Use of fecal occult blood testing in hospitalized patients: results of an audit.

BACKGROUND: The fecal occult blood test (FOBT), widely used as a colorectal cancer screening tool, continues to be used in hospitalized patients. However, the utility of this test for hospitalized patients is unclear. OBJECTIVE: To assess FOBT use in a large urban regional health authority. METHODS: Reports of all FOBTs performed between April 1, 2011 and March 30, 2012 from two academic and four community hospitals in Winnipeg (Manitoba) were extracted. Of 650 hospitalizations with a positive FOBT result and 1254 with a negative FOBT result, random samples of 230 and 97 charts, respectively, were reviewed. Information including demographics, admission diagnos(es), indication(s) for ordering the FOBT and clinical management was extracted. RESULTS: Thirty-four percent (650 of 1904) of hospitalizations with an FOBT had a positive FOBT result. Family medicine physicians ordered approximately one-half of the reviewed FOBTs. The most common indication for ordering an FOBT was anemia. Of those with a positive FOBT, 66% did not undergo further gastrointestinal investigations. Of those with a positive FOBT and overt gastrointestinal bleeding and/or melena who underwent endoscopy, 60% had their endoscopy performed before the FOBT result being reported while 38% underwent their endoscopy ≥3 days after the stool sample was collected. There were minimal differences in clinical practices between academic and community hospitals. CONCLUSIONS: The present study suggests that FOBT results in hospitalized patients may have little beneficial impact on clinical management. Hospital laboratories may be better served in directing resources to other tests.

Practice and documentation of performance of colonoscopy in a central Canadian health region.

OBJECTIVE: To evaluate the reporting and performance of colonoscopy in a large urban centre. METHODS: Colonoscopies performed between January and April 2008 in community hospitals and academic centres in the Winnipeg Regional Health Authority (Manitoba) were identified from hospital discharge databases and retrospective review of a random sample of identified charts. Information regarding reporting of colonoscopies (including bowel preparation, photodocumentation of cecum/ileum, size, site, characteristics and method of polyp removal), colonoscopy completion rates and follow-up recommendations was extracted. Colonoscopy completion rates were compared among different groups of physicians. RESULTS: A total of 797 colonoscopies were evaluated. Several deficiencies in reporting were identified. For example, bowel preparation quality was reported in only 20%, the agent used for bowel preparation was recorded in 50%, photodocumentation of colonoscopy completion in 6% and polyp appearance (ie, pedunculated or not) in 34%, and polyp size in 66%. Although the overall colonoscopy completion rate was 92%, there was a significant difference among physicians with varying medical specialty training and volume of procedures performed. Recommendations for follow-up procedures (barium enema, computed tomography colonography or repeat colonoscopy) were recorded for a minority of individuals with reported poor bowel preparation or incomplete colonoscopy. CONCLUSIONS: The present study found many deficiencies in reporting of colonoscopy in typical, city-wide clinical practices. Colonoscopy completion rates varied among different physician specialties. There is an urgent need to adopt standardized colonoscopy reporting systems in everyday practice and to provide feedback to physicians regarding deficiencies so they can be rectified.

Colonoscopy and its complications across a Canadian regional health authority.

BACKGROUND: Defining the complication rate of endoscopy performed across an entire city will capture usual as opposed to referral center data. OBJECTIVE: Our purpose was to evaluate the current practice of colonoscopy and complications associated with lower GI endoscopy in usual clinical practice. DESIGN: All admissions within 30 days of an outpatient lower GI endoscopy at any of the 6 adult-care Winnipeg hospitals were identified. This includes endoscopy for both complex and routine patients. A chart audit of all cases with potential complications was performed. RESULTS: A total of 24,509 outpatient lower GI endoscopies for adults were performed at the 6 hospitals over the 2 study years (April 1, 2004, to March 31, 2006). There were 303 admissions with potential complications. The colonoscopy completion rate was 65% (72% for gastroenterologists vs 59% for general surgeons, P < .005). Quality of bowel preparation and nature of polyps were often not documented. The overall rate of complications was 2.9/1000 procedures; the perforation rate after polypectomy was 1.8/1000; and the postpolypectomy bleeding rate was 6.4/1000. Most (67%) complications were recognized after discharge for the index procedure. The complication rate was highest for the endoscopists performing fewer than 200 procedures per year (5.4/1000 vs 2.7/1000 for the rest, P = .02, relative risk 2 [95% CI, 1.1-3.7]). LIMITATIONS: Chart audit was limited to cases requiring admission within 30 days of the index procedure. CONCLUSIONS: The overall complication rate after lower GI endoscopy in usual clinical practice in Winnipeg is comparable to that previously reported. A higher complication rate after endoscopy by low-volume endoscopists needs to be further evaluated. The reporting of endoscopy must be standardized to enhance outcomes interpretation.

Low incidence of adverse events in outpatient pediatric renal allograft biopsies.

In 1999, our center implemented a policy of outpatient protocol biopsies as standard practice for the clinical management of pediatric renal allograft recipients. In order to determine the safety of this procedure, we conducted a retrospective chart audit of all outpatient renal allograft biopsies performed at our center. Biopsies were performed under conscious (midazolam) or procedural (propofol/fentanyl) sedation. Localization of the lower pole of the renal allograft was achieved with renal ultrasound. Using a Biopty gun with a 16-gauge needle, two cores were obtained. Patients were discharged four h post-biopsy. Patient demographics, hospital length of stay (LOS), specimen adequacy (per Banff criteria) and major and minor adverse events were recorded in a central database. Data were expressed as mean +/- SD. From June 1999 to July 2004, we performed 162 biopsies in 43 pediatric renal allograft recipients. Most patients underwent extraperitoneal transplantation (42/43, 97.7%) and were greater than five yr of age at biopsy (129/131 biopsies, 98.5%). The majority of these procedures (131/162, 80.9%) were conducted in the outpatient department, with 113 of 131 (86.3%) being obtained for protocol (n = 89) and one-month follow-up acute rejection therapy (n = 24) indications. Patients underwent 3.7 +/- 2.7 biopsies (range = 1-11). Specimen adequacy was achieved in 119 of 124 (96.0%) of documented cases. The overall incidence of adverse events was 12 of 131 (9.2%) biopsies, all of which were minor in severity. Macroscopic hematuria was the most common minor adverse event, occurring after 11 of 131 (8.4%) biopsies. While macroscopic hematuria prolonged LOS (adverse events vs. no adverse events: 23.0 +/- 26.0 vs. 8.6 +/- 4.1 h, p = 0), none of these episodes required major surgical or radiographic interventions. We conclude that in patients greater than five yr of age with extraperitoneal renal allografts, outpatient protocol biopsies using a 16-gauge needle are sufficiently safe to justify their inclusion in the routine clinical management of pediatric renal allograft recipients and in pediatric clinical trials.