Faecal incontinence

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Faecal incontinence (bowel control problems)
Implementing NICE guidance
June 2007
NICE clinical guideline 49
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What this presentation covers

• Background to the guideline
• Key recommendations
• Implementation advice
• Costs and savings
• Resources from NICE

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Changing clinical practice

• NICE guidelines are based on the best available
  evidence
• The Department of Health asks NHS organisations
  to work towards implementing NICE guidelines
• Compliance with developmental standards will be
  monitored by the Healthcare Commission

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Background definition

• Faecal incontinence is defined as involuntary
  loss of faeces
• Commonly classified according to
• symptom
• character of leakage
• patient group
• presumed primary underlying cause
• May be the result of complex contributory factors

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Background why this guideline matters

• Faecal incontinence
• can have an adverse effect on quality of life
• can cause severe social restriction
• is a stigmatising condition
• significant cost to the NHS

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Incidence and prevalence

• Perry et al, 2002. Prevalence of faecal
  incontinence in adults aged 40 years or more
  living in the community

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Key recommendations

• Good practice in management
• Baseline assessment and initial management
• Specialised management
• Long-term management
• Specific groups
• Surgery

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Good practice in management

• Offer care managed by healthcare professionals
  who
• have relevant skills, training and experience
• work within an integrated continence service
• Be aware that faecal incontinence is a symptom,
  often with multiple contributory factors
• Avoid simplistic assumptions that cause is due to
  a single primary diagnosis (diagnostic
  overshadowing)

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High-risk groups

• Actively yet sensitively enquire about symptoms
  in the following groups
• frail older people
• people with loose stools or diarrhoea from any
  cause
• women following childbirth (especially following
  obstetric injury)
• people with neurological or spinal
  disease/injury
• people with severe cognitive impairment
• people with urinary incontinence
• people with pelvic organ prolapse and/or rectal
  prolapse
• people who have had previous colonic resection,
  anal surgery or pelvic radiotherapy
• people with perianal soreness, itching or pain
• people with learning disabilities.

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Treatment pathway
Adult with faecal incontince
Carry out baseline assessment
Initial management
Review intervention. If symptoms persist
discuss further options
Provide long-term management strategy if
required
Baseline assessmentInitial management
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Baseline assessment

• A focused baseline assessment should comprise
• relevant medical history
• general examination
• anorectal examination
• cognitive assessment, if appropriate

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Initial management

• Before progressing to initial management address
  condition-specific interventions for
• faecal loading
• potentially treatable causes of diarrhoea
• warning signs for lower gastrointestinal cancer
• rectal prolapse or third-degree haemorrhoids
• acute anal sphincter injury
• acute disc prolapse/cauda equina syndrome
• Initial management should address bowel habit,
  aiming for ideal stool consistency and
  satisfactory bowel emptying at a predictable time

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Specialised management

• If symptoms continue after initial management,
  refer to a specialist continence service, which
  may include
• pelvic floor muscle training
• bowel retraining
• specialist dietary assessment and management
• biofeedback
• electrical stimulation
• rectal irrigation

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Long-term management

• Offer the following to symptomatic patients who
  do not wish to continue with active treatment or
  who have intractable faecal incontinence
• advice on preservation of dignity and
  independence
• psychological and emotional support
• at least 6-monthly review of symptoms
• discussion of management options
• contact details for support groups
• advice on coping strategies, skin care and
  products
• advice on how to talk to friends and family
• strategies such as planning travel routes

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Specific groups

• Proactive bowel management is recommended where
  any of the following are present
• faecal loading or constipation
• limited mobility
• hospitalised patients with faecal loading and
  associated incontinence
• cognitive or behavioural issues
• neurological or spinal disease/injury resulting
  in faecal incontinence
• learning disabilities
• severe or terminal illness
• acquired brain injury

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Surgery

• Refer to a specialist surgeon when considering
  surgery to discuss
• surgical and non-surgical options
• benefits and limitations, with attention to
  long-term results
• realistic expectations of effectiveness of
  surgical procedures

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Implementation advice

• Feedback to NICE suggests that there are likely
  to be three key areas for successful
  implementation
• awareness raising and patient support
• training and education
• commissioning

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Awareness raising and patient support

• Communication is vital to relationships between
  services and patients and carers. Raising
  awareness will encourage people to seek help.
• Provide written information about services and
  treatment options
• Provide protocols to enable local referrals

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Training and education

• Staff need to be competent in identifying,
  assessing and managing faecal incontinence.
• Review competencies of staff
• Ensure training reflects a multi-agency approach
• Review who is offering specialised management
  training
• Consider training other staff in pelvic floor
  muscle training in primary care

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Commissioning

• Commissioners will have a key role to play.
• Consider where joint commissioning is feasible
• Apply the principles of Good practice in
  continence services, Section 3
• Review services to ensure that they are meeting
  need
• Use national audit data to check status of local
  services
• Use local area agreement levers

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Costs and savings
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Resources from NICE

• Implementation advice
• Costing tools
• costing report
• costing template
• Audit criteria

www.nice.org.uk/CG049
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Access the guideline online

• Quick reference guide a summary
• NICE guideline all of the recommendations
• Full guideline all of the evidence and
  rationale
• Understanding NICE guidance a version for
  patients and carers

www.nice.org.uk/CG049