What’s New in the Patient Safety World

February 2019

Constipation Costs Hospital

 

 

A California hospital was fined $30,000 for overlooking a serious case of constipation that led to significant patient morbidity (CDPH 2018). The patient did not have a bowel movement for 10 days. The patient had been prescribed numerous opioids known for causing constipation, yet, the facility waited 8 days after her last bowel movement to respond to her constipation symptoms. Ultimately, the patient had a toxic megacolon and required additional surgery.

 

CDPH noted the facility failed to develop a post-operative plan of care that included bowel care and failed to implement a care plan requiring assessment of pain medication side effects. It also failed to recognize a nursing diagnosis of severe constipation and intervene by promptly notifying the physician.

 

The patient was a 71 year old who was admitted to the hospital on 11/20/17 for lung surgery. A pre-operative note stated her last bowel movement was on 11/18/17. Post-operatively she was administered numerous opioid pain medications. She had no bowel movements postoperatively but a physician was first notified of the problem on 11/26/17. Then the physician’s orders for a stool softener and a twice daily laxative (milk of magnesia) were delayed 12 hours because the facility’s protocols for orders written after 9:00 AM defaulted to begin at 9:00 PM. Obstipation persisted and, on 11 /28/17, a nurse noted that the patient's abdomen was tender throughout, with no bowel sounds and was not passing gas. Multiple Fleet’s enemas were administered and the patient was given magnesium citrate and lactulose. After a soap suds enema on 11/29 there was “medium sized” bowel movement but a soap suds enema was repeated again with no results.

 

Multiple enemas followed by a Gastrografin enema and an attempt to try to decompress the bowel by use of suction through a tube were unsuccessful. White count progressively rose and follow up CT scan revealed persistent cecal dilatation. The patient returned to surgery on 11 /29/17 at 11 :30 PM to evacuate the colon, where it was discovered she had toxic megacolon (acute colonic distension characterized by a very dilated colon) with areas of ischemia.

 

Very timely was a recent article in ACP Hospitalist (Butterfield 2018) suggesting we approach constipation aggressively and offering tips on inpatient constipation (based on a talk Melissa Latorre, MD had given at American College of Gastroenterology 2018).

 

Dr. Latorre’s first tip is to be proactive. Rather than leaving orders for “prn” bowel care, she recommends standing orders for laxatives, with an opt-out policy to hold if the patient has had more than two bowel movements or is having diarrhea (keeping in mind that occasionally you might be fooled by “overflow” diarrhea).

 

She recommends both “induction” and “maintenance” therapies and “above” and “below” approaches. The induction phase may consist of an osmotic laxative such as polyethylene glycol, 17 g in 8 ounces of water, either two or three times a day, or colonoscopy prep if the patient can tolerate it. She avoids use of fiber or lactulose or oral stimulants upfront, because they may exacerbate symptoms like bloating, abdominal pain, and abdominal distension. From below, induction can include manual maneuvers and suppositories. “Glycerin may help to soften the stool and bisacodyl may help with rectal motility.” Once there has been a bowel movement, some enemas (mineral oil or tap water) may help.

 

Once the patient is eating again, a maintenance phase would include providing fiber, water or IV fluids, and oral laxatives. For those patients on opioids, an opiate-receptor antagonist may be indicated. Optimizing the patient's underlying medical condition is also important.

 

She also cautions that not all constipation is functional or opioid-induced. You always need to consider small-bowel obstruction, large-bowel obstruction, acute pseudo-obstruction, volvulus, toxic megacolon, and perforation. We especially refer you to our May 14, 2013 Patient Safety Tip of the Week “Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)”.

 

She notes that postoperative ileus is also a common condition. But constipation beyond 4 days is of concern, particularly if two or more of the following are present: nausea, vomiting, inability to tolerate diet over the prior 24 hours, absence of flatus in the preceding 24 hours, abdominal distension, radiologic evidence. Management includes IV fluids, electrolyte repletion (especially potassium and magnesium), mobilization as tolerated, and nutritional support. Anti-emetics or laxatives may be needed for symptomatic relief. You should try to identify any drugs that may be exacerbating the problem. GI decompression might be appropriate for some patients (as we discussed in our column on Ogilvie’s Syndrome). Pharmaceutical interventions require some caution. Neostigmine is approved for acute pseudo-obstruction and large-bowel ileus but you must closely monitor patients for severe bradycardia and bronchospasm. Alvimopan is FDA-approved to accelerate upper and lower GI recovery following a partial small-bowel resection with primary anastomosis but carries a black box warning about the risk of myocardial infarction.

 

Butterfield also ends the ACP Hospitalist article with Latorre’s comment that chewing gum has also been reported to be of some benefit!

 

While we generally recommend that standardized order sets avoid “prn” orders for certain things that may not be necessary during a hospital stay (such as sleep medications), there are clearly patients at risk for constipation in whom proactive standing orders make sense. It is particularly important that such do address constipation in patients who are prescribed opioids, particularly following surgery. We like the approach Latorre has outlined.

 

 

References:

 

 

CDPH (California Department of Public Health). Complaint Intake Number: CA00563555. CDPH 2018; December 6, 2018

https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Immediate%20Jeopardy/Mercy%20Medical%20Center%20-%20Redding%20230013715%20Redacted%20POC_ADA%20compliant.pdf

 

 

Butterfield S. Approach constipation aggressively. An expert speaking at American College of Gastroenterology 2018 gave tips on inpatient constipation. ACP Hospitalist 2018; December 2018

http://acphospitalist.org/archives/2018/12/approach-constipation-aggressively.htm

 

 

 

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