Integrated Trust Policy for Bowel Care Management in Adult Patients

Transcription

1 Integrated Trust Policy for Bowel Care Management in Adult Patients 1

2 Policy : Integrated Policy for Bowel Management in Adults Executive Summary: This policy aims to enable bowel management and bowel care to be undertaken by healthcare professionals deemed competent in both the primary and secondary healthcare settings. It is envisaged that this will: Reflect evidence based best practice guidance Provide staff with a consistent framework and application to practice Improve patient experience and patient outcomes Provide healthcare professionals with evidenced based information to undertake bowel procedures and management. Supersedes: May 2014 Description of Limited Financial Impact Amendment(s): Financial Implications: Policy Area: Community Nursing Document ECT Reference: Version Number: 4 Effective Date: December 2016 Issued By: Fiona Carlin Review Date: December 2019 Author: (Full Job title ) Fiona Carlin Clinical Specialist Practitioner Bladder and Bowel Specialist Service Impact Assessment Date: February 2017 Consultation & Approval Committee: APPROVAL RECORD Committees / Group District Nursing Service Manager/Team Leader, Matrons, Bladder and Bowel Nurse Specialists, and Learning and Development. Date Dec 2016 Ratified by Director: Director of Nursing & Quality Feb

3 Contents Section Topic Page 1. Policy Statement 5 2. Background Responsibilities All Directors Trust Committees Infection Prevention and Control Team (IPCT) Bladder and Bowel Specialist Nurses Line managers All Staff Community Nursing Team Leaders to ensure all team members are aware of the guidelines and monitor adherence Scope of Policy 6 5. Introduction 6 6. Responsibility 6 7. Training Bowel Care Assessment Laxatives Bulking Agents (Bran products / Ispaghula Husk Stimulant laxatives (Bisacodyl / Danthron / Docusate Sodium/ Senna) Osmotic agents (Lactulose / Macrogol) Suppositories Indications for use of Suppositories Contraindications for use Administering suppositories Enemas Indications for use Administering enemas Other drugs used to treat and manage constipation Trans-anal Irrigation Anal Plugs Digital Rectal Examination of Rectum (DRE) and Digital Removal of Faeces (DRF) Digital Rectal Examination (DRE) Signs and symptoms to look for in the perineal and perianal area prior to undertaking a DRE or Digital Removal of Faeces (RCN 2012) Performing DRE Digital Removal of Faeces When should Digital Removal of Faeces be performed? Contra-indications to carrying out Digital Removal OF Faeces Performing Digital Removal of Faeces

4 Bowel Care for Patients with Spinal Cord Injury Bowel Management in Spinal Cord Injured Patients Autonomic Dysreflexia Manifestations of Autonomic Dysreflexia Interventions that may be used to manage a eflex or Upper Motor Neurone Bowel Interventions that may be used to manage a flaccid or Lower Motor Neurone Bowel Appendices 1. References Fiber Scoring Sheet Bowel Chart S.O.P Performing a Digital Rectal Examination (DRE) S.O.P Digital Removal of Faeces (DRF) Equality and Human Rights Impact Assessment Form 24 4

5 1. Purpose East Cheshire NHS Trust is committed to producing policies and procedural documents of a consistent standard that comply with the recommendations of external agencies by which we are monitored. This policy aims to offer a consistent and safe approach for patients requiring bowel management 2. Background This document provides evidence based guidance to support the delivery of high quality standards of clinical care to patients undergoing bowel management. It encompasses bowel assessment, and bowel care procedures in adults. 3. Organisational Responsibilities 3.1. Chief Executive Has ultimate responsibility for the implementation and monitoring of the policies in use in the Trust Executive Director The Director of Nursing, Performance & Quality is responsible for the review of the policy and the final ratification prior to the policy actually being implemented. This ratification process will take place following the consultation and approval process by the appropriate committee Deputy Director of Corporate Affairs and Governance Is responsible for the approval, ratification, implementation and monitoring of this policy and for the maintenance of an archive of superseded policies and procedures Trust Committees As a group are responsible for the consultation and approval process required during the development of policies for the Trust. The committees are responsible for the review of policies submitted to them to ensure that policies are appropriate, workable and follow the principles of best practice All Staff It is incumbent on all staff, when asked, to provide comments and feedback on the content and practicality of policies that are being developed and reviewed. It is the duty of all staff, when asked, to provide assistance during the development and review stages of policy formulation Staff Responsible for Developing/Writing/Implementing/Reviewing Trust Policies. Staff responsible for the development, writing, implementing and reviewing of Trust policies must ensure that the guidance written in this protocol is followed and that all policies are developed to be workable and follow the latest best practice guidance Community Nursing Team Leaders to ensure all team members are aware of the guidelines and monitor adherence. 5

