P0503 - Decreasing Enema Administration for Constipation in a Large Pediatric Emergency Department

Background: Constipation is a frequent diagnosis in pediatric emergency department (PED) patients. Enema administration for acute treatment of constipation in the PED is common despite the lack of standardization. The use of enemas in the PED is associated with increased patient distress. Outpatient treatment with polyethylene glycol is effective and aligns outpatient and PED constipation treatment and management.

Objective: To reduce the total number of PED administered enemas weekly by 20% from 23 to 18 within 12 months.

Methods: To coordinate management of constipation between primary care, gastroenterology and the PED, a multidisciplinary team reviewed baseline data and determined key drivers in order to identify areas of improvement and intervention. Interventions were initiated March 2019 and consisted of in-service education with providers and nursing and individual provider feedback on enemas ordered per hours worked. A discharge electronic health record (EHR) SmartSet including weight-based outpatient treatment and constipation discharge instructions was implemented. Primary measure was total enemas administered weekly in the PED. Additional measures included ED length of stay (LOS) and individual provider enema ordering rates. Balancing measure was ED return visits with the diagnosis of constipation/abdominal diagnoses within 14 days. Pre post intervention measures were assessed using statistical process control, chi square tests and Wilcoxon rank sum tests, as data indicated.

Results: Enemas administered per week shifted from 23 to 13 over the course of the initiative, a 43% reduction (Figure 1). The average rate of enemas ordered per hours worked for core pediatric emergency medicine providers decreased from 0.026 in the pre-intervention phase to 0.016 in the last three months of the initiative (Figure 2).
There was no difference in return visit frequency for constipation/abdominal diagnoses in the pre intervention period (5.2% when compared to the post intervention period (4.9%) (p = 0.8). There was no difference in PED LOS when comparing the pre and post intervention periods, however PED LOS was significantly shorter for patients not receiving enemas in the ED (median LOS = 139 (96, 209) minutes) when compared with patients receiving enemas in the ED (median LOS = 186 (137, 250) minutes) (p < 0.0001).

Conclusion: Using quality improvement methodology, we reduced the number of enemas administered weekly in the PED by 43%. Enema reduction did not result in increased return visits for constipation/abdominal diagnoses. Our goal has been sustained over time.