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Audit of a pathway for childhood idiopathic constipation

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VOL: 101, ISSUE: 29, PAGE NO: 59

Jenny Gordon, BSc, RGN, RSCN, is complementary therapies nurse specialist/postgraduate research training fellow, Napier University/Royal Hospital for Sick Children, Edinburgh

Pamela Reid, BA, RGN, RSCN, DipDN, Christine Thompson, BA, RGN, RSCN, RHV, are both community children's nurse case managers, Royal Hospital for Sick Children, Edinburgh

Constipation is a common condition in developed and industrialised nations. Although its exact prevalence is unknown it is estimated that between five and thirty per cent of the UK population suffer with it, depending on the criteria used for diagnosis (Candelli, 2001). Constipation that cannot be explained by any underlying abnormalities is known as idiopathic constipation.

Constipation is a common condition in developed and industrialised nations. Although its exact prevalence is unknown it is estimated that between five and thirty per cent of the UK population suffer with it, depending on the criteria used for diagnosis (Candelli, 2001). Constipation that cannot be explained by any underlying abnormalities is known as idiopathic constipation.

Childhood idiopathic constipation
Normal stool frequency in infants and children in industrialised countries ranges from an average of four bowel movements a day in the first week of life to two a day at the age of one. The normal adult range of three a day to three a week is usually attained by the age of four (Fontana, 1989).

Constipation accounts for three per cent of general paediatric referrals and between 10 and 25 per cent of paediatric gastro-enterology referrals (Gallagher et al, 1998). It often requires prolonged periods of management from a multidisciplinary team. Treatment involves interventions that are unpleasant and traumatic, and which are believed to involve a high level of non-adherence, leading to repeated long-term treatment. Youssef and Lorenzo (2001) suggest that children do not respond to a single treatment option. Gordon et al (2002) concur with this view; they believe that childhood constipation is a complex condition and that effective management requires a multifaceted approach. Inadequate management of acute constipation, although frequently short-lived, may lead to chronic problems. Early effective intervention is therefore vital (Elshimy et al, 2000; Gallagher et al, 1998; Clayden, 1994).

Management of idiopathic constipation
In 1996, two members of the community children's nurse team at the Royal Hospital for Sick Children, Edinburgh, devised and implemented a community nursing guideline to support the management of children with idiopathic constipation and their families.

By 1998 there were increasing concerns that the management of these children was uncoordinated and that there was a lack of consensus regarding pharmacological treatment. To ensure that these concerns were legitimate, an audit of children attending the hospital was undertaken. The results showed that an average of 17 children had attended the A&E department for problems associated with idiopathic constipation over a three-month period and that there had been an average of nine surgical admissions each month over the same period. The children had often experienced idiopathic constipation for some time. Their management involved manual evacuation under anaesthetic, laxative preparations administered orally or by nasogastric tube, enemas and suppositories, toileting programmes and dietary advice. The treatment in A&E could be described as crisis management. Few of the children and families attending hospital were referred to other health professionals for ongoing support and/or management. This lack of support was the catalyst for action: a constipation steering group was formed in 1999 comprising of multidisciplinary advisers from both the primary and acute health sectors, with the aim of assessing current practice and defining best practice for the treatment of children with constipation.

Developing a pathway
In order to gain an understanding of current practice, the steering group completed a survey of the management of idiopathic constipation in paediatric surgery and an audit in primary care. The findings indicated that management guidelines were needed in both areas. The health professionals requested pharmaceutical guidelines, information and support leaflets for families and access to specialist support when necessary. After two years of consultation and collaboration, a pathway, entitled Tough Going. Childhood idiopathic constipation management pathway - a resource for health professionals was developed. The pathway provides a comprehensive resource that covers all aspects of the management of childhood idiopathic constipation. It is not intended to be prescriptive; rather, it is a dynamic document that incorporates changes in practice as they arise. It was issued in January 2002 to health care professionals from both the community and hospitals in the City of Edinburgh, East Lothian and Midlothian.

Audit of the Tough Going pathway
An audit in 2002-2003 aimed to determine the effectiveness of the Tough Going pathway. It addressed the following questions:

- Whether the pathway was being used;

- How the pathway was being used, and which parts were being used;

- Whether the pathway had changed practice;

- Whether the referral criteria had been followed appropriately;

- The experience of families with children being treated for constipation since the introduction of the pathway.

The sample was made up of all health professionals who had been issued with a copy of the pathway between February 1, 2002 and January 31, 2003, in the geographical areas of the City of Edinburgh, East Lothian and Midlothian, and parents of children who had been referred to either a continence adviser, the children's community nurse or the complementary therapists between the same dates.

Information was collected about the number of attendees at the A&E department between June 1 and August 31, 2003; the number of surgical admissions between November 2, 2002 and December 31, 2002, and referrals to the community children's nursing service and the child and family mental health service between February 1, 2002, and January 31, 2003. Data collection tools were developed (Box 1).

The data were collected and collated by the Constipation Working Group, a volunteer project worker, clinicians and members of the Royal Hospital for Sick Children audit department.

Formal ethical approval was not required for the audit, but ethical issues were given due consideration. All questionnaires were anonymous. Parents were sent an invitation to participate and given a copy of the questions before the telephone interview.

Results
Questionnaire response - The questionnaire was sent to 173 health professionals who had received a copy of the pathway in the designated health care facilities within the City of Edinburgh, East Lothian and Midlothian. There were 92 responses, 76 of which were from the community services and 16 from the hospital services, a response rate of 53.2 per cent. In contrast, the response rate from the audit in 1999 was only 25.8 per cent. These figures demonstrate that there has been a raised awareness and interest in the management of childhood idiopathic constipation since the earlier audit.

