Nursing Conference Insider
ICS 2013 - Podcast: Emmanuel Chartier-Kastler, MD, PhD discusses highlights of the intermittent catheterization sessions from the Annual Scientific Meeting of the International Continence Society
BARCELONA, SPAIN (UroToday.com) - An interview conducted at the 43rd Annual Scientific Meeting of the International Continence Society (ICS) - August 26 - 30, 2013 - Barcelona, Spain, by Anna Forsberg, medical director for UroToday.com.
Prof. E. Chartier-Kastler received his MD from Paris VI University in 1989 and was accredited as a urologist in 1992. He is also accredited as general surgeon. From 1992 to1998 he was fellow and assistant professor in the department of urology at the Pitié-Salpêtrière Hospital. Since September 2001, he is professor of urology at the department of urology, medical school Pierre et Marie Curie, University Paris VI. He is head of the functional urology programme -- including female and male urinary incontinence (diagnosis, and management), female pelvic floor disorder, urological malformations, and neurourology. His research areas include incontinence diagnosis and management (pharmacological treatment, devices and surgery), overactive bladder (neuromodulation, botulinum toxin studies, and other new treatments under development), BPH (new treatments) and neurourology.
Prof. Chartier-Kastler is active member of the board of the French Association of Urology (AFU), past general secretary (2004-2007) and current chairman of the scientific committee, past member of the AFU Neurourology Committee and active member of the French speaking group of Neurourology (GENULF). He is involved in all major international urologic congresses as speaker, chairman, and/or guest speaker. He was involved in the French consensus conference regarding urinary nosocomial infections (2004) and has been an active member of the committee for conservative treatment in the neuropathic area during the International Consultation on Incontinence (ICI) from 1998 to 2004.
Prof. Chartier-Kastler has published more than 254 peer-reviewed articles and book chapters on topics related to urology, especially in the field of incontinence and neuro-urology. He is leading, with Prof. Giuliano (chair), Prof. Denys and Prof. Lebret, a research unit dedicated to neuropharmacology of the bladder and sexual dysfunction. His ongoing projects concern botulinum toxin for overactive bladder and BPH, evaluation of new drugs in this area, and interstitial cystitis evaluation and treatment.
As a neurourologist, he prepared the final report of the 2006 French Congress of Urology (100th congress, November 2006, Paris): “Neurogenic Bladder and Urological Management,” with Alain Ruffion, MD, PhD.
He has been member of the organizing committee of major international (ICS-IUGA (2004) and the 100th SIU (2007) congress which took place in Paris) and national meetings (French Congress organizer (2005, 2006 and 2007)). He has led the IUGA/ICS application process for the organisation of their joint meeting in Lyon (France) in 2015.
WOCN 2013 - Session Highlights: Effective application of bowel management systems for fecal incontinence
SEATTLE, WA USA (UroToday.com) - Fecal incontinence (FI) prevalence ranges from 2-15% in the community and up to 19% in women presenting to specialty pelvic floor disorders practices. Prevalence of FI in non-institutionalized U.S. adults is 8.3%; consisting of liquid stool in 6.2%, solid stool in 1.6%, and mucus in 3.1%.(NHANES FI data). The prevalence is similar in women (8.9%) and men (7.7%), and increases with age from 2.6% in 20-29 year-olds and up to 15.3% in person’s aged 70 and over. Like urinary incontinence (UI), FI is under-detected and under-reported. Treatments for FI may be conservative (dietary manipulation, drug therapy, or anal sphincter exercises/pelvic floor muscle training with or without biofeedback), or surgical repair (e.g. sphincter repair, sacral neuromodulation).
And like UI, many with severe symptoms turn to self-care practices to manage stool leakage. A survey of community-dwelling respondents (n=1352) > 65 years of age enrolled in a Minnesota HMO found that 18% reported experiencing FI several times per year, or more. If the person soiled their outer clothing, they were likely to use multiple self-care strategies (e.g., diapers, altered diet) than those with less severe FI (Bliss, 2004).
Prevalence of FI in the acute care setting, in a prospective cohort investigation of 152 hospitalized patients, showed that 33% of the acutely or critically ill participants had FI, while a significantly greater percentage of patients with diarrhea had FI compared to patients without diarrhea (27 out of 99, 27%) (Bliss, 2000).
