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All Wales Guidelines for Faecal Management Systems Guidelines for Best Practice IN ASSOCIATION WITH Supported by an unrestricted educational grant Fforwm Nyrsys Hyfywedd Meinwe Cymru Gyfan Association for Continence Advice Professionals united in continence care Endorsed by

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Page 1: All Wales Guidelines for Faecal Management Systems · 2 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 3 Foreword Professor Jean White, Chief Nursing

All Wales Guidelines for Faecal Management SystemsGuidelines for Best Practice

IN ASSOCIATION WITH

Supported by an unrestricted educational grant

Fforwm Nyrsys Hyfywedd Meinwe Cymru Gyfan

Association for Continence Advice Professionals united in

continence care

Endorsed by

Page 2: All Wales Guidelines for Faecal Management Systems · 2 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 3 Foreword Professor Jean White, Chief Nursing

2 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 3

Foreword

Professor Jean White, Chief Nursing Officer for WalesFaecal incontinence is an embarrassing and undignified condition for the patient, which significantly reduces a person’s quality of life. It can affect all ages, with certain groups of individuals at greater risk than others. If poorly managed, it can lead to other health problems, particularly damage to the skin’s integrity, infection and an increased likelihood of pressure ulcer formation. Faecal incontinence is a difficult condition to manage and the introduction of Faecal Management Systems is a significant advance in caring for individuals. I welcome these All Wales Guidelines for Faecal Management Systems, which are the culmination of a joint project undertaken by nurses from three nursing specialties: continence, infection prevention and tissue viability. The nurse leads for the project all work in NHS and higher education organisations in Wales and have shown real inspiration and dedication in the development of these guidelines. They are:

Julie Evans Tissue Viability Nurse, Abertawe Bro Morgannwg University Local Health BoardJoanna Price Infection Control Nurse, Cwm Taf Local Health BoardAnn Yates Director of Continence, Cardiff and Vale University Local Health BoardTrudie Young Lecturer in Tissue Viability, Bangor University The purpose of the All Wales Guidelines is to support clinical staff in deciding whether the Faecal Management System is appropriate and suitable for an individual patient. The guidance can also be used as part of local policies and protocols for tissue viability, management of continence and infection prevention. I commend these guidelines to you.

Introduction

There are, at present, no national guidelines available for the management of faecal incontinence with regard to Faecal Management Systems (FMS).

The National Institute for Health and Clinical Excellence (NICE) (2007) recommends that health professionals should consider a faecal collection device on the basis that severe uncontrolled diarrhoea is a threat to skin integrity. In addition, uncontrolled diarrhoea has an impact on psychological health, and increases the risk of cross-contamination and infection from pathogens such as Clostridium difficile.

Padmanabhan et al (2007) published a clinical evaluation of a FMS. Even if the study lacked a control group, they demonstrated an improvement in skin condition using FMS.

In 2007, the Rapid Review Panel (Health Protection Agency) recommended FMS (level 1), indicating that it should be available to NHS bodies as part of their cleaning, hygiene and infection control protocols. The HCAI Technology Innovation Programme (2009) commissioned a Showcase Report which showed that FMS was favourably received by staff and patients, with use being decided locally by healthcare organisations.

The purpose of these guidelines is to ensure the appropriate use of the FMS within the seven Health Boards, one Health Trust and independent sectors in Wales, and to provide guidance to staff during the decision-making process for its suitability to patients. It is suggested that this guidance should form part of continence, infection prevention and tissue viability protocols.

The guidance provided by this document is based on expert consensus, which along with audit has been suggested as a positive method of directing care (Ousey et al, 2010)

BackgroundThe treatment and care of patients in hospital is often complicated by the development of an infection which arises from a variety of factors that make people susceptible to microbial challenge. These include reduction of the body’s

immune system by many illnesses, the presentation of disease in the elderly (who are particularly prone to infection), medical interventions which compromise normal protective mechanisms, and the potential for transmission of pathogenic organisms from patient to patient when they are managed in close proximity.

The prevention and control of infection is a significant challenge, and despite our efforts, hospital-acquired infections remain common. National surveys suggest that 8% of inpatients have a hospital-acquired infection at any one time. The effects of a hospital-acquired infection vary from discomfort to prolonged or permanent disability, and in some circumstances can result in death (Department of Health (DH), 2007).

DefinitionsMost people acquire bowel control at a young age and then take it for granted, however if something goes wrong the incontinence can have devastating effects on the individual and family.

