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E - Bowel Continence

Best Practice Indicators • Examination and documentation of type of bowel dysfunction, based on history and physical examination, with ancillary testing, only as required • Design of a conservative bowel program to include education of patient and support personnel, and to incorporate patient goals • Documentation of the results of bowel care • Documentation of adverse results with evidence of redesign, reassessment and modification of bowel program and care, as appropriate. Documentation according to current best evidence of the consideration of adjunctive measures, as available. Which Outcome Measures Should We Use? 1. Routine Documentation of NBD Impairments On a routine clinical basis, the basic clinical NBD data set should take 30 minutes to complete. For those with issues of NBD, completion of a bowel diary is indicated. • International Neurogenic Bowel Data Set22 The International SCI Bowel Function Basic and Extended Data Sets are the preferred outcome measure, in this population. Designed specifically for individuals with SCI, the data set includes the Cleveland Clinic, St. Marks and Neurogenic Bowel Dysfunction Scores, which can be calculated from the included data fields. Juul et al.22 published results of a validation study demonstrating acceptable inter-rater reliability for most items. • Autonomic Standards23 • Neurogenic Bowel Diary Figure 5.0 Bowel Diary Trained by: Date: Name of caregiver who trained on Peristeen Date Time (Start - Finish) # of pumps Water (ml) Consistency (Bristol Scale) Fecal Incon��nence Abdominal pain Medica��on Comments Mar 18 9:00-10:15 3 500 3 No No No Bowel Empty 2. Additional Outcome Measures/Bowel Function Measures • Modified American Society of Colon and Rectal Surgeons (ASCRS) Fecal Incontinence Score, Inflammatory Bowel Disease Questionnaire (IBDQ) • Cleveland Clinic Incontinence (CCI) Score • Cleveland Clinic Constipation Scoring System (CCCSS) • Mark’s Fecal Incontinence Grading System (FIGS). 3. Research Priorities Basic science advancements are needed to inform clinical practice, and to answer the following questions: • What is happening to smooth muscle in the bowel with time, post injury? • There are conflicting results regarding the impact of level and completeness of lesion, and degree of autonomic dysfunction, on the pattern and severity of bowel impairment. What happens to any preserved colonic motility, with time post injury, and why? Are these age-related changes or changes specific to time post injury? • Does the degree of autonomic dysfunction predict bowel function following SCI? • Does the rectoanal inhibitory reflex diminish over time? • Can we develop physiologic tests of bowel function (beyond manometry and colonic motility)? • How would recruitment of smooth muscle physiologists assist in the exploration of these issues, and what new knowledge would they contribute to the field? 4. Policy priorities • Develop attendant care funding and policy with respect to scope of practice to support optimal bowel care • Determine/clarify whose scope of practice should include provision of interventions beyond the anal verge. This is especially a problem for clients in hospital or dependent on an agency for delivery of bowel care, in the community • Advocate for appropriate disability supports that include funding of bowel medications, standard care items (i.e. Magic Bullet®, polyethylene glycol) and appropriate equipment • Advocate for changes in the disability supports benefits for individuals with disability to include funding for transanal irrigation, similar to the funding provided for colostomy supplies • Align current best practice for optimizing bowel care with the private and public funding for required assistive care, equipment, medications and supplies • Reflect the complexity and intensity of service, required in the care of individuals of SCI, in the reimbursement for involved health care professionals. BOWEL CONTINENCE | BODY STRUCTURE AND FNUCTION 67


E - Bowel Continence
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