Adoption of the Peristeen transanal irrigation system through a nurse led bowel clinic

• Increase the choice of treatment options available for patients with bowel dysfunction
• Support patients in using transanal irrigation with specialist training by experienced clinicians for users and carers, as recommended in the NICE medical technologies guidance on Peristeen (MTG 36)
• Adopt the technology as part of a holistic structured multidisciplinary care pathway

There were a number of patients under the care of the colorectal surgeons and gastroenterology consultants with functional bowel problems in whom conservatory management had failed and lifestyle changes had not worked and surgery was not an option or appropriate at that time. These patients would commonly be taking a mixture of laxatives and strong analgesia such as opioids for pain relief if required. This group of patients required frequent appointments with a variety of healthcare professionals including GP’s. They reported feeling anxious and socially withdrawn. The costs to the NHS of this dependent group were associated with multiple medications and frequent out-patient attendances.

Pelvic Floor Specialist Nurses provide Nurse-Led Bowel clinics from an outpatients department at Manchester Royal Infirmary, Healthy Bowel clinics based at Wythenshawe Hospital and community continence clinics at various Health Care Centres. Patients are referred to the service from Consultants in the North West Region. Based on the Pelvic Floor Specialist Nurse experiences of inpatient management of people with chronic constipation, she identified a technology that allowed bowel washout in an outpatient setting may help these patients. The specialist nurse sourced an approved bowel washout kit from Australia, and source this equipment for selected patients who met a specific agreed protocol. Evaluation of this service through audit demonstrated that the intervention was effective at improving patient’s quality of life and reducing costs to the NHS through:

• Transferring patients from the consultant caseload to the nurse led bowel clinics (if Peristeen trans-anal irrigation is successful the patient is discharged from the consultants caseload and put under the care of the nurse led bowel service)
• Reduces unscheduled patient presentations to health care professionals,
• Reduces bowel medications and opioids.
• Reduces the number of hospitalisations
• Reduces the need for surgery e.g. defunctioning stoma

These savings offset the procurement costs involved. When Peristeen Trans-anal Irrigation (TAI) system became available via NHS prescription, the service then used Peristeen as their preferred rectal irrigation system. Notwithstanding the benefits of reducing procurement costs, the team were keen to use Peristeen because it is a UK prescribed medical device with published evidence with a RCT to support its use. Patients said the Peristeen system was easier to use, it has a small air filled balloon to hold the catheter in place, a pump to insert the water and had a much softer flexible catheter.   

Assessment for Suitability of Peristeen is based on the patients having a long-term bowel disorder (>6 months) where previous treatment methods have failed or proved ineffective including toilet training, laxatives, dietary modifications, lifestyle changes and must include at least one or more of the following bowel symptoms:  

1. Incomplete bowel emptying
2. Slow-transit constipation
3. Neurogenic bowel dysfunction
4. Faecal incontinence  

If a patient is considered suitable they were then offered a trial of Peristeen.

The Specialist nurse writes to the patient’s GP (and if applicable Community Continence Prescription Nurse) to request that the monthly consumables for Peristeen are prescribed. A template GP letter (attached) is used. The team noted that a small number of GP practices have been apprehensive about the ongoing costs of prescribing Peristeen however on these occasions via correspondence, the Specialist nurse details the ongoing costs to the practice and Hospital of not using Peristeen such as increased out-patient and GP attendances, increased laxative use, and on occasions if a stoma is proposed as the only alternative, the monthly costs of stoma bags. The GP practices have reported that they find this overview helpful in their decision making.

On the rare occasion a GP will not prescribe Peristeen the lead nurse prescriber within the service will do this for 3 months. When TAI treatment is then demonstrated to be well-established to the patients GP they generally agree to continue prescribing this effective treatment option.

The success of the adoption of Peristeen has driven the case for adoption of Peristeen in continence services across the area. The Greater Manchester Medicines Management Group transanal irrigation pathway has been developed with involvement from the multidisciplinary team (including Specialist Nurses, Continence Advisors, Clinical Specialist Physiotherapists, Colorectal Surgeons, GI Physiologists) to ensure a regional consistent approach to the selection of patients and use of trans-anal irrigation is an option available in all clinics where trained Healthcare Professionals (HCP) offer this technology.

