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E - Bowel Continence

Current Practice In a review of Canadian rehabilitation centres, with respect to bowel treatment protocols, six of 12 sites used the PVA Neurogenic Bowel Clinical Practice Guidelines as their source of information for neurogenic bowel management. Two of 12 had a uniquely articulated treatment protocol, five of 12 had an established standard of care, and three of 12 had a clinical practice guideline. This would suggest that there is an opportunity for knowledge translation, in the area of neurogenic bowel management, across Canadian rehabilitation sites. The review also surveyed the sites regarding available equipment – specifically, the number of SCI-specific commode chairs, and the number of reclining commode chairs available, per patient. The number of chairs, in either category per patient, ranged from a low of .04 chairs/ patient, to a high of .63 chairs/patient (mean .19 chairs/patient). More than half the sites felt that this was not an adequate supply of equipment to support bowel care. Current Practice Bias and Dilemmas The E-Scan data, with respect to current practice, are based on anecdotal reports from clinicians involved in the care of individuals with SCI. In addition to routine documenting of NBD, there is a need for documentation of the current NBD practice. Design and optimization of a conservative bowel care routine is within the scope of practice and abilities of all physiatrists, primary care physicians and nurses, given appropriate training. Unfortunately, the availability, interest and training of other colorectal experts, particularly surgeons, able to assess the appropriateness of, and to perform catheterizable stomas, implant stimulators or create stomas, is not uniformly available in Canada. Key Practice References 1. Coggrave M. Guidelines for management of neurogenic bowel dysfunction in individuals with central neurological conditions. Spinal Cord Injury Centres of the United Kingdom and Ireland. Multidisciplinary Association of Spinal Cord Injury Professionals; September 2012. 2. Consortium for Spinal Cord Medicine. Neurogenic bowel management in adults with spinal cord injury. Washington, DC: Paralyzed Veterans of America; 1998. 3. Furlan JC, Urbach DR, Fehlings MG. Optimal treatment for severe neurogenic bowel dysfunction after chronic spinal cord injury: a decision analysis. Br J Surg. 2007;94(9):1139–50. 4. Krassioukov A, Eng JJ, Venables B. Neurogenic bowel following spinal cord injury. In: Eng JJ, Teasell RW, Miller WC, et al., eds. Spinal Cord Injury Rehabilitation Evidence. Version 4.0. Vancouver, BC; 2012:1-39. 5. National Collaborating Centre for Acute Care. Faecal incontinence: the management of faecal incontinence in adults. London, UK: National Institute for Health and Clinical Excellence (NICE); 2007. Canadian Experts Likely to Influence NBD Practice, in the Next Five Years 1. Karen Ethans, MD (Physiatry) and Alan Casey, MD (Physiatry), Winnipeg: Physiatrists with evolving expertise in the implementation and evaluation of transanal irrigation. 2. Anthony Burns, MD (Physiatry), Toronto; Daphne St. Germain, RN, PhD, Québec: Leading a qualitative study regarding the lived experiences of persons with SCI and NBD to inform development of patient-focused NBD outcome measures. 3. Julio Furlan, MD (Neurology), Toronto: Developed a decision support tool to assist in the selection of surgical NBD intervention(s). 4. Paul Belliveau, MD (General Surgery), Kingston: Colorectal surgeon with an interest in neurogenic bowel function. 5. Karen Smith, MD (Physiatry); Margaret Power, RPN, Kingston: Acquired a significant volume of experience with TAI and NBD. 6. Nicole Mittman, PhD (Pharmacology), Toronto: Evaluating the economic burden of NBD care. Key Clinical Questions 1. Can we prevent long-term bowel problems with early introduction of adjunctive bowel measures, in the acute and subacute phases of injury? 2. How do we customize bowel care for patients? Which intervention is appropriate for which client? 3. Are there ways to optimize some features of the adjunctive techniques? What is the ideal irrigation fluid, and optimal frequency for transanal irrigation? 4. How do we create adequate supports in primary care to allow for examination of patients, to determine the need for UMN versus LMN type bowel care? How do we enable appropriate training on initial design of bowel care programs, by primary care physicians, in order to reach the broadest number of individuals with NBD, in the community? There is ample evidence of the barriers to the provision of primary care, to individuals with SCI.21 Some are knowledge barriers but there are also policy, system, physical and attitudinal barriers. BOWEL CONTINENCE | BODY STRUCTURE AND FNUCTION 65


E - Bowel Continence
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