The audit data showed that 75 per cent of respondents use the Tough Going pathway. The 25 per cent who reported that they did not use it included respondents who were not actively managing children with idiopathic constipation, such as those in management positions.

The pathway has eight evidence-based sections, and these support the constipation treatment pathway. Fig 1 illustrates that Principles, Pitfalls and packages of care, Pharmacy guidelines, and Assessment were the most popular sections, and that the document met the needs of health care professionals who had taken part in the initial audit in 1999.

Of the 92 respondents, 65 (70.7 per cent) stated that they had changed their practice in relation to the overall management of children with idiopathic constipation. Forty-one (44.6 per cent) respondents stated they had changed from using rectal preparations to oral medication to manage constipation as a direct result of implementing the pathway. In addition, 42 (45.7 per cent) respondents reported that they were already using oral medications. These figures suggests that 90.3 per cent of respondents from the City of Edinburgh, East Lothian and Midlothian are following best practice in that they are using oral medication effectively in their work.

The A&E perspective - Over the three-month period, four children were admitted straight to a ward, and 30 children were treated for constipation in A&E (Fig 2). Eight children had been referred by their GP. The remaining 26 were self-referrals. Of the total sample, 10 were under one year of age, 16 were between one and five years, and eight were over five years. The 34 children were referred to the following services:

- GP: 17;

- Outpatient appointments: 7;

- Admitted to a ward: 6;

- Community paediatrician: 1;

- No follow-up: 3.

Further analysis of the data for the 26 children who self-referred to A&E showed that they were then referred as follows: 15 back to their GP, five to outpatient clinics, four were admitted, and two had no follow-up. This suggests that families were attending A&E inappropriately rather than accessing community services.

The interventions received by the six children who were admitted to wards were invasive: three received Klean Prep/Citramag by nasogastric tube, one had a manual evacuation under general anaesthetic and two received rectal medication.

In the audit of 1998, the average number of children attending A&E each month was 17, of whom nine were admitted to the ward. The audit of 2002/2003 showed that the average monthly attendance was 12, two of whom were admitted (Fig 3).

Since the implementation of the Tough Going pathway, the number of children attending A&E with constipation each month has fallen by 29 per cent, and the number of children being admitted with constipation has fallen by 36 per cent. This suggests that health professionals in the community are following the treatment pathway effectively, and referring to A&E only those patients who require a differential diagnosis.

Family experiences by telephone interview - The views of parents and carers were elicited by means of telephone interviews; 16 interviews were completed. The parents interviewed had had children with constipation referred to A&E between February 1, 2002 and January 31, 2003. In 47 per cent of these families the condition had been present for between one and eight years. The majority of the parents initially sought help from their GP.

Discussion
The audit showed that there are areas in the City of Edinburgh, East Lothian and Midlothian community and hospital health services where the pathway is not being used or not being used effectively.

Some respondents stated that they were not using the document and some that they were using sections in isolation. There were also inappropriate referrals to the A&E department and, in some instances, to specialist services. The reasons for this may include not being aware of the document, lack of access to it, a resistance to change practice, a failure to give childhood idiopathic constipation the recognition it requires and a lack of support for those managing the condition.

There is a need to remarket the pathway, to distribute additional hard copies to the community and the hospital health services and to advertise the availability of the document on the internet.

Farrell et al (2003) suggested that health professionals may resent being consulted about a common problem such as constipation, as they believe families should be able to manage the problem themselves. They also suggested that parents may feel the condition is attributable to a lack of good parenting. In addition, Farrell et al (2003) suggested that parents may delay seeking help for fear of a negative response from health professionals. Our data support the view that families do delay seeking help.

Elshimy et al (2000) reported that the median duration of symptoms was 12.5 months (range 1-48 months) at the time children present for their first outpatient appointment.

The responses from families, and their actions, indicate a lack of knowledge about normal bowel function and about where help can be sought. This is illustrated by self-referrals to the A&E department and not using the primary health care services appropriately. The reasons for this may be that many still perce ive bowel function as a taboo subject and that there is a lack of information about normal bowel function and self help-strategies that parents can employ when difficulties arise.

Parents need to identify and manage altered bowel patterns in their children. It may be helpful to include information about normal and altered bowel function and self-help strategies in child health documentation and health promotion materials for families. It is important, too, to facilitate and support the development of health education and psychological education materials for health care professionals, and of nursery and school services, so as to raise awareness of the problem and empower them to offer appropriate support to families.

Conclusion
Tough Going was developed in response to concerns about the management of care of children with idiopathic constipation and the fragmentation of care.

The audit results suggest that the pathway is meeting the expressed needs of health care professionals who use the document in that it provides a comprehensive resource. The evidence demonstrates that their practice has changed as a direct result of using the pathway. To sustain the momentum it is imperative to support users and encourage non-users by ensuring the resource continues to be relevant and up-to-date. The views elicited from families highlight the need for a co-ordinated and supportive multidisciplinary team approach, which the pathway facilitates.

The successful implementation of the pathway has resulted in a less traumatic experience for children undergoing treatment of idiopathic constipation. This outcome was fundamental to the ethos of the project.

The audit was not designed to incorporate all the factors believed to contribute to childhood idiopathic constipation. These include: lack of exercise, poor dietary choices, national recognition of obesity, inadequate school toilet facilities and limited access to sufficient drinking water in school. In order to investigate the impact of these factors, further research and audit are required, together with associated funding. It will also be necessary to raise the profile of childhood idiopathic constipation to ensure inclusion on local and national health agendas.

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