Julie Jordan-Ely, Prof John Hutson & Dr Bridget Southwell Royal Childrens Hospital, Melbourne Murdoch Childrens Research Institute University of Melbourne Disimpaction of chronic constipation patients in Emergency Department using high dose Polyethylene Glycol +E and Sodium Picosulphate

Nurse initiated treatment model – Nunyara Method PhD Candidate – Dept. Pediatrics, School Medicine, University of Melbourne Diploma Nursing Graduate Certificate Continence Assessment & Management Advanced Diploma Community Services (Management, Disability & Youth work) Private Community Continence Practice Mother of three children (son Autism & daughter Complex Motility Disorders)

Background Clinical rotation Casey Hospital Emergency Department 43,000 pts presented to Casey ED 2010/ pts per day, 59% non-Urgent (69/117) Sourced: Health.gov.au 12 hour shift – 9 pts presented with bowel related symptoms (Jan 2012) Current management -Suppository/enema ($2,500 ED cost) -Manual disimpaction as inpatient ($5,000 Inpatient cost) -No tx, referred to general medicine outpatients clinic for review

Previous use of disimpaction method Community clinic and Aged-Care facility Disimpaction using PEG+E (Osmotic) and Sodium Picosulphate (Stimulant) Oral, effective & good compliance Aim : To determine the effect of colonic disimpaction using high levels of PEG+E plus stimulant in patients with acute constipation at a public hospital emergency department (ED).

Methods one x 12 hour shift. 9 patients (5-68 years) with faecal impaction were triaged by senior nursing and specialist medical staff. 57 M56 F26 M20 M6 M, 4 F, 22 M, 56 F& 2 M 4 days post TURP PainfulheamariodsPostheamariodectomySevere rectal pain Faecal impaction 4 days5 days2 days9 days 3-14 days

Intervention Nurse led method Bowel & dietary history ( 7 days) Palpation to determine stool volume & medication dosage required Medication rationale Movicol (PEG+E) and Dulcolax SP Drops (Sodium Picosulphate) (1 sachet per cup of stool + stimulant) Patients ‘day one’ dosage provided in ED Remaining day 2 & 3 dosage taken home with written instructions

Resources: patients were in department for an average 4 hours including medical assessment, basic continence education (30 minutes) and to administer initial medication dosage. Follow-up and monitoring: patients were telephoned by nurse daily for 1 week to obtain data and support.

So what’s new about this method… Improved patient outcomes in shorter timeframe No inpatient admissions Cost savings (minimum $2500 per patient) Patient educated in self-management Using well established OTC medications in a new combination Very effective

Emergency Department (current study) Suburban Continence Clinic Aged Care FacilityRCH Childrens Surgical Clinic 9 patients Kids & adults 49 patients Kids & adults 10 patients adults 38 patients kids Further pilot data

Nunyara Method Borrowed Aboriginal word that means …to become well again… Questions

So what’s the trick with the meds ? Presented at Joint American & European International Neurogastroenterology and Motility Meeting, Boston 2010