In the acute care setting, an indwelling fecal management device (IFMD) is used to divert, collect, and contain fecal leakage. These indwelling catheters are usually a 20 to 30 French size, have an inflatable cuff, and are held in place by an inflated balloon. Stool is drained through the lumen of the tube. The advantages of a rectal catheter are similar to those of urinary containment systems and include a closed system, decreased exposure to possibly infectious body substances, and protection of perineal skin (avoiding contact with irritating stool). However, currently available devices have differences in retention cuff design and contact area with rectal tissue that can impact patient comfort or safety, or device function. The use of these devices is increasing because of Medicare cost guidelines, which do not provide compensation for hospital-acquired pressure ulcers.
Marchetti and colleagues (2011) conducted a pilot study to compare retention cuff pressures of 3 indwelling stool management systems in different body positions with cuffs inflated to different volumes. Cuff pressures were assessed by manometry and rectal mucosa by digital examination and small diameter, flexible endoscopy. The 3 devices tested were:
A. DigniCare® Stool Management System (Bard Medical Division, C. R. Bard)
B. Flexi-Seal® Fecal Management System (ConvaTec),
C. ActiFlo Indwelling Bowel Catheter System (Hollister, Inc.)
In this small sample size study, retention cuff pressure was at least 2-fold lower in device A than in devices B and C, in all body positions, and patient comfort level was similar in the 3 devices.
Complications can occur with the use of these devices and include rectal bleeding (Popek, 2013; Page, 2008).
At the Wound Ostomy Continence Nurses 45th Annual Conference in June, there were 3 abstracts presented on the use of fecal containment systems and they are summarized here.
Randomized controlled study of the effects of two fecal management systems on incidence of anal erosion
MA Sammon, Cleveland, OH
As noted, there have been published case studies about the presence of anal erosion from the use of IFMD, but randomized, controlled studies have not been conducted. This study was conducted in a single center (1 200 + bed) quaternary care medical center. This study was necessary as staff nurses perceptions of anal erosion from fecal management systems (FMSs) was estimated at 40%. This randomized controlled study was designed to compare incidence of anal erosions between 2 fecal management systems (FMSs) (DigniCare® or Flexi-Seal®). The authors wanted to know if anal erosion occurs at the same rate when using 2 different systems. The setting was adult ICUs (n=59 MICU, n=3 SICU) and general floor patients (n=17) requiring FMS placement (total enrolled: n=79, 52% female, mean age 64). Participants were randomized to 1 of 2 systems (DigniCare®, n=41, Flexi-Seal®, n=38). Nurses were trained to apply both systems.
Results: The frequency of anal ulcer or erosion between FMSs was compared using logistic regression models that adjusted for length of stay and times to event using Kaplan-Meier estimates and logrank tests. Incidence of anal erosion was 12.7% and there were no differences in incidence between the two types (FMS 1 & FMS 2, 12.2% versus 13.2%, P=0 .88). Overall, leakage of stool occurred in 70% of patients and was associated with anal erosion, P = 0.027. Overall anal erosion rate was 13%, much below the rate perceived by nurses before the study. Patients with anal erosions had a trend toward lower amounts of water in the balloon (P = 0.072) and lower balloon pressures in the rectum (P = 0 .080). An additional factor associated with anal erosion, in both groups, was peri-anal stool leakage occurring anytime FMS was in place, which may relate to amount of water in the balloon.
Conclusion: There were no differences in the incidence of anal erosion between groups. Limitations noted was small sample size, single center with high acuity patients so results may not apply to other patients.
Assessment of the impact of fecal containment on the cost of care for patients undergoing surgical repair of pressure ulcers
R I. Murahata, M Riemer, MS, Hollister Inc, Libertyville, IL; E Gläser, Independent Medical Consultant, Herdecke
Aim: A balanced, randomized controlled study to determine the effect of using a bowel management system during the preoperative bowel cleansing phase and for the 14-day period following surgery for pressure ulcer revision. N=30 patients, n=16 intervention group, n=14 control group.