Definition of Faecal IncontinenceFaecal incontinence has a variety of definitions. The Royal College of Physicians (1995) state ‘the involuntary or inappropriate passage of faeces’, while Kenefick (2004) defines it as the ‘uncontrolled passage of solid or liquid faeces at socially inappropriate times and place’. The most recognised and used definition is for anal incontinence which includes not only liquid or solid faeces, but also the inappropriate passage of flatus developed by the World Health Organization Consultation on Incontinence (Norton et al, 2002): ‘Anal incontinence is the involuntary loss of flatus, liquid or solid stool that is a social or hygienic problem’.

Definition of Diarrhoea Diarrhoea derives from the Greek ‘to flow through’. Diarrhoea is usually the passage of frequent (more than three times daily) loose, watery or unformed stools. It usually presents as either acute or chronic diarrhoea. Chronic diarrhoea is identified if the symptoms persist for 1 month or more (Talley and Martin, 1996).

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4 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 5

The Extent of the ProblemEpidemiological information highlights that between 1% and 10% of adults are affected by faecal incontinence, depending on definition and frequency (NICE, 2007). However, most of the studies relate to chronic problems rather than acute. The management of faecal incontinence has traditionally taken the form of meeting patients’ hygiene needs, changing bed linen and using incontinence pads, etc. While appropriate for some patients after a full assessment has been undertaken, it may be less effective for others. Before any device or treatment is instigated, a full assessment by a health professional trained, skilled and competent in bowel dysfunction should be undertaken (NICE, 2007). One of the main reasons is the importance of excluding RED FLAG risk groups, which could include: passing of blood; excessive mucus/wind not associated with lifestyle changes; unintentional weight loss; anaemia; and altered bowel habits over the previous 6 weeks. Patients identified with any of these symptoms should be immediately referred to a medical practitioner.

The risks of cross-infection, skin excoriation, incontinence-associated dermatitis (IAD), wound contamination, and dehydration should also be considered (Ousey and Gillibrand, 2010).

The exact extent of the prevalence of faecal incontinence is unknown. It has been postulated that this may be complicated by the different definitions of faecal incontinence (Ousey et al, 2010). However, faecal incontinence is a common denominator among hospitalised patients (Wishin et al, 2008). In the UK, a small prospective study reported a high prevalence of faecal incontinence within intensive care settings (Ousey and Gillibrand, 2010). A similar study gathered data on 1106

patients, of whom 31.6% (n=350) were incontinent of urine, faeces or doubly, and 1.54% (n=17) had incontinence lesions. Of those at a very high risk of pressure damage according to the Waterlow scoring system (2005), 78% (n=125) were incontinent (Evans, 2010).

C. difficile infection is the most important cause of hospital acquired diarrhoea and is responsible for considerable morbidity and mortality. When certain antibiotics disturb the balance of bacteria in the gut, C. difficile can multiply rapidly and produce toxins that cause diarrhoea. C. difficile is usually spread via the hands of healthcare staff and other people who come into contact with infected patients, or with environmental surfaces contaminated with the bacteria or its spores. Spores are produced when C. difficile bacteria encounter uncomfortable conditions such as being outside the body. They are very hardy and can survive on clothes and environmental surfaces for up to 5 years (Health Protection Agency (HPA), 2009).

Mandatory surveillance of C. difficile in inpatients aged over 65 years in Welsh hospitals was introduced by the Welsh Assembly Government in 2005. The total number of C. difficile cases in Wales reported in 2008–2009 was 2744, representing rates of 15.46 per 1000 hospital admissions (Welsh Healthcare Associated Infection Programme (WHAIP), 2009). Organisations throughout Wales are mandated to reduce the level of healthcare-associated C. difficile infections by at least 20% year-on-year.

Patients with C. difficile associated diarrhoea may experience faecal incontinence, which has direct implications regarding environmental contamination and cross-infection (Starr, 2005). The FMS is a fully closed system that collects and contains liquid or semi-liquid stools, and is therefore effective in containing faeces and helpful in preventing faecal contamination of the environment (Johnston, 2005).

Individuals at Risk Skin DamagePeople over the age of 65 years are more susceptible to contracting infections. 80% of C. difficile cases reported are in this age group (HPA, 2010). The risk for C. difficile acquisition significantly increases in patients with recent exposure to antibiotics and in particular, with the use of broad-spectrum antibiotics. Other factors that increase the risks of acquiring C. difficile infection include patients who have undergone recent gastrointestinal surgery, patients who have serious underlying illnesses, immunosuppressed

patients, and patients who have been hospitalised frequently or for long periods of time. The risk of patient-to-patient transmission is increased when caring for patients who are faecally incontinent (WHAIP, 2009).