HCP offer TAI in Secondary and Primary care settings. A trained HCP is usually a qualified nurse, qualified physiotherapist or qualified GI physiologist who has attended bowel care education and training which includes Anatomy and Physiology, colorectal surgery, gastrointestinal disorders and attended study days relating to TAI. They must have experience and evidence of competence regarding teaching TAI.

In 2009 the team did an audit of all the patients who had been offered TAI since 2003. This included those using the bowel washout kit from 2003 – 2007.

• 85 patients were offered TAI
• 75 enrolled to using Peristeen after receiving information and watching a DVD about it
• 41/85 were still using TAI as their choice of bowel management at the point the audit was conductedThe team estimate they have offered Peristeen to over 1000 patients since they started using it in 2007. Around 8-14% of the patients referred to the Nurse-Led Bowel clinic with ongoing chronic bowel symptoms trial transanal irrigation.
• The team have observed the following benefits of Peristeen for their patients:
• Reasons for stopping using TAI included; surgery - formation of MIC-KEY antegrade irrigating button, ileostomy, colostomy, other interventions - sacral nerve stimulation, repeat biofeedback treatment, discomfort, poor dexterity, too busy lifestyle, leakage.

• Improved quality of life
• Reduced use of analgesia for the abdominal and pelvic pain associated with constipation.
• Reduction or complete discontinuation of laxatives.
• Reduction in reflux symptoms due to increased transit time and overall reduction in polypharmacy.The Specialist Nurse recently visited a teenage patient with learning disabilities who had suffered chronic constipation from the age of 3. He had been faecally incontinent most of his life and had never been able to go swimming. The nurse assessed him as suitable and following a successful trial of Peristeen he has since had his first swimming lessons and is now able to consider attending college. His parents have described the use of the technology as ‘life changing’ for the whole family, his general mood is so much happier. They have finally stopped buying mattresses several times each year and noted big cost savings themselves.
• Another patient with spina bifida was receiving enemas and digital removal of faeces 3 times per week from the district nurses. She had to wait in for their visits, and was unable to work or make any plans. Following a successful trial of Peristeen, which she is able to perform herself she is now looking for paid employment and reports ‘getting her life back’. This also frees up valuable District Nursing hours.
• One lady who started Peristeen was able to stop a total of 8 medications, she had been prescribed Lactulose, Senna, Docusate Sodium, Movicol, Gaviscon, Co-codamol, Colpermin and Buscopan over a period of 4 years all related to her chronic painful bowel symptoms.

• Thorough patient assessment and selection. The success of the intervention can in part be attributed good patient selection. Always obtain consent from a motivated patient (and carer/relative if relevant) before you start TAI and provide them detailed information before you consider TAI. They need to understand the anatomy of the bowel and the purpose of using regular water irrigation to improve their bowel symptoms.
• Complete a full bowel assessment form to help your treatment decision making to ensure suitability for TAI training. Obtain a full medical and surgical history, investigation results; be aware of red flag symptoms.

• Record previous treatments and results, previous surgery (especially colorectal), patient concordance, water volume requirements (normal or low) and patient dexterity.

• Performing the procedure in the out-patient clinic, the specialist nurse finds this helpful to resolve initial teething problems, although it is recognised that this isn’t possible in every clinic environment.

• Review patients (at 1 week, 4 weeks, 3-6 months [via telephone call], and then yearly), to discuss progress and results; provide advice, support, encouragement and reassurance. Consider whether other medications need to be reduced, increased, and prescribed.

• Provide patients with the details of relevant key contacts and ensure they feel supported and can contact at any time for support and advice.

• When requesting a patients GP prescribes Peristeen, ensure the rationale and benefits are stated (including; patient benefits - reducing prescription of laxatives, reducing analgesia for related abdominal pain as stated, system benefits - reducing the costs associated with frequent GP appointments, Consultant appointments, which can often prevent the need for surgery). State previous failed treatments/ surgery, current medications related to their bowel dysfunction.
• To support consistent adoption across a locality, develop a locally agreed pathway which involves members of the multidisciplinary team in its development and implementation.