Primary objective: Measure of patient care costs including overall nursing time and supplies, length of stay, loss of operating room time due to soiling during preoperative phase, and cost of treating secondary infection.
Secondary objective: Incidence of secondary infection during recovery, the number of delayed surgeries due to preoperative soiling, and the number of diversionary ostomies that were avoided. Results: No reported adverse events and no withdrawals. There was a significant difference in favor of the intervention group with respect to nursing time, cost of supplies, physician time, and length of stay. No significant difference regarding loss of operating room time was noted. None of the patients in the intervention group developed infection, while 3 patients in the control arm had infections by the end of the study (not statistically significant).
Conclusion: Bowel management system provided a significant economic benefit in this small group of surgical patients and may yield a similar benefit in patients who are at risk of self contamination with fecal material.
Risky business: Fecal management system use? Development of an algorithm to ensure safety
S Creehan, C Adams, B Brunel, VCU Medical Center, Richmond, VA
This poster discussed evidence-based “best practice” for use of a fecal management system (FMS). The goal was to develop an evidence-based nurse-driven FMS insertion algorithm, based on the literature, for nursing use of a FMS in an adult population with fecal incontinence. The literature review yielded 11/14 Level 4 non-research evidence. The algorithm was necessary as the authors noted there was an overuse in their institution of the FMS in inappropriate patients. A second expert reviewer was enlisted to ensure critical evaluation and determine patient appropriateness prior to insertion validated FMS patient selection process. After implementation of the algorithm, average monthly use decreased by 75%, and there have been no adverse events.
References:
- Benoit R, Watts C. The effect of a pressure ulcer prevention program and the bowel management system in reducing pressure ulcer prevalence in an ICU setting. JWOCN. 2007;34(2):163-175.
- Bliss DZ, Fischer LR, Savik K, Avery M, Mark P. Severity of fecal incontinence in community-living elderly in a health maintenance organization. Res Nurs Health. 2004;27:162-173
- Bliss DZ, Johnson S, Savik K, Clabots CR, Gerding DN. Fecal incontinence in hospitalized patients who are acutely ill. Nurs Res. 2000;49(2):101-108
- Bright E, Fishwick G, Berry D, Thomas M. Indwelling bowel management system as a cause of life-threatening rectal bleeding. Case Rep Gastroenterol 2008;2:351–5. PMID: 22513927
- Brown HW, Wexner SD, Lukacz ES. Factors associated with care seeking among women with accidental bowel leakage. Female Pelvic Med Reconstr Surg. 2013 Mar-Apr;19(2):66-71. doi: 10.1097/SPV.0b013e31828016d3. PMID: 23442502
- Deutekom M, Dobben AC. Plugs for containing faecal incontinence. Cochrane Database Syst Rev. 2012 Apr 18;4:CD005086. doi: 10.1002/14651858.CD005086.pub3. Review.
- Hurnauth C. Management of faecal incontinence in acutely ill patients. Nurs Stand. 2011;25(22):48-56.
- Jelovsek JE, Barber MD, Paraiso MF, Walters MD. Functional bowel and anorectal disorders in patients with pelvic organ prolapse and incontinence. Am J Obstet Gynecol 2005; 193:2105-11
- Jodorkovsky D, Dunbar KB, Gearhart SL, Stein EM, Clarke JO. Biofeedback therapy for defecatory dysfunction: "real life" experience. J Clin Gastroenterol. 2013 Mar;47(3):252-5. doi: 10.1097/MCG.0b013e318266f43a. PMID: 23328298
- Kowal-Vem A, Poulakidas S, Barnett B, et al. Fecal containment in bedridden patients: economic impact of 2 commercial bowel catheter systems.Am J Crit Care. 2009 May;18(3 Suppl):S2-14: quiz S15. Erratum in: Am J Crit Care. 2010 Nov;19(6):488. PMID:19623696
- Langill M, Yan S, Kommala D, Michenko M. A budget impact analysis comparing use of a modern fecal management system to traditional fecal management methods in two canadian hospitals. Ostomy Wound Manage. 2012 Dec;58(12):25-33. PMID: 23221016
- Marchetti F, Corallo JP Jr, Ritter J, Sands LR. Retention cuff pressure study of 3 indwelling stool management systems: randomized study of 10 healthy subjects. JWOCN. 2011 Sep-Oct;38(5):569-73. doi: 10.1097/WON.0b013e31822ad43c.
