Constipation Audit Tool Implementation
NDT 1: Constipation: Audit in
Motion
Lesley Rutherford
Nurse 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 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 data
Collection form
from the guidelines
Formulate an
action plan
Re-audit using the same
tool and measure
changes in practice
Sample:
101 patients were included
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
Aimed at piloting a constipation audit tool in adult palliative care settings across Ireland, this project focuses on assessing current practices, tool applicability, clinician feedback, and future recommendations. The process involved developing an audit proposal, creating a staff questionnaire, seeking approvals, conducting audits, and collating data for analysis. The audit cycle follows guidelines, sets standards, measures practice, re-audits, reflects on changes, ensures compliance, and formulates action plans for improvement.
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Presentation Transcript
NDT 1: Constipation: Audit in Motion Lesley Rutherford Nurse Consultant in Palliative Care, Marie Curie Hospice
NDT: Audit in Motion Constipation Audit Tool Edith Geraldine Lesley Rutherford, Nuala Ginnelly, Trish Curran McMahon, Tracey, Fiona Jean Gilmour, Barber, 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 representation across the Island of Ireland and representation from a range of settings clinical areas were identified ensuring geographical Explanatory information developed for staff participating in the audit Approval sought ( where necessary) from audit groups within each organisation.
Process contd; NDT setting who were willing to participate in the audit. Members identified colleagues within their own 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 from the recommendations in Management of Constipation in Adults Receiving palliative Care Guidelines Set standards Using the data Collection form from the guidelines Measure current practice Re-audit using the same tool and measure changes in practice Re-audit Reflect, plan, change and implement change Compare results to the recommendations in the guidelines. Compliance aims to be 100% Compare results to standards Formulate an action plan
Sample: 101 patients were included OLH & CS Blackrock IPU OLH &CS Blackrock Community Palliative Care OLH & CS Blackrock Day Hospice St Michaels Hospital North West Hospice IPU North West Hospice Community palliative care Sligo Regional Hospital palliative care team University Hospital Limerick Havenwood Nursing Home Macmillan Specialist Palliative Care Unit in AAH NHSCT Regional Cancer Centre; BHSCT 11 14 10 6 4 6 11 15 7 12 ROI ROI ROI ROI ROI ROI ROI ROI RO1 NI 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 contd: 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 contd: 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 contd: 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
