A3 - Symptom Management
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Improving bowel management in a specialist palliative care service: A clinical project Emilie Clark
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A3 - Symptom Management
- 1. Click to edit Master title style • Click to edit Master text styles Improving bowel management in a specialist palliative care service A clinical project Emilie Clark - Donny Trust Specialist Nurse Trainee 2014
- 2. Click to edit Master title style • Click to edit Master text styles Background • Perceived gap in clinical documentation • Transition period
- 3. Importance of effective bowel Click to edit Master title style • Click to edit Master text styles management Constipation is highly prevalent at the end-of- life. • Distressing and uncomfortable. Effective management may alleviate distress (MacLeod, Vella-Brincat & Macleod, 2012). • 70% of patients receiving palliative care experience constipation during admission to a specialist inpatient unit. (Clark, Smith & Currow, 2012)
- 4. Constipation Click to edit Master title style • Click to edit Master text styles “It was all I thought about, all the time. I never want to experience that again” Hospice Patient (2013)
- 5. Bowel Care Guidelines Click to edit Master title style • Click to edit Master text styles PRINCIPLE Maintenance of palliative care patient’s own individual bowel regime and prevention of discomfort and complications due to constipation will be achieved by full assessment, attendance to Bowel Care Plan and acknowledgement of the changing condition of the patient. Arohanui Hospice (2013)
- 6. Method Click to edit Master title style • Click to edit Master text styles 1. Was there a nursing bowel assessment completed on admission? 2. Does the patient have an individualised bowel care plan? 3. Are laxatives prescribed regularly for the patient if they are prescribed opiates? 4. Was the bowel status of the patient recorded on each shift? Including: –Frequency –Number of days since bowels last opened –Bristol Stool Chart –Quality –Quantity –Abnormalities present (if applicable) 5. If interventions were used, was effectiveness documented?
- 7. Audit 1 - Results Click to edit Master title style All Admission - Was there a bowel assessment on admission? • Click to edit Master text styles Individualised bowel care plan 7/10 had no plan 2/10 on paraplegic bowel regime 1 had a care plan from PNH – new colostomy Laxatives - are the prescribed regularly for those patient with opiates All If interventions were used, was effectiveness documented Yes - 4/10 had interventions Recording’s Minimal recordings of quality using Bristol Stool Chart Often descriptive wording used eg. Large, soft. Erratic documentation - no structure, sometimes recorded very well but others no recording at all. ? - used frequently.
- 8. Bowel Record Bowel Record Click to edit Master title style • Click to edit Master text styles Date Shift Initial Stool Scale Continent Amount Comments – ie. Description (colour, odour etc), BNO, specimen, melaena, infection control. (1-7) Y N S M L Patient Label Specific Patient Instructions: Diet /fluid specifications: Toileting requirements: Independent/Assistance/Dependent: Must be filled in EVERY shift, if bowels do not open please record under the COMMENTS. Royal Melbourne Hospital (2012)
- 9. Feedback Click to edit Master title style • Click to edit Master text styles • Do you use the bowel chart on a regular basis? • Do you find it simple and easy to use? • Do you feel the form adequately captures the patient’s bowel pattern whilst a patient in the IPU?
- 10. Click to edit Master title style • Click to edit Master text styles “The bowel chart is great and a vast improvement on how we were recording bowel routines before.” “It’s good to have the scale on the chart. At least then we are all reading from the same page.” “...it’s only as good as the recording and staff need to be responsible.”
- 11. Audit 2 - Results Click to edit Master title style • Click to edit Master text styles Admission - Was there a bowel assessment on admission? All Individualised bowel care plan 9/10 had no plan 1 had a care plan from the community palliative care team Laxatives - are the prescribed regularly for those patient with opiates Yes If interventions were used, was effectiveness documented None had interventions Recording’s Perfect documentation on patient with a care plan "Unknown" used frequently in regards to quality of stool. Not recorded on all shifts majority of the time - exception is the patient with care plan and a patient admitted with a bowel obstruction.
- 12. Click to edit Master title style • Click to edit Master text styles Findings 1. Change 2. Care plans 3. Autonomy and self-recording
- 13. Click to edit Master title style • Click to edit Master text styles Implications for practice • Further development • Care plans
- 14. Objective or Subjective? Click to edit Master title style • Click to edit Master text styles “Different things to different people.” (Andrews & Morgan, 2013) “Despite the attention of staff on quantifying the frequency or character of the stools, ultimately constipation is a highly subjective sensation” (Clark & Currow, 2014).