6 4. Scope of the Policy The purpose of the policy is to: Provide a framework and guidance for bowel care management Provide a framework and guidance for the management of Diarrhoea and Constipation Provide healthcare professionals with the necessary knowledge, support and evidencebased guidance to enable them to manage bowel care safely and competently. Clarify the use of Digital Rectal Examination [DRE] and Manual Removal of Faeces. Clarify the procedure for DRE and Manual Removal of Faeces This policy cross references with the following East Cheshire Policies: Consent to Treatment Policy Infection Control Policy and Procedures Drug Administration/Supply Patient Group Directions Non-medical Prescribing Mental capacity assessment 5. Introduction Constipation and faecal incontinence affect people of all ages, and can impact on all aspects of the patients life. The All Party Parliamentary Group for Continence Care Report (2012) identified that constipation, although preventable and treatable, resulted in 20,710 elderly people (over 75), requiring emergency hospital admissions in The report also identified that 50% of care home residents in the UK have faecal incontinence (FI), and faecal overflow due to constipation, and that integrated continence services, with personnel trained to assess and deliver appropriate care, improves treatment outcomes, reduces the need for surgery and social care, and reduces the high cost of NHS continence products, through provision of timely intervention and conservative treatment. 6. Responsibility Staff are responsible for being able to access clinical policies that cover their areas of practice, prior to undertaking procedures they cover Familiarity with pertinent clinical policies should be incorporated into employee s appraisal sessions All current clinical policies will be published on the East Cheshire INFONET. 7. Training Healthcare professionals performing bowel care assessment and management (including Digital Rectal Examination and the Manual Removal of Faeces) are required to complete the Trust s Theory to Practice Bowel Management half day study course available via Learning and Development prospectus. This should be undertaken once every 3 years. The Trust s Bowel Management training programme is provided and delivered by the Bladder and Bowel Specialist Nurse Service. Responsibility for delegation of a procedure, monitoring and evaluation of standards remains with the registered healthcare practitioner. Any bowel procedures delegated to private 6

7 carers, Health Care Support Workers, and Agency staff will be client specific and clearly documented within the clinical notes 8. Bowel Care 8.1 Assessment The identification of the underlying cause of constipation or faecal incontinence is important in achieving successful treatment and management. Healthcare practitioners are expected to use and implement locally agreed assessment tools, i.e. fiber scoring sheet and bowel diaries should be included in the establishment of an individual assessment (see Appendix 2 & 3 for template) Many factors may affect normal bowel functioning, these may include: Change in diet Change in fluid intake Lack of exercise Use of drugs e.g. analgesics, iron preparations, use of over the counter products First line management and treatment options include: Dietary advice, increasing fibre intake (caution should be taken in the older person and frail patients) Advice on appropriate fluid intake Advice on lifestyle changes Regular toileting (maximising the gastro-colic reflex) Good seating position to defaecate (raise knees higher than hips, lean forward and put elbows on knees, bulge out abdomen and straighten spine) Laxatives Enema or suppositories Digital removal of faeces Rectal irrigation Specialist referral 8.2 Laxatives In general, there is much uncertainty over what constitutes effective management of constipation and laxatives may not be appropriate in all patients with constipation. It has been suggested that in mobile people (including the older person), a change in lifestyle involving changes in diet, increasing fluid intake and increasing physical activity may be sufficient. Healthcare practitioners are reminded that they will normally administer or prescribe (if they are nurse prescribers) those laxatives that are recommended in the local prescribing formulary. All medicines should be used only according to their licensed indications. For further information please refer to the latest edition of the British National Formulary (BNF). Although laxatives are not always necessary, they may be required in the short term to provide rapid initial relief of symptoms (MeReC Bulletin, 2011). This section refers to some of the laxatives available in three groups. Laxatives alter the normal functioning of the alimentary tract and can be grouped in to three types according to their action: Bulking agents Osmotic agents Stimulants 7

