Impact of a Nurse-Driven Bowel Protocol on Rates of Constipation in Critically Ill Patients

Introduction: Critically ill patients are at an increased risk of constipation due to inadequate nutrition, prolonged immobility, and opioid medication use. Constipation is associated with increases in ICU and hospital length of stay (LOS), and intra-abdominal infections. Effective use of laxatives can reduce constipation and improve outcomes. We hypothesized that the implementation of a nurse-driven bowel protocol would reduce rates of constipation in ICU patients.


Methods: This is a retrospective before-after cohort study of ICU patients between July 2019-February 2020 and July 2023-February 2024 at an academic medical center. Patients were included if they were ≥18 years old, admitted to the medical ICU, and intubated for >72 hours. Patients who received the nurse-driven bowel protocol were compared to those who did not. The primary outcome was constipation for >72 hours at any point during ICU admission. Key secondary outcomes included constipation for >6 days during ICU admission, LOS, and diarrhea.


Results: A total of 116 patients were included, and patient characteristics were well balanced between the groups with the exception of the bowel protocol group having a higher SAPS II score (52 vs. 48, p=0.05) and lower rates of acute hypoxic respiratory failure (60% vs. 79%, p=0.03) compared to the no bowel protocol group. The primary outcome of constipation for >72 hours during ICU stay did not differ significantly between groups (79% vs. 78%, p = 0.82) and remained nonsignificant after adjusting for covariates including morphine milliequivalents (MMEs), SAPS II score, and age (OR 0.93, p = 0.88, 95% CI [0.37-2.32]). However, patients in the bowel protocol group had lower rates of prolonged constipation, defined as constipation for >6 days (18% vs. 44%, p=0.043) which remained significant after adjusting for covariates (OR 0.30, p = 0.047, 95% CI [0.09-0.98]). No difference in safety outcomes including diarrhea, vomiting, and rate of Clostridioides difficile infections were observed.


Conclusions: Patients receiving the nurse-driven bowel protocol experienced no difference in rates of constipation; however, they were less likely to have prolonged constipation (>6 days) during their ICU stay. Prospective studies evaluating the optimal strategy for an ICU nurse-driven bowel protocol are warranted.