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Discussion

Managing faecal incontinence: a joint approach to guideline development

Faecal management systems help prevent cross infection and preserve skin integrity. Nurses in Wales developed guidelines to ensure these systems are used appropriately

In this article

  • The prevalence and effects of faecal incontinence
  • Indications and contraindications of management systems
  • Developing guidelines for use of faecal management systems

Author

Ann Yates is director of continence services at Cardiff and Vale University Health Board, Wales.

Abstract

Yates A Managing faecal incontinence: a joint approach to guideline development. Nursing Times; 107: 12, early on-line publication.

Faecal incontinence is an embarrassing and painful condition common among hospital patients. Faecal management systems (FMS) collect and contain liquid or semi-liquid stool, helping to preserve skin integrity and prevent environmental contamination. Nurses from three health boards across Wales joined together to produce guidelines for using FMS in practice. Backed by the chief nursing officer for Wales, this was published in March 2011.

Keywords: Faecal management system, Incontinence, Guidance

  • This article has been double-blind peer reviewed.

 

5 key points

1.  Nurses working with people with faecal incontinence should be aware of the physical and emotional impact of the condition

2.  Patients reporting faecal incontinence should be offered a focused assessment by a health professional qualified in bowel management

3.   A faecal management system is a fully closed system that collects and contains liquid or semi-liquid stools, helping to preserve skin integrity and prevent faecal contamination of the environment

4.  The indications, contraindications and possible adverse events must be considered before any faecal management system is used

5.  When producing clinical guidelines, nurses from all the relevant disciplines should be involved

 

Faecal incontinence is an embarrassing and undignified condition. It can have a detrimental effect on psychological, social and physical functioning, significantly reducing quality of life (Wishin et al, 2008). The National Institute for Health and Clinical Excellence says all staff working with people who have faecal incontinence should be aware of its physical and emotional impact. Healthcare professionals should ensure all patients who report faecal incontinence are offered a focused baseline assessment, including relevant medical history, an anorectal examination and a cognitive assessment if appropriate (NICE, 2007).

In some cases, containment measures may also be needed.Most management and containment of faecal incontinence, especially in acute settings, focuses on meeting patients’ hygiene needs, changing bed linen and using incontinence pads. However, severe uncontrolled diarrhoea is a threat to skin integrity, and nurses should consider using a faecal collection device (NICE, 2007). Uncontrolled diarrhoea also increases the risk of cross contamination and infection from pathogens such as Clostridium difficile.

Background

Studies have shown that 1–10% of adults are affected by faecal incontinence (NICE, 2007). It has been suggested that the different definitions of faecal incontinence make it difficult to determine the exact prevalence of the condition (Ousey et al, 2010a), but it is common among hospital patients (Wishin et al, 2008).

A UK study by Ousey et al (2010b) found a high prevalence of faecal incontinence in intensive care patients. A study of 1,106 patients also found more than a third were incontinent of urine, faeces or both. Of the 125 patients considered at very high risk of pressure damage, 78% were incontinent (Evans, 2010).

Three nursing groups in Wales - continence, infection control and tissue viability - had all considered producing guidelines on the use of faecal management systems (FMS). However, we acknowledged that all relevant disciplines would need to be involved in producing guidelines if they were to be fit for purpose. We therefore convened a group to produce the All Wales Guidance for the use of Faecal Management Systems.

The purpose of the guideline is to ensure the appropriate use of FMS within Welsh health boards and independent sector organisations, and to give staff guidance on the most appropriate systems for patients. It is based on expert consensus that, along with audit, is suggested as a positive method of directing care (Ousey et al, 2010a).

High-risk groups 

Groups at high risk of faecal incontinence include frail older people, women after childbirth, and people with neurological or spinal disease (Box 1).

Box 1. Faecal incontinence: high risk groups

  • Frail older people;
  • People with loose stools or diarrhoea from any cause;
  • Women following child birth (especially following third and fourth degree obstetric injury);
  • People  with neurological or spinal disease (such as spina bifida, stroke, multiple sclerosis or spinal cord injury);
  • People with severe cognitive impairment;
  • People with urinary incontinence;
  • People with pelvic organ prolapse and /or rectal prolapse;
  • People who have had colonic resection or anal surgery;
  • People who have undergone pelvic radiotherapy;
  • People with perianal soreness, itching or pain;
  • People with learning disabilities.

Source: NICE, 2007

Before using any device or treatment to manage faecal incontinence, a full assessment should be undertaken by a healthcare professional with the relevant skills, training and experience in bowel dysfunction (NICE, 2007).

Effects of faecal incontinence

Faecal incontinence can have a detrimental effect on psychological, social and physical functioning, and the stigma associated with the condition can result in significant psychological trauma (Wishin et al, 2008). It is seen as undignified, and the subsequent care as an invasion of personal space. The associated odour is a further source of embarrassment and humiliation (Wishin et al, 2008). It causes distress, embarrassment, anxiety, and a loss of personal control and dignity. It is also inconvenient, and a threat to self-esteem and self-confidence.

People with faecal incontinence can feel stigmatised, as if they no longer fit societal “norms”. An extensive study of teenagers living with faecal incontinence found they faced exclusion, humiliation, ignorance and ridicule (Cavet, 1998). Maintaining privacy and dignity should therefore be paramount when caring for people with faecal incontinence.

Physical symptoms of faecal incontinence include abdominal discomfort, pain or bloating, and bowel urgency and frequency (Box 2). This can lead to dehydration, skin problems, and urea and electrolyte imbalance if it is not treated or managed effectively.