High-risk groups for faecal incontinence include (NICE, 2007): frail older people; women after child birth (especially third/fourth degree tear, instrumental delivery, midline episiotomy, first baby, birth weight over 4 kg); people with loose stools or diarrhoea from any cause; neurological or spinal disease; people with severe cognitive impairment; pelvic organ prolapse and or rectal prolapse; colonic resection or anal surgery; undergone pelvic radiotherapy; perianal soreness; itching or pain; and people with learning disabilities.

Wishin et al (2008) identified that hospitalised patients are predisposed to skin damage. In addition, certain patient groups are at risk of skin/pressure damage, specifically those undergoing surgery with or without epidural anaesthesia and those individuals suffering with a degree of sensory impairment (e.g. multiple sclerosis, cerebral vascular accident, epidural anaesthetic) (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (EPUAP and NPUAP), 2009). This risk is due, in part, to reduced mobility and exposure of the skin to uncontrolled moisture from incontinence and/or wound exudate, and prolonged contact with faecal material (Kingsley, 2007). Individuals with established wounds as a result of trauma/burns may also have their skin further compromised by incontinence. In addition, areas of broken skin can restrict the use of adhesive dressings which, being unable to use these products, may have a detrimental effect on skin protection and wound healing (Beldon, 2008).

Effects of Faecal IncontinenceFaecal incontinence has a detrimental impact on psychological, social and physical functioning. The stigma of incontinence is not socially acceptable and results in significant psychological trauma for the individual (Wishin et al, 2008). It is viewed as undignified and the subsequent care is an invasion of personal space. The odour associated with incontinence is a further source of embarrassment and humiliation (Wishin et al, 2008). It causes distress, embarrassment, anxiety, inconvenience, threat to self-esteem and self-confidence, loss of personal control, loss of dignity and degradation. Cavet (1998) undertook an extensive study of teenagers living with faecal incontinence and stated that they faced exclusion, humiliation, ignorance and ridicule. Therefore, people with faecal incontinence feel they no longer fit societal ‘norms’ and can feel stigmatised. They feel that if they can continue to manage and conceal symptoms they will not be excluded from society (Leigh and Turnberg, 1982). This is just one of the many reasons they do not discuss with health professionals and it remains a hidden topic.

Maintenance of patient’s privacy and dignity should be paramount when caring for these individuals.

Physical symptoms of faecal incontinence can include feelings of abdominal discomfort, pain or bloating, bowel urgency and frequency leading to potential dehydration, urea and electrolyte imbalance, and skin problems if not treated or managed effectively.

Local Effects of Faecal IncontinenceThe exact mechanism of skin damage due to incontinence is debatable; however, the following mechanisms of action are recognised as common denominators in skin breakdown.

InfectionFaecal contamination can increase the risk of post-surgical

wound breakdown in the susceptible areas such as groins and perineal region (Estrada et al, 2009).

Skin has a mean pH of 5.5, which is slightly acidic. Faeces can be alkaline in nature; it’s presence on the skin can immediately change the pH, resulting in skin irritation (Beldon, 2008).

The increase in moisture resulting from episodes of incontinence, combined with bacterial and enzymatic activity, can result in the breakdown of vulnerable skin. If the skin is exposed to fluid for sustained periods of time, it becomes waterlogged, causing it to become soft and wrinkled, and increases its friction coefficient (White and Cutting, 2003). As a result, the protective barrier of the skin is breached, which allows enzymatic onslaughts (Wishin et al, 2008). Damage caused by pressure and shear force is exacerbated by the presence of surface moisture through incontinence (Collier, 1996).

Systemic Effects of Faecal IncontinenceDehydration owing to faecal/urinary incontinence may result in skin changes such as dryness and loss of turgor (Beldon, 2008). It is also acknowledged that skin damage produces pain, which is exacerbated with the addition of incontinence (Beldon, 2008).

Maintenance of Bowel Continence Faecal incontinence is a sign or symptom of an underlying condition which is usually multifactorial. Understanding this requires health professionals to have a basic knowledge of the mechanics of bowel continence and what can go wrong. Normal defecation relies on movement of faeces into the rectum causing distension and the desire to defecate, known as ‘the call to stool’ (Norton, 2001). A person then adopts a sitting or squatting position which allows for an increase in abdominal pressure and contraction of the abdominal muscles. This is followed by relaxation of the puborectalis muscle and anal sphincters, which allow the stool to then be evacuated.

To achieve all of this and prevent leakage, a compliant, distensible and evacuable rectum is required with intact anal/rectal sensation, intact mucosal cushions, bulky and formed faeces, and intact internal/external anal sphincters. The internal sphincter is not under voluntary control and if weak, can lead to passive soiling and incontinence of flatus. The external anal sphincter is under voluntary control and weakness in this muscle will lead to urge faecal incontinence and an inability to hold on (Emmanuel, 2004).

