Changing Bowel Hygiene Practice Successfully: A Program To Reduce Laxative Use In A Chronic Care Hospital

Transcription

1 Changing Bowel Hygiene Practice Successfully: A Program To Reduce Laxative Use In A Chronic Care Hospital A gradual approach one patient at a time is a major factor in creating an enduring change in clinical practice. BY JEAN M. BENTON/ PATRICIA A. O'HARA/ HILDA CHEN/ DAN W. HARPER/ STEPHEN F. JOHNSTON Laxative use was significantly reduced in our long-term care facility when an interdisciplinary program based on a philosophy of prevention and health promotion was implemented. Specifically, increased fluid and fiber intake, timely toileting habits, and regular activity~exercise led to a halving of the number of patients receiving laxatives as required, relative to pre-program levels and relative to a control unit not receiving the program. (Geriatr Nurs 1997;18:12-7.) he desire to decrease the use of laxatives in our long- T term care facility--sisters of Charity of Ottawa Hospital-Saint Vincent Pavilion (SCOH-SVP)--has resulted in a bowel care program that represents the work of an interdisciplinary committee comprised of nursing, medicine, physiotherapy, dietetics, and pharmacy staff. After reviewing the literature on constipation and bowel care and soliciting staff input, a program was designed to JEAN M. BENTON, RN, Bsc, is a nursing coordinator in Research and Development at The Sisters of Charity of Ottawa (SCO) Hospital, St. Vincent Pavilion in Ottawa, Ontario, Canada. PATRICIA A. O'HARA, PhD, is a research associate at SCO Hospital. HILDA CHEN, RN, is a unit nurse at SCO Hospital. DAN W. HARPER, PhD, is a researcher at SCO Hospital and adjunct professor at Carleton University and University of Ottawa in Ottawa. STEPHEN F. JOHNSTON, BA, is a research assistant at SCO Hospital and a master's student at Carleton University. Supported by the SCO Hospital Foundation and the Chawkers Foundation. Copyright 1997 by Mosby-Year Book, Inc /97/$ /1/78850 shift the focus away from managing episodes of constipation to restoring and maintaining patterns of normal bowel elimination. The SCOH-SVP Bowel Hygiene Practice Guidelines (known hereafter as the SVP Bowel Program) are based on the use of increased fluid and fiber intake, timely toileting habits, and regular activity/exercise as first-line interventions. 1-4 The main elements of the program are described in Table l. This approach is meant to embody a philosophy of health promotion and prevention of bowel dysfunction, rather than the common strategy of dealing with constipation through pharmaceutical means once the problem has become manifest. The program is based on the notion that, with elderly longterm care patients, it is essential to look beyond episodes of constipation and concentrate on patterns of normal bowel elimination. The primary purpose of this article is to describe the implementation of these standards and the results of a retrospective comparative study involving a pilot test unit and a traditional unit. We will outline what we believe contributed to the successful change in our practice and some of the clinical outcomes and staff results gained from our experience. As of April 1995, 30 of 38 continuing care patients on our pilot test unit had been recipients of the revised practice guidelines. Of these, 26 were having patterns of normal bowel elimination without the use of laxatives: It should be noted that, whereas the outcome standard of the SVP Bowel Program includes the use of stool softeners and bulk-forming agents, these 26 patients did not need to use these agents. For the four patients not meeting the outcome standard, the amount of laxative interventions used was decreased. 12 Benton et al. January/February 1997 GERIATRIC NURSING

2 1. A. Fluid intake restricted because of medical condition B. Dietary restrictions (for example, diabetic diet) deficits: feeding) other fluids.) of hydration. drink small amounts of level of the patient. 8. A fluid intake of _>2.0 L/24 hours must be consistently maintained when patient is receivin 9, Baseline and continuous monitorin. cal to bowel hygiene care. I 0. Levels of fluid intake are defined as Inadequate Marginal Adequate <1.5 L/24 hours >_1.5 to <2 L/24 hours >_2 L/24 hours How Was This Change Made? From our experience, the key factors underlying the successful implementation of the bowel hygiene program include the following: 1. Clear expectations as defined by specific and measurable outcome- and intervention-specific, performance, and process standards 2. Reasonable expectations regarding the implementation of the practice guidelines 3. Direct care provider involvement in determining how the standards would be implemented Baseline assessment for fluid intake. On-going assessment For all patients, RNS, R PNs, and HCAs are to monitor and evaluate fluid intake and patient response to the planned fluid intake on a daily basis. GERIATRIC NURSING Volume 18, Number 1 Benton et ai. 13

