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Evaluation of the implementation of a bowel management protocol in intensive care: effect on clinician practices and patient outcomes

Authors

  • Serena Knowles RN, BN, GradCertClinNurs,

    PhD Candidate, Clinical Nurse Specialist
    1. School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia
    2. Intensive Care Service, St. Vincent's Hospital, Sydney, NSW, Australia
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  • Elizabeth McInnes RN, PhD,

    Associate Professor
    1. Nursing Research Institute, St. Vincent's and Mater Health Sydney, Sydney, NSW, Australia
    2. Australian Catholic University, Sydney, NSW, Australia
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  • Doug Elliott RN, PhD,

    Professor
    1. Faculty of Nursing, Midwifery & Health, University of Technology, Sydney, NSW, Australia
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  • Jennifer Hardy RN, PhD,

    Senior Lecturer
    1. Clinical Education Academic, Sydney Nursing School, University of Sydney, Sydney, NSW, Australia
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  • Sandy Middleton RN, PhD

    Professor, Director, Corresponding author
    1. Nursing Research Institute, St. Vincent's and Mater Health Sydney, Sydney, NSW, Australia
    2. Australian Catholic University, Sydney, NSW, Australia
    • Correspondence: Sandy Middleton, Professor, Nursing Research Institute, St. Vincent's and Mater Health Sydney and Australian Catholic University, Executive Suite, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW 2010, Australia. Telephone: +612 8382 3790/+612 83823792.

      E-mail: sandy.middleton@acu.edu.au

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Abstract

Aims and objectives

To evaluate the effect of a multifaceted implementation of a bowel management protocol on outcomes for intensive care patients, in particular the incidence of constipation and diarrhoea, and on clinicians' bowel management practices.

Background

Complications associated with poor bowel management for critically ill patients result in adverse outcomes. Implementation of protocols requires strategies proven to change clinician behaviour.

Design

Before and after study.

Methods

Our bowel management protocol was implemented using three evidence-based elements: education sessions, printed educational materials in the form of a fact sheet and reminders. We retrospectively collected data from patients' medical records admitted at two time points within three Sydney metropolitan intensive care units (preimplementation, n = 101; postimplementation, n = 107).

Results

No significant difference was found in the incidence of constipation and diarrhoea pre and postimplementation of the protocol. Seventy-two per cent (n = 73) of patients preimplementation and 70% (n = 75) of patients postimplementation experienced one or more episodes of constipation (bowels not open for 72 hours or greater), and 16% (n = 16) of patients preimplementation and 20% (n = 21) of patients postimplementation experienced one or more episodes of diarrhoea. There was a slight nonsignificant increase in bowel assessment on admission by medical officers postimplementation (pre, 47%, n = 48; post, 60%, n = 64).

Conclusion

Targeted multifaceted implementation of a bowel management protocol did not have an impact on the incidence of constipation or diarrhoea for intensive care patients or on clinician practices. The lack of impact on patient outcomes may be due to clinicians' nonadherence to our bowel management protocol. Reasons clinicians' practices did not change may include the influences of clinical decision-making on behaviour.

Relevance to clinical practice

This study highlights difficulties inherent in changing clinician behaviour and practices to improve patient outcomes despite using an evidence-based multifaceted implementation strategy. Further research is required to ascertain the most effective implementation strategies.

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