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6 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 7

AssessmentPatients presenting with acute diarrhoeal symptoms should undergo a thorough assessment performed by a competent health professional, and include recent travel history, recent contacts with people who have experienced similar symptoms, and antibiotic history for the previous 3 months. In addition to persistent diarrhoea (type 6–7 on the Bristol stool chart developed by Lewis and Heaton (1997); appendix 1), patients who have C. difficile may experience fever, raised white cell count, signs of dehydration, hypotension, mental status changes, abdominal tenderness, abdominal distension and in severe cases, absent bowel sounds.

C. difficile infection should be suspected on clinical judgement and confirmed by laboratory testing. Where C. difficile is suspected or confirmed, the patient should be isolated and standard infection control precautions adhered to. A comprehensive bowel assessment will have been undertaken by a competent practitioner in the assessment of bowel dysfunction before the procedure is undertaken (NICE, 2007). The bowel assessment will have identified high-risk patients and RED FLAG such as those patients with indications of bowel cancers, and will exclude faecal impaction as a cause of overflow (NICE, 2007).

The bowel assessment should be carried out by an appropriate qualified and competent health professional trained in the skill of undertaking a bowel assessment and relevant investigations (i.e. digital rectal examination (DRE)) to determine faeces in the rectum or anal tone if appropriate (NICE, 2007). A structured approach

should be applied during the assessment of the patients with bowel dysfunction according to evidence-based guidance and All Wales/local directives (Skills for Health, 2008). Patient suitability for the FMS should also be assessed and documented in the patient’s records in accordance with organisation policy.

The sites at risk of skin damage due to incontinence are predominantly: the perineum, groins, buttocks, and sacrum (Johnston, 2005). In addition, the lower abdomen may also be classed as a vulnerable site (Beldon, 2008).

It has already been stated that defining incontinence is problematic. However, this also relates to the diagnosis of skin damage resulting from incontinence; for example, the confusion between category/grade 2 pressure damage and IAD (Defloor et al, 2005).

The correct differentiation between pressure damage and IAD is essential (Defloor et al, 2005), and in the absence of validated tools will largely depend on clinical assessment based on the patient’s recent history. Skin damage as a result of exposure to excessive moisture is defined as ‘a skin lesion associated with incontinence and not caused by pressure or shear’ (Defloor et al, 2005), with moisture contributing to the formation of pressure ulcers (EPUAP and NPUAP, 2009).

Padmanabhan et al (2007) devised a skin condition rating scale as part of a larger study into the management of faecal incontinence. However, to date this tool has not been subjected to further validation, so its use in clinical practice remains limited.

ContraindicationsFMS should not be used on patients with the following conditions:1 Lower bowel surgery or rectal surgery within the last year2 Sensitivity or allergies to any of the materials used in the FMS (i.e. silicone)

Current Skin Care RegimensThe aim of any skin care regimen is to protect skin integrity (Padmanabhan et al, 2007). The different actions of barrier products should be carefully considered (Beldon, 2008).

Liquid barrier films:These products consist of polymers combined with solvents; they are applied as a preventive method to intact skin. If applied to broken skin, some of them can cause dermal irritation (Donovan et al, 2002; Kingsley, 2007).

Emollients: These are grease-based substances and when applied to the skin either trap water in or allow water to be pulled from the dermis to the epidermis (Loden, 2003). Emollients can also be used as wash products. Once the washing is complete, emollients can be applied to the skin in the form of lotions, creams or ointments to seal water into the skin (Burr and Penzer, 2005).

Ointments: These are highly oil-based and offer water protection to the

skin, acting as an occlusive barrier to faecal contamination (Nix, 2006).

Creams: Many creams are water-based preparations and therefore have a lower oil content than ointments. They act by allowing the oil to sink into the skin, thus providing a barrier. Being less occlusive than ointment, they should be applied more frequently.

Examples of emollients, ointments and creams can be found in the Wounds UK product directory: http://tinyurl.com/wound-directory.

Alternative recommendations to contain faecal matterAnal bags; FMS; Pad containment products.

Other considerationsBeldon (2008) suggests that, when clinically indicated, catheterisation for urinary incontinence can protect the skin from damage. The same principle suggested that FMS could be of use for the same purposes with regard to skin damage caused by faecal incontinence.

Indications for use of FMS 1 Patient has liquid to semi-liquid stools (type 6–7 as per

Bristol stool chart)2 Patient is bed-bound

Additional Indications for Use of FMS3 C. difficile infection has been identified by laboratory

confirmation and/or clinical judgment4 Complications secondary to enteral feeding5 Patient has persistent diarrhoea6 Patient must have little or no bowel control7 Patient must have adequate anal sphincter tone (if lacking

in anal tone will not be able to support balloon) 8 Patient receiving palliative care with faecal leakage9 Patient has skin breakdown caused by exposure to faecal

incontinence and/or faecal leakage.

