COMPLEX BOWEL CARE POLICY AND PROCEDURE

The purpose of this policy is to demonstrate that Gill Support and Care Services understands that some participants may require additional support with their activities of daily living including complex bowel care. Gill Support and Care Services will ensure that any support provided to a participant of this nature is done in partnership with the participant to ensure their needs and preferences are given priority.

Background

For the purposes of this document, bowel care refers to the care and management of the process of the elimination of faecal matter from the body. Bowel care can encompass personal hygiene, assistance with toileting, medications to promote bowel function, and the administration of same.

Historically, bowel care was provided in a hospital or facility setting or by a community nurse. This was due to lack of guidelines or legislation regarding support workers safe practice in community service delivery. However, risk analysis by government departments and changes in the way community services are delivered has identified the skills and competencies required for this task. This has led to significant shifts in practice. It is now acceptable for support workers with appropriate competency training and assessment to provide bowel care.

As participant involvement and service direction has increased it is imperative to involve the participant in all aspects of the service delivery and the direction of their services to their ability. It is further acknowledged that dignity of risk is an important part of this choice and control.

Policy

All complex bowel care support will be delivered by appropriately trained staff and in line with a Complex Care Plan that is developed with the relevant health practitioner and the participant and/or family.

Gill Support and Care Services ensures that all participants requiring complex bowel care receive the best quality support relevant to their individual needs.

Procedures

• Gill Support and Care Services’s service delivery model is based on person centred approaches. As such all participants and or their family/carer are involved in the assessment and development of the plan for their complex bowel care management.
• If a participant requires complex bowel care a Complex Care Plan will be developed in partnership with a nominated health practitioner specifically for the participants needs. This care plan will be developed in partnership with the participant, their family/carer and any relevant health professional (with the consent of the participant/family). The plans include nature and frequency of the procedure, who will deliver it, timeframes for review by a health professional, any potential or actual risks involved and how incidents and emergencies are managed and actions/procedures to refer any situation that requires further expertise to the appropriate agency or health professional.
• Wherever possible it is the preference of Gill Support and Care Services to have some form of complex care delivered by qualified nursing staff. Where this is not possible, or not the preference of the participant/family, Gill Support and Care Services will ensure that the preferred support worker(s) is provided with the appropriate training from a qualified and experienced health professional. This training will encompass the specific needs of each participant, the type of complex bowel care required and will comply with the NDIS High Intensity Support Skills Descriptor for providing complex bowel care.
• All staff required to deliver complex bowel care will have a training plan devised to ensure they can competently deliver the type and nature of bowel care required and that they have a good understanding of the basic anatomy of the digestive system, the importance of regular bowel care and an understanding of stool characteristics indicating healthy bowel functioning and related signs and symptoms. As well as a basic understanding of related conditions including autonomic dysreflexia; symptoms/indications of need for intervention and when to refer to health practitioner e.g., overflow, impaction, perforation; infection, understanding of intervention options and techniques including administering enemas and suppositories, digital stimulation, massage etc. and related guidelines and procedures, nutrition and hydration requirements.
• All training and training plans will be delivered and devised by and in partnership with a qualified health practitioner.
• All Complex Bowel Care must be done in accordance with the Gill Support and Care Services Waste Management and Infection control Policy and Procedures.
• As a part of the community service or support delivered by Community Support Professionals, Gill Support and Care Services will:
• Assess the initial care needs with the participant.
• Determine the areas of bowel care that the Community Support Professional may attend.
• Develop plans with identified outcomes.
• Provide written procedures on the provision of bowel care by the Community Support Professional – this may be included as part of the plan.
• Policies and procedures for bowel care should be clearly documented in the home and only changed by the participant’s doctor or a registered nurse.
• Identify education needs for Community Support Professionals. Provide relevant competency-based training and assessment processes for the Community Support Professional/s to ensure they are competent to perform the prescribed duties, tasks and interventions.
• Monitor, review, evaluate and adapt as required the service, plans and outcomes with the involvement of the participant.
• It is recommended wherever possible, that initial bowel care training should be provided by the discharging hospital or specialist registered nurse.

