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Idiopathic constipation management pathway

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VOL: 98, ISSUE: 43, PAGE NO: 48

Jenny Gordon, RGN, RSCN, BSc, is research training fellow, Royal Hospital for Sick Children, Edinburgh

Pam Reid, RGN, RSCN, DipDN, andChristine Thompson, RGN, RSCN, RHV, BA, are community children's nurses;Carol Walford, RSCN, OPTEK Cert, is specialist in continence and stoma management, Royal Hospital for Sick Children, Edinburgh

In 1996 two members of the community children's nursing team at The Royal Hospital for Sick Children (RHSC), Edinburgh, devised and implemented a community guideline to support the management of children with idiopathic constipation (Box 1 and 2) and their families. By 1998 there were increasing concerns regarding the management of these children. There appeared to be no coordinated approach to management or consensus regarding pharmacological treatment. To ensure these concerns were legitimate, a basic audit of children attending RHSC was undertaken. The results showed that there were nine surgical admissions and 17 attendees to the hospital A&E department each month.

In 1996 two members of the community children's nursing team at The Royal Hospital for Sick Children (RHSC), Edinburgh, devised and implemented a community guideline to support the management of children with idiopathic constipation (Box 1 and 2) and their families. By 1998 there were increasing concerns regarding the management of these children. There appeared to be no coordinated approach to management or consensus regarding pharmacological treatment. To ensure these concerns were legitimate, a basic audit of children attending RHSC was undertaken. The results showed that there were nine surgical admissions and 17 attendees to the hospital A&E department each month.

The children and families referred to these areas had often had idiopathic constipation for some time. Treatment was varied and often invasive. The 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 the A&E department could be described as crisis management.

Few of the children and families attending the hospital were referred for ongoing support and management. This was the catalyst for change, resulting in the coordination of a constipation steering group.

The constipation steering group
The membership of the steering group comprised multiprofessional advisers from both primary and acute health sectors. Those included were from paediatric surgery, paediatric gastro-enterology, child and family mental health, general practice, acute paediatric nursing, health visiting, school nursing, complementary therapies, community children's nursing, community child health and pharmacy.

The primary purpose of the steering group was to gain an understanding of each other's roles and responsibilities for children with idiopathic constipation. We shared knowledge, experiences and current practices. Despite being a common disorder there is relatively little information regarding treatment and prognosis.

A year of negotiation led to a consensus that a comprehensive resource in the form of an integrated management pathway was desirable. A core working group was formed to drive the changes forward. Its first task was to survey children referred to paediatric surgery and audit the number of children receiving treatment for constipation by GP practices within the city of Edinburgh, East Lothian and Midlothian.

Survey of paediatric surgery
The survey sampled the case notes from all referrals from November to December 1998. This informed the development of referral criteria.

Audit of primary care
The constipation working group audited children being treated within primary care for idiopathic constipation. Out of 37 children treated, 27% had previous related admissions, 73% required prescribed medicine and 54% had a consultant follow-up.

The findings of the audit supported the consensus of the steering group that there was a need for management guidelines.

Childhood idiopathic management pathway
The pathway, entitled 'Tough Going', is the outcome of two years of consultation and collaboration and provides a comprehensive resource covering all aspects of childhood idiopathic constipation management. It is not intended to be prescriptive but rather a dynamic document that will incorporate changes in practice as they develop.

Inadequate management of acute constipation, although frequently short-lived, may lead on to chronic difficulties. Early effective intervention is therefore vital and is associated with better prognosis than when treatment is delayed (Elshimy et al, 2000; Clayden, 1994; Gallagher, 1998).

The pathway provides an opportunity to facilitate early identification of constipation and increase understanding of management issues.

Aims of 'Tough Going'
The aims of the pathway are as follows:

- To provide a quality service for children who have idiopathic constipation and their families;

- To ensure the care provided is evidence-based and coordinated.

Content of the pathway (Box 3)

The resource is presented in a ring binder to accommodate additional and updated information. A constipation treatment pathway provides the framework for management. At each point the constipation treatment pathway is identified with an icon which refers the user to detailed information pertinent to each section for the pathway. The icons enable easy reference throughout and ensure that the package is user-friendly.

Outcomes
'Tough Going' has been distributed throughout the City of Edinburgh, East Lothian and Midlothian to primary and acute health care professionals. It provides equity for children and their families at the point of access. The resource is evidence-based and facilitates health promotion strategies. Successful implementation of 'Tough Going' will potentially prevent chronic constipation and associated problems.

There has been considerable interest from health care professionals nationwide. 'Tough Going' is being utilised by the British Paediatric Society of Gastroenterology, Hepatology and Nutrition Constipation Working Party as part of the consultation process for a national guideline. It was a finalist in the Scottish Executive Evidence-Into-Practice awards 2002.

As 'Tough Going' is evidence-based, an audit of the current document is planned for January 2003 - a year after the initial launch.

- Copies of Tough Going can be purchased from the Constipation Working Group, Community Children's Team, Royal Hospital for Sick Children, 14 Rillbank Terrace, Edinburgh EH9 1LF

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