2. Diabetic Colon Preparation for GI Procedure Ann Hayes BSN, RN, CGRN Marti Buffum DNSc, RN, PMHCNS-BC Joyce Hughes MS, RN, CGRN Veterans Affairs Medical Center San Francisco

3. Background  Colon cancer second leading cause death from a cancer in North America  150,000 colon cancer diagnosed per year  Totally preventable

4. Colonoscopy  Increasingly used for screening  Adequate bowel prep significant for GI units and patients

5. Clinical Problem  Inadequate colon preparation means repeat procedure  Colonoscopy has potential risks Bleeding and perforation Bleeding and perforation Sedation complications: Sedation complications: CardiacCardiac respiratoryrespiratory

6. Required bowel cleansing  Day prior to procedure  Wide variety of colon preps  Patients often complain about prep

7. Preventing repeat procedure  Decreases availability of colon screening  Maximizes patient safety  Ensures organizational efficiency

10. Clinical Problem in GI unit  1997 Survey of 64 patients colonoscopy preps 19% had good preps 81% poor prep means repeat exam  GI nursing staff began QI project to improve patient care by improving colon preps

11. Nursing Interventions to Improve Colon Preps  Improve patient education  Phone call week prior to procedure

12. 2001 Survey  50 colon preps = 79% good to excellent  But diabetic colon preps = only 63% good New finding!!

13. Prep Survey  Suggests diabetic patients having more difficulty attaining adequate colon prep  Needs to improve / change the way diabetic patients are prepped

14. Are diabetics different?  Need to do a literature review  Found no colon prep studies with diabetic

15. Literature review  Nakahara et al., (2002) Gastroparesis: slow emptying of stomach Gastroparesis: slow emptying of stomach  Well known in medicine  Causes nausea and often vomiting

16. Literature  Taylor & Schubert (2001) diabetic patients prepped significantly less effective prep  Using PEG solution for colonoscopy  17 of 45 diabetic patients had inadequate colon prep

17. Literature  Fincher et al (1999) : preps for sigmoidoscopy less likely to be adequate  Study of 299  Regardless of which 3 preps used, diabetics less likely to have adequate prep

18. Literature review  Study by Maleki et al., (1998): significantly slower colonic transit times  Ascending and transverse colon slower  Study by Celik et al., (2001)  Constipation a problem for 2/3 diabetics

19. Special Needs of Diabetic  Approach to colon prep in diabetic patients needs to be different  Need to change standard prep used

20. PEG Solution  Polyethylene glycol-based isotonic salt solution  Davis et, al 1980  Safest and most commonly used

21. Sodium Phosphate Solution  Low volume, strong laxative  Associated with dangerous fluid & electrolyte shifts  FDA issued a warning

22. Magnesium Citrate (Mg)  Study by Berkelhammer 2002 showed Mg citrate milder, low volume laxative  Minimizes electrolyte imbalance, dehydration & aphthous ulcers Sodium phosphate solution = 5.5% ulcers Sodium phosphate solution = 5.5% ulcers Mg = 1% ulcers Mg = 1% ulcers Significant finding: p< 0.01 Significant finding: p< 0.01

23. Mg Citrate  Aphthous ulcers lead to diagnosis confusion  Could be: IBD, ischemic colitis or infection

24. Mg Citrate  Available over the counter & low cost  Minimal fluid and electrolyte shift  Fewer incident aphthous ulcers

25. Mg Citrate & Electrolytes  Sharma et, al 2001 study showed: No significant shifts in BP, pulse and electrolytes No significant shifts in BP, pulse and electrolytes Mg citrate safe & effective for colon cleansing Mg citrate safe & effective for colon cleansing

26. Usual Reaction to failed colon prep  Repeat colonoscopy  Double PEG = 8 liters

27. Double Prep Problem  Diabetics have slow gastric emptying  Would have difficult consuming large volumes  Possible vomiting and non adherence

28. Constipation Problem  Large percentage of diabetic are constipated  Need to correct this prior to starting colon prep

29. Decision Process  Conferred with Dr McQuaid, Chief GIDC  Tried new prep on small group with good success

30. Standard Colon Prep  Clear liquids day prior to colonoscopy  Late afternoon: 10 oz Mg citrate 10 oz Mg citrate 4 liters PEG 4 liters PEG

31. New Diabetic Colon Prep  All patients have clear liquid diet day prior  Diabetics: two days prior to exam 10oz. Mg citrate  All patients: day before test, 10oz Mg citrate and 4 liters PEG

32. Research Question  Will new colon prep two 10oz Mg citrate (1 day apart) & 4 liters PEG solution improve diabetic prep over original prep 10oz Mg citrate and 4 liters PEG solution?

