NDT 1: Constipation: Audit in Motion

Lesley RutherfordNurse Consultant in Palliative Care,

Marie Curie Hospice

NDT: “Audit in Motion”Constipation Audit Tool

Edith McMahon, Fiona Gilmour, Geraldine Tracey, Jean Barber, Lesley Rutherford, Nuala Ginnelly, Trish Curran

October 2015

Aim:

To pilot the constipation audit tool in a variety of adult palliative care settings , across the Island of Ireland, to ensure its suitability nationally

Objectives:

To obtain an overview of current practice within a variety of clinical settings

To determine the applicability of the tool within the individual settings

To determine the experience of using the tool from the clinicians’ perspective

To make recommendations in relation to the design and content of the tool for future use

Process:

Audit proposal was developed

A brief staff questionnaire was developed to accompany the audit tool in order to elicit feedback on the design/usability of the tool itself

Pilot clinical areas were identified ensuring geographical representation across the Island of Ireland and representation from a range of settings

Explanatory information developed for staff participating in the audit

Approval sought ( where necessary) from audit groups within each organisation.

Process cont’d;

NDT Members identified colleagues within their own setting who were willing to participate in the audit.

All participating staff were given an explanation of the background to the project and rationale for audit.

The audit was undertaken on one day only.

NDT members collated data from each individual site which was then subsequently recorded on a master copy on Excel database.

Audit Cycle:

Set standards

Measure current practice

Compare results to standards

Reflect, plan,

change and implement

change

Re-audit

Set from the recommendations in “Management of Constipation in Adults Receiving palliative Care Guidelines”

Compare results to the recommendations in the guidelines. Compliance aims to be 100%

Using the dataCollection form from the guidelines

Formulate an action plan

Re-audit using the same tool and measure changes in practice

Sample: 101 patients were included

OLH & CS Blackrock IPU 11 ROI

OLH &CS Blackrock Community Palliative Care 14 ROI

OLH & CS Blackrock Day Hospice 10 ROI

St Michaels Hospital 6 ROI

North West Hospice IPU 4 ROI

North West Hospice Community palliative care 6 ROI

Sligo Regional Hospital palliative care team 11 ROI

University Hospital Limerick 15 ROI

Havenwood Nursing Home 7 RO1

Macmillan Specialist Palliative Care Unit in AAH NHSCT

12 NI

Regional Cancer Centre; BHSCT 6 NI

Areas included in the audit:

Assessment

Digital rectal examination

Rationale for plain films of abdomen ( if undertaken)

Education on non drug measures

Consideration of non-pharmacological strategies

Prescribing

Use of pharmacological agents in bowel obstruction

Staff Questionnaire

What was your experience of using the tool?

How do you feel about auditing your own practice?

Is this tool applicable in your clinical setting?

What adaptations do you deem necessary?

What did you learn from using the tool?

What adaptations would you deem necessary?

Results in relation to practice:

Findings have been analysed and discussed in the final report.

Overall the auditors were very receptive to auditing their own practice and welcomed the use of a tool. This positive response lends itself to considering such an approach with other guidance documents implemented locally and nationally

The auditors found the concept of an audit tool a good resource for education when implementing new guidance.

The auditors welcomed the opportunity to reflect on their own practice

Results cont’d:

It highlighted gaps in current practice in comparison to the best practice approved recommendations. This was evident not just in acute settings but also in the specialist palliative care settings.

Some of the best practice recommendations were questioned e.g “maximising on one single laxative before the addition of another” and optimisation of a stimulant agent before adding a softener”

The consistent challenge for auditors were the recommendations related to “DRE” . Concerns were raised re roles, responsibilities and competency.

It was highlighted that some recommendations would be difficult to implement in particular clinical settings e.g plain film x-ray for patients in a nursing home setting

The auditors found some of the questions ambiguous

Recommendations:

There should be explicit instructions as to when and with whom the audit tool should be used (eg all palliative care patients or only palliative care patients who are constipated )

Some of the questions need to be reviewed and made more explicit and concise. In particular, questions that have several parts need to allow for each part to be answered individually, instead of one global answer.

The tool may need modification to suit the various clinical settings( however if questions are made more explicit and concise this may not be necessary)

More room for making comments would be useful, especially when “ Not applicable” is selected

Recommendations cont’d:

The inclusion of more patient related information, such as diagnosis, would make analysis of the data more meaningful.

An appendix at the back of the guidelines with a flow chart outlining the management of constipation would be useful

The issue of DRE needs particular attention and if the recommendations remain unchanged , there would need to be a robust, competency based training programme and assessment process.

Given that fact that some of the recommendations from the National document differ from current practice and has been challenged by some auditors, it is recommended that individual organisations formally endorse the National document.

Recommendations cont’d:

As the auditors on this occasion were nurses, it remains to be seen what challenges remain when implementing the national guidance document with medical staff therefore suggest consideration of this group before launching the document

The wording on the formal audit report on the Excel Clinical Audit Tool database needs to be reviewed to accurately reflect the findings ( e.g Criteria 11)

Challenges:

Work commitments imposed by own and other colleagues annual leave, limited members availability for collating data and connecting remotely to discuss progress.

Technical issues re inputting data to excel data base over multiple sites for relatively novice users.

Continuous remote collaboration to overcome hiccups as they occurred via teleconference and email

Time management