3 4. Planning for initial successful experiences for staff 5. Monitoring of outcomes for both the individual patient and the unit 6. Management, clinical, and educational support All of the above-listed factors collectively supported the change in thinking and practice regarding the management of constipation. Each of these factors will be discussed separately. Clear Expectations Performance standards specify areas of accountability for each of the levels of nursing personnel, whereas the process standards provided the rationale and guidelines for decision-making (Table 2). Having clear expectations facilitated effective team functioning, improved our sense of accountability, and provided the basis for educational planning for each of the various levels. These expectations were strongly supported by the explicit direction and leadership of our nurse manager. Reasonable expectations. It was decided that the practice standards would be implemented gradually, that is, one patient at a time. This supported the individualization of the standards, a key premise of the practice guidelines. Staff had the time to master the standards, acquire the necessary knowledge base and skills, and develop expert clinical decision-making skills. Staff could then address the more complex conditions of patients such as those in case studies 1 and 2 (Boxes 1 and 2). It is our opinion that Staff had the time to master the standards, acquire the necessary knowledge base and skills, and develop expert clinical decision-making skills. this gradual approach--one patient at a time--is a major factor in creating an enduring change in clinical practice. During the past 4 years, for the patients meeting the established outcome standards, we have not had to administer any enemas or suppositories. These patients have continued to have patterns of normal bowel elimination as defined by the SVP Bowel Program. 14 Benton et al. January/February 1997 GERIATRIC NURSING

4 100 PRN &... + % 80 O F P A T I E N T S REGULAR / / I I I I O- BOWEL PROGRAM UNIT -4- CONTROL UNIT FIGURE 1. Percentage of patients in bowel program unit and the control unit actually taking regularly prescribed and asneeded laxatives over 4-year study period (starting with baseline preprogram data in 1991), Direct care provider involvement. The Interdisciplinary Bowel Hygiene Committee established the operating outcome- and intervention-specific standards, but our direct care providers creatively decided how these standards would be made operational on the unit. For example, we decided that the most efficient way to track fluid and dietary fiber intake was to use the patient's menu slips. The direct care provider would enter the We decided that the most efficient way to track fluid and dietary fiber intake was to use the patient's menu slips. amount of fluid taken, as well as the amount of food consumed at a meal. At the end of the shift, these patient data were entered into the bowel elimination record. Other examples of staff creativity included offering and.,assisting the patient to take a drink of water as part of all staff-patient interactions, offering a warm fluid before breakfast and for patients not demonstrating a triggering meal, and selecting a toiletting time that helped balance the work load. Gearing for successful experience. Initially choosing patients for whom implementation of the standards would Woman, age 89 years Activity level: Up in chair daily BOX 2. CASE STUDY 2 Initial clinical observations: bowel elimination Bowel movement: Every 3 to 4 days, hard stool Fluid intake: 1.3 to 1.5 L/24 hours Fiber intake: Approximately 8 gm daily Started on bowel hygiene program: September 1994 Bowel hygiene interventions Fluid intake increased to 2 L/24 hours (achieved in 1 month) Fiber increased to 22 gm (achieved in 2 months) Senokot discontinued after I month; Dulcolax discontinued after 4 months Outcome by April 1995 Normal bowel elimination every 2 to 3 days without the use of laxatives. No episodes of acute constipation. Outcome by January 1996 Has maintained outcome established in April 1995 be relatively straightforward and for whom a successful outcome could be expected is important. Criteria for the first patients included in the program were as follow: 1. The patients did not have swallowing impairments 2. The patients were able to understand GERIATRIC NURSING Volume 18, Number 1 Benton et al. 15

5 3. The patients were able to cooperate reasonably well with expectations 4. The patients were relatively easy to transfer to the toilet 5. The patients did not have any medical condition that would restrict fluid intake or negate the patient coming onto the program Monitoring of outcomes both for the individual patient and for the unit. Two types of laxative utilization reports were used: (1) a pharmacy computer-generated printout of all laxative prescriptions, regularly prescribed and as needed, and (2) an as-needed usage report completed by the nurse on the unit. A preimplementation and postimplementation snapshot picture of each patient reinforced individuality of the care plan. A unit-based Bowel Hygiene Committee reviews these data on a regular basis. This feedback helps us with effective problem-solving. Accountability for what was happening with each of the patients in a module facilitates continuity of care. Provision of management, clinical, and educational support. The infrastructure that supported us to change included modular nursing, the provision of educational and clinical support from nursing education, an active continuous quality improvement philosophy, and a facilitated documentation system. The same nursing staff (registered nurses [RNs], RPNs, and HCAs) had the same group of patients and developed a strong sense of " ownership" for the patient care that occurred. Accountability for what was happening with each of the patients in a module facilitates continuity of care. Modular team members know the patient's current plan of intervention and evaluation status. We compliment each other as the patient progresses and hold each other accountable when the plan of intervention is not followed. The coaching skills of the nurse manager and educator helped us to develop our critical thinking skills. Having a documentation system designed to capture essential patient information, accessible at the bedside, facilitated the recording of patient data, which forms the basis for continuous evaluation of the patient's response to interventions and overall progress. Documentation forms specific to the bowel hygiene standards include the bowel elimination record; plan of care: chronic constipation form; nursing care flow sheet; and progress evaluation form. Copies of these forms are available from the authors. 16 Benton et al. January/February 1997 GERIATRIC NURSING

