VOL: 102, ISSUE: 26, PAGE NO: 51
June Rogers, MBE, BA, MSc, RN, RSCN, is a paediatric continence adviser, and team director, PromoCon, Disabled Living, ManchesterA review of paediatric continence promotion services carried out in 2003 by the NHS Modernisation Agency found that...
A review of paediatric continence promotion services carried out in 2003 by the NHS Modernisation Agency found that, overall, the standard of service provision was poor, with little evidence of a child-centred approach or of integrated working (NHS Modernsisation Agency, 2003). The review was followed by a recommendation in the Children's National Service Framework that primary care trusts develop integrated paediatric continence promotion services. It was hoped that the development of care pathways and locally agreed guidelines would help to facilitate an evidenced-based integrated approach to the promotion of continence in children.
However, there are very few large, randomised, controlled, trials that identify optimum treatments (Benninga et al, 2004). Care pathways to manage continence problems in adults had been well established (Bayliss et al, 2003), but none had been developed for children.
Developing the care pathways
Care pathways are more likely to succeed if they are developed by those who will be using them. The paediatric continence pathways discussed here were developed by three multidisciplinary groups, led by June Rogers, with a number of health professionals from around the UK who were all actively involved in the management and treatment of children with bowel and bladder problems.
Following an extensive review of the literature and consideration of expert opinion to identify current best practice and up-to-date treatments and interventions, four pathways were completed:
- Children with daytime wetting;
- Children with nocturnal enuresis;
- Children with constipation and soiling;
- Children with delayed toilet training who may require continence products.
Improving healthcare outcomes
Using care pathways and guidelines leads to improved outcomes, but it is important to remember that the best treatment choice may depend not only on the preference of the family but also on the risks and benefits of different therapeutic options.
For example, following the pathway for a child with nocturnal enuresis with lack of arousal and using the clinical assessment tool, the most appropriate treatment option to be considered may be the enuresis alarm. However, if the family feel that this treatment would be too disruptive or if they have negative feelings towards it and doubt that the child would wake, it would not be the best treatment of choice at that time. The family may want to consider an alternative such as desmopressin or to defer treatment until a later date.
By being involved with the treatment decisions, families feel a sense of satisfaction and empowerment even if they decide that no treatment is the best option.
Nurses need to be an advocate for the child and if they are aware of evidenced-based treatment options that reduce the risk of adverse events, these should be considered as the first treatment of choice. For example, traditional practice for a child with constipation who required dissimpaction was to use enemas or suppositories. However, this method is very distressing for the child and is also costly in terms of nursing time. There is now considerable emerging evidence regarding the use of oral therapy (Movicol Paediatric plain) for dissimpaction, which is effective, safe to use and not distressing for the child.
It is important that nurses keep up to date and incorporate any new evidence into the pathways as it becomes available.
Adapting pathways for local use
The care pathways will need to be adapted for local use. The first step to effective implementation in local settings is to form a multidisciplinary team that involves the key stakeholders in the clinical process. People who feel 'ownership' of service developments and who are involved with their implementation are less likely to be resistant to any recommendations and changes.
Care pathways and guidelines used in conjunction with clinical expertise can lead to high quality care, be cost-effective and lead to increased satisfaction for both the family and health professional involved. However, it must be remembered that they need to be reviewed and changed as advances in healthcare are made and consistent variances are identified.
Further information regarding the care pathways can be obtained from PromoCon: 0161 834 2001. www.promocon.co.uk.