Optimising Guideline-Based Laxative Prescribing in Older Adult Inpatients: A Quality Improvement Project

Title:

Optimising Guideline-Based Laxative Prescribing in Older Adult Inpatients: A Quality Improvement Project

Introduction:

Constipation is common in older adult inpatients and is associated with delirium, urinary retention, abdominal discomfort, prolonged hospital stay and increased polypharmacy. Despite national guidance, laxatives are frequently prescribed without adequate assessment of reversible causes or documentation of the indication. We aimed to improve guideline-based, individualised laxative prescribing on two geriatric wards, targeting 85% appropriate management within 8–12 weeks.

Method:

We undertook a Quality Improvement Project using the Plan–Do–Study–Act (PDSA) methodology on two geriatric wards. Baseline data were collected from 42 inpatients prescribed laxatives. We assessed prescribing practice against evidence-based standards, including documentation of hydration, mobility, medication review, assessment for faecal impaction, appropriate laxative selection according to the underlying cause, and documentation of the treatment indication.

Following baseline assessment, we implemented a ward-based educational intervention consisting of an evidence-based poster displayed on both wards, a practical constipation management and laxative prescribing guide, and a scheduled teaching session to orient staff to the project and reinforce assessment of reversible causes before prescribing laxatives. We then conducted a post-intervention re-audit of 30 inpatients prescribed laxatives to assess changes in guideline-concordant constipation management and prescribing practice.

Results:

The baseline audit showed that only 41.5% of patients received overall guideline-concordant constipation management. Hydration assessment was documented in 95.1% of patients, while mobility assessment was documented in 43.9%. Medication review was documented in only 2.4% of cases. Furthermore, 58.5% of patients prescribed two or more laxatives had no documented review of ongoing need, highlighting substantial opportunities to improve prescribing practice and reduce unnecessary polypharmacy.

Following the ward-based intervention, overall guideline-concordant constipation management improved from 41.5% at baseline to 60% at re-audit, representing an 18.5 percentage-point improvement. Improvements were seen in hydration, mobility, diet, stool-type assessment and documentation of a clear indication for treatment. However, important gaps remained, particularly in medication review (0%) and assessment for impaction, red flags and DRE (0%)

Conclusions:

A multifaceted ward-based educational intervention was associated with improved overall guideline-concordant constipation management, from 41.5% at baseline to 60% at re-audit.
The re-audit demonstrated improvement in several aspects of constipation assessment and documentation. However, important gaps remained, particularly in medication review and assessment for constipation-related complications.
Further targeted interventions and additional PDSA cycles are required to achieve the target of 85% appropriate management and sustain improvement.