Impact of Bowel Management Guidelines on ICU Documentation and Patient Outcomes
Patients in the intensive care unit (ICU) are at a higher risk of developing diarrhea and constipation. The etiology of these bowel movement abnormalities can be disease, medications, decreased mobility and diet. Adverse outcomes of diarrhea and constipation can be skin irritation and breakdown leading to:
- Pressure ulcers
- Delayed weaning or prolonged mechanical ventilation
- Bowel obstruction or perforation
- Increased length of stay
Critically ill patients are also vulnerable to urinary tract infections and other nosocomial infections such as wound- or intravascular catheter-related infections, and ventilator-associated pneumonia. Bowel dysfunction, especially diarrhea, can also have a financial impact in terms of
- Use of supplies
- Human resources
- Care team workload
An interprofessional research team designed and conducted a descriptive, observational study composed of two phases: Phase I – 2017, Phase II – 2018-2019. The first phase (IRB #1006399-1) was a retrospective chart review that focused on analyzing baseline data on bowel management practices in 4,118 ICU patients. These findings were used to identify areas for improvement in documentation and to develop evidence-based bowel management guidelines.
We developed bowel management guidelines in 2017 and 2018, gathering staff input and feedback through surveys and daily open discussion forums. The final guidelines were implemented in 2018. Roll out strategies included:
- Express in-service posters
- One-on-one education
- 30-minute education sessions
- Reminder emails
- Standardized documentation of bowel movements with a stool assessment scale
- Sidebar reference in the electronic health record that can be used as a daily rounding tool
During phase II (IRB#1369741-1), a second retrospective chart review was conducted to study changes and improvements in patient outcomes. This phase also included an observational analysis, with a goal to evaluate cost and impact of diarrhea on caregivers’ workload. The chart review findings suggested that one year after the beginning the project, incorporation of the new bowel management guidelines into nursing practice had started to be established. The second chart review also showed improvement in the consistency of stool reporting with a significant decrease in incidence of diarrhea. The observational analysis validated that bowel management guidelines can have a positive impact on costs, standardization of patient care and ICU workflow.
- Interprofessional team members: Paul Blakeslee RD, LD, CNSC; Erin Corica PharmD., BCNSP; John Dziodzio BA; Kristiina Hyrkas PhD, LicNSc, MNSc, RN; Sonja Orff MS, RN, CNL; Shawn Taylor BS, RN; Alana Trottier BS, RN, CCRN; Elizabeth Turner, MD; and Martha Weatherhead, RN.
- Awards: This study received the 15th Annual Research Award in 2020
- Evidence-bases practice award: Sonja Orff RN, MS, CNL, received the Kappa Zeta-at Large grant for this initiative in 2017.