- Nelson RL. Epidemiology of fecal incontinence. Gastroenterology 2004; 126:S3-7. Padmanabhan A, Stern M, Wishin J, et al. Clinical evaluation of a flexible fecal incontinence management system. Am J Crit Care 2007;16:384–93.
- Page BP, Boyce SA, Deans C, Camilleri-Brennan J. Significant rectal bleeding as a complication of a fecal collecting device: report of a case. Dis Colon Rectum 2008;51:1427–9.
- Popek S, Senagore A. Indwelling rectal tubes: an unusual cause of significant rectal bleeding in two critically ill patients. Am Surg. 2013 Feb;79(2):219-20. No abstract available. PMID: 23336667
- Wishin J, Gallagher T, McCann E. Emerging options for the management of fecal incontinence in hospitalized patients. JWOCN. 2008;35(1):104-110.
Presented at the Wound, Ostomy and Continence Nurses Society (WOCN) 45th Annual Meeting - June 22 - 26, 2013 - Seattle, WA USA
Written by Diane K. Newman, DNP, FAAN, BCB-PMD for UroToday.com
WOCN 2013 - Abstract: Randomized controlled study of the effects of two fecal management systems on incidence of anal erosion
SEATTLE, WA USA (UroToday.com) - Previously, 3 published case studies documented the presence of anal erosion associated with the use of indwelling fecal management devices. However, we could not find any prospective, randomized controlled studies in the literature that addresses the topic. A randomized, controlled comparative effectiveness research study was designed to compare emergence of anal erosion after placement of 2 fecal management devices.
Background: At our 1 200+bed quaternary care medical center, nurse perceptions of anal erosion from fecal management systems (FMSs) was estimated at 40%. A randomized controlled study was designed to compare incidence of anal erosions between 2 FMSs.
Methods: Adult medical ICU and floor patients requiring FMS placement were randomized to 1 of 2 systems. Frequency of anal ulcer or erosion between FMSs was compared using logistic regression models that adjusted for length of stay and time to event using Kaplan- Meier estimates and log rank tests.
Results: Of 79 patients, 41 received type 1 and 38 received type 2; mean (SD) age was 64 ± 13.6 years, 52% were female and 74.7% received FMS in the medical ICU. Incidence of anal erosion was 12.7%; there were no differences in incidence between type 1 and type 2 groups, 12.2% versus 13.2%, P = .88, or in anal erosions based on day of occurrence, P = .82. Overall, leakage of stool occurred in 70% of patients and was associated with anal erosion, P = .027. Patients with anal erosions had a trend toward lower amounts of water in the balloon (P = .072) and lower balloon pressures in the rectum (P = .080).
Conclusion: In this randomized, controlled comparative effectiveness research study, there was no difference in the incidence of anal erosion between groups. Decisions about purchasing a company’s FMS product should not be based on perceived differences in general product quality. Results regarding the amount of balloon water, pressure, and anal erosions require further study.
Presented by Mary Ann Sammon, RN, BSN, CWCN at the Wound, Ostomy and Continence Nurses Society (WOCN) 45th Annual Meeting - June 22 - 26, 2013 - Seattle, WA USA
Cleveland Clinic, Cleveland, OH
WOCN 2013 - Abstract: Assessment of the impact of fecal containment on the cost of care for patients undergoing surgical repair of pressure ulcers
SEATTLE, WA USA (UroToday.com) - Contamination of wounds and dressings with fecal material can lead to an increased risk of nosocomial infections. This was a balanced, randomized controlled study to determine the effect of using a bowel management system during the preoperative bowel cleansing phase and for the 14-day period following surgery for decubitus ulcer revision. Patients in the control arm received the institution’s standard of care. The study was approved by the Ethikkommission, Ernst-Moritz-Arndt Universität Greifswald and was conducted at the Neurologisches Rehabilitationszentrum in Greifswald, Germany. All patients provided written informed consent prior to being screened and enrolled in the study. The primary measure was patient care costs including overall nursing time and supplies, length of stay, loss of operating room time due to soiling during preoperative phase, and cost of treating secondary infection. Secondary objectives included incidence of secondary infection during recovery, the number of delayed surgeries due to preoperative soiling, and the number of diversionary ostomies that were avoided. The study completed with a total of 30 patients, 16 in the test arm and 14 in the control arm. There were no reported adverse events and no withdrawals. There was a significant difference in favor of the Test Group with respect to nursing time, cost of supplies, physician time, and length of stay. No significant difference regarding loss of operating room time was noted. None of the patients in the test arm ended the study with an infection, while 3 patients in the control arm had infections by the end of the study. This difference in proportions of secondary infections is not statistically significant. The results of this study showed that the use of a bowel management system provided a significant economic benefit. A similar benefit may be observed in other circumstances where patients are at risk of self contamination with fecal material.