- 15. Click to edit Master title style • Click to edit Master text styles Implications for practice • Education • Further research
- 16. Click to edit Master title style • Click to edit Master text styles Any questions? THANK YOU
- 17. Click to edit Master title style • Click to edit Master text styles References Arohanui Hospice. (2013). Guidelines service continuum clinical procedures gastro-intestinal bowel care guidelines. Palmerston North: Arohanui Hospice. Andrews, A., & Morgan, G. (2013). Constipation in palliative care: Treatment options and considerations for individual patient management. International Journal of Palliative Nursing, 19(6), 266-273. Retrieved from ScienceDirect database. Clark, K., Smith, J.M., & Currow, D.C. (2012). The prevelance of bowel problems reported in a palliative care population. Journal of Pain and Symptom Management, 43(6), 993-1000. Retrieved from ScienceDirect database. DeRoo, M.L., Leemans, K., Claessan, S.J.J., Cohen, J., Pasman, R.W., Deliens, L., & Francke, A.L. (2013). Quality indicators for palliative care: Update of a systematic review. Journal of Pain and Symptom Management, In Press. Retrieved from ScienceDirect database. Dhingra, L., Shuk, E., Grossman, B., Strada, A., Wald, E., Portenoy, A., Knotkova, H. & Portenoy, R. (2012). A qualitative study to explore psychological distress and illness burden associated with opioid-induced constipation in cancer patients with advanced disease. Palliative Medicine, 27(5), 447-456. Retrieved from ProQuest database. Hospice New Zealand. (2012). Standards for palliative care: Quality review programme and guide 2012. Retrieved from http://www.hospice.org.nz/HNZ_Standards_Book_Online_-_May_2013(1).pdf. Kyle, G. (2011). End of life: A need for bowel care guidance. Retrieved from http://www.nursingtimes.net/nursing-practice/ specialisms/continence/end-of-life-a-need-for-bowel-care-guidance/5029189.article
- 18. Click to edit Master title style • Click to edit Master text styles References MacLeod, R., Vella-Brincat, J., & Macleod, A.D. (2012). The palliative care handbook: Guidelines for clinical management and symptom control. (6th ed.). Retrieved from http://www.hospice.org.nz/cms_show_download.php? id=377. Royal Melbourne Hospital. (2012). Bowel Chart.
Hinweis der Redaktion
- As you know from my introduction.... As part of my training, I was required to undertake a project. I chose to look at a way of improving bowel management in a specialist palliative care service.
- Arohanui Hospice is located in Palmerston North – has a 10 bed inpatient unit providing specialist palliative care to people from Palmerston North City, the greater Manawatu district, Horowhenua District, Tararua District and the towns of Bulls, Marton, Hunterville, Taihape and surrounding areas. Currently, Arohanui Hospice is undergoing a clinical review process and clinical notes were being transitioned from paper to electronic documentation. Therefore, this provided an opportunity for review of how well current inpatient’s bowel function was being assessed and allow a chance to identify gaps for improvement.
- [CLICK] Effective bowel management is a highly prevalent and potentially underestimated aspect of palliation across specialist and primary services, even though altered bowel function is common in those with terminal disease, particularly constipation. [CLICK] Constipation often being described as one of the most distressing and uncomfortable symptoms of those with advanced disease. It is the third most troublesome side effect after pain and anorexia, and the literature shows that as many as [CLICK] 70% of patients receiving palliative care experience constipation during admission to a specialist inpatient unit.
- [CLICK] For those at an already very distressing stage of life, constipation can be physically and psychologically scarring and those with life-threatening disease often cite constipation as a deeply embarrassing and distressing problem. This can result in a decrease in health-related QOL which in turn contradicts the very essence of what palliative care is all about.
- Looking at the Bowel Care Guidelines by Arohanui Hospice, I constructed an audit tool to identify if the principles of the guideline correlated with practice in the inpatient unit. The principle of the policy affirms the importance of maintaining the patient's own individual bowel regime, suggesting that bowel regime is an individualised and subjective and therefore should be treated as such.
- To undertake the audit, I chose to look at the current patient’s in the IPU. On this day there were 10 – looked at a period of 7 days maximum with some staying less than that and looked at these questions as guided by best practice guidelines and Arohanui Hospice’s bowel care guidelines. These were the questions asked.
- Whilst all had an assessment, they were minimal with very little detail. None stated the “normal” bowel routine for the patient and only 1 stated when bowels last open prior to admission. 2.[Read results from point 2] * The two patients who had individualised plans had been constructed from other health care settings and one began during the seven days audited due to being commenced on a paraplegic bowel regime. These patient’s had very good recording of frequency – nearly all shifts. [REASON] The policy states that for every patient there “must be an individualised plan”. Although it states this however, it does not elaborate further to provide any guidance. This possibly could influence the poor results from this audit, combined with the recent changing from paper to electronic nursing documentation. 3. [READ LAXATIVES AND INTERVENTION RESULTS] 4. Looking at recordings: The documentation was minimal majority of the time. Often use of ? Or nothing at all. [REASON] - Guidelines state to “reassess daily” but no clear guidelines suggested as to what should be assessed. Currently in the process of two notes systems. Paper format has little room to add descriptive writing.
