A Unique Method to Enhance Vesicostomy Pouching in a School Aged Child

Authors

Tim Luttrell BSN, RN, CWOCN

Lisa Kirk MSN, RN, CWOCN

Comparative study of bowel management methods

Introduction

Fecal incontinence and associated incontinence associated dermatitis (IAD) is estimated to occur in27-30% of patients in the acute care setting.

Background

Fecal incontinence and IAD were problems identified by staff nurses in our critical care units. Optionsfor management were limited because of past problems with internal devices.

Purpose

Compare three methods of bowel management for IAD in the intensive care unit:

1. Bowel management system catheter (BMS)

2. Nasopharyngeal trumpet (NT) fecal incontinence device

3. Usual care (UC)

Methods

Design - Prospective longitudinal randomized comparative study

Sample - Adult patients in critical care with liquid fecal incontinence

Setting – Six critical care units in large healthcare system.

Procedure - Consent was obtained, subjects randomly assigned to one of three groups: BMS catheter,nasal trumpet or usual care (protection of peri-rectal skin using moisture barrier products andexternal fecal incontinence collector). IAD severity, pressure ulcer presence and stage, and variousclinical data were collected every 24 hours.

Measures - IAD evaluation tool, NPUAP staging guidelines, and clinician satisfaction self-administeredsurvey.

AuthorsJoyce Pittman,

PhD, FNP-BC, CWOCN

Terrie Beeson,

MSN, CCRN

Lisa Kirk,

MSN, CWOCN

Colin Terry,

MS

Results

� No significantly different IAD scores and number of pressure ulcers at baseline among groups.

� No significant difference in proportion of patients experiencing pressure ulcers during the studyamong groups.

� There were significant differences in the change in IAD scores across groups over time,specifically over the first 10 days. Potential confounding variables include: varying duration oftime in study, high IAD scores in NT and UC groups were discontinued after short time, whilehigh IAD scores in BMS group were observed longer, and possibility that patients in the UCgroup received enhanced bedside care due to being study subjects.

� There was a significant difference in satisfaction across groups (p=0.001). Satisfaction wassignificantly greater with both the BMS device (p=0.007) and trumpet rectal device (p=0.001)than with usual care.

BMS NT UC n n n P value

Any pressure ulcer 21 9 (42.9%) 20 7 (35.0%) 18 5 (27.8%) 0.625

Aim 1: Table 1. Pressure ulcer prevalence over duration in study

Question Method n Disagree AgreeI was satisfied with the method Trumpet Rectal Device 22 4 (18.2%) 18 (81.8%)

BMS catheter 9 2 (22.2%) 7 (77.8%)

Usual Care 6 6 (100%) 0 (0.0%)

Aim 2: Table 2. Clinician Satisfaction among groups

Clinical Data BMS NT UC n Mean (sd) n Mean (sd) n Mean (sd) Pvalue

Age (years) 19 60.9 (13.6) 20 57.3 (9.6) 17 61.7 (12.9) 0.491

Gender (female) 20 13 (65.0%) 20 12 (60.0%) 18 10 (55.6%) 0.943

Race 19 17 17 0.577

African American 1 (5.3%) 3 (17.7%) 3 (17.7%)

Caucasian 17 (89.5%) 14 (82.4%) 14 (82.4%)

Other 1 (5.3%) 0 (0.0%) 0 (0.0%)

BMI 19 32.8 (10.5) 19 33.5 (10.6) 15 33.2 (7.8) 0.972

Braden Score 21 10.2 (2.7) 19 12.2 (2.2) 18 12.1 (2.2) 0.018

IAD score 21 11.2 (10.9) 19 11.4 (10.8) 18 12.7 (8.8) 0.886

Albumin 13 2.9 (2.0) 14 1.8 (0.5) 14 2.1 (0.7) 0.058

Hgb 21 8.9 (1.4) 20 10.2 (3.6) 18 9.2 (1.0) 0.188

Hct 20 27.1 (4.3) 20 27.2 (6.6) 18 27.2 (2.9) 0.999

APACHE 13 22.9 (11.9) 11 31.4 (28.3) 10 20.6 (7.3) 0.359

Pressure Ulcer

present at baseline 16 n(%) 14 n(%) 12 n(%)

Stage 1 1 (6.3%) 1 (7.1%) 1 (8.3%)

Stage 2 1 (6.3%) 2 (14.3%) 4 (33.3%)

Stage 3 0 (0.0%) 1 (7.1%) 0 (0.0%)

Stage 4 1 (6.3%) 0 (0.0%) 0 (0.0%)

Unstageable 3 (18.8%) 2 (14.3%) 0 (0.0%)

DTI 0 (0.0%) 1 (7.1%) 0 (0.0%)

None 10 (62.5%) 7 (50.0%) 7 (58.3%)

Nutrition 20 n(%) 18 n(%) 18 n(%)

NPO 1 (5.0%) 2 (11.1%) 0 (0.0%)

Tube Fed 17 (85.0%) 15 (83.3%) 17 (94.4%)

TPN 2 (10.0%) 0 (0.0%) 1 (5.6%)

Other 0 (0.0%) 1 (5.6%) 0 (0.0%)

C-diff (yes) 20 3 (15.0%) 18 0 (0.0%) 17 2 (11.8%) 0.304

Pressor drug (yes) 21 3 (14.3%) 19 5 (26.3%) 18 4 (22.2%) 0.661

Chem Sedated (yes) 21 11 (52.4%) 20 10 (50.0%) 18 4 (22.2%) 0.117

Aim 3: Table 3. Demographic, clinical characteristics, IAD, and pressure ulcers baseline among groups

Implications

Fecal incontinence and IAD are major concerns in critical care and often lead to seriouscomplications. This study examined three methods for management for fecal incontinence andidentified no safety concerns with any of the internal methods. These findings provide newevidence for fecal incontinence management in the ICU.

