Historically the management of children with continence problems such as constipation was based purely on clinicians’ experience and ‘custom and practice’.
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Author June Rogers, BSc, BA, SN (Cert), DPSN, RSCN, RN, is paediatric continence adviser and director of PromoCon, Disabled Living NW, Manchester.
Abstract Rogers, J. (2008) The IMPACT paediatric bowel care pathway. Nursing Times; 104: 18, 46–47.
Care pathways to manage continence problems in adults are well established (Bayliss et al, 2003). However, little work had been carried out to develop care pathways in paediatrics. There are increasing numbers of nurse-led clinics for children with continence problems, and nurses need structured systems to guide practice. June Rogers explains how the IMPACT paediatric bowel care pathway was developed.
Critical examination of clinical practice should be an integral part of care. In a study by Banning (2005), while nurses were aware of research,
many admitted that they did not read research papers. An essential component of clinical governance is clinical effectiveness, which is achieved through evidence-based practice. This has enormous implications for the way nurses work. It requires them to keep up to date
with research and to challenge traditional, outdated practices.
Historically the management of children with continence problems such as constipation was based purely on clinicians’ experience and ‘custom and practice’. It is now recognised that this is no longer sufficient to provide optimum levels of care (Schattner and Fletcher, 2003).
However, there is only a small number of large randomised, placebo-controlled trials to inform treatment decisions in the management of children with continence problems (Benninga et al, 2004). The concern is that treatments in children may continue to be based on local custom and practice rather than on current expert thinking and consideration of new treatments.
Evidence-based practice integrates clinical experience and patient values with the best available research information (Craig et al, 2001). Clinical practice guidelines and protocols have been shown to improve the quality of care by reducing inappropriate variations, producing optimal outcomes, minimising harm and promoting cost-effective practices (AmericanAcademy of Pediatrics, 2004).
Care pathways and guidelines are systematically developed statements to help both practitioner and patient to make decisions in specific circumstances. They are useful tools for making care more consistent and efficient and for
closing the gap between what clinicians do and available evidence (Eccles and Mason, 2001).
Care pathways determine locally agreed multidisciplinary standards that are based on current evidence, where available, for a specific patient group.
Developing the pathway
The management of children with constipation should follow evidence-based algorithms and care pathways written by expert panels (Bell and Wall, 2004). Guidelines are more likely to succeed if they are developed by practitioners who use them in their own work. The IMPACT pathway was developed by a multidisciplinary group of practitioners from around the UK who were actively involved in the management and treatment of children with bowel problems.
The aim of developing the IMPACT document was to improve the knowledge of all healthcare professionals who deal with children who suffer from constipation and faecal impaction and to improve the treatment of such children by developing best practice (see case study, Box 1).
A paediatric care pathway developed by the author at another trust was used as a basis for discussion and the group undertook a literature search to identify new evidence. In the absence of pertinent research evidence, the working party used best practice taken from centres around the UK and the consensus opinion and experience of all the team members.
Clinical experience provides clinicians with an intuitive sense of which findings made during assessment, examination and any investigations are critical in making an accurate diagnosis (McGinn et al, 2000). There are very few randomised controlled studies to provide the evidence regarding treatment recommendations within paediatrics, with as much as 72% of the evidence coming from expert opinion (Bergman, 1999). Combining the clinical experience of the group members in the development process meant a more accurate pathway was developed.
The group met on numerous occasions over an 18-month period and drafted several versions until the document was ready to be piloted. Following a six-month pilot, final changes were made and the IMPACT resource was launched in 2005.
The IMPACT resource folder comprises:
Background, definitions and causes of constipation and faecal impaction;
Patient assessment forms and tools;
Information for the child and family;
Using the resource locally
The IMPACT paediatric bowel care pathway will need to be adapted to local policies, procedures and guidelines, as well as local best practice and taking into account local resources.
Wirtschafter et al (1994) has demonstrated that combining written guidelines with an educational programme leads to improved clinical practice and reduced variability in outcomes.
The education programme was developed to go along with the pathway in conjunction with IMPACT and was disseminated at a series of study days across the UK. The feedback from the training sessions was extremely positive with an estimate of around 1,000 healthcare professionals undertaking the training.
The IMPACT resource is a dynamic document that develops and improves as the evidence changes and in response to feedback from healthcare professionals. As a result, a new section regarding children with soiling and learning disabilities is being developed.
Within the UK there is now a number of consensus documents regarding the management of children with constipation and soiling including ERIC minimum standards (ERIC, 2001) and IMPACT. Services should be developed that take on board the evidence.
For further information, email firstname.lastname@example.org
Box 1. Taking a holistic approach to care
I could hear three-year-old Ella screaming ‘No, no, no!’ as soon as I pressed the front door bell. Ella had a long-standing history of constipation and soiling. She had been seen by numerous health professionals and had two hospital stays, including visits to theatre in an effort to resolve the problem. As the paediatric continence adviser, I had been asked to administer an enema at the request of the district nurses following several failed attempts.
Ella had shut herself in her bedroom wardrobe and was refusing to come out. Her mother was angry and upset that her child was suffering and nobody could give her the right answer about how to make her child better.
Ella had been on various laxatives over the years, and her mother said that every time she saw a different health professional she was given different advice, none of which appeared to result in any real improvement.
It was clear that a number of issues needed to be addressed, including Ella’s fear of the toilet. Nobody had looked holistically at the problem and practitioners had continued with treatments that were potentially exacerbating the problem. Working with the paediatrician it was decided that the laxatives Ella was on, including the enemas and suppositories, should be discontinued and a new laxative introduced (Movicol). The pressure for Ella to defecate in the toilet was taken away by leaving her in a nappy (she had yet to be potty-trained because of the continued soiling).
Time was also spent with the family. Ella’s mother felt guilty as the first doctor she consulted blamed Ella’s constipation on her poor diet and her approach to potty-training. However, the history indicated that Ella’s problems had started long before then.
Once the new regimen was introduced, the results were dramatic. Within two weeks, Ella’s mother reported that Ella was a different child. She had now started to defecate happily with no screaming or apparent fear, her appetite had returned and the aggressive behaviour had disappeared.
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