PROCEDURE FOR THE USE OF PERISTEEN ANAL IRRIGATION SYSTEM FOR ADULTS (FOR THE PURPOSE OF RECTAL IRRIGATION)

Transcription

1 PROCEDURE FOR THE USE OF PERISTEEN ANAL IRRIGATION SYSTEM FOR ADULTS (FOR THE PURPOSE OF RECTAL IRRIGATION) Issue History Issue Version Purpose of Issue/Description of Change Planned Review Date One To promote the safe use of anal irrigation through the use of the Peristeen Anal Irrigation System March 2015 Named Responsible Officer:- Approved by Date Quality and Governance Service Risk and Governance Group December 2012 March 2012 Section: - Continence C06 Target Audience Wirral Integrated Continence Service UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

2 CONTROL RECORD Title Procedure for the use of Peristeen Anal Irrigation System (for the purpose of rectal irrigation) Purpose To promote the use of anal irrigation through the use of the Peristeen Anal Irrigation System Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Norma Hayes/Caroline Hewitt Document Librarian QGS Groups consulted with :- Clinical Policies and Procedures Group Infection Control Approved 22/11/11 Date formally approved by Risk and Governance Group December 2011 Method of distribution Intranet Archived Date 16 th March 2012 Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 Quality and Governance Service N First version Status New / Revised / Trust Change Page 2 of 11

3 PROCEDURE FOR THE USE OF PERISTEEN ANAL IRRIGATION SYSTEM FOR ADULTS (FOR THE PURPOSE OF RECTAL IRRIGATION) INTRODUCTION Trans-anal irrigation is reported to benefit some patients with faecal incontinence, rectocele and constipation (Gardiner et al 2004; Crawshaw 2004). It is possibly more effective in patients with passive soiling than those with urge incontinence secondary to loose stool (Briel et al 1997). It has been more widely reported in children with spina bifida than in adults (Lipak & Revell 1992; Scholler-Gyure et al 1996; Shandling & Gilmour 1987). Trans-anal irrigation has been found in a randomised controlled trial to be effective for both constipation and faecal incontinence in people with spinal cord injury (Norton & Chelvanayagam 2000). In scintigraphic studies anal irrigation has been found to empty stool as far up as the splenic flexure (Christensen et al 2003) Trans-anal irrigation is widely used in Europe but until recently seldom in the United Kingdom (UK). More widespread implementation has been limited until recently because no purpose designed equipment was easily available in the UK, necessitating the use of often unsuitable colostomy irrigation equipment. Rectal irrigation will usually only be tried if other less invasive methods of bowel management have failed to adequately control constipation and/or faecal incontinence. Depending on each individual's assessed symptoms and need this will often include dietary measures, adjusting fluid intake, bowel habit, ensuring toilet access, evacuation techniques, medication and pelvic floor muscle training (Norton & Chelvanayagam 2000; NICE 2007) There is a relatively small evidence base for this procedure at present (Gardiner et al 2004; Briel et al 1997; Christensen et al 2006). It is recommended that community nursing staff discuss individual patients whom they feel may benefit from this procedure with the Continence Service and the patient s GP and/or consultant prior to commencing the procedure. TARGET GROUP This procedure applies to the Wirral Integrated Continence Service and the relevant community nurses employed by the Trust who are required to carry out this role. TRAINING All registered nurses need to attend the in-house Core Continence Training within 6 months of coming into post. Each nurse will have also have completed a practical session in addition to the theory, within their clinical workplace. This will be supported by the Continence team. As this is a bespoke procedure the Wirral Integrated Continence Service will provide support to the community nurses who are undertaking this procedure as part of their patient care until they are able to undertake this clinical task independently. Page 3 of 11

4 PRIVACY AND DIGNITY Every member of staff has a duty to ensure that the privacy and dignity of all patients are respected. Patients have the right to be treated with dignity at all times, to have their modesty protected and to remain autonomous and independent wherever possible. Examples of good practice to achieve patient privacy and dignity during the anal irrigation procedure include: All staff need to introduce themselves and at all times wear their identity badge which must include their name and designation. Communication between staff and clients will always be of a respectful nature that is the use of full title otherwise requested or agreed by the patient/client. Patients will at all times be treated with respect and dignity, regardless of age, gender, religion, sexual orientation, disability or race. All trust staff should avoid personal conversations with co-workers that exclude the patient during the anal irrigation procedure. Closing curtains or doors in areas where patients are expected to undress and also where the procedure will be performed. Patients undergoing anal irrigation should be allowed the opportunity to limit the degree of nudity by, for example, uncovering only the part of anatomy that is required. Following the procedure, patients should have the opportunity to re-dress before the consultation continues. Wherever possible, the Trust will offer patients a choice of health care practitioner to meet their needs. A chaperone should be offered to patients as appropriate and they should also be offered a choice as to who is present during the procedure. RELATED POLICIES Please refer to relevant Trust policies and procedures INDICATIONS Neurogenic bowel dysfunction, e.g. spinal cord injury, spina bifida, multiple sclerosis Chronic constipation, including both evacuation difficulties and slow transit constipation Chronic faecal incontinence Page 4 of 11

