When you’ve got to go, you’ve got to go. And when you’re a child given a bowel preparation in the lead-up to a colonoscopy, you have to go very urgently.
Suzie Jackson and Nicole Armitage are Clinical Nurse Specialists who’ve worked together for 15 years. Now on Possum Ward, a short-stay surgical ward, they administer the preparation for a bowel washout to an average of one child a fortnight.
Toileting accidents compound the distress these children have already gone through since admission. In order for the preparation to be given, a nasogastric tube needs to be inserted into the nose, down the throat and into the stomach. This may be performed with or without sedation and sometimes multiple attempts are needed which can be traumatic for the child and their family members watching on.
“We’d say, ‘Oh, no! Here we go again’,” said Suzie. “We need to do something to better support the preparation, admission and management of these children.
“We went to a presentation about the BEST Practice program and were inspired to apply. We were keen to find a way to improve this issue and being accepted into the program gave us the opportunity to learn research methods.”
Professor Fiona Newall mentored the two nurses across nine study days that began with them identifying the chain of problems that added up to an unnecessarily tough and messy hospital stay.
The pair collected data from the hospital’s electronic medical records using key terms and identified 20 patients around four years of age as their study cohort.
“Most children having this procedure are capable of drinking the bowel preparation solution at home,” said Nicole. “No problem there.
“The small number that require admission the day before for the preparation to be given were our target group. Their families didn’t seem to be fully informed that this would involve insertion of the nasogastric tube.”
Sedation is optional for nasogastric insertion but if it is used the child must have fasted for two hours beforehand. This was another detail often not passed on to parents and the process would subsequently be delayed two hours.
Admission times were generally late in the afternoon with no play therapists available after hours to help minimise the child’s anxiety and gently lead them through the insertion procedure. Late admission also meant missing out on double nurse time when the morning and afternoon shifts crossover; an issue on a ward like Possum which has only a small staff.
Nitrous Oxide is the preferred sedation agent for nasogastric insertion but it’s not available in Possum Ward. Patients need to be transferred to another ward and wait for accredited staff to assist.
It’s now late afternoon, delays are accumulating and the clock is ticking towards bedtime and a rough night ahead. Urgent bowel movements may start within an hour of receiving the bowel preparation and may lead to toileting accidents and interrupted sleep in the lead-up to the colonoscopy.
“We asked a question of our practice and Fiona backed us to find a solution,” said Suzie. “We identified the issues as work-flow, a problem with timing and a lack of advance notice.”
After six months, they came back with a series of recommendations that will form a new practice guideline.
“Children need to be admitted earlier having already fasted to avoid a delay,” said Nicole. “They need a written plan of care with orders for sedation, bowel prep and rehydration.”
Nicole and Suzie are developing a parent information leaflet so families arrive earlier and are fully informed. It encourages parents to try and get children to drink the preparation at home to avoid an overnight hospital stay, and links them to practical supports like educational play therapy. It also describes the insertion of the nasogastric tube so it’s not a nasty surprise.
Suzie and Nicole’s work-flow recommendations also smooth the flow of these children through their hospital stay. With admission through to toileting taking place much earlier, children are now more likely to sleep through.