33. Method  Design: Experimental design  Randomized controlled trial  Double blinded: physician-nurse team and patient

34. Conducted at GIDC  University-affiliated VA Medical Center  IRB approval form University of California and VA Research Committee  200 subjects

35. Procedure  Consent  Randomization: random table of numbers  Blinded procedure staff  Patient drinks one of two preps: experimental or standard

36. Instruments  Demographic Information Age Age Sex Sex Use of narcotics Use of narcotics Years of being diabetic Years of being diabetic Signs of peripheral or retinal neuropathy Signs of peripheral or retinal neuropathy Serum creatinine Serum creatinine

37. Instruments  Patient 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 ?

38. Instruments  Colon cleansing scale Used by GI staff since 1998 Used by GI staff since 1998 Adams et al., (1994) Adams et al., (1994) Scale of 1 to 5 Scale 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 and endoscopistColon rated at cecum, consensus between nurse and endoscopist

39. Inclusion Criteria  Outpatient colonoscopy  Diabetic  English speaking

40. Exclusion Criteria  Dementia  Psychosis  Prior colon surgery

41. Procedures  Recruitment: all diabetic outpatients being scheduled for colonoscopy  Consented patients  Select randomized envelope (table of random numbers)

42. Procedure  Give prep and instructions: standard or experimental  All patients received verbal and written instructions from GI RN

43. Procedures Continued  Day of procedure: admitting nurse completes demographics  MD and patient (blinded): completed colon prep evaluation during colonoscopy

44. Study Results: Demographics  Mean age 62 years  Men 187; women 8  IDDM = 53; NIDDM = 143  Demographics not significantly different between the two groups

45. Study Results  Good colon prep: Diabetic (experimental) prep = 70% Standard prep = 54% Diabetic (experimental) prep = 70% Standard prep = 54% Chi-square = 5.14 Chi-square = 5.14 P = 0.02 P = 0.02 Diabetic patients who used Diabetic prep had significantly cleaner colon Diabetic patients who used Diabetic prep had significantly cleaner colon

46. Chi-square = 5.14, p=0.02 Percent of Patients for Whom Colon was Easily Visualized

47. Percent of Patients Who Drank 4 Liters of PEG as Directed p=.96, NS

48. Conclusion  Diabetic patients having a colonoscopy will get better colon cleansing if given 10 oz Mg citrate two days prior to procedure then 10 oz Mg citrate and 4 liters PEG the day prior to procedure  Other GI procedure units could confidently implement this prep for diabetic patients

49. Practice Change  Diabetic prep routinely for all diabetic patients scheduled for colonoscopy  Expanding the use of this prep to patients with constipation and those who had inadequately cleans colon on past colonoscopy

50. Diabetes Serious & Common Problem in US  2008: 8% (24 million)  2010 increase to 15%  Veterans 20% in 2000  Most are 60 years and older

51. Safety of Mg Citrate  There were no adverse events in study No clinical evidence of: No clinical evidence of: HypovolemiaHypovolemia Electrolyte imbalance Electrolyte imbalance

52. Patient tolerance to Mg Citrate  No patient in study voiced complaint Flavor tolerated Flavor tolerated Comfort Comfort Significant fewer repeat colonoscopy

53. Limitations of Study  Small number of women in study  Question concerning constipation not effective

54. Strengths of Study  Large sample size  Experimental design  Double blind  Hence finding are generalizable

55. Goal is Clean Colon  When prepping patient consider: Bowel habits Bowel habits Medical conditions Medical conditions Difficulty swallowing Difficulty swallowing Lack of mobility Lack of mobility Above may warrant change is colon prep

56. Nursing Research  Effects the nursing culture  Nurse involved in research are likely to: Develop innovations Develop innovations Find best practices to improve patient care Find best practices to improve patient care