Improving ER Performance for Suspected Constipation

While the ultimate goal would be for most constipation to be prevented or managed by primary care physicians, the reality is that a lot of children are seen in the ER setting.  Particularly in the hospital setting, many practitioner’s have relied on abdominal xrays (AXRs) and this practice has been criticized previously (What’s Wrong with Ordering an AXR for Constipation in the …).

It is gratifying that efforts are underway to reverse this tendency.  A recent study (J Kurowski et al. J Pediatr 2015; 167: 706-10) document the effect that a 10 minute training session can have.

In this retrospective chart review, the researchers examined a 2 month baseline period and then a 2 month period after institution of a 10-min educational module for ER healthcare providers.  The module included the following:

  1. Rome III criteria for constipation  -at least 2 criteria weekly for >2 months:
    • ≤2 defecations in the toilet per week
    • at least 1 episode of fecal incontinence per week
    • history of retentive posturing or excessive volitional stool retention
    • history of painful or hard bowel movements
    • presence of a large fecal mass in the rectum
    • history of large stools which may obstruct toilet
  2. Review of the lack of utility of abdominal radiographs
  3. Use of rectal exam

Patients were identified who were discharged from the ER (without hospital admission)  with a diagnosis of constipation and with a chief complaint of abdominal pain.  In the baseline period, there were 105 patients and in the followup period, there were 91 patients.

Key findings:

  • Digital exams increased: 22.9% —>47.3%
  • AXR decreased: 69.5% –>26.4%

This study has numerous limitations; these include retrospective study and patient selection. Nevertheless, it makes several useful points.  If constipation is suspected, better care at a lower cost can be achieved by including a digital exam.  The authors note that “there is no strong evidence to support the utility of radiographs for this diagnosis [constipation] or even reliable standards to evaluate the normal stool burden across different ages.”

My take: The lessons from this study are applicable to primary care physicians and gastroenterologists as well as to ER physicians.  While this educational module is a good start, if I were designing a module, I would include information on irritable bowel syndrome which is often confused with isolated constipation.

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