ConsentIt is imperative that, where possible, the patient gives valid consent prior to this procedure being carried out. The Welsh Assembly Government (2010) endorsed guidelines with regard to legal consent as follows:1 The patient must have the mental capacity to consent to

examination or treatment2 Consent should be given voluntarily by an appropriately

informed person3 Treatment of an adult who lacks capacity will be lawful

provided that the professional reasonably believes that the patient lacks the capacity to make a decision with regard to this matter, and the treatment proposed is in the patient’s best interests (Department of Health, 2005).

Nursing staff must ensure that it is documented in the patient’s nursing and/or medical records that he/she has given consent prior to the procedure (Nursing and Midwifery Council (NMC), 2008).

Please refer to individual organisation policy for additional guidance regarding consent.

3 Rectal or anal injury4 Severe rectal or anal stricture or stenosis5 Suspected or confirmed rectal mucosal impairment6 Confirmed rectal/anal tumour7 Severe haemorrhoids8 Faecal impaction9 Spinal cord injury above T5 because of the risk of autonomic dysreflexia.

FMS should not be used:1 For longer than 29 days2 For patients under the age of 18 years3 For patients with solid or semi-formed stools4 For patients who sit out in a chair for long periods

of time. In some cases, clinicians can consider whether it is required or beneficial to sit the patient out even if he/she has a FMS in situ. If that is the case, the sitting position should avoid compressing or kinking the device, and the sitting period should be the shortest possible and include a very close surveillance to avoid any risk of pressure damage.

Further considerations:1 Close attention should be exercised with the use of the

device in patients who have inflammatory bowel conditions (seek advice from colorectal nurses/clinicians)

2 Caution should be exercised when considering use in patients with thrombocytopenia and/or clotting disorders and individuals taking anticoagulant medication (seek advice from consultant haematologist)

3 To avoid injury to the patient, do not insert anything into the anal canal while the device is in place. Remove the device prior to insertion of anything into the anal canal (e.g. suppositories)

4 There is no specific evidence to contraindicate use of the system in cancer and haematological oncology patients, but because of the higher risk of proctitis and clotting disorders, its use must be sanctioned by the patient’s consultant.

Possible adverse events while using FMS:1 Loss of anal sphincter muscle tone2 Pressure necrosis of rectal or anal mucosa3 Infection4 Bowel obstruction5 Perforation of the bowel6 Persistent rectal pain7 Rectal bleeding8 Abdominal distension9 Unable to open bowels for more than 48 hours.

If any of the above adverse events occur, remove device, inform consultant and report as a clinical incident.

Guidance on Skin Care and Appropriate use of FMS

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8 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 9

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Directions for UseIt is imperative that the registered nurse and qualified medical staff follow the manufacturer’s instructions relating to the system, removal of the system, and maintenance of the system. More information can be found at:

http://www.bard.com http://www.convatec.com http://www.hollister.com

Currently the only system available through Welsh Health Supplies is Flexi-Seal from ConvaTec and directions for its use can be found in appendix 2, or via the clinical support helpline, freephone: 0800 289 738.

Conflict of InterestThe guideline development group received an unrestricted educational grant from ConvaTec for the development, production and dissemination of this document.

Resources and TrainingThe majority of staff within the NHS and independent sectors in Wales will not have received any formal training in this procedure. Professionals have to prove competency in assessment and procedure. Nursing staff should be deemed competent under the NMC Code of Professional Conduct (NMC, 2008). This document provides an example of a competency checklist for Flexi-Seal, along with a maintenance checklist and using the FMS Patient Information Leaflet. It is also necessary that staff demonstrate that they have kept their knowledge and skills up-to-date, acknowledging their limitations, and seek expert supervision if required.

Organisational Issues Each Local Health Board/organisation should identify a ‘champion’ who will be responsible for allocating the resources and implementation of FMS within the clinical setting.

A Patient Information Leaflet for the use of Flexi-Seal FMS is also available in both English and Welsh (see: www.welshwoundnetwork.org).

An advanced care optionYour Flexi-Seal® FMS containment device consists of the following connecting items:

A catheter ▢ (the long plastic tube) which is inserted into the rectum and held in place by…

A low-pressure balloon ▢ that is gently inflated with water or saline once inside the rectum, just enough to provide a leak-proof seal

A leak-proof collection bag ▢ at the end of the catheter, which is monitored and regularly replaced by a qualified member of staff

Flexi-Seal® FMS is an excellent alternative to the traditional methods of managing acute diarrhoea, such as pads, nappies, faecal pouches and rectal tubes.Whether you’re a patient, a carer or a nurse, if you have further questions or for more information, call our helpline on 0800 289 738

®/™: Flexi-Seal is a trademark of ConvaTec Inc.ConvaTec Ltd is an authorised user.© 2008 ConvaTec Inc.