Box 2. Effects of faecal incontinence

  • Faecal contamination can increase the risk of post-surgical wound breakdown in susceptible areas, such as the groin and perineal  regions (Estrada, 2009);
  • Alkaline faeces can change the slightly acidic pH of skin, causing skin irritation (Beldon, 2008);
  • Increase in moisture from episodes of incontinence, combined with bacterial and enzymatic activity, can cause skin breakdown;
  • Dehydration due to faecal incontinence can cause skin changes, such as dryness and tugor;
  • Cross contamination if patients have infected diarrhoea;
  • Containment products, laundry, nursing time, drug therapies and extra bed days make faecal incontinence expensive.

C. difficile

Patients with C. difficile-associated diarrhoea can experience faecal incontinence, which has direct implications for environmental contamination and cross infection (Starr, 2005). In recognition of this the Welsh Assembly Government introduced mandatory surveillance of C. difficile in hospital patients aged 65 and over in 2005. In 2008-09, a total of 2,744 C. difficile cases were reported in Wales, representing 15.46 per 1,000 hospital admissions (Welsh Healthcare Associated Infection Programme, 2009). Health boards throughout Wales are required to reduce the level of healthcare-associated C. difficile infections by at least 20% year on year (WHAIP, 2009).

Faecal management systems

The FMS is a fully closed system that collects and contains liquid or semi-liquid stools, helping to prevent faecal contamination of the environment (Johnston, 2005) A clinical evaluation of a flexible faecal incontinence system found it also improved skin condition (Padmanabhan et al, 2007). In 2007, FMS were awarded rapid review panel (RRP) recommendation 1 by the Department of Health’s HCAI Technology Innovation Programme The programme, which identifies and supports the development of new initiatives for tackling healthcare-associated infections, found the system was both clinically and cost-effective. It recommended decisions on its implementation be made at local level (HCAI, 2009).

FMS guidance 

Members of the group (Julie Evans, tissue viability nurse; Joanna Price, infection control nurse; Trudie Young,lecturer in tissue viability; Ann Yates, director of continence services) convened to produce the guidance work for a range of health boards across Wales.

We first met in March 2010 to set the aims and objectives of the project. We completed a review of the available literature and existing faecal management policies and then undertook a scoping exercise to define the development process and individual roles. The first draft of the document was produced and reviewed by May 2010. After further amendments it was reviewed by local and nationally recognised organisations and returned by September 2010. Our final group meeting took place in October 2010, when we reviewed all comments and feedback and integrated them into the document as appropriate.

Guideline content

The guideline includes the background to faecal incontinence, the extent of the problem, individuals most at risk and basic advice on how to carry out a faecal incontinence assessment. It also includes:

  • Guidance on skin care and use of FMS;
  • Alternatives to the use of FMS;
  • Consent;
  • Indications and contra indications for using FMS, and possible adverse events (Box 3);
  • Directions for use;
  • Resources, training and organisational issues;
  • A quick reference guide (Fig 1).

 

Box 3. Indications and contra indications for using faecal management systems (FMS) and possible adverse events

Indications:

  • Patient has liquid to semi liquid stool (type 6-7 on the Bristol Stool Chart);
  • Patient is bed bound;
  • Confirmed diagnosis of Clostridium difficile infection;
  • Complications secondary to enteral feeding;
  • Persistent diarrhoea;
  • Little or no bowel control;
  • Patient must have adequate anal sphincter control and tone;
  • Approval from medical team;
  • Patient receiving palliative care with faecal leakage;
  • Patient has skin breakdown caused by faecal incontinence or faecal leakage

 Contraindications:

  • Large bowel surgery or rectal surgery within the past year;
  • Sensitivity or allergy to any of the materials used in FMS;
  • Rectal or anal injury;
  • Severe rectal or anal stricture or stenosis;
  • Suspected or confirmed rectal mucosal impairment;
  • Confirmed rectal or anal tumour;
  • Severe haemorrhoids;
  • Faecal impaction;
  • Spinal cord injury above T5 due to risk of autonomic dysreflexia

 Possible adverse events:

  • Loss of anal tone;
  • Pressure necrosis of rectal or anal mucosa;
  • Infection;
  • Bowel obstruction;
  • Perforation of the bowel;
  • Persistent rectal pain;
  • Abdominal distension;
  • Unable to open bowels for more than 48 hours

Its foreword was written by Professor Jean White, the chief nursing officer for Wales, while local bodies such as the Welsh Wounds Network, and national organisations including the Association for Continence Advice, Infection Prevention Society, and Wound Care Alliance UK have also endorsed it.

We are happy to share it with all health professionals, irrespective of where they work, and will continue to work on other aspects of the guidance, such as implementation and education.

Conclusion 

The underlying philosophy behind the guideline is recognition that people with faecal incontinence have complex needs, which require a interdisciplinary approach. This project has demonstrated effective interdisciplinary working between nursing groups in Wales, resulting in a document that provides clear guidance for practice in the absence of definitive research on the use of faecal management systems. Working electronically enabled us to produce the guidance with few face-to-face meetings. The document has already attracted interest from nursing groups in Scotland and England, who are considering adopting it to form part of national guidance on the use of faecal management systems and good practice in containing faecal incontinence if appropriate for that individual.

  • The group received an unrestricted educational grant from ConvaTec for the development, production and dissemination of the guidance.
  • To access, All Wales Guidelines for Faecal Management Systems, go towww.welshwoundnetwork.org

 

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