Adopting Transanal irrigation as a treatment option for people with bowel problems at St Helens and Knowsley Teaching Hospitals NHS Trust

The hospital based Pelvic Floor Service team aims to provide high quality, patient-centred care for people with a variety of bowel and bladder problems, including bowel dysfunction. The team aims were to:

• Develop a structured care pathway, incorporating the use of transanal irrigation systems, including Peristeen
• Provide specialist training and support for users and carers as detailed in recommendations 1.2 of the NICE Peristeen guidance.
• work closely with the community continence team to enhance the quality of care offered to patients with bowel problems, including bowel dysfunction
• Offer additional treatment options and choice in the form of transanal irrigation systems for patients in order to improve quality of life and promote digity and independence as highlighted in the NICE recommendations for Peristeen.
• Select the most appropriate system based upon the patient’s need, clinical indications and preferences

In the past 18 months, St Helens and Knowsley NHS Trust have developed and established a specialist pelvic floor service and team to enhance the quality of care provided for patients with a variety of bowel and bladder problems, including bowel dysfunction. Within this service transanal irrigation, including Peristeen, is offered.

People often endure many years of suffering having tried numerous medicinal and dietary interventions as recommended in the NICE guideline.  Many patients are reluctant to have surgery and want to delay or prevent this as their final option. The team identified that offering transanal irrigation provided an additional option to help patients manage their condition.

As Peristeen is usually self-administered, the team anticipated that by increasing the patient’s control of their bowel function, there could be improvements in their quality of life. For the NHS, the team anticipated a reduction in costs through reduced use of medication to control bowel function and delay or prevention of the need for surgery for stomas, ileostomies and antegrade colonic enema (A.C.E) procedures (and the inpatient and after care costs that these entail). They also believed that use of Peristeen and other transanal irrigation systems could reduce acute admission to hospital caused by constipation which they estimated to cost £150 per night. The team were therefore keen for transanal irrigation to become an established management option as part of their structured care pathway.

The pelvic floor multidisciplinary team (MDT) consists of; Urology consultant, 2 colorectal surgeons with special interest in pelvic floor, Gynaecologist, Urogynaecologist (from a neighbouring trust), Care of the elderly consultant, Rehab/head injury consultant, Urology continence nurse specialist, Colorectal pelvic floor nurse specialist and physiotherapist with a specialised  interest in pelvic floor issues. The MDT meet regularly to discuss patients and agree on treatment options.

Patients are referred to the service from their GP, other trusts, district continence teams, district nursing teams, the trusts hospital continence team and consultants and ward nurses within the trust. Following referral, the patient is fully assessed and response to interventions such as dietary advice, medication and physiotherapy are reviewed before considering transanal irrigation. In the last 2 years they have offered transanal irrigation, including Peristeen, to between 450 and 500 patients.

Patients referred to the pelvic floor service follow a structured care pathway which incorporates examination, assessments and treatment options including dietary and lifestyle advice as well as medications, transanal irrigation and surgery. The patient’s journey is documented in the Whiston Passport (attached) which facilitates a consistent approach and ensures other members of the MDT are aware of the patient’s journey and specific needs. The healthcare professionals offering care along the pathway from patient selection to education and support for patients, have extensive training and experience in this clinical area.

The team treat all patients individually and therefore adopted a number of transanal irrigation systems at the same time. The team researched the available devices through conference attendance and meeting with manufacturers.

Someone is only offer TAI after discussion of the case at MDT and agreement by the consultant. The device which is considered most suitable would be agreed in collaboration with the patient and will take into account test results, nature of the condition, patient preferences and costs of the device and consumables. Commonly Peristeen is considered for patients with chronic constipation.

The initial appointment with the nurse specialist for training in use of the system lasts for one hour. People are followed up at 6 and 12 weeks during 15-30 minute reviews. At these reviews the nurse specialist evaluates correct use of the device, its effectiveness and the impact it is having on quality of life. If the patient is stable and happy with their treatment they will be discharged back to the GP. The nurse specialist remains available to provide advice and support via phone. If there are any problems or uncertainties the nurse specialist continues to follow up every 3 months until it is appropriate to refer back to the GP. The pelvic floor nurse specialist runs 3-4 clinics per week.

In order to ensure appropriate use and patient support for TAI and secure agreement for funding, the team members, have organised open days for GPs and teaching and training sessions with district nursing and continence teams. In these sessions the potential for cost savings and patient benefits are highlighted. By educating patients about the device, the patients acted as champions for the technologies with their other healthcare professionals including their GP and this has also raised awareness of the technology.

Following the adoption of transanal irrigation, including Peristeen, as part of the structured care pathway for people with bowel problems the team have identified the following:

• Transanal irrigation can be very effective in helping people diagnosed with chronic constipation to lead a normal life. Being able to control their bowel function often increases confidence with daily living.
• Patients using the systems report a better quality of life, feeling confident and clean.
• Some patients have been able to return to work because they can manage their bowel problem in a predictable way (medications can be unpredictable).
• Many patients have stopped using other strategies for managing their bowel function including medications for bowel function, medications for depression and anxiety, continence pads and creams to help with sore ulcerates and excoriated perineal areas.
• Reduced emergency admissions resulting from constipation.

The team have lots of examples from patients where TAI including Peristeen have improved their quality of life. One patient with bowel dysfunction did not want to get married for fear of an accident whilst in her wedding dress. She begun regularly using TAI. The improvement in her bowel management meant that she got married in a white wedding dress and did not have to worry. Another patient with bowel dysfunction wanted to visit her son in Australia but would not travel because of being on the plane for so long with the small communal toilets. She started using TAI regularly. This gave her the control she needed to take the long haul flight and she went to visit her son in Australia.

• The healthcare professionals responsible for selecting patients for TAI and offering them ongoing support should be trained and competent to do this
• People should have a thorough assessment to rule out other problems and ensure the most suitable device is selected.
• Securing funding for the devices is a challenge in practice. Seeking ways to overcome this will support adoption.

Some GPs prescribe the device and monthly consumables once it has been initiated by the pelvic floor team however, other GPs are reluctant to do this. The devices are not commissioned by the clinical commissioning group therefore patients whose GPs do not prescribe the devices risk having the treatment stopped.

The team are currently liaising with their local CCG to seek a solution which would secure funding for the patients who require TAI.

• Supporting patients through training and an open access approach to contacting the nurse specialist. Training using diagrams and drawings has worked well for patients.
• Communicating the messages with other health professionals that for patients with the condition it can significantly impact on their quality of life. The technology is easy to use, has no side effects and can improve quality of life
• Encouraging patients who are using TAI and finding improved quality of life to tell their GP in order to support the request for funding.
• Highlighting to finance teams, GP’s and other healthcare professionals that the technology saves money
• Working with a team of enthusiastic people with the same aims and objectives for offering a high quality service
• Networking and learning from the experiences of other areas who have adopted the technology