charts by the nurses to the involvement of junior doctors and pharmacists we are making progress one step a time.
Laxatives prescription monitoring for an overlooked problem
There are some opioid-induced constipation treatments that are NICE approved. Has your health board considered including these in your guideline?
I believe you are pointing towards Naloxegol, Methylnaltrexone and probably Naldemedine (though I believe it is yet to be approved)
Yes! They are in the wider guideline of our trust as a separate "specialist use" section, as these are often third/forth line treatments which require specialist supervision. We have worked closely with pharmacy and gastroenterology teams to ensure the guideline is approachable for all grades of clinical prescriber. The flowchart on the poster is aimed towards more junior prescribers with first/second line treatments. There is a recommendation at the bottom to seek specialist help in the event of treatment failure.