Neurogenic bowel dysfunction can have significant life limiting affects and is often poorly understood by the wider Health care professional population. The fear of faecal incontinence can be a huge influential factor in quality of life. If bowel management is unpredictable, patients can often spend hours on the toilet making sure their bowels are empty.
As a spinal centre, we have historically only offered Peristeen Transanal Irrigation to our outpatient population when adjustments to diet/fluids/laxatives alongside conservative methods (digital removal of faeces –DRF and Manual evacuation –ME) have not been successful in resuming a reliable, bowel routine. Our experience of using the system in the outpatient population has been varied. Setting patient expectation, support in the early stages and perseverance are key to achieving a positive outcome for the patient.
Aims and objectives
To audit against NICE MTG36 specifically to collect data regarding improvement in;
• Reducing the severity of chronic constipation- measured with the Cleveland constipation score.
• Reducing the severity and frequency of faecal incontinence –measured with the adapted St. Mark’s Hospital Incontinence score.
• Improves quality of life for people with bowel dysfunction- measured with the adapted NBD score.
• Reduces the cost of treating neurogenic bowel dysfunction in people who have already had unsuccessful care.
Objectives of data collection:
• Identify measurable improvements against the above criteria in the patient experience of bowel management using Peristeen vs conservative management (DRF/ME).
• Identify measurable cost and nursing time saving for the Trust with the use of this equipment.
• To implement a formalised Peristeen Transanal Irrigation pathway for inpatients to allow more timely assessment and greater access to this equipment (following successful assessment).
• Avoid or minimise any delays in the discharge process due to bowel management.
Reasons for implementing your project
As a centre we strive to offer as much choice as possible to the patient during their inpatient stay, this should also include options for bowel management. We have had a small number of inpatients using the system, however; there is no formalised patient pathway so access is not universal.
Following the publication of NICE Guidance for Peristeen Transanal Irrigation for managing bowel dysfunction (MTG36) we were inspired to make this equipment more available, using a formalized pathway, earlier in the inpatient rehabilitation process. We identified that a key point to assess for and potentially introduce Peristeen would be in phase two of the rehabilitation process, when the patient is mobilized for 4 hours.
How did you implement the project
As is standard within our Trust, we ensured all documentation has been viewed and agreed for use by the patient and public involvement board and the clinical audit team. There were some discussions at the beginning of the project as to whether this was a research project or an audit, the general consensus being it should be an audit as it involves patients with the same problem being given different treatments, but only after full discussion of the known advantages and disadvantages of each treatment. The patients are allowed to choose freely, with informed choice which bowel management approach they feel is best for them. https://www.rqia.org.uk/RQIA/files/fe/fe8b6683-a3ea-428b-9e19-b1d1e05bcac1.pdf
We have been working in conjunction with Coloplast to develop a Peristeen patient passport which contains assessment documents, adapted NBD scoring and QoL scoring to capture relevant data at key points during the irrigation journey. As we are also keen to receive feedback from the nursing staff using the system with the patients we have also developed a nurse feedback form which captures data regarding time spent and ease of use. We have also been supported by the Peristeen Nurse Advisor who covers our area. She has attended to deliver staff training sessions and to support patients who are using the system. Coloplast have also developed a comprehensive flow chart for the inpatient staff to use, to guide their selection and assessments of the inpatients using the system. I undertook a number of CPD sessions with the MDT inpatient team. Initially, this was to introduce the NICE MTG36 when it was published in February 2018.
We would like to share our initial findings and challenges as the audit is still in progress.
Patient enrolment at the correct time in the rehabilitation process has been a challenge – establishing a routine where patients are systematically assessed at +4hours has been slow to embed.
An example of this is a young paraplegic who was nearing his discharge date and was identified as being suitable to commence use of Peristeen to manage his bowels. Following an MDT discussion during ward round, the team decided against the patient starting use of the system as he was so near to his discharge date, which was later revoked due to lack of suitable discharge destination. We re-visited commencement of the system with this patient and he has now been enrolled into the audit, the system is working well for him so far.
The second biggest challenge is staff perception of use of the system. We were initially met with some resistance from ward staff who were concerned that bowel care may take longer and were unfamiliar with using Peristeen. The Peristeen Nurse Advisor who covers our Spinal centre has provided a lot of support to the staff via regular training sessions and drop in sessions for patients to learn more about the system. We have also identified two senior nursing assistants as Peristeen ambassadors within the ward environment with the aim of early identification of suitable patients plus support to staff and patients in the use of transanal irrigation.
Staff feedback from the nurse assessment forms, completed at every irrigation; show an increase in confidence and ease of use of the system over a number of weeks, as well as a reduction in actual nursing time to complete bowel management.
Key learning points
- Patient should be offered every available option to manage their bowel care during their first admission.
- Early identification of patients is key in relation to this audit to avoid any delay in discharge.
- Re-referral via clear pathways allows the patient to follow a easily accessible bespoke pathway for their bowel management.
- Training, support and staff involvement is essential when introducing a new piece of equipment/ way of working.
- Change is challenging to embed within an established and experienced team.