8 8.3 Bulking Agents (Bran products / Ispaghula Husk) Bulk laxatives are of particular value for people complaining of small, hard stools but should not be used unless fibre cannot be increased in the diet. A person should aim to eat at least one fibre-rich food at each meal. A fluid intake of litres a day if possible should also be taken (unless specified by the clinicians otherwise). These agents supplement dietary fibre intake to increase the weight and water absorbency of the stool. This increases faecal mass production and increases peristalsis. These agents need an increased fluid intake in order to work and should be taken with at least one glass of water. They take 2-3 days to exert their effect and so are not suitable for acute relief (MeReC Bulletin, 2011). Adequate fluid intake must be maintained to avoid intestinal obstruction. The use of them is contra-indicated in patients with faecal impaction, existing bowel obstruction and should be used with caution in debilitated patients. Bulking agents may cause transient bloating and flatulence. 8.4 Stimulant laxatives (Bisacodyl / Danthron / Docusate Sodium/ Senna) Stimulant laxatives increase intestinal motility with a laxative effect seen in 6-12 hours. They can cause abdominal cramping and should be avoided in cases of intestinal obstruction. An osmotic laxative may be used in combination with this group of laxatives. 8.5 Osmotic agents (Lactulose / Macrogol) These act by retaining fluid in the bowel by osmosis or by changing the pattern of water distribution in the faeces. They can cause bloating, flatulence and cramping and must be taken regularly for up to three days before an effect is seen. They are unsuitable for rapid relief of constipation (MeReC, 2011). Lactulose is a synthetic disaccharide which exerts an osmotic effect in the small bowel. Distension in the small bowel induces propulsion which in turn reduces transit time. Macrogol include Movicol and Laxido, which are preparations containing polyethylene glycol and various electrolytes. According to a Cochrane Review, macrogol has some advantage over Lactulose (Lee-Robichaud et al 2010). It has a license for the treatment of faecal impaction and chronic constipation. Bowel cleansing products such as Picolax, Citrafleet, Fleet Phospho-Soda, Klean Prep, Moviprep should not be used for the treatment of constipation (NPSA 2009). 8.6 Suppositories When oral laxatives have not produced a bowel movement, or when rapid relief from rectal loading is required or there is difficulty with emptying, a suppository may be appropriate. Lubricant suppositories e.g. glycerin, should be inserted directly into the faeces and allowed to dissolve to enable softening of the faecal mass. Stimulant suppositories e.g. bisacodyl, must come into contact with the mucus membrane of the rectum i to be effective. They should not a be inserted into a faecal mass. 8.7 Indications for use of Suppositories To relieve acute constipation or to empty the bowel when other treatments for constipation have failed To empty the bowel before surgery To introduce prescribed medication into the system As part of a bowel management programme with someone who has a neurogenic bowel 8.8 Contraindications for use Colonic Obstruction 8

9 Paralytic ileus 8.9 Administering suppositories Prior to the administration of suppositories healthcare practitioners should undertake appropriate assessment and adhere to the guidance below:- In cases of suspected rectal loading, the healthcare practitioner must perform a DRE (digital rectal examination) to determine the presence of faeces in the rectum. Medicated suppositories should be inserted with the blunt end first to aid absorbency Do not insert a medicated suppository into a faecal mass as its effect will be minimal (except for lubricant suppositories which can be inserted into the faecal mass, in order to dissolve and soften the faecal mass) Lubricant suppositories should be inserted pointed end first although they may also be inserted blunt end first if the suppository is not easily retained better retained if Glycerine suppositories can be moistened with water before insertion. All other types of suppository require the use of a lubricating agent e.g..ky Jelly Advance the suppository approximately 4cms into the rectum, using the index finger A suppository usually takes 20 minutes to dissolve 8.10 Enemas When laxatives or suppositories have not produced a bowel movement or when rapid relief from rectal loading is required, an enema may be appropriate. An enema is the introduction of fluid into the rectum or lower colon for the purpose of producing a bowel action or instilling medication. There are two types of enema: retention enemas and evacuant enemas. A retention enema is a solution introduced into the rectum or lower colon with the intention of being retained for a specified period of time. An evacuant enema is a solution introduced into the rectum or lower colon with the intention of its being expelled along with faecal matter. Phosphate enemas (large volume) and sodium citrate micro-enemas (small volume) come under this group Indications for use To administer prescribed medication into the system Severe constipation or impaction of faeces Neurogenic bowel Where large amounts of fluid into the colon may cause perforation or haemorrhage Following gastrointestinal or gynaecological surgery where suture lines could be ruptured (unless medical consent has been given) In patients with a known cardiac condition where intervention could cause possible collapse 8.12 Administering enemas Before an enema is administered healthcare practitioners should be aware of: In the case of suspected rectal loading, the HCP should perform a DRE prior to administering an enema to determine the presence of faeces in the rectum. HCP should have knowledge of the relevant anatomy before administering enemas into the rectum or lower bowel Position the patient lying in the left lateral position Enemas should be administered at room temperature Steroid enemas should be administered after defaecation, preferably at bed time 9

