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Establishing a bowel dysfunction service within primary care.

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VOL: 100, ISSUE: 20, PAGE NO: 68

Karen Irwin, BA, RGN, DN, is clinical nurse specialist (bowel dysfunction), Bolton Primary Care Trust

Having acknowledged these difficulties, Bolton Primary Care Trust secured funding to support a project across Wigan and Bolton Health Authority to develop an adult faecal incontinence service.

Having acknowledged these difficulties, Bolton Primary Care Trust secured funding to support a project across Wigan and Bolton Health Authority to develop an adult faecal incontinence service.

The initial aims of the project were to provide a comprehensive service and ensure that the local population was effectively screened for faecal incontinence problems.

Establishing the extent of the problem
At the beginning of the project local key stakeholders were identified and a picture of current service provision was established. A steering group was also set up (Box 1) to formulate a strategy for developing an adult faecal incontinence service within primary care.

The steering group found that adults commonly presented to health care practitioners with bowel and defecation disorders. As a result the project was widened to include guidance on assessing and treating other bowel symptoms such as constipation.

Baseline audit
A literature search was undertaken and baseline audits were conducted within the community trust and the continence services.

Community nurse practitioners reported that they received referrals for patients who not only presented with faecal incontinence but also had other significant bowel symptoms such as constipation, faecal impaction, and defecation disorders.

In comparison, the continence services received a smaller number of referrals, and therapy treatments such as biofeedback and neuromuscular electrical stimulation focused on the care of patients with urinary symptoms.

There were no formal bowel continence assessment tools or guidelines to support staff in the assessment and treatment of patients with faecal incontinence and/or bowel dysfunction.

Most staff had received minimal training on bowel assessment and treatment. Where staff had received training, it was usually part of a larger course or study day, such as a course on palliative care.

Nurses identified a need for training in clinical procedures such as digital rectal examination and manual evacuation of faeces.

Results of the project
As a result of the project recommendations, the community trust in Bolton identified additional resources and appointed a clinical nurse specialist for bowel dysfunction to work with the continence advisory team.

The continence team now works across services with closer partnerships between the local colorectal and gastroenterology consultants, and the nurse specialists within those services.

Facilitating primary care assessment
Training Health care practitioners within primary care are given training to improve and build on their existing knowledge and skills in treating and managing faecal incontinence and bowel dysfunction. Evaluation of these sessions has proved very useful and has set the scene for future training and education.

Guidelines These have been developed to support staff in their practice. The overall aim is to improve the treatment and management offered to adults with bowel problems and to identify those who would benefit from specialist assessment and treatment.

The guidelines and information include:

- Assessment documentation;

- Treatment and management guidelines;

- Bowel care procedures (Table 1).

Community nurses take the lead in caring for housebound patients and those who are unable to attend clinics. The nurse specialist supports the community nurses with their patients if requested.

Developing the service
The initial project recommended that specialist treatment clinics were required for people with faecal incontinence and/or defecation problems. It was recommended that the clinics should be based in the community, within the primary care trust, and should take referrals from the primary health care team or secondary care after an initial baseline assessment.

Bowel dysfunction clinic The continence team in Bolton is multiprofessional with both nurse specialists and specialist continence physiotherapists working together. The development of a joint specialist bowel dysfunction clinic utilises the multiprofessional skills of both the specialist nurse for bowel dysfunction and a clinical specialist continence physiotherapist.

Patients attending this clinic have usually been seen by either a colorectal surgeon or gastroenterologist and will have been investigated extensively to exclude any underlying pathology that could explain their bowel symptoms.

Specialist tests - for example colonoscopy, colonic transit studies, defecating proctogram and ano-rectal physiology studies - will have been undertaken to establish the cause of their problem.

Assessment and treatment service People of any age can be referred to this service. Components of the assessment are listed in Table 2. Treatment and management programmes are then planned, such as bowel management strategies and specific therapies including neuromuscular electrical stimulation, sphincter re-education, and biofeedback.

Members of the primary health care team now have clear guidelines to follow during the assessment, treatment, and management of patients with faecal incontinence, faecal loading/faecal impaction and constipation. There has been a significant increase in the number of patients with bowel problems being referred to the continence service by district nurses, health visitors, and GPs (following baseline assessment).

The outcome for patients is looking more favourable, with an established bowel dysfunction service within the continence service and a clinical nurse specialist for bowel dysfunction in post. The service also acts as a resource for patients and their carers to access information and advice regarding their bowel problems.

Colorectal, gastroenterology, women's health, physiotherapy, and continence services are now working together. Each has a key role to play in screening, treating, and managing patients with bowel dysfunction. Referrals are made between these health care professionals, which provides continuity of care.

An audit is currently being planned to measure outcomes of clinical interventions, quality of life of clients accessing the service and specialist clinics, and efficacy of the guidelines in general nursing practice.

A large section of the population have symptoms of bowel dysfunction. In terms of health care provision, this can potentially incur unnecessary costs to the NHS in terms of prescription laxatives, doctor consultation time, and nursing time. There is substantive research to suggest that after accurate diagnosis, many bowel problems can be treated and effectively managed (Chelvanayagam and Norton, 1999; Norton, 1997).

In many cases symptoms such as faecal incontinence can be pre-empted if individuals, professionals and carers are appropriately educated.

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