Gill Support and Care Services Management Team will review this policy and procedure at least annually. This process will include a review and evaluation of current practices and service delivery types, contemporary policy and practice in this clinical area, the Incident Register and will incorporate staff, participant and another stakeholder feedback. Feedback from service users, suggestions from staff and best practice developments will be used to update this policy.

Gill Support and Care Services’s Continuous Improvement Plan will be used to record and monitor progress of any improvements identified and where relevant feed into Gill Support and Care Services’s service planning and delivery processes.

DEFINITIONS

Term	Definition
Constipation and poor bowel emptying	It is described as difficulty or pain when passing faeces or passing faeces infrequently.
Diarrhoea	loose watery faeces and is usually frequent.
Faecal Incontinence	uncontrolled passing of faeces and creates social or hygiene problems for the person.

PRINCIPLES OF COMPLEX BOWEL CARE

• To follow personal hygiene and infection control procedures.
• To maintain dignity, respect and consent throughout all activities in complex bowel care management
• To observe and record changes to bowel habits and report issues arising from the delivery of bowel care.
• To administer laxatives, enemas or suppositories including non-routine medication as required according to procedure
• To identify when to seek health practitioner advice.

ROLES AND RESPONSIBILITIES

Gill Support and Care Services’s Registered nurse is responsible for the overall clinical management and medication management of the high intensity support activities for participant’s care. This policy is to be used in conjunction with Gill Support and Care Services’s Management of Medication Policy (where required).

Gill Support and Care Services’s participants are ensured their desired level of involvement is respected and maintained. A participant’s Complex Bowel Care Plan is overseen by Registered nurse and health practitioners (e.g., Medical doctor, Bowel care specialist, Registered Nurse). This support plan will be regularly reviewed where procedures and information will be given to the participant/carer/advocate and Registered nurse.

Please Note: Any changes to a Complex Bowel Care Plan regarding medication management will be conducted by Registered nurse and health practitioners (e.g., Medical doctor, Bowel care specialist, Registered Nurse).

Nursing (Registered Nurse)

• Completes a bladder and bowel assessment within 7 days of commencement of service, quarterly (13 weeks) and any change in condition that affects continence.
• Initiates and communicates a plan of care to address the participant’s bladder and bowel issues.
• Makes referral to other interdisciplinary team members.
• Provides education to family/participant/carer about bladder and bowel management.
• Evaluates the plan of care and updates as necessary.
• Assesses Community Support Professional’s skills and encourages staff development, e.g., transfer skills.
• Review bladder and bowel record and addresses constipation with interdisciplinary team.
• Responds to Community Support Professional’s assessment, re: bladder and bowel management concerns.

Community Support Professionals

• Offers privacy and develops rapport with participant when toileting/changing.
• Encourages fluid and nutritional intake, e.g., 1500 ml of fluid daily.
• Follows procedure and care plan to promote continence.
• Assists participant when transferring, ambulating or walking to the toilet.
• Maximises mobility and passive exercises.
• Toilets the participant as per care plan.
• Completes the voiding and bowel record and reports concerns or changes to the Coordinator.
• Recognises and reports participant verbalisations and behaviours indicative of discomfort.
• Reports any signs and symptoms of bladder and bowel discomfort to the coordinator.

CARE PLAN

Plan means a Care Plan or Individual Plan (however titled – the plan) and is a document developed in response to a request for service. It is developed by a registered nurse (or other appropriately, similarly skilled professional) from the Gill Support and Care Services, prior to the commencement of service delivery. It outlines the expected outcomes of the requested care/services and the tasks, duties and interventions required to meet the care and service needs of the participant (within the parameters of the funding program). The plan guides and directs the individual support worker in their day-to-day delivery of the services.

Gill Support and Care Services’s participant support plan is developed with the involvement of the participant/carer/advocate and Registered nurse and health practitioners (e.g., Medical doctor, Registered Nurse). Included in the plan is:

• Information on normal stool appearance for the individual participant.
• how to identify symptoms that require action.
• the timing of interventions (how long before action is taken) and the action required.
• detailed instructions on medication selection and administration procedures.
• emergency management options and procedures.