Date of preparation: September 2008

AP-00-5881-GBWCON422

Designed for your comfort

This document is also available in Welsh via www.welshwoundnetwork.org

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10 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 11

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Continence Essentials Journal 1: 22–7

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Collier ME (1996) Pressure-reducing mattresses. J Wound Care 5(5): 207–11

Defloor T, Schoonoven L, Fletcher J et al (2005) Pressure ulcers and moisture lesions. Oral Presentation at European Pressure Ulcer Advisory Panel open meeting, Aberdeen

Department of Health (2005) The Mental Capacity Act 2005. http://tinyurl.com/5w2s93l (accessed 22 February 2011)

Department of Health (2007) Third prevalence survey of healthcare associated infections in acute hospitals in England 2006. http://tinyurl.com/379zst (accessed 22 February 2011)

Donovan A, Ratliff C, Gray M (2002) Perineal skin care for the incontinent patient. Adv Skin Wound Care 15(4): 170–5

Emmanuel A (2004) The physiology of defecation and continence. In: Norton C, Chelvanayagam S. eds, Bowel Continence Nursing. Beaconsfield Publishers Ltd, Buckinghamshire

Estrada O, Martinez I, Del Bas M, Salvans S, Hidalgo LA (2009). Rectal diversion without colostomy in Fournier’s gangrene. Tech Coloproctol 13(2): 157–9

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) Prevention and treatment of pressure ulcers: quick reference guide. www.npuap.org/Final_Quick_Prevention_for_web_2010.pdf (accessed 7 January 2011)

Evans J (2010) Using pressure ulcer prevalence survey to collect data of the prevalence of incontinence and associated skin damage. Poster presentation at European Pressure Ulcer Advisory Panel annual conference, Birmingham

Healthcare Associated Infections (HCAI) Technology Innovation Programme (2009) Showcase Hospitals Report number 5, The Flexi-Seal® Faecal Management System. HCAI Technology Innovation Programme, London

Health Protection Agency (2010) Summary Points on Clostridium difficile Infection. http://tinyurl.com/36ezs6k (accessed 7 January 2011)

Johnston A (2005) Evaluating Flexi-seal FMS: A faecal management system. Wounds UK 1(3): 110–4

Kenefick N (2004) The epidemiology of faecal incontinence. In: Norton C, Chelvanayagam S. eds, Bowel Continence Nursing. Beaconsfield Publishers Ltd, Buckinghamshire

Kingsley A (2007) A retrospective review linking diarrhoea to pressure ulcers. Wounds UK 3(4):14–7

Leigh RJ, Turnberg LA (1982). Faecal incontinence: the unvoiced symptom. Lancet 319(8285):1349–51

Lewis SJ, Heaton KW (1997) Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 32(9): 920–4

Loden M (2003) Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders. Am J Clin Dermatol 4(11):771–88

National Institute for Health and Clinical Excellence (2007) Faecal Incontinence: The Management of faecal incontinence in Adults. www.nice.org.uk/CG049 (accessed 7 January 2011)

Nix D (2006) Skin matters: Prevention and treatment of perineal skin breakdown due to incontinence. Ost Wound Manag 52(4): 26–8

Norton C (2001) Nursing for Continence. Beaconsfield Publishers Ltd, Buckinghamshire

Norton C et al (2002) Anal incontinence. In: Abrams P, Khoury SE, Cardozo L. eds, Incontinence. Plymouth Health Books, Plymouth

Nursing and Midwifery Council (2008) Code of Professional Conduct. Nursing and Midwifery Council, London

Ousey K, Gillibrand W, Lui S (2010) Effective management of acute faecal incontinence in hospital: review of continence management systems, Frontline Gastroenterol 1: 94–7

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Padmanabhan A, Stern M, Wishin J et al (2007) Clinical evaluation of a flexible faecal incontinence system. Am J Crit Care 16(4): 384–93

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Appendix 1: Bristol Stool Chart

ADDRESSOGRAPH LABEL

Date TimeType of Stool as per Bristol Stool Chart

Comments includingAmount (Small/Moderate/Large)

Specimen sentYes / No

State Investigation

Ward..................................................................................

BRISTOL STOOL CHART

Type 1 Separate hard lumps, like nuts.

Type 2 Sausage-like but lumpy.

Type 3 Like a sausage but with cracks in the

surface.

Type 4 Like a sausage or snake, smooth and

soft.

Type 5 Soft blobs with clear-cut edges.