Presented by Richard I. Murahata, PhD,a Michael Riemer, MS,a and Eberhardt Gläser, MDb at the Wound, Ostomy and Continence Nurses Society (WOCN) 45th Annual Meeting - June 22 - 26, 2013 - Seattle, WA USA
aHollister Incorporated, Libertyville, IL; bIndependent Medical Consultant, Herdecke
WOCN 2013 - Abstract: Risky business: Fecal management system use? Development of an algorithm to ensure safety
SEATTLE, WA USA (UroToday.com) - Fecal incontinence can be a difficult challenge for the patient and bedside providers. Over time fecal incontinence may complicate the patient’s course contributing to discomfort, skin breakdown, decreased strength, and poor self-image. Bedside providers struggle to maintain the patient’s dignity and confront the substantial time involved in caring for patients with fecal incontinence. There is limited research on the effective management of fecal incontinence, but best practice guidelines include the use of fecal management systems. In our large university health system, a commercial fecal management system (FMS) was being used without clearly defined indications. The nursing policy did not effectively guide nursing to safely care for patients requiring an FMS. As the benefits of the system were realized, device utilization increased to approximately 100 per month, which in turn increased the rate of device-related adverse events. A team of invested clinicians sought to bring evidence-based practice to this clinical issue by seeking an answer to the question: In the adult population what is the best practice for the use of an FMS? After conducting a literature search, an evidencebased insertion algorithm and competency plan were developed. To ensure critical evaluation and determine patient appropriateness prior to insertion, the patient selection process must be validated by a second expert reviewer. Additionally, to assist in timely removal of the FMS, the unit-based experts ensure device necessity daily. The IT system was leveraged to support documentation of these new requirements. Since implementation of the new standards, the average monthly use of FMSs has dramatically decreased by 75% and there have been no adverse events.
Learner Outcomes:
(1) Describe evidence-based practice review in the use of fecal management systems.
(2) Review the nurse driven algorithm for best practices in management of a patient with fecal incontinence.
References:
Benoit R, Watts C. The effect of a pressure ulcer prevention program and the bowel management system in reducing pressure ulcer prevalence in an ICU setting. J Wound Ostomy Continence Nurs. 2007;34(2):163-175.
Bright E, Fishwick G, et al. Indwelling bowel management system cause of life-threatening rectal bleeding. Case Rep Gastroenterol. 2008;(2):351- 355.
Hurnauth C. Management of faecal incontinence in acutely ill patients. Nurs Stand. 2011;25(22):48-56.
Padmanabhan A, Stern M, et al. Clinical evaluation of a flexible fecal incontinence management system. Am J Crit Care. 2007;16(4):384-392.
Wishin J, Gallagher T, McCann E. Emerging options for the management of fecal incontinence in hospitalized patients. J Wound Ostomy Continence Nurs. 2008;35(1):104-110.
Presented by Suzanne Creehan, RN, CWON, Chisti Adams, RN, MSN, CCRN, CCNS, and Bonnie Brunel, RN, MSN, PCCN at the Wound, Ostomy and Continence Nurses Society (WOCN) 45th Annual Meeting - June 22 - 26, 2013 - Seattle, WA USA
VCU Medical Center, Richmond, VA