10 8.13 Other drugs used to treat and manage constipation Linaclotide is licensed for the use of irritable bowel syndrome associated with constipation. Lubiprostone is licenced for chronic idiopathic constipation in adults where there has little or no response to conservative measures. Prucalopride is a NICE approved medication, which is licensed for chronic constipation in women where laxatives have failed to provide adequate response 8.14 Trans-anal Irrigation If first-line methods of managing constipation and faecal incontinence have failed or do not adequately control the symptoms, rectal irrigation may be considered. It is important to note that introduction of this procedure is agreed and discussed with the patient s GP, consultant if applicable and that the healthcare practitioner is competent to undertake this procedure, fully aware of the potential implications and subsequent management 8.15 Anal Plugs Anal plugs may offer some comfort and dignity to people where faecal leakage is passive. Anal plugs should not be used in patients with the following conditions:- Disease of the bowel or rectum Spinal cord injury patients are at risk from autonomic dysreflexia Without documented patient consent If an anal plug disrupts the patients established routine and lifestyle 8.16 Digital Rectal Examination of Rectum (DRE) and Digital Removal of Faeces (DRF) The Healthcare Professional (HCP) may delegate DRE and DRF procedures to carers or patients as appropriate, ensuring their own competence has been assessed prior to assessing the competency of the patient/carer (RCN 2012). The Healthcare Professional is responsible for informing their immediate line manager/team leader if s/he does not feel competent in these procedures and for identifying any training needs. Heath Care Support Workers (HCSW) should have received approved training and been assessed as competent in carrying out DRE and DRF. If these conditions are met, the HCSW can be expected to carry out these procedures on patients who have been prescribed these bowel care interventions as part of their ongoing, pre-planned nursing care. It is not expected that HCSWs would carry out these procedures on patients that have not previously been assessed by a HCP Digital Rectal Examination (DRE) DRE can be used as part of a clinical assessment when carried out by a HCP who can demonstrate professional competence or as delegated by such a professional providing competence of carer or patient is assessed and reviewed, as required (RCN 2012). DRE should not be used as a first line investigation into the assessment and treatment of constipation (RCN 2012) DRE is an invasive procedure and should only be performed when necessary and after individual assessment. Cultural and religious beliefs must be respected Healthcare practitioners must identify and document patient allergy status prior to undertaking DRE or DRF DRE is used to establish (RCN 2012) The presence of faecal matter in the rectum, the amount and consistency of stool Anal tone and ability to initiate a voluntary contraction, and to what extent anal/rectal sensation 10

11 The need for digital removal of faeces and evaluating of rectal emptiness To establish and evaluate the effectiveness / of rectal/colonic washout/irrigation With the patient s consent, apply digital stimulation in order to trigger defeacation by stimulating the recto-anal reflex Contra-indications to performing DRE and Digital Removal of Faeces Absence of patient consent Specific, documented instructions from the patient s consultant/gp/bladder and bowel nurse specialist that the procedure should not be undertaken Recent rectal/anal surgery or trauma The patient gains sexual satisfaction from these procedures and the HCP performing them finds this embarrassing. Consultation with a doctor is advised, involving the patient in that consultation. Circumstances when additional assessment and care is required Particular caution should be exercised when performing DRE and Digital Removal of Faeces with patients who have the following diseases/conditions: Active inflammation of the bowel, including Crohn s disease, Ulcerative Colitis and Diverticulitis Recent radiotherapy to the pelvic area Rectal/anal pain Rectal surgery/ trauma to the anal/rectal area Tissue fragility due to age, radiation, loss of muscle tone in neurological diseases or malnourishment Fresh, rectal bleeding and evidence of anticoagulation medication If the patient has a known or suspected history of sexual abuse Spinal Injury patients due to autonomic dysreflexia Known allergies e.g. latex 8.18 Signs and symptoms to look for in the perineal and perianal area prior to undertaking a DRE or Digital Removal of Faeces (RCN 2012) Rectal prolapse Haemorrhoids Anal skin tags Wounds Discharge Anal lesions Skin conditions Gaping anus Bleeding Foreign bodies The presence of any of the above necessitates consultation with either the Consultant/GP or Bladder and Bowel Nurse Specialist Team for additional advice before undertaking DRE or DRF 8.19 Performing DRE See Appendix 4 for details of how to perform a DRE 8.20 Digital Removal of Faeces 11

12 Digital removal of faeces from the rectum should be avoided if possible and should only be performed if all other methods of relieving constipation have failed as part of a patient s routine bowel management When should Digital Removal of Faeces be performed? Faecal impaction/loading Incomplete defaecation Inability to defaecate 8.22 Contra-indications to carrying out Digital Removal OF Faeces Additional assessment and care should be under taken when: The patient is experiencing severe abdominal/rectal/anal/pain Acute inflammation of the bowel Recent radiotherapy to the pelvic area If patient has a known or suspected history of sexual abuse 8.23 Performing Digital Removal of Faeces See Appendix 5 for details of how to perform Digital Removal of Faeces 8.24 Bowel Care for Patients with Spinal Cord Injury After a spinal cord injury the connection between brain and bowel is lost and the effects on Bowel Function can be as follows: The brain does not transmit messages to the bowel which prevents the patient from being aware of the urge to defaecate or ability to control the anal sphincter The ability to coordinate what is under voluntary control and influence reflex activity in the bowel is lost The enteric nervous system in the bowel continues to produce peristalsis but because the brain cannot coordinate it this is less effective. As a result the stool takes longer to pass through the bowel. Slower transit time through the colon may result in greater absorption of water resulting in harder, more constipated stools. Constipation causes stretching of the colon, which makes peristalsis less effective. The presenting picture of bowel disorder following spinal cord injury depends on the level at which the damage has occurred and whether the damage is complete or incomplete. The remaining bowel function is described as either reflex or flaccid but maybe a mixture of the two in incomplete lesions Bowel Management in Spinal Cord Injured Patients A bowel management plan is developed and agreed between the appropriate healthcare professionals who take into account the area of damage to the spinal cord, optimising any preserved function of reflex systems. The bowel management plan proposed should be discussed, individualised and agreed with the patient and carers to facilitate compliance. It is designed to promote as much independence as possible (Spinal Cord Injury Centres 2012). Any changes to the bowel management plan or patient noncompliance must be discussed with the designated Spinal Injuries Centre to facilitate appropriate review and specialist advice The aim of a bowel management plan and importance of establishing a routine is: 12