Conclusions

This study is an example of direct care nurses identifying a problem related to fecalincontinence management, developing a research study to examine the problem, andcomparing management methods. These nurses made an important difference in their clinicalsetting, leading to improved patient care.

References

Benoit, R., Watts, C. (2007). The effect of a pressure ulcer prevention program and the bowelmanagement system in reducing pressure ulcer prevalence in an ICU setting. J Wound OstomyContinence Nurs., 34(2), 163-175.

Bliss, D., Johnson,S., Savik, K., Clabots, C., Gerding,D. (2000). Fecal incontinence in hospitalizedpatients who are acutely ill. Nursing Research, 49, 101-108.

Gray, M. (2007). Incontinence-related skin damage: essential knowledge. Ostomy/WoundManagement. , 53(12), 28-32.

Gray, M., Bliss, D., Doughty, D., Ermer-Seltun, J., Kennedy-Evans. K., Palmer, M. (2007).Incontinence-associated Dermatitis

Grogan, T., Kramer, D. (2002). The rectal trumpet: Use of a nasopharyngeal airway to containfecal incontinence in critical ill patients. J Wound Ostomy Continence Nurs., 29 193-201.

Contact information

Contact: Joyce Pittman, PhD, FNP-BC, CWOCN, jpittma3@iuhealth.org

© 2011 Indiana University Health

William Kessler,

MD

Clara Monroe,

RN, CCRN

Mandy Schultz,

RN, CCRN

Melissa Johnson,

RN

Introduction

Background

Purpose

MethodsA vesicostomy is a urinary diversion procedure most commonly performed in infants and young children for temporary bladder drainage. Diapers are typically used to manage the urine output in infants and young children. However, when a child reaches school age diapering is no longer an effective and acceptable method to contain output and manage the odor associated with the urine.

J is a 7-year-old female with spina bifida and neurogenic bowel and bladder. Due to recurrent urinary tract infections and hydronephrosis, a vesicostomy was performed in 2013. The patient now attends school and struggles socially due to leakage of urine and the odor associated with it. She is removed from the classroom multiple times a day due to soiled clothing. Her mother reports changing and washing bed linen daily along with multiple clothing changes throughout the day – both of which are time consuming and costly. Despite her mother’s effort to keep J clean and dry, Social Work has documented concerns that J is not being properly cared for at home. In addition to the social concerns, urinary tract infections (UTI’s) are a common occurrence.

Due to the anatomical location of the vesicostomy (just above the symphysis pubis and in a deep abdominal fold), pouching has not been successful. This has resulted in multiple pouch changes per day and challenges with moisture associated dermatitis (MAD). The WOC nurses have utilized a cross disciplinary care team to identify a solution. The team is comprised of the WOC nurses, a developmental pediatrician, a urologist, and a Social Worker.

The purpose of this case study is to devise a method to contain the urine and manage the associated odor. The containment system must be cost effective and easy for the family to use at home. Furthermore, the system should not restrict the child from participating in her normal daily activities.

An adhesive coupling wafer was placed around the vesicostomy in the standard fashion.To facilitate urine to drain into the pouch, a unique Active Fluid Management (AFM) Ag wound care dressing was tucked into the vesicostomy os. A pouch was then adhered to the wafer and the 5 to 6 inch strip of AFM dressing provided a wicking mechanism that allowed the urine to drain through the strip directly into the pouch.

This solution allowed for the ostomy management system to remain intact, reducing appliance changes to the recommended two times per week. The AFM Ag dressing was replaced with each wafer change.

Conclusion

Data Results

References

Contact Information

• Urine output is successfully wicked into the ostomy pouch and a significant reduction in odor has been noted.• There have been no UTI’s in the seven months since employing the modified ostomy management system.• The use of the AFM Ag strip dressing has been effective in preventing the urine from pooling under the wafer. The vesicostomy tissue is healthy and the surrounding skin remains intact and non-irritated.• The use of this system has allowed the caregivers to extend the time between wafer changes from multiple times per day to two times per week.

The mother is having success with pouching the Vesicostomy since using the AFM Ag strip dressing. The system is changed approximately twice a week. Laundry time and expenses have decreased substantially since J is no longer waking up wet. J has avoided UTI’s, remained odor free, and no longer struggles with MAD. She is thriving in school and no longer feels isolated from her friends. The goals for this patient established by the cross disciplinary team have been met both clinically and in regards to quality of life.

1. Doughty, D.B., & Lightner D.J. (1992) Genitourinary Surgical Procedures. In R. A. Bryant & B.G. Hampton (Eds), Ostomies and Continent Diversions: Nursing Management (pp. 259), St. Louis, MO: Mosby-Year Book

2. Singh, C.D. Use of a moisture wicking fabric for prevention of skin damage around drains and parenteral access lines. J Wound Ostomy Continence Nurs 2016; 43:5, 551-553. doi:10.1097/WON.000000000000249

Contact: Tim Luttrell BSN, RN, CWOCN tluttrel@iuhealth.org