5 CONSIDERATIONS RISKS Some types of patient may require additional supervision or monitoring; at least until it is clear that irrigation is not producing any problems. This will depend on the judgement of the assessing practitioner, but may include: Spinal cord injury above T6 (monitor for autonomic dysreflexia) until it is clear that the technique is well tolerated and does not provoke autonomic dysreflexia Unstable metabolic conditions (frail, known renal disease or liver disease: may need to monitor electrolytes). Under 18 years old (consult paediatric consultant and use saline for younger children). An inability to perform the procedure independently or comply with the protocol in the absence of close involvement of carers. (e.g. due to physical disability, cognitive impairment, major mental/emotional disorder) Experience to date with irrigation by a carer suggests that it is no more problematic than self irrigation for physically disabled individuals. Anorectal conditions that could cause pain or bleeding during the procedure (e.g. third degree haemorrhoids, anal fissure). Worsened faecal incontinence Minor discomfort or abdominal cramps Minor rectal or anal bleeding. Perforation of the bowel: likely to be very rare, but a possible complication as with any invasive procedure. POTENTIAL PROBLEMS 1. Bleeding - Minor bleeding on the catheter is not a concern. More major or regular bleeding or altered bleeding should prompt urgent referral to colorectal services. If the patient experiences a haemorrhage with or without pain, emergency care is indicated as the rectum could theoretically be perforated. This might necessitate emergency surgery and the patient should know to gain emergency medical help in this VERY UNLIKELY event. 2. Difficulties with catheter insertion - Check for impaction, anorectal abnormalities. Check patient's insertion technique CONTRAINDICATIONS (use only after careful discussion with relevant medical practitioner) Pregnant or planning pregnancy (women). Active perianal sepsis. Diarrhorea Anal fissure Page 5 of 11

6 Large haemorrhoids that bleed easily Faecal impaction (clear, if possible before starting irrigation: digital rectal examination if unsure) Past pelvic radiotherapy that has caused bowel symptoms Known severe diverticular disease Use of rectal medications for other diseases Congestive cardiac failure Anal surgery within the past 6 months ABSOLUTE CONTRAINDICATIONS (IRRIGATION SHOULD NOT BE USED): Acute active inflammatory bowel disease CONSENT Known obstructing rectal or colonic mass Rectal or colonic surgical anastomosis within the last 6 months Severe cognitive impairment (unless carer available to supervise/administer) Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient s health records with a clear rationale stated at all times. Refer to Trust Consent Policy for further information and guidance. EQUIPMENT Irrigation bag, Control unit Single-use rectal catheter 1000 mls tepid tap water measured using thermometer (20 30 degrees Celsius) Single use disposable non sterile gloves Single use disposable apron Tissues/wipes Waste bag Access to toilet/commode Hand washing facilities Page 6 of 11

7 PROCEDURE ACTION Verbally confirm the identity of the patient by asking for their full name and date of birth. If client unable to confirm, check identity with family/carer Introduce yourself as a staff member and any colleagues involved at the contact Wear identity badge which includes name, status and designation Ensure verbal consent for the presence of any other third party is obtained Explain procedure to patient including risks and benefits and gain valid consent. Establish that the patient has no known allergies, check in patients health records and also ask patient/family of known allergies Obtain valid consent and document in patients health records Follow Trust Consent Policy if unable to gain consent, to demonstrate treatment is in patients best interests Clarify if the patient requires a formal chaperone Ask the patient if they wish to use the toilet prior to undertaking the procedure. Prepare the environment i.e. commode, toilet Decontaminate hands prior to procedure Apply single use disposable apron Apply single use disposable non-sterile gloves Clean the skin as required (when visibly soiled) Fill water bag to the Zero indicator with tepid tap water measured using thermometer (20-30 degrees Celsius) Peel the catheter pack slightly To avoid mistaken identity RATIONALE To promote mutual respect and put client at their ease (CQC 2010) For patients to know who they are seeing and to promote mutual respect Students for example, as the client has the choice to refuse To ensure client understands procedure and relevant risks (DH 2010) To reduce risk of allergic reactions To gain co-operation and patients agreement to care (CQC 2010; DH 2010) Needs to be in discussion with other members of the team, carers, G.P and in spinal cord injured patients, their spinal injury centre It is the patient s choice to have a chaperone if wanted. Discuss with line manger if nurse considers a chaperone is needed as part of risk assessment For comfort of the patient To facilitate easy access for defecation ensuring privacy and dignity To reduce the risk of transfer of transient microorganisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of micro-organisms To protect hands from contamination with organic matter and transfer of micro-organisms To prevent skin excoriation and promote comfort (Mallet & Dougherty 2000) For patient comfort Following procedure Page 7 of 11

