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Developing a paediatric bowel care pathway

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Constipation and soiling is a very common problem in childhood yet there is a wide variation in how well these children were treated.

Constipation and soiling is a very common problem in childhood yet there is a wide variation in how well these children were treated.

In paediatric continence promotion there are very few large randomised, placebo-controlled trials available regarding identifying optimum treatments, therefore the treatment of these children is often mainly based on personal clinical experience.

There is a concern that treatments for constipation in children are based on a local 'custom and practice' basis rather than current 'expert' thinking and the availability of new treatments.

Our service was aware, for example, that many children were still being subjected to hospital admissions and having to undergo distressful procedures such as enemas to resolve impaction when newer oral treatments had been available for a number of years.

Also, there are concerns that the inappropriate perception of many health professionals is that soiling is the child?s fault because they were being 'naughty? or 'lazy?.

To address this, a group led by specialist paediatric continence advisor June Rogers set about to develop a consensus document for the management of children with constipation and soiling. This was later called the IMPACT paediatric bowel care pathway.

This was intended to improve the management of children who suffer from constipation and faecal impaction by:

  • Bringing together expert opinion regarding current evidence-based treatments
  • Increasing the knowledge of healthcare professionals to whom these children present
  • Providing information to children and their carers about constipation and faecal impaction and the medicines used to treat them.
  • Developing and disseminating best practice
  • It has been identified that for good practice in the management of children with constipation, evidence-based algorithms and care pathways written by expert panels should be used, which should also offer assessment and treatment guidelines (Bell and Wall, 2004).

By combining the clinical experience of the group members in developing the care pathway a more accurate tool than what was previously available in terms of assessment, diagnosis and treatment was developed. This was combined with an extensive literature search to identify current best practice and up to date treatment interventions.

The IMPACT folder is split into three sections:

  1. Health professional education - this section contains all the basic background information you must have to ensure a thorough grounding in anatomy, physiology, definitions, taking a medical history and guidelines to treating paediatric constipation and faecal impaction.
  2. Patient assessment forms - it is important that all our patients are assessed in a systematic and thorough manner. In this section there are assessment forms, symptom profiles, risk assessment forms, bowel record charts and medication plans.
  3. Patient information and star charts - in this section we concentrate on the patients and their carers. We wanted to empower them with knowledge of their child?s condition and what they can do to help. We have patient information leaflets, fibre charts, food and drink diaries and star charts.

The final drafts of the IMPACT document were piloted locally before being sent more widely to the ACA, RCN and colleagues nationally to review. The final version was completed in the beginning of 2005.

IMPACT has achieved a great deal. First, it has promoted child and family centred care. The statements within the care pathways are child focused and the treatment guidelines promote the inclusion of the child and family in the treatment decision making and empower the family to manage the problem more effectively

Second, it has reduced the number of children requiring secondary referral. Since its introduction none of the children referred to our service with constipation have had to be referred to the acute sector for treatment.

Third, it encourages standardisation of treatment. By using the care pathway and the standardised documentation and assessment forms children should be receiving the same assessment and treatment interventions for the same condition regardless of who sees them.

Since April 2005, with the help of an unrestricted educational grant from Norgine, June Rogers, two children?s continence nurse specialists and one of the consultant paediatricians from the working group have been involved with 30+ training meetings around the UK and Ireland to promote IMPACT.

Almost 1,000 healthcare professionals - from school nurses to paediatric consultants - have now been instructed in the IMPACT bowel care pathway. The study days are targeted at those already seeing children with constipation and every delegate is encouraged to hold their own training meetings to pass on their knowledge at a local level.

Each delegate leaves the course with a full understanding of the contents of the training package, an IMPACT folder and a CD-ROM of all the paperwork, plus a set of training slides to facilitate each delegate training their own teams. These training meetings have been well evaluated.

Bell EA, Wall GC. (2004) Pediatric constipation therapy using guidelines and polyethylene glycol 3350. The Annals of Pharmacotherapy; 38: 686-693.

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