Type 6 Fluffy pieces with ragged edges, a

mushy stool.

Type 7 Watery, no solid pieces.

 

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12 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 13

Procedure: as an example. Please refer to other company instructions for guidance of individual products.

1. Create privacy2. Explain the procedure to the patient and gain consent3. Assemble equipment including gloves, water-soluble lubricant

and 45 ml of tap water in a clean container4. Open kit, fill syringe with water at room temperature and

attach the syringe to the inflation port5. Securely snap the collection bag to the connector at the end

of the catheter and label it with the date and time6. Unfold the length of the catheter to lay flat on the bed,

extending the collection bag towards the foot of the bed7. Insert a gloved index finger into the retention balloon cuff

finger pocket8. Coat the balloon end of the catheter in lubricating jelly9. Assist the patient and position left lateral side with

knees flexed10. Undertake effective digital rectal examination and check for

adequate rectal sphincter tone11. If type 6–7 stools are present, or if rectum is empty, proceed

with insertion of the Flexi-Seal12. Gently insert the balloon end through the anal sphincter until

the black line is inside the rectum13. Inflate the balloon with 5 ml water by slowly depressing the

syringe plunger14. Remove finger and inflate with the remaining 40 ml of water.

If the FMS has a balloon pressure indicator, stop the filling when the indicator pops up. Average volume required is between 37 ml and 42 ml. Never exceed 45 ml

15. Remove the syringe from the inflation port and gently pull on the soft silicone catheter to ensure the balloon is securely in the rectum and is positioned against the rectal floor. You should now see the black line reappear from the rectum

16. Remove gloves and apron, and wash hands17. Position the length of the flexible silicone catheter along

patient’s leg avoiding kinks and obstruction18. Hang the bag by the strap at a convenient location

at the bedside19. Record in the appropriate documents that the Flexi-Seal has

been inserted and record all output20. Reassure patient and inform them of the outcome.

TroubleshootingIf leakage occurs the device should be inspected to ascertain that there is no external obstruction. If no obstruction can be found, attempt deflating the balloon by withdrawing up to 10 ml from the inflation port. If the silicone device becomes blocked with

solid particles, it can be irrigated by filling the syringe with 30 mls of tap water as many times as required, attaching the syringe to the irrigation port, and depressing the plunger. Repeat this procedure as often as necessary to maintain function of the device. If this fails to rectify the problem then the use of the device should be discontinued.

Removal of FMS1 Wash hands with soap and water prior to

commencing procedure2 Ensure personal protective equipment is worn prior to

any risk of exposure to bodily fluids3 Deflate retention balloon by attaching the syringe to the

inflation port and withdraw all the water4 Disconnect the syringe and dispose safely5 Grasp the catheter as close to the patient as possible and

slowly slide it out of the anus6 Dispose of the device, gloves and apron in accordance with

Healthcare Waste Strategy for Wales/Health Board policy7 Wash hands following removal of personal protective

equipment with soap and water.

Maintenance of the FMS1 Wash hands with soap and water prior to

commencing procedure2 Ensure personal protective equipment is worn prior to any

risk of exposure to bodily fluids3 Change the collection bag as required4 Snap the cap onto each used bag and dispose as per

Healthcare Waste Strategy for Wales/Health Board policy5 Do not reuse bags once detached6 Observe the device for obstructions, e.g. kinks, faecal particles

or external pressure7 Ensure regular hygiene is maintained around anal region8 Document skin integrity as per patient care plan9 Record faecal output at least every 8 hours on fluid

balance chart10 When stool samples are required they should be taken from

the tubing of the system rather than the bag to ensure a recent sample is taken

11 Dispose of the gloves and apron in accordance with Healthcare Waste Strategy for Wales/Health Board policy

12 Wash hands with soap and water following removal of personal protective equipment.

Appendix 2ConvaTec’s instructions for use

Competency Check List

Name: Job Title:

Hospital: Ward/Unit:

Aim : -

To record demonstration of competency in the appropriate selection of patients forwhom the Flexi-Seal® Faecal Management System would be appropriate and the correct insertion, maintenance and removal procedures working within the individual’s scope of professional practice.

Com

petency Check List

© 2008 E.R. Squibb & Sons, L.L.C. ® Flexi-Seal is a registered trademark of E.R. Squibb & Sons, L.L.C.ConvaTec is an authorised user. ConvaTec Ltd., Harrington House, Milton Road, Ickenham, Uxbridge UB10 8PU.GB-08-437

Met Not met CommentsCritical Competencies

Patient Selection

1 Checks for appropriate patient selection criteria• Liquid to semi-liquid stool• Adequate sphincter tone• No contraindications (identified in package insert)

2 Demonstrates understanding and ability to implement the Hospital’s policy for:• Appropriate person performing digital rectal

examination in every case before insertion of Flexi-Seal® FMS and recording satisfactory outcome before insertion

• Explains procedure to patient and obtains patient consent where appropriate according to Hospital policy before insertion.