The Registered nurse will confirm consent prior to complex bowel care and the administration of medications; according to the Complex Bowel Care Plan received from the participant/carer/advocate. The participant’s bowel care will have regular reviews by Registered nurse and a qualified health practitioner (e.g., Medical doctor, Registered Nurse). The support plan will identify how to exercise judgement in complex bowel care, and when to administer medication. It will also include how to manage risks, incidents and emergencies including required actions and escalation to ensure participant wellbeing and safety.

A participants’ Complex Bowel Care Plan will be reviewed weekly to ensure there are updated strategies in place for acting upon information from the participant/carer/advocate, Registered nurse and health professionals.

Registered nurse is to follow documentation procedures which include:

• Monitoring and recording changes in bowel habits.
• Administration of laxatives, enemas or suppositories according to procedure.
• Administration of non-routine medication as required.
• Emergency management procedures.
• Recording any changes requested by a health practitioner (e.g., Medical Doctor, Registered Nurse).
• Documentation and communication to the Director and participant/carer/advocate when there is a request for a change in Bowel Care.

Any of the following signs require immediate referral to the GP or local hospital:

• Vomiting blood or faecal matter.
• Diarrhoea and/or vomiting that is more than a one-off event.
• Bleeding from the bowel.
• Fresh (red) or old (black) blood in faeces.
• Unusual pain before, during or after a bowel action.

*NOTE: Black faeces occur when a participant is taking iron supplements.

STAFF TRAINING

Community Support Professionals/ support workers may:

• Perform any task on the plan apart from those that must be performed by a registered nurse.

Registered Nurses must:

• Complete competency training and assessment in the task prior to undertaking said task. Skills-based competency shall be reassessed annually by Gill Support and Care Services.
• Follow the plan as provided by Gill Support and Care Services.
• Report to their supervisor/coordinator any changes or variations for advice
• Not change any plan.
• Report any issues arising from the delivery of bowel care (such as: bowels not open, bleeding, constipation, diarrhoea) to their Gill Support and Care Services coordinator for further advice.
• Identify and report to their supervisor any gaps in their ability to deliver the required service.

Staff Training

Gill Support and Care Services’s Registered nurse will have received training (according to their training plan), relating specifically to the specific needs of each participant they support including the appropriate use of equipment. Training should be delivered by an appropriately qualified health practitioner or a person who meets the expectations of this skills descriptor.

Gill Support and Care Services will ensure workers delivering complex bowel care supports have the following skills and knowledge.

Skills Required:

• Understanding the support plan, confirming it is correct and the current plan for the participant, checking the participant’s specific support requirements for example: timing, frequency and type of support.
• Checking with the participants on their expectations, capacity and preferences for being involved in the delivery of support.
• Checking with the participants on their preferences for communication, including the use of aids, devices and/or methods.
• Communicating with participants using participant-specific communication strategies, communication aids, devices, or resources, including resources in the participant’s preferred language.
• Preparing for hygiene and infection control
• Checking that required equipment and consumables are available and ready for use.
• Recognising the intensely personal nature of this type of support and making sure the participant is ready to receive support.
• Identifying and immediately informing an appropriate health practitioner in response to signs of poor bowel function or related problems.
• Working collaboratively with others to ensure continuity and effective delivery of support.
• Identifying, documenting, and reporting information where a support plan is not meeting a participant’s needs.
• Supporting the participant to provide feedback and request changes to their support plan as required.

For workers who support participants with a stoma:

• Supporting the participant to clean and maintain healthy condition of the stoma site.
• Replacing and disposing of ileostomy and colostomy bags as required.
• Monitoring and recording information required by the support plan such as outputs, hydration, and appearance of the stoma.
• Identifiying and responding to problems such as blockages and immediately informs an appropriate health practitioner in response to indicators of deteriorating health condition of the participant.
• Actively involving the participant in their support,

Knowledge Required:

• NDIS Code of Conduct and Practice Standards.
• The role of good bowel care in supporting participants to lead the life they choose.
• Understanding common and participant-specific communication supports, for example, assistive technologies, alternative and augmentative communication, communication devices.
• Principles of infection control and personal hygiene, for example hand washing, disinfecting, use of appropriate Personal Protective Equipment (PPE) such as gloves.
• Scope of worker responsibilities including supervision and delegation arrangements.
• Roles and responsibilities of others involved in providing complex bowel care, including carers, health practitioners and other workers.
• Features of a safe environment for working and delivering complex bowel care support.
• Common bowel care and stoma equipment and consumables.
• Requirements for handling, storing and administering bowel care-related medication.
• Signs and symptoms of common problems, and action required for example, reflux, vomiting, stomach pain, changes in bowel habits.
• Signs and symptoms, and action required in case of autonomic dysreflexia.
• When and how to involve or get advice from the appropriate health practitioner.
• Purpose of ileostomy and colostomy stomas and related equipment, and consumables such as stoma bags, skin sealants, barriers or powders.
• Reporting responsibilities, including handover, recording observations and incident reporting.
• Purpose of ileostomy and colostomy stomas and related equipment, and consumables such as stoma bags, skin sealants, barriers or powders.
• Common methods to clean and protect skin around the stoma.
• Characteristics of a healthy stoma and how these can change over time.
• Indicators and actions are required to respond to common health problems at the stoma site, such as wetness or signs of infection or inflammation.
• Reporting responsibilities, including handover, recording observations and incident reporting.

Upon successful completion of this training, a Statement of Attainment is required to be sighted and a copy retained by Gill Support and Care Services. In addition, it is recommended that the Community Support Professional be assessed in the workplace within one month of the completion of this course, by a suitably experienced registered nurse or healthcare professional.

Gill Support and Care Services training system complies with the high intensity support activities skills descriptor for providing complex bowel care including how to follow procedures and exercise judgement on when to respond/report problems such as blockages, signs of deteriorating health or infection. Gill Support and Care Services has policies and procedures in place which identify, plan, facilitate, record and evaluate the effectiveness of training for their frontline staff. This system facilitates training which is mandatory in relation to staff obligations under the NDIS Practice Standards and NDIS rules.

Competency of Clinical Staff in Bowel Management & Emergencies

• All clinical staff providing direct care must be trained and assessed in this bowel management procedure, including the clinical response to bowel emergencies. This can be completed through the Evaluation of competency-High intensity support activity Form.
• Participants who require bowel management must be cared for in an environment where staff are competent in bowel management and the clinical response to an emergency.
• All RNs, ENs, and support workers caring for a participant must be educated in bowel management by a designated assessor (allied health professional) with the appropriate clinical expertise).

Authority by a Medical Practitioner

If the participant needs a bowel care plan, the general practitioner (GP) develops one with the person, their families and/or their carer. Before leaving the surgery, the participant and carer should be certain that they understand how to implement the bowel management plan.

It is important to confirm with the GP what should happen following implementation of the bowel management plan, and how long it should take for the problem to be resolved.

Prior to the decision to allow a community support professional to administer an invasive bowel care procedure, the Gill Support and Care Services should consider and ensure:

1. That the treating doctor who prescribed the bowel care medication/management program to the participant has agreed in writing to support the arrangement of a trained and supervised community support professional administering same to the participant.
2. The procedure and doctor’s approval are retained in the home of the participant with a copy retained by Gill Support and Care Services
3. They (the medical practitioner) recognise consumer directed care and dignity of risk.
4. A registered nurse provides support and supervision of the participants’ program and bowel care administration.

Doctor’s order for bowel care to be administered by community support professionals as per the Gill Support and Care Services Bowel Care Guidelines and to be in place prior commencing any care for the participant.

Authority is only to be sought for adult participants of Gill Support and Care Services.

*Community Support Professionals are not permitted to administer invasive bowel care procedures on paediatric participants.

PPE required for Bowel care

• Disposable gloves (powder free).
• Disposable apron.
• Lubricant (water based).
• Gauze swabs.
• Incontinence pad or kylie.
• Commode.
• Bag for waste.
• Medications.

Monitoring and Review

Gill Support and Care Services Management Team will review this policy and procedure at least annually. This process will include a review and evaluation of current practices and service delivery types, contemporary policy and practice in this clinical area, the Incident Register and will incorporate staff, participant and another stakeholder feedback. Feedback from service users, suggestions from staff and best practice developments will be used to update this policy.

Gill Support and Care Services Continuous Improvement Plan will be used to record and monitor progress of any improvements identified and where relevant feed into Gill Support and Care Services service planning and delivery processes.