8 Assemble the equipment: connect the irrigation bag, control unit and single-use rectal catheter blue to blue and grey to grey. Turn the control unit knob to the water symbol and pump the control unit a few times until water has reached the catheter Turn the control knob to the Balloon symbol. Do not pump yet. Transfer the patient to the toilet / commode if not on it already Holding the catheter by the finger grip, gently insert into the anus as far as the finger grip will allow. If you feel any resistance while inserting the catheter NEVER use force. Take the catheter out, check that there is not hard stool blocking the insertion, and gently try again. While still holding the catheter in place, pump the balloon (typically this is 3 to 4 times). This will inflate the balloon. Now let go of the catheter as the balloon will hold in place. Turn the control unit knob to the water symbol and start to pump water into the rectum. About one pump each two seconds is the usual speed. People with a high spinal injury may need to pump more slowly than this. Continue pumping until the required volume has been instilled (usually between mls) It may take up to minutes to pump in all the water. Turn the control unit knob to the air symbol Use the catheter package to dispose of the catheter. Water and stool should start to pass into the toilet very soon after the catheter is removed. Advise the patient to AVOID THE TEMPTATION TO STRAIN. It can take minutes for the bowel to stop emptying. Clean and dry the anal area. Dispose of catheter packet Empty any remaining water from the bag and tubing To ensure all equipment is ready prior to procedure To prime the tubing with water and activate the self-lubricating coating on the catheter Following procedure Where procedure takes place To ensure catheter is positioned correctly To inflate the balloon to: 1. hold catheter in place 2. Ensure water stays in rectum To avoid discomfort To prevent autonomic dysreflexia To ensure optimum water is inserted To deflate the balloon. The catheter is likely to drop out under gravity. If not, a gentle pull will remove it. To prevent cross infection and environmental contamination Demonstrates procedure has been successful Avoids complications post procedure To prevent skin excoriation and promote comfort (Mallet & Dougherty 2000) To prevent cross infection and environmental contamination Empty any remaining water from the bag and tubing Page 8 of 11

9 On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of Personal Protective Equipment Clean reusable equipment (if required) in line with Trust policy and manufacturers instructions. Record information in patients health records, this should include:- Valid consent If a chaperone was required Reason for rectal Irrigation procedure Date and time Problems negotiated during the procedure Review date to assess the need for next procedure Report any comments/ concerns made by the patient To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE Decontamination of medical equipment is essential for the effective delivery of patient care. To record patient care given, provide seamless care and comply with health records policy (CQC 2010; DH 2010). EQUIPMENT The Peristeen Anal Irrigation System is prescribed via a FP10 Prescription either by a General Practitioner or by a non-medical prescriber when within their scope of practice. The equipment must be replaced by the patient or Nurse every three months through direct order from Coloplast. WERE TO GET ADVICE FROM If guidance or advice is required by a member of staff please contact the Wirral Integrated Continence Service on INCIDENT REPORTING Clinical incidents or near misses must be reported and a Trust Incident Form must be completed SAFEGUARDING ADULTS In any situation where staff may consider the patient to be a vulnerable adult, they need to follow Trust Safeguarding Policy and discuss with their line manager and document outcomes. Page 9 of 11

10 REFERRALS Any referrals to health professionals, therapists or other specialist services must be followed up and all professional advice or guidance documented in the patients health records. EQUALITY ASSESSMENT During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place. REFERENCES Briel, J. W., Schouten, W. R., Vlot, E. A., Smith, S. and van Kessel, I. (1997) Clinical value of colonic irrigation in patients with continence disturbances. Dis Colon Rectum. Jul; 40 (7): Care Quality Commission (2010) Guidance about compliance. Essential standards of quality and safety. Christensen, P., Olsen, N., Krogh, K., Bacher, T. and Lauberg, S. (2003) Scintigraphic assessment of retrograde colonic washout in faecal incontinence and constipation. Dis Colon Rectum. 46; (1): Christensen, P., Bazzocchi, G., Coggrave, M., Abel, R., Hultling, C. and Krogh, K. (2006) A randomized controlled trial of transanal irrigation versus conservative bowel management in spinal cord injured patients. Gastroenterology. 131: Crawshaw, A. (2004) How to establish a rectal irrigation service. Gastrointestinal Nursing. 2; (2): Department of Health (2010) Essence of Care. e/dh_ Gardiner, A., Marshall, J. and Duthie, G. S. (2004) Rectal irrigation for relief of functional bowel disorders. Nursing Standard. 19; (9): Lipak, G. S. and Revell, G. M. (1992) Management of bowel dysfunction in children with spinal cord disease or injury by means of the enema continence catheter. Journal of Paediatrics. 120: Mallet, J. and Doherty, L. (2000) Royal Marsden Hospital Manual of Clinic al Nursing Procedures. Blackwell Scientific Publications: London. Page 10 of 11

11 National Institute for Health and Clinical Excellence (2007) Management of faecal incontinence in adults. London. Norton, C. and Chelvanayagam, S. (2000) A nursing assessment tool for adults with faecal incontinence. Journal of Wound, Ostomy, and Continence Nursing. 27: Norton, C. and Chelvanayagam, S. (2004) Bowel Continence Nursing. Beaconsfield: Beaconsfield Publishers. Scholler-Gyure, M., Nesselaar, C. H., van Wieringen, H. and Van Gool, J. D. (1996) Treatment of defecation disorders by colonic enemas in children with spina bifida. European Journal of Paediatric Surgery. 6: Page 11 of 11