Quality statement 2: Baseline assessment

Quality statement

Adults reporting bowel control problems are offered a full baseline assessment, which is carried out by healthcare professionals who do not assume that symptoms are caused by any existing conditions or disabilities.

Rationale

Faecal incontinence may have different underlying causes and contributing factors. There is a risk that healthcare professionals could make assumptions that faecal incontinence is related to a pre-existing condition or disability (such as a neurological condition or cognitive impairment) without carrying out a full assessment. Faecal incontinence may have different contributing factors in people with the same long-term condition. A baseline assessment that takes account of the individual person, rather than assuming incontinence is related to a pre-existing condition, is therefore essential. Correct identification of contributing factors will promote better access to care and ensure that appropriate management can be planned.

Quality measures

Structure

a) Evidence of local pathways for accessing full baseline assessments when adults report bowel control problems.

Data source: Local data collection. The National Audit of Continence Care (NACC) collects data on whether services have a protocol or pathway that is initiated when a patient reports that they have a bladder or bowel problem. The audit also collects data on whether services have a written protocol on providing basic assessments for people who have problems with urinary and/or faecal incontinence. The APPG Continence Care survey includes a question on what pathways are available for people with incontinence within the organisation.

b) Evidence of local initiatives to raise awareness of factors contributing to faecal incontinence so that healthcare professionals carrying out full baseline assessments do not assume that symptoms are caused by existing conditions or disabilities.

Data source: Local data collection.

Process

Proportion of adults reporting bowel control problems who receive a full baseline assessment.

Numerator – the number of people in the denominator receiving a full baseline assessment.

Denominator – the number of adults reporting bowel control problems.

Data source: Local data collection. Also contained in NICE audit support for Faecal incontinence (NICE clinical guideline 49), criterion 2. The National Audit of Continence Care (NACC) collects data on whether an assessment focusing on finding the cause(s) of faecal incontinence was performed, and specifically on cognitive assessments, rectal examination, medication review and impact on quality of life. The 2010 National Audit of Continence Care collected data on documented evidence of a bowel history.

Outcome

Feedback from adults with faecal incontinence (or their carers) that symptoms were properly assessed and not assumed to be caused by any pre-existing conditions or disabilities.

Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that local pathways are in place for accessing full baseline assessments when adults report bowel control problems. Providers should also raise awareness among healthcare professionals carrying out the assessments of the many forms and causes of faecal incontinence.

Health and social care practitioners to whom adults with bowel control problems report symptoms, but who are not competent to carry out a full baseline assessment themselves, refer the person for assessment according to local pathways.

Healthcare professionals who are competent to carry out a full baseline assessment themselves ensure that they offer adults reporting bowel control problems (or refer for) a full baseline assessment, which they carry out without assuming that symptoms are caused by any existing conditions or disabilities.

Commissioners ensure that they commission services with capacity and expertise to provide full baseline assessments for adults reporting bowel control problems.

What the quality statement means for patients, service users and carers

Adults who report bowel control problems are offered a full assessment, which includes a physical examination and questions about their medical history, medication, diet and how the bowel problems affect their day-to-day life. Healthcare professionals should not assume that the problems are caused by conditions or disabilities that people already have.

Source guidance

  • Faecal incontinence (NICE clinical guideline 49), recommendations 1.1.6, 1.2.1 and 1.2.2 (key priorities for implementation).

Definitions of terms used in this quality statement

Faecal incontinence

This is any involuntary loss of faeces that is a social or hygiene problem [NICE clinical guideline 49, scope].

Baseline assessments

These are ideally carried out when symptoms are reported and include medical history, physical examination (including anorectal examination) and medication review [adapted from NICE clinical guideline 49, recommendation 1.2.2]. Examples of specific questions to ask as part of a baseline assessment are available in table 1 of NICE clinical guideline 49. Coping strategies should also be provided at the time of assessment (see quality statement 3) [NICE clinical guideline 49 recommendation 1.3.11]

Medical history

This includes:

  • history of bowel habit (including warning signs for lower gastrointestinal cancer such as rectal bleeding and change in bowel habit, as defined in section 1.5 of Referral guidelines for suspected cancer [NICE clinical guideline 27])

  • previous medical history

  • medication review (see below)

  • diet and fluid history

  • consequences of faecal incontinence

  • impact of symptoms on quality of life.

Physical examination

This includes:

  • general examination (as indicated)

  • cognitive and behavioural assessment (if indicated)

  • assessment of person's ability to use the toilet

  • anorectal examination

    • visual inspection of anus

    • assessment of perineal descent

    • digital rectal examination for anal tone and ability to squeeze anal sphincter voluntarily

    • assessment of faecal loading.

Medication review

This considers whether the person with faecal incontinence is taking any drugs that may exacerbate faecal incontinence (see table 4 of NICE clinical guideline 49) and the effectiveness of any alterations already made.

Equality and diversity considerations

Faecal incontinence is associated with many protected characteristics that are covered by the Equality Act 2010, including age, disability, sex, and pregnancy and maternity. The consequences may also impact on others, including religion and belief. If people with faecal incontinence do not have assessments that take account of individual factors, and if healthcare professionals assume that faecal incontinence is caused by an underlying condition, effective management and treatment may not be provided. This may adversely affect people whose condition is associated with a protected characteristic. Undertaking detailed baseline assessments for each person with faecal incontinence is an important step in removing any unequal access to the most effective care. Extra steps may need to be taken to ensure physical access to clinics and allow extra time to meet the needs of all disabled people, including people with learning disabilities. It may sometimes be appropriate for carers to be involved in the assessment process (for example, helping people to answer questionnaires).