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Convatec Flexiseal Signal Faecal Management System (FMS ... Flipbook PDF
Patients may have one or more of the following: • Patients judged to be at risk of tissue/skin breakdown due to faecal i
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Flexiseal signal FMS
Title of Guideline (must include the word “Guideline” (not protocol, policy, procedure etc) Contact Name and Job Title (author)
Convatec Flexiseal Signal Faecal Management System (FMS) Guideline
Directorate & Speciality
Fiona Branch, Nurse Consultant Adult Critical Care. Anne Illsley, Service Improvement Sister Adult Critical Care. Adult Critical Care, Specialist Support
Date of submission
March 2013
Date on which guideline must be reviewed (this should be one to three years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis)
March 2016 Selection Criteria: Patients may have one or more of the following: • Patients judged to be at risk of tissue/skin breakdown due to faecal incontinence (Bristol Stool score 6-7). • Diarrhoea persisting for >48h where all correctable factors have been addressed (see below) diarrhoea defined as > 3 loose stools/day or >300ml/day if rectal bag in use. • Laboratory confirmation of C. Difficle or VRE patients. • Patient is bed-bound – If it is beneficial to sit the patient out even if he/she has a FMS in situ. Avoid compressing or kinking the device, and the sitting period should be the shortest possible. • Patient must have adequate anal sphincter tone (if lacking in anal tone will not be able to support balloon). • Massive persistent malaena, e.g. in patients with bleeding oesophageal varices. • Wounds in or near the sacral or perineal area likely to be contaminated with stool. • Patient has skin breakdown caused by exposure to faecal incontinence and/or faecal leakage (ensure tissue viability are involved in the patient care). Patient suitability for the FMS should also be assessed and documented in the medical notes. Contraindications to FMS use: • Patients under the age of 18 years • Presence of impacted stool • Know sensitivity/allergy to silicone • Rectal or anal injury • Severe rectal or anal stricture or stenosis • Suspected or confirmed rectal mucosal impairment • Confirmed rectal/anal tumour • Severe haemorrhoids • Spinal cord injury above T5 because of the risk of autonomic dysreflexia. • Patient’s distal rectum unable to accommodate the inflated volume of the retention cuff (e.g. secondary tumour, inflammatory condition, IBS, Ulcerative colitis, radiation injury, scarring) • Lower bowel surgery or rectal surgery within the last year including anal sphincter reconstruction • Compromised rectal wall integrity (e.g. ischaemic proctitis) • Patients requiring medication in suppository form
Abstract
The purpose of these guidelines is to provide guidance on the appropriate use of the Flexiseal Management System (FMS) within the Nottingham University Hospitals NHS Trust. The guidance provided by this document is based on expert consensus from within NUH and the All Wales Guidelines for faecal management systems (2010).
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Key Words
Flexiseal Management System (FMS)
Statement of the evidence base of the guideline – has the guideline been peer reviewed by colleagues?
3 4
Evidence base: (1-5) 1a meta analysis of randomised controlled trials 1b at least one randomised controlled trial 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasiexperimental study 3 well –designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer
Consultation Process Target audience
Ward Managers Sisters / Charge Nurses , Matrons, Clinical Leads, Consultants, Infection Control Team, PDM’s Ward Managers Sisters / Charge Nurses , Matrons, Clinical Leads, Consultants, Infection Control Team, PDM’s
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
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Convatec Flexiseal Signal Faecal Management System (FMS) Guideline The National Institute for Health and Clinical Excellence (NICE) (2007) recommends that health professionals should consider a faecal collection device on the basis that severe uncontrolled diarrhoea is a threat to skin integrity. There are a number of faecal collection devices available including rectal tubes, external faecal collection systems and FMS. This guideline is only about the FMS. In addition, uncontrolled diarrhoea has an impact on psychological health, and increases the risk of cross-contamination and infection from pathogens such as Clostridium difficile and increases length of stay. The purpose of these guidelines is to provide guidance on the appropriate use of the FMS within the Nottingham University Hospitals NHS Trust. The guidance provided by this document is based on expert consensus from within NUH and the All Wales Guidelines for faecal management systems (2010). Background: The treatment and care of patients in hospital is often complicated by the development of an infection which arises from