13 To facilitate the patient to empty the rectum on a regular predictable basis taking into consideration individual timings and lifestyle To avoid constipation, faecal incontinence and soiling To avoid Autonomic Dysreflexia (Essat 2003) 8.26 Autonomic Dysreflexia This is a medical emergency that unresolved may give rise to serious consequence such as cerebral haemorrhage, seizure or cardiac arrest. The condition arises as a result of an autonomic sympathetic reflex that occurs as a result of perceived pain or discomfort below the level of the lesion. The reflex creates extensive vaso-constriction below the level of the lesion causing a pathological rise in blood pressure that can be life threatening if allowed to continue unchecked. This occurs mostly in lesions above T6. Individuals with injuries below T6 are not as susceptible It is essential that all healthcare practitioners/carers are deemed competent to provide 24 hour patient care as per bowel management plan to facilitate the delivery of safe patient care 8.27 Manifestations of Autonomic Dysreflexia Flushing Sweating and goose pimples Peripheral cyanosis Pounding headache Blurred vision and dizziness Shortness of breath Slow pulse Common Causes Over- full bladder Overloaded bowel Actions to Take Identify and remove cause by performing a manual evacuation of faeces. Sit upright as soon as possible Give GTN OR Nifedipine as prescribed 8.28 Interventions that may be used to manage an eflex or Upper Motor Neurone Bowel The aim is to produce a soft-formed stool that is easy to pass by stimulating the reflex activity that is preserved in the rectum to evacuate stool. It would usually consist of these types of interventions: Stimulate gastro-colic reflex by having a warm drink or something to eat minutes before starting the routine Abdominal massage or use of posture to raise intra-abdominal pressure Use of ano-rectal stimulation-either digital or chemical by a competent healthcare professional 13

14 8.29 Interventions that may be used to manage a flaccid or Lower Motor Neurone Bowel Spinal cord injury at or below L1 will give rise to lower motor neurone or flaccid bowel function. The aim is to produce a firmly formed stool that can be removed digitally. It would usually consist of these types of interventions: Stimulate gastro-colic reflex by having a warm drink or something to eat minutes before starting the routine Abdominal massage or use of posture to raise intra-abdominal pressure Use of gentle digital evacuation to remove stool from rectum by a competent healthcare professional 14

15 Appendix 1 References BNF (2016). British National Formulary. British Medical Association. London Essat Z (2003) Management of autonomic dysreflexia Nursing Standard Vol 17 No 3 Kyle G, Prynn P & Dunbar T (2008) The procedure for the digital removal of faeces guidelines (supported by Association for Continence Advice; Royal College of Nursing and Spinal Injuries Association). NHS, Thames Valley University & Norgine Pharmaceuticals Limited Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus Polyethylene Glycol for Chronic Constipation. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD DOI: / CD pub2. MeRec Bulletin (2011) The Management of Constipation. National Prescribing Centre, Vol 21 No 2 Mental Capacity Act 2005 Statutory Code of Practice/Policy/Practice Guidance/ Assessment and Recording Tool and Guidance NPSA (2009) Party Parliamentary Group for Continence Care Report. Cost Effective Commissioning For Continence Care (2010) accessed at on 15/12/11 Royal College of Nursing (2012). Management of lower bowel dysfunction, including DRE and DRF Publication code September 3 rd Edition Spinal Cord Injury Centres (2012) Guidelines for management of neurogenic bowel dysfunction in individuals with central neurogenic conditions. Initiated by Multidisciplinary Association of Spinal Cord Injured Professionals 15

