1. 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

2. 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)

3. Background Clinical rotation Casey Hospital Emergency Department 43,000 pts presented to Casey ED 2010/11 117 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

4. 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).

5. 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

6. 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

7. 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.

9. 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

10. 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

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

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