Nurses in the Faecal INcontinence and Constipation Healthcare (FINCH) team at Sandwell and West Birmingham Hospitals introduced an innovative integrated care pathway (ICP) for their patients. It has had a positive impact on both patient outcomes and experience.
Where to look
Nurses and colleagues in the multi-disciplinary FINCH team identified unwarranted variation in the service for faecal incontinence (FI) patients, when benchmarked against guidance from NICE (National Institute for Health and Clinical Excellence (NICE) 2007, Clinical Guideline Faecal incontinence: The management of faecal incontinence in adults. no.49. June 2007. NCC-AC, RCS London, UK.) and a Good Practice report (Department of Health. 2000. Good practice in continence services. HMSO London). They identified the potential for local improvement in access and referrals to the service, the triage process and the management of people with FI.
What to change
The referral pathway for FI patients was disjointed, resulting in them being seen by multiple clinicians. This created a barrier because some patients were only offered containment rather than treatment, and not made aware of treatment available. The patients themselves articulated how dispiriting the experience was.
How to change
Nurses in the FINCH team worked with local CCGs, GPs and community colleagues to develop an integrated FI pathway across primary and secondary settings. The aim was to improve accessibility, raise awareness of patients with FI, and get patients seen by the right healthcare professional, in the right place, at the right time.
To achieve this, key elements were required within the ICP including GP and patient education to improve awareness, a clearly defined referral pathway for GPs in conjunction with a clinical pathway to ensure that triage, assessment and patient management were consistent.
All of this was to be delivered using an electronic pathway document for healthcare professionals which included all the assessment tools used by the services. Patients were offered paper document, including information on how to carry out some of the conservative management techniques.
The ICP has three key differences:
- Clinics moved from hospital to general practices, closer to patients’ homes
- A bowel function nurse specialist taking over triage from a consultant
- The inclusion of the community continence team
Nurses raised awareness of the service through promotion in supermarkets and other public venues, presentations to community colleagues, and an education programme for local GP practices.
A qualitative study, was undertaken and evaluated by the University of Birmingham to identify the perspectives of patients using the new ICP compared to their previous experience with continence services. This was done through questionnaires, individual interviews, focus groups and diaries pre/post treatment with 13 FI patients participating.
Better outcomes –The service was already evidence based and clinical audits had shown good patient outcomes. In the study eight patients in the old pathway reported delays in referral or no referral at all. Five in the new ICP were referred quickly by their GP once their symptoms were known. All were happy with the improvement in their symptoms to date, and found the handheld document useful for tracking them, reminding them how to perform some of their management exercises and as an aid when discussing their treatment with clinicians.
Better experience – Patients in the new ICP spoke positively about the ease of access to the service in a community setting. They felt at ease talking to nurse specialists, with some saying they felt they could now discuss their problems more openly.
Better use of resources – There has been a cost-saving reduction in pad usage by patients, and an indication of fewer hospital admissions, although this hasn’t been fully quantified.
The introduction of the ICP for faecal incontinence ensured that the patient was seen in a timely fashion, by the correct clinician, in the right setting closer to their home.
Challenges and lessons learnt for implementation
An ICP for FI has the potential to solve some, if not all, of the issues related to previously fragmented and disjointed continence services. Service redesign has been possible and initial results suggest that patients are benefitting. However, is it essential to promote the service effectively to key stakeholders such as GPs, to ensure that the right patients are referred promptly. There is also a need for more community clinics in different locations to enhance patient access.
Watch this video on faecal incontinence and constipation healthcare
Sandwell and West Birmingham Hospitals NHS Trust have developed a nurse-led Faecal Incontinence and Constipation Healthcare (FINCH) service, where an integrated care pathway has been designed to increase accessibility, streamlining of the patient pathway and provide a dedicated service for the management of faecal incontinence and constipation:
Find out more
For more information contact:
Elizabeth Clarson, Senior Bowel Function Clinical Nurse Specialist, firstname.lastname@example.org