- This is the record I developed. It identifies which areas should be assessed and has a copy of the BSC for reference when assessing stool quality. Design based on the Bowel Chart from The Royal Melbourne Hospital. For bowel regime to be recorded once a shift eg. AM, PM, N. Implemented into the IPU – education was given to staff during handover. This was trialled over a period of three months.
- After three months – feedback was gained from the IPU nurses who were using it on a daily basis. [These were the questions asked...] [CLICK] READ Q1 [CLICK] READ Q2 [CLICK] READ Q3
- Feedback – Majority of the feedback was positive. A couple of examples of “comments” [CLICK] [Read slide] [CLICK] [Read slide] There were two suggestions on improvement: A box for BNO to tick as opposed to writing it in the “comments” Needs a space to record ‘normal’ bowel pattern and any relevant issues such a patient who is CDiff positive. Another point was [CLICK] “Of course it needs to be filled in every duty... It’s only as good as the recording and staff need to be responsible” This was interesting as it pointed out an issue I soon discovered when I conducted another audit using the new tool.
- I undertook a repeat audit using the same method as the first time. The results showed: 1. All patients had some form of bowel assessment on admission, outlining usual habits and when bowels last moved. This was a vast improvement on the previous audit before the tool was introduced. [Look at question] Unfortunately, only 1 patient had an individualised care plan even though this is outlined as essential to providing optimum bowel management in the Arohanui Hospice Bowel Care Guidelines. This was created in the community by the AH community nurses. Unfortunately, at the time of this audit new care plans which had been implemented recently had been removed and a new care plan system was in the process of being created. This definitely impacted on these results. The patient with the care plan had impeccable recording. [Look at laxatives and interventions] Recordings: Perfect documentation for the patient with a care plan. As pointed out in the feedback – the chart can only be as good as those utilising it. With the exception of the patient with a care plan, majority of the time the patient’s bowel pattern was NOT recording on all shifts. There was still documentation such as "Unknown" used frequently in regards to quality of stool and “not sighted” when patient’s who were perhaps more independent had reported their bowels opening.
- [CLICK] Change – Change can be difficult to implement especially if processes have been in place for a long time. Although there seemed to be an acceptance of the new tool, their seemed a breakdown when actually utilising the tool and therefore more education or clearer instructions around the use of the tool may be necessary 2. [CLICK] Care Plans - I think the biggest point highlighted in this small project was just how important an “individualised” care plan actually is. The proof being in the impeccable recording of bowel routine in those patients who had a care plan already in place. 3. [CLICK] One thing I noted during this study was that those patient’s who are more “independent” did not have accurate bowel recording. A way to possibly combat this is to educate them on the Bristol Stool Chart and work with them at either keeping their own record of their bowel routine that can be discreetly given to staff at the end of the day, or provide on admission education that allows the patient to report to staff in a simple and straight to the point way eg. “have your bowels opened today? “yes type 4, large”. I think it would be beneficial to give these patient’s a copy of the chart, or place the charts in the bathrooms of the inpatient unit and educate patient’s on their use on admission.
- [CLICK] Further development – the tool can be developed further using the recommendations by the staff. Also ?the need for actual clarification eg. AM PM N so that it is obvious where to record for every shift. [CLICK] Care plans – this project has highlighted the absolute need for individualised care plans as recommended in the clinical guidelines along with some clearer guidelines as to what actually needs to be assessed. The patient experience needs to be assessed along with set guidelines, as the challenge of a definition based solely on subjective data is that many people have their own, possibly erroneous concept of what actually constitutes a normal bowel habit. At this stage – a one page care plan have been finalised and has recently been rolled out in the inpatient unit.
- Research suggests that constipation should be treated as an individualised experience and therefore, an individualised care plan is imperative. [CLICK] Andrews & Morgan state that personal bowel regime “means different things to different people” and propose that the patient’s own understanding and interpretation of aspects of their bowel regime is KEY to providing effective assessment. [CLICK] Clark & Currow agree, by stating in their research that “despite the attention of staff on quatifying the frequency or character of the stools, ultimately constipation is a highly subjective sensation”.
- [CLICK] Education – there is a need to provide more education for the staff around the use of the tool. There is also a chance to empower patients who are able to utilise the tool themselves and manage the tool themselves in collaboration with the team. [CLICK] Further research – Whilst researching the literature on this topic I found that there is still a lack of clarity over what constitutes a good bowel assessment and how to transpose this into our documentation. Clark & Currow suggest that although there have been promising and important initial steps towards understanding constipation as a patient defined symptom, there are still gaps within our knowledge and more research on bowel management at the end of life would be beneficial in providing optimal patient care. I think my project, albeit small, shows there is certainly a place for this locally.
- Any questions? Thank you very much for listening to my presentation and thank you to Arohanui Hospice for allowing me to undertake this small audit.