a variety of factors that make people susceptible to microbial challenge. The prevention and control of infection is a significant challenge, and despite our efforts, hospital-acquired infections remain common. Definitions: Faecal incontinence has a variety of definitions. The Royal College of Physicians (1995) state ‘the involuntary or inappropriate passage of faeces’. The most recognised and used developed by the World Health Organisation is for anal incontinence which includes not only liquid or solid faeces, but also the inappropriate passage of flatus. Diarrhoea derives from the Greek ‘to flow through’. Diarrhoea is usually the passage of frequent (more than three times daily) loose, watery or unformed stools. It usually presents as either acute or chronic diarrhoea. 3
Flexiseal signal FMS
Chronic diarrhoea is identified if the symptoms persist for 1 month or more. C.difficile is a bacterial infection found in the gastrointestinal tract. It is the most common bacterial cause of hospital-acquired infectious diarrhoea in developed countries. C.difficile is usually spread via the hands of healthcare staff and other people who come into contact with infected patients, or with environmental surfaces contaminated with the bacteria or its spores. Spores are very hardy and can survive on clothes and environmental surfaces for up to 5 years (Health Protection Agency (HPA)). Patients with C. difficile associated diarrhoea may experience faecal incontinence, the FMS is a fully closed system that collects and contains liquid or semi-liquid stools, and is therefore effective in containing faeces and helpful in preventing faecal contamination of the environment (Johnston, 2005). Assessment: Patients presenting with acute diarrhoeal symptoms to persistent diarrhoea (type 6–7 on the Bristol stool chart) should undergo a thorough assessment to include • recent travel history • recent contacts with people who have experienced similar symptoms • antibiotic history for the previous 3 months • identify high-risk patients i.e indications of bowel cancers, and exclude faecal impaction as a cause of overflow (NICE, 2007). C. difficile infection should be suspected on clinical judgement and confirmed by laboratory testing. Sometimes laboratory testing can give a false negative or false PCR result for C.diff, therefore flexisigmoidoscopy should ideally be performed in these cases when c.diff is suspected to exclude pseudomembraneous colitis this is included in the infection prevention guidance for the trust.
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Selection Criteria: Patients may have one or more of the following: • Patients judged to be at risk of tissue/skin breakdown due to faecal incontinence (Bristol Stool score 6-7). • Diarrhoea persisting for >48h where all correctable factors have been addressed (see below) diarrhoea defined as > 3 loose stools/day or >300ml/day if rectal bag in use. • Laboratory confirmation of C. Difficle or VRE patients. • Patient is bed-bound – If it is beneficial to sit the patient out even if he/she has a FMS in situ. Avoid compressing or kinking the device,and the sitting period should be the shortest possible. • Patient must have adequate anal sphincter tone (if lacking in anal tone will not be able to support balloon). • Massive persistent malaena, e.g. in patients with bleeding oesophageal varices. • Wounds in or near the sacral or perineal area likely to be contaminated with stool. • Patient has skin breakdown caused by exposure to faecal incontinence and/or faecal leakage (ensure tissue viability are involved in the patient care). Patient suitability for the FMS should also be assessed and documented in the medical notes. Contraindications to FMS use: • Patients under the age of 18 years • Presence of impacted stool • Know sensitivity/allergy to silicone • Rectal or anal injury • Severe rectal or anal stricture or stenosis • Suspected or confirmed rectal mucosal impairment • Confirmed rectal/anal tumour • Severe haemorrhoids • Spinal cord injury above T5 because of the risk of autonomic dysreflexia. • Patient’s distal rectum unable to accommodate the inflated volume of the retention cuff (e.g. secondary tumour, inflammatory condition, IBS, Ulcerative colitis, radiation injury, scarring) • Rectal inflammation – discuss with consultant • Lower bowel surgery or rectal surgery within the last year including anal sphincter reconstruction • Compromised rectal wall integrity (e.g. ischaemic proctitis) • Patients requiring medication in suppository form 5
Flexiseal signal FMS
Further considerations: • Caution in patients who have inflammatory bowel conditions(seek advice from colorectal nurses/clinicians). • Caution should be exercised when considering use in patients with thrombocytopenia and/or clotting disorders and individuals taking anticoagulant medication (seek advice from medical staff). • There is no specific evidence to contraindicate use of the system in cancer and haematological oncology patients, but because of the higