For World Patient Safety Day 2022, Nurse Lead, Sarah Marshall, provided us with a case study that highlights supply issues and dispensing.

 Case synopsis

Endoscopy received a referral for a 78-year-old male with a change in bowel habit and a positive Faecal Immunochemical Test (FIT) result from the GP. The patient was pre-assessed and has an American Society of Anaesthesiologists (ASA) grade of II. It is noted he is taking laxatives due to suffering with constipation over the last 6 months. The patient went to their GP after seeing recent publicity from Dame Deborah James and ‘Good Morning Britain', highlighting the symptoms of bowel cancer.

The patient is very anxious and worried about taking the oral bowel cleaning agents. Currently, in the endoscopy unit there is a shortage of Polyethylene glycols (also known as PEG or macrogols) bowel preparations. Within this endoscopy unit a person over 70 years with hypertension would normally receive a PEG based bowel preparation as a default. The patient was extremely apprehensive to take two to three litres of polyethylene glycol. There were noted concerns of the volume, taste and the effects that normally follow taking bowel preparation.

 The patient had bloods taken from their GP over 90 days. The patient’s estimated glomerular filtration rate (eGFR) was noted to be over 90 ml/min and there were no absolute contraindications. After clinical review, the patient was given magnesium carbonate and citric acid. This was based on a holistic patient assessment.

There is a higher risk of hyponatraemia and a higher risk of hypermagnesemia in patients with advanced chronic kidney disease, when taking magnesium carbonate and citric acid, than with other oral bowel cleansing agents. It is particularly important that patients with conditions predisposing to hypovolaemia are evaluated prior to receiving this oral bowel cleansing agent (OBCA) too, hence the pre-assessment.

Due to the complications and contraindications potentially associated with this OBCA, specific written advice was provided on fluid and medication management (as with all OBCA). A further renal blood sample was taken as there were none available within 90 days. The patient requested to have a lower volume to ensure compliance too.

On the day of the colonoscopy, the patient called to say that they could not take any more bowel preparation. They were nervous and anxious about getting to the hospital and were feeling nauseous. The nurse in charge informed the patient to come to the endoscopy unit where they could review the patient and where they would feel more comfortable to take the remaining bowel preparation. The colonoscopy was undertaken, and a large 2cm polyp was removed.

Things to consider

• European Society of Gastrointestinal Endoscopy (ESGE) endorsed by British Society of Gastroenterologists (BSG) recommends the use of high volume or low volume PEG-based regimens, as well as that of non-PEG-based agents that have been clinically validated for routine bowel preparation. In patients at risk for hydroelectrolyte disturbances, the choice of laxative should be individualised. (Strong recommendation, moderate quality evidence).

• Currently there is a national shortage of bowel preparation in the UK

• Units should have a plan in place with their clinical leads on the use of the available bowel preparations within their unit and possibly their region.

• Detailed and enhanced instructions for bowel preparation and patient information should be available and include information on fluid management, medication management and who to call in and out of hours should there be a problem whilst taking an OBCA

• The safe prescribing and distribution of OBCA is a core clinical protocol to support patient safety.

• There should be evidence that a patient’s fitness for OBCA has been assessed prior to dispensing bowel preparation (GRS Section 8/ 8,3 – consent and patient information)

• Units should have a bowel preparation and dispensing policy which details how a patient's fitness or OBCA are assessed and documented prior to OBCA being dispensed. (GRS standard – section 2 Safety 2.3)

• Staff should be educated and trained to know absolute contraindications to OBCA and understand the potential complications and contraindications with each OBCA that their patients have prescribed and dispensed (GRS standard – section 2 Safety 2.3/).

• All staff should be educated and trained to deal with patient queries and concerns regarding bowel preparation and know who to escalate to as required.