Developing a Fecal Incontinence Decisional Protocol for Critical Care

BACKGROUND:  Patients in critical care may develop short term fecal incontinence.  At our 507 bed, Magnet® designated level 1 trauma center, patients requiring a commercially-available, internal fecal collection system are evaluated by nurses from the Memorial Ostomy and Wound Service (MOWS). However, MOWS nurses are not always available on-site, creating a potential delay in initiating the fecal collection system.  Critical care nurses requested consultation in developing a decisional protocol to allow insertion of the device during after-service hours.

PURPOSE:  To pilot, evaluate, and implement an evidence based decisional protocol for safe, effective, appropriate and timely management of fecal incontinence for critically ill patients.

METHODS:  The project was guided by the Iowa Model of Evidence Based Practice to Promote Quality Care: define the problem, form a team, and critique and synthesize relevant literature. MOWS nurses worked with the Critical Care Collaborative, a multidisciplinary team of nurses and other professionals responsible for evidence-based practice across critical care units, to develop a decisional protocol. The protocol was piloted for three months using the Transforming Care at the Bedside model, with an n=1, the medical ICU, as a test of change. Two Unit Champions directed the pilot to insure that the protocol was consistently followed. The decisional protocol pilot resulted in a total of 15 uses during after-service hours, resulting in appropriate use of the device without delay in treatment.  This test of change has been spread to all critical care units.

RESULTS:  Implementation of the algorithm has facilitated patient care delivery. Since it was implemented in January 2010, 89 patients have received an ICFS without delay.

CONCLUSION:  Nurse-driven protocols may be effective in early intervention for fecal incontinence in critical care.