16 Appendix 2 FIBRE SCORING SHEET we need to say in the policy that a fibre scoring sheet should be implemented make it more explicit under that section How to Rate your Diet for Fiber Content Please pick and circle the foods you eat on a regular basis to determine your overall score SCORE FOOD Write your score here BREAD White Brown Wholemeal/Granary BREAKFAST CEREAL 3 Times/week or more Rarely or never eat or eat sugar coated cereal e.g. Frosties Corn Flakes Rice Crispies Cheerios Special K Bran Flakes Weetabix Shredded Wheat Muesli Shreddies Porridge POTATOES PASTA RICE PULSES BEANS NUTS VEGETABLES ALL KIND OTHER THAN PULSES, POTATOES AND ANY TYPES OF BEANS FRUITS ALL KINDS Rarely or never eat Rarely or never eat Less than once a week Less than once a week Eat potatoes, white rice or pasta most days Once a week or less 1-3 times per week 1-3 times per week Eat potatoes in jackets, brown rice or pasta every day Three times/ week or more Daily Daily YOUR TOTAL SCORE SCORE GUIDE 0-12: There is a need to increase the fibre content in your diet 13-17: There is enough fibre content in your diet 18: There is plenty of fibre content in your diet 16

17 Appendix 3 BOWEL CHART Please complete for 14 consecutive days in a row Day 1 Did you have a bowel movement today? If not leave blank. If yes and complete the other boxes How many movements? Using the chart opposite, what type was it? Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 17

18 Appendix 4: S.O.P Performing a Digital Rectal Examination (DRE) Title of Standard Operation Procedure: Performing a Digital Rectal Examination (DRE) Reference Number: Version No: 1.0 Issue Date: December 2016 Review Date: December 2019 Purpose and Background The purpose of the Standard Operating Procedure is to enhance explicit guidance outlined in the Bowel Management Policy for Adult Care in both Acute and Community Settings based upon best available evidence. The accompanying Policy and SOP identifies and considers the indications for DRE inclusive of contraindications. DRE can be used as part of a clinical assessment when carried out by a healthcare professional who can demonstrate professional competence or as delegated by such a professional providing competence of carer or patient is assessed and reviewed, as required (RCN 2012). DRE should not be used as a first line investigation into the assessment and treatment of constipation (RCN 2012) Scope (i.e. organisational responsibility) Vital functions affected by this procedure: DRE is an invasive procedure and should only be performed when necessary and after individual assessment Individual healthcare professionals undertaking DRF must take responsibility with regards to self-assessing their competency prior to undertaking the procedure to ensure patient safety, privacy and dignity are maintained and if applicable refer to other Trust Policies such as Safeguarding, Consent, Chaperone to further inform and guide clinical practice, documentation and actions taken. Organisational responsibility provides access for staff to undertake the training once every three years Monitoring Compliance Requirement to be Process to Requirement to Process to Requirement Process to monitored. be used for be monitored. be used for to be be used for monitoring e.g. audit monitoring e.g. audit monitored. monitoring e.g. audit Staff Training ESR records Staff Training ESR records Staff Training ESR records Escalations (if you require any Fiona Carlin further clarification regarding this procedure please contact): Team Leader Bladder and Bowel Specialist Service Committees / Group Date 18

19 Consultation: District Nurse Service Manager/Team Leader, Corporate Nursing, Matrons, Bladder and Bowel Specialist Nurses, Directorate SQS Approval Committee Ratified by Committee: Operating Procedure: Action Additional Information: Rationale 1. Collect equipment To be prepared supporting the maintenance of patient privacy and dignity 2. Ensure the patient has privacy To avoid unnecessary embarrassment 3. Explain the procedure to the patient and gain their consent and co-operation To ensure the patient is involved in care decisions and understands the reasons for 4. Cover the bed with a protective layer and assist the patient into an appropriate and comfortable position, normally lying in the left, lateral position with the knees well flexed 5. Perform hand hygiene and put on disposable apron and non-latex gloves 6. Examine the perineal/perianal area for any adverse signs and symptoms before proceeding 7. Reassure the patient throughout the procedure 8. Ensure the index finger is well lubricated with gel and insert gently in the anus on into the rectum 9. Assess for the presence of faecal matter using the Bristol Stool Scale Assess for anal tone at rest with voluntary contraction 10. Wipe the residual lubricating gel from the anal area to prevent soreness or irritation 11. Ensure the patient is left feeling as comfortable as possible 12. Dispose of all equipment according to Trust Received for information the examination, providing valid consent To reduce possible infection caused by soiled linen and to avoid embarrassment. The positioning allows ease of entry into the rectum following the natural anatomy of the colon To minimize the risk of cross infection and comply with PPI control policy To ensure that it is safe to proceed To avoid unnecessary distress or Embarrassment, maintaining effective communication Lubricating reduces surface friction and thus eases insertion and avoids anal mucosal trauma To ensure that there is faecal material present and to establish the consistency of the stool. To evaluate sphincter contractility. To ensure the patient's comfort and avoid anal excoriation To minimize embarrassment and distress maintaining privacy and dignity To reduce the risk of infection Policy 13. Perform hand hygiene To reduce the risk of infection 14. Assist the patient to get up or with dressing To ensure that the patient is composed and comfortable 15. Document the procedure and the patient consent in clinical notes To monitor the patient's bowel function and to provide a record of the procedure and condition of the patient 19

20 Back up information (if appropriate) Document Change History Roles and Responsibilities Abbreviations References 20

21 Appendix 5: S.O.P Digital Removal of Faeces (DRF) Title of Standard Operation Procedure: Digital Removal of Faeces (DRF) Reference Number: Version No: 1.0 Issue Date: December 2016 Review Date: December 2019 Purpose and Background: The purpose of the Standard Operating Procedure is to provide healthcare professionals with explicit guidance that supports Digital Removal of Faeces and associated indications, contraindications, risks and is intended for both acute and community healthcare settings. The SOP is intended for use in relation to the standards and guidance outlined in the Bowel Management Policy. Scope (i.e. organisational responsibility) Vital functions affected by this procedure: Digital removal of faeces from the rectum should be avoided if possible and should only be performed if all other methods of relieving constipation have failed as part of a patient s routine bowel management. Individual healthcare professionals undertaking DRF must take responsibility with regards to self-assessing their competency prior to undertaking the procedure to ensure patient safety, privacy and dignity are maintained and if applicable refer to other Trust Policies such as Safeguarding, Consent, Chaperone to further inform and guide clinical practice, documentation and actions taken. Organisational responsibility provides access for staff to undertake the training once every three years Monitoring Compliance Requirement to be monitored. Process to be used for monitoring e.g. audit Responsible individual/ committee for carrying out monitoring Staff Training ESR records Team Leader/Line Manager Escalations (if you require any further clarification regarding this procedure please contact): Consultation: Approval Committee Frequency of monitoring On going Responsible individual/ committee for reviewing the results Team Leader/Line Manager Responsible individual/ committee for developing action plan Team Leader/Line Manager Fiona Carlin Team Leader Bladder and Bowel Specialist Service New Alderely Building, ECNHST Committees / Group District Nursing Service Manager/Team Leader, Corporate Nursing Team, Matrons, Bladder and Bowel Specialist Nurse, Directorate SQS Responsible individual / committee for monitoring action plan Team Leader/Line Manager Date Received for information: 21

22 Operating Procedure: Action 1. Complete bowel assessment with the patient using Appendix 2 and 3 template 2. Check the individual situation to identify exclusions, contra-indications or circumstances when additional caution/advice may be required 3. Discuss this possible treatment option with the patient 4. Explain the advantages and disadvantages of the procedure, gain patient consent, document if consent is given or document why the procedure is in the best interest of the patient if they are unable to give valid consent. Refer to mental capacity and safeguarding policy for further advice 5. Ensure the patient has privacy prior, during and following the procedure 6. Take the patient's pulse rate at rest prior to the procedure and document 7. Take the patient s baseline blood pressure in all spinal injury patients 8. Cover the bed with a protective layer and ensure a suitable receiver is at hand 9. Assist the patient into an appropriate and comfortable position, normally lying in the left, lateral position with the knees well flexed, not sitting 10. Examine the perineal/perianal area for any adverse signs and symptoms before proceeding, document and report any abnormalities and proceed if confident 11. Perform hand hygiene and put on disposable apron and non-latex gloves 12. For patient's receiving this treatment on a regular basis use a water-based lubricating gel on the gloved index finger 13. Reassure the patient throughout the procedure and inform of imminent examination 14. Insert the non-latex gloved, lubricated index finger slowly and gently, encouraging the patient to relax, into the anus and on into the rectum 15. Assess for the presence of faecal matter using the Bristol stool scale Additional Information: Rationale To establish patient baseline to elicit if the procedure is necessary To identify if there is a particular risk for the patient and document in clinical notes e.g. allergy status To ensure that the patient understands and consents to the intervention explaining that this is a last resort To ensure the patient understands what the procedure entails and gives valid consent without compromising their individual rights To avoid unnecessary embarrassment maintaining privacy and dignity at all times To establish patient s baseline pulse, assess to proceed safely and to monitor any changes post procedure To establish patient s the baseline blood pressure to monitor any changes post procedure To reduce possible infection caused by soiled linen and to avoid embarrassment This positioning, if feasible allows ease of entry into the rectum following the natural anatomy of the colon To ensure that it is safe to proceed To minimize the risk of cross infection and comply with PPI control policy Lubricating reduces surface friction and thus eases insertion and avoids anal mucosal trauma To avoid unnecessary distress or embarrassment, maintain patient privacy, dignity and respect To minimize trauma To establish rectal loading and the consistency of the stool 22

23 16. Ensure the procedure is performed gently using one finger only 17. If stool is type I on the Bristol stool scale remove the faecal material slowly one lump at a time until no more can be felt, place in the suitable receiver 18. If the patient becomes distressed, check the pulse again and check against the baseline reading, stop if the pulse rate has dropped or the patient is clearly distressed, if there is pain or anal area bleeding 19. In a solid faecal mass, push the finger into the middle of the mass to split it, then remove small pieces with a hooked finger until no more can be felt 20. If the faecal mass is too hard or larger than 4cm across or you are unable to break it up, stop and refer to the medical team as a general anaesthetic may be required 21. For patients receiving this care on a regular basis encourage them to rest for 10 minutes to allow further faecal matter to descend into the rectum, To minimize the risk of trauma and prevent raising concerns eg safeguarding, human rights act etc. The stool can be manipulated and evacuated without causing trauma To monitor condition and document in clinical notes escalating concerns to an appropriate healthcare professional as required To remove the faecal matter To minimize risk and trauma to the patient is paramount To maximize quantity of faecal material removed, the Valsalva manoeuvre assists with the faecal descent 22. Use extra lubrication as required To minimize friction, trauma and patient discomfort 23. Check the patient's pulse and stop if the heart rate slows or the rhythm changes 24. Check the blood pressure on all spinal injury patients regardless of lesion type Stop immediately at the first sign of autonomic dysreflexia or any concern 25. When the procedure is completed wash and dry the patient's buttocks and anal area 26. Ensure the patient is left feeling as comfortable as possible and inform them of the outcome 27. Dispose of all equipment/waste as indicated in Trust Policy To monitor the patient's condition, document and escalate any concerns to the appropriate person To monitor the patient s condition, document and escalate any concerns to the appropriate patient To remove any lubricating gel/faecal material that may cause excoriation and to leave the patient clean and fresh To inform patient of level of success, outcome and potential onward management To minimize the risk of cross infection and comply with infection and prevention control policies 28. Perform hand hygiene To minimize the risk of cross infection and comply with Trust policy 29. Document the procedure and outcome, monitor the after-effects and report any abnormal findings Back up information (if appropriate) To monitor the patient's bowel function and to provide a record of the procedure and condition of the patient Please refer to Bowel Management Policy in Adults for further guidance 23

24 Appendix 6: Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. E.g. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Impact upon bowel management policy with regards to patient privacy, dignity, care and experience related to protected characteristics. Details of person responsible for completing the assessment: Fiona Carlin/Jeanette Sarkar Team Leader/Head of Nursing, Quality Bladder and Bowel Specialist Service State main purpose or aim of the policy, procedure, proposal, strategy or service: (Usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) This policy set out standards and procedures relating to bowel and management of bowel care in adults to ensure the highest standards of care and practice are consistently delivered. The purpose of this policy is to ensure the Trust meets strategic and clinical best practice standards in delivering direct patient care to patients with or who require bowel care or interventions appropriate to clinical assessment and clinical need. It encompasses indications and choice of agents to support treatment and care thereafter based upon individual patient assessment inclusive of contraindications. It also contains specific SOP s to support and guide staff. This policy applies to East Cheshire NHS Trust staff with a responsibility for the bowel care of adults over the age of 18 years. It excludes children. As with all procedures, where possible the patient s informed consent should be obtained and documented following a discussion of the risks and benefits of bowel management and subsequent treatment/care options. Valid consent to undertake an initial insertion of suppositories, enema or irrigation must be obtained verbally from the patient where possible and with approval from the person with continuing medical responsibility for the patient. This consent should be recorded in the patient s clinical health record. If there is doubt that the patient does not have capacity to consent to urinary catheterisation then please refer to the ECT Mental Capacity Policy ECT Mental Capacity Policy. Some bowel assessments and subsequent treatments may be subject patients to an invasive procedure and should not be undertaken without full consideration of the benefits and risks. Patient needs should be assessed and only considered as a last resort or if it is considered the best option available. 24

25 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document lyn this will probably be different now in terms of now only covering East Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally. Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common 3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: 25

26 The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just over 11% (37,000) of the population in CWAC. 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) No 2.3 Does the information gathered from indicate any negative impact as a result of this document? No 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes No x Explain your response: The policy and associated procedures require assessment and therefore discussion and explanation with the patient, reassurance and also discussion to obtain consent. If the patient s first language is not English, staff must follow the trust interpretation policy. GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes No x Explain your response: Discussed throughout the policy is the need to maintain the patient s privacy and dignity in what can be distressing and extremely personal examinations. Every effort will be made to accommodate requests for same gender staff, and this is especially the case for certain cultures where a female cannot be uncovered in front of a male who is not her spouse. For transgender patients who have undergone or not undergone surgery, these procedures may prove particularly distressing. Staff will be mindful of this and there is a trust transgender policy to support staff which all staff should be aware of. 26