1. NDT 1: Constipation: Audit in Motion Lesley Rutherford Nurse Consultant in Palliative Care, Marie Curie Hospice

2. NDT: “Audit in Motion” Constipation Audit Tool Edith McMahon, Fiona Gilmour, Geraldine Tracey, Jean Barber, Lesley Rutherford, Nuala Ginnelly, Trish Curran October 2015

3. Aim:  To pilot the constipation audit tool in a variety of adult palliative care settings, across the Island of Ireland, to ensure its suitability nationally

4. Objectives:  To obtain an overview of current practice within a variety of clinical settings  To determine the applicability of the tool within the individual settings  To determine the experience of using the tool from the clinicians’ perspective  To make recommendations in relation to the design and content of the tool for future use

5. Process:  Audit proposal was developed  A brief staff questionnaire was developed to accompany the audit tool in order to elicit feedback on the design/usability of the tool itself  Pilot clinical areas were identified ensuring geographical representation across the Island of Ireland and representation from a range of settings  Explanatory information developed for staff participating in the audit  Approval sought ( where necessary) from audit groups within each organisation.

6. Process cont’d;  NDT Members identified colleagues within their own setting who were willing to participate in the audit.  All participating staff were given an explanation of the background to the project and rationale for audit.  The audit was undertaken on one day only.  NDT members collated data from each individual site which was then subsequently recorded on a master copy on Excel database.

7. Audit Cycle: Set standards Measure current practice Compare results to standards Reflect, plan, change and implement change Re-audit Set from the recommendations in “Management of Constipation in Adults Receiving palliative Care Guidelines” Compare results to the recommendations in the guidelines. Compliance aims to be 100% Using the data Collection form from the guidelines Formulate an action plan Re-audit using the same tool and measure changes in practice

8. Sample: 101 patients were included OLH & CS Blackrock IPU11ROI OLH &CS Blackrock Community Palliative Care14ROI OLH & CS Blackrock Day Hospice10ROI St Michaels Hospital6ROI North West Hospice IPU4ROI North West Hospice Community palliative care6ROI Sligo Regional Hospital palliative care team11ROI University Hospital Limerick15ROI Havenwood Nursing Home7RO1 Macmillan Specialist Palliative Care Unit in AAH NHSCT 12NI Regional Cancer Centre; BHSCT6NI

9. Areas included in the audit:  Assessment  Digital rectal examination  Rationale for plain films of abdomen ( if undertaken)  Education on non drug measures  Consideration of non-pharmacological strategies  Prescribing  Use of pharmacological agents in bowel obstruction

10. Staff Questionnaire  What was your experience of using the tool?  How do you feel about auditing your own practice?  Is this tool applicable in your clinical setting?  What adaptations do you deem necessary?  What did you learn from using the tool?  What adaptations would you deem necessary ?

11. Results in relation to practice:  Findings have been analysed and discussed in the final report. Overall the auditors were very receptive to auditing their own practice and welcomed the use of a tool. This positive response lends itself to considering such an approach with other guidance documents implemented locally and nationally The auditors found the concept of an audit tool a good resource for education when implementing new guidance. The auditors welcomed the opportunity to reflect on their own practice

12. Results cont’d:  It highlighted gaps in current practice in comparison to the best practice approved recommendations. This was evident not just in acute settings but also in the specialist palliative care settings.  Some of the best practice recommendations were questioned e.g “maximising on one single laxative before the addition of another” and optimisation of a stimulant agent before adding a softener”  The consistent challenge for auditors were the recommendations related to “DRE”. Concerns were raised re roles, responsibilities and competency.  It was highlighted that some recommendations would be difficult to implement in particular clinical settings e.g plain film x-ray for patients in a nursing home setting  The auditors found some of the questions ambiguous

13. Recommendations:  There should be explicit instructions as to when and with whom the audit tool should be used (eg all palliative care patients or only palliative care patients who are constipated )  Some of the questions need to be reviewed and made more explicit and concise. In particular, questions that have several parts need to allow for each part to be answered individually, instead of one global answer.  The tool may need modification to suit the various clinical settings( however if questions are made more explicit and concise this may not be necessary)  More room for making comments would be useful, especially when “ Not applicable” is selected

14. Recommendations cont’d:  The inclusion of more patient related information, such as diagnosis, would make analysis of the data more meaningful.  An appendix at the back of the guidelines with a flow chart outlining the management of constipation would be useful  The issue of DRE needs particular attention and if the recommendations remain unchanged, there would need to be a robust, competency based training programme and assessment process.  Given that fact that some of the recommendations from the National document differ from current practice and has been challenged by some auditors, it is recommended that individual organisations formally endorse the National document.

15. Recommendations cont’d:  As the auditors on this occasion were nurses, it remains to be seen what challenges remain when implementing the national guidance document with medical staff therefore suggest consideration of this group before launching the document  The wording on the formal audit report on the Excel Clinical Audit Tool database needs to be reviewed to accurately reflect the findings ( e.g Criteria 11)

16. Challenges:  Work commitments imposed by own and other colleagues annual leave, limited members availability for collating data and connecting remotely to discuss progress.  Technical issues re inputting data to excel data base over multiple sites for relatively novice users.  Continuous remote collaboration to overcome hiccups as they occurred via teleconference and email  Time management