Water-soluble contrast in the management of adhesive small-bowel obstruction: a Canadian centre’s experience with guideline development and implementation

BACKGROUND: Orally administered water-soluble contrast (WSC) can track resolution of small-bowel obstruction (SBO), but no universal pathway for its use exists. We developed and implemented an evidence-based guideline for the use of WSC in the management of adhesive SBO, to be implemented across hospitals affiliated with the University of Toronto. METHODS: We performed a systematic review and created a clinical practice guideline for WSC use in the management of adhesive SBO. The guideline was approved through consensus by an expert panel and implemented in 2018. We performed a prospective cohort study of guideline implementation at 1 pilot site (a large academic tertiary care centre), facilitated by the centre’s acute care general surgery service. Primary outcomes included compliance with the guideline and hospital length of stay (LOS). Secondary outcomes included rates of failure of nonoperative management, morbidity, mortality and readmission for recurrence of SBO within 1 year. Patients with adhesive SBO admitted in 2016 served as a control cohort. RESULTS: We analyzed the data for 152 patients with adhesive SBO admitted to the centre, 65 in 2016 (historical cohort), 56 in January–June 2018 (transitional cohort) and 31 in July–December 2018 (implementation cohort). There was a significant increase in compliance with the WSC protocol in 2018, with the proportion of patients receiving WSC increasing from 45% (n = 25) in the transitional cohort to 71% (n = 22) in the implementation cohort (p < 0.001). The median LOS did not differ across the cohorts (p = 0.06). There was a significantly lower readmission rate in the transitional and implementation cohorts (13 [23%] and 9 [29%], respectively) than in the historical cohort (29 [45%]) (p = 0.04). Among patients assigned to nonoperative management initially, a significantly higher proportion of those who received WSC than those who did not receive WSC went on to undergo surgery (14.6% v. 3.6%, p = 0.01), with no difference in median time to surgery (p = 0.2). CONCLUSION: An evidence-based guideline for WSC use in SBO management was successfully developed and implemented; no difference in LOS or time to surgery was seen after implementation, but rates of immediate operation increased and readmission rates decreased. Our experience shows that implementation of an evidence-based clinical practice guideline is feasible through multidisciplinary efforts and coordination.