• Makes provision for patient privacy and dignity to be maintained during the procedure.

3 Before proceeding follows Hospital policy for the consultation with medical staff.

Insertion Competencies

1 Obtains appropriate equipment• Flexi-Seal® Faecal Management System kit• Gloves• Incontinent Pad• Lubricant• Protective barrier

2 Pre-assembles the system, removes air from the balloon and fills syringe with no more than 45ml of tap water or saline

3 Positions patient in left-side lying position or other appropriate position

4 Demonstrates proper insertion technique and positions balloon beyond the external orifice/rectal sphincter and well inside the rectal vault before inflating

5 Describes how to tell if the balloon is properly inflated and what to do in the event of improper balloon inflation

Page 8: All Wales Guidelines for Faecal Management Systems · 2 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 3 Foreword Professor Jean White, Chief Nursing

14 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 15

Maintenance Check List

Patient Name: Inserted by:

Unit Number: Date of Insertion:

Recommended to check device every two hours

Maintenance C

heck List

© 2008 E.R. Squibb & Sons, L.L.C. ® Flexi-Seal is a registered trademark of E.R. Squibb & Sons, L.L.C.ConvaTec is an authorised user. ConvaTec Ltd., Harrington House, Milton Road, Ickenham, Uxbridge UB10 8PU.GB-08-435

Date: / /

Day No:

Blac

k Li

nePo

sitio

nCh

ecke

d (v

)

Cons

iste

nty

of S

tool

(Sol

id,S

emi S

olid

,Se

mi L

iqui

d or

Liq

uid)

Skin

Inte

grity

(e.g

.int

act,

redd

ened

etc

)

Tube

Posi

tion

Corr

ect

(y/n

)

Chec

k Ba

g (v

)Ch

eck

Drai

nage

(v)

Irrig

atio

nYe

s/No

-vo

lum

eus

ed?

Sign

atur

eS

tart

Tim

e:

12am

-2am

2am

-4am

6am

-8am

10am

-12p

m

2pm

-4pm

6pm

-8pm

10pm

-12p

m

Com

men

ts

Quick Reference Guide

� Patient Name:

� Unit Number:

� Clinicans Name:

You need to be able to answer True to ALL the questions below inorder to use Flexi-Seal® Faecal Management System.

The patient is incontinent with liquid or semi-liquid stool

The Patient is over 18

The patient is not sensitive or known to have had allergic reactions to any component within the kit

The patient has not had lower large bowel or rectal surgery within the last year

The patient does not have suspected or confirmed rectal mucosal impairment

The patient does not have any rectal or anal injury

The patient does not have a confirmed rectal/anal tumour or stenosis or stricture

The patient does not have hemorrhoids of significant size and/or symptoms

The patient does not have a faecal impaction

The patient does not have any in-dwelling or anal device (e.g. thermometer) or delivery mechanism (e.g. suppositories or enemas in place)

If you have answered ‘True’ to all the above, please refer to Pre-Insertion Checklist and Product Guidelines as patient is suitablefor Flexi-Seal® FMS use.

Please discuss the above with a healthcare professional if you have any doubts abuot the

answer to the above questions.

Quick R

eference Guide

© 2008 E.R. Squibb & Sons, L.L.C. ® Flexi-Seal is a registered trademark of E.R. Squibb & Sons, L.L.C.ConvaTec is an authorised user. ConvaTec Ltd., Harrington House, Milton Road, Ickenham, Uxbridge UB10 8PU.GB-08-438

Page 9: All Wales Guidelines for Faecal Management Systems · 2 Guidelines for Faecal Management Systems Guidelines for Faecal Management Systems 3 Foreword Professor Jean White, Chief Nursing

Published by © MA Healthcare Ltd, 2010.

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Healthcare Ltd or in accordance with the relevant copyright legislation.

This publication is also available in Welsh.

Although the editor and MA Healthcare Ltd have taken great care to ensure accuracy, MA Healthcare Ltd will not be liable for any errors of omission or inaccuracies in this publication.

Opinions expressed in this publication are those of the authors only and do not necessarily reflect those of MA Healthcare Ltd.

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Published on behalf of Julie Evans, Joanna Price, Ann Yates and Trudie Young, by MA Healthcare Ltd, St Jude’s Church, Dulwich Road, London SE24 0PB, UKTel: +44 (0) 20 7738 5454 Email: [email protected] Web: www.markallengroup.com