6 A Comparative Evaluation of the Program To examine the usefulness of this program in terms of the most salient aspect of any bowel care protocol--patterns of laxative use--a retrospective evaluation of the medication records of two comparable chronic care units (differing only in their adherence to the bowel program) was undertaken. In 1992 one unit at SCOH-SVP adopted the newly created SVP Bowel Program. By comparing data about laxative use on this unit from 1991 to 1994 with data from a demographically similar unit that had not adopted the bowel program, it was possible to track changes in laxative usage unit over time and differences in laxative usage between two units with differing protocols regarding bowel care. Figure 1 illustrates these findings. In 1991, before the implementation of the SVP Bowel Program, both study units were similar in the proportion of patients receiving regularly prescribed and as-needed laxatives, and in other demographic and diagnostic characteristics. With the implementation of the health measures of hydration, dietary fiber, and regular and consistent toileting, use of as-needed laxatives on the bowel program unit dropped from almost universal usage (9!.2%) to less than 40%. This significant decline in the actual usage of as-needed laxatives is a reflection of the impact of the SVP Bowel Program on the most widely used method of prescribing laxatives to patients receiving long-term care and is consistent with the findings of other authors.5-1 There was also a marked decline in the use of regularly prescribed laxatives on the bowel program unit (from 23.5% to 15.8%). Although this decrease is not as dramatic as the drop in use of as-needed laxatives, it should be noted that levels of regularly prescribed laxatives are lower than as-needed laxatives to begin with. The relative stability of the rate of patients receiving regular prescriptions may serve to identify the subset of patients who can be diagnosed with "true" clinical constipation and who may require some type of laxative intervention. Outcomes of our experience Besides the decreased laxative use, we have noted other clinical and staff results as outlined in Table 3. These clinical trends need to be validated with well-constructed and well-conducted research studies. In summary, what seemed to be an impossible task has turned out to be a great learning and growth process. As important, if not more important, is the improved quality of life for our patients. Gradually bringing patients onto the bowel hygiene standards proved to be key to successful implementation. The first experience of a patient having a pattern of normal bowel elimination surprised even the most hardened nonbeliever. Successful achievement supported us in making the paradigm shift, that is, moving from viewing constipation as inevitable to knowing that constipation is highly preventable. We thank the patients and staff of the two continuing care units at SCOH-Saint Vincent Pavilion, C. FauIkner, nurse manager, C. Madigan, nurse educator, and J. Sigouin, secretary-department of Research, SVP. REFERENCES 1. Resnick B. Constipation: common but preventable. Geriatric Nursing 1985;6: Burkitt DR Dietary- fiber: is it really helpful? Geriatrics 1982;37: Castle C. Constipation: a pressing issue. Arch Intern Med 1987;147: Donnatelte ER Constipation: pathophysiology and treatment. AFP Pract Therap 1990;42: Pattee J, West M. Clinical aspects of a fiber supplementation program in a nursing home population. Curr Ther Res 1988;43: Behm RM. A special recipe to banish constipation. Ger Nuts 1985;6: Bradford L, Dunbar J. Behavioral home management of cathartic withdrawal in a laxative-dependent elderly woman. Arch of Psych Nurs 1987;1: Hope A. The relief of constipation in the elderly. Austr Nurs J 1983;12(10): Hull C, Greco RS, Brooks, DL. Alleviation of constipation in the elderly by dietary fiber supplementation. J Am Geriatr Soc 1980;28: Rodriques-Fisher L, Bourguignon C, Good BV. Dietary fiber nursing intervention: prevention of constipation in older adults. Clin Nurs Res 1993;2: GERIATRIC NURSING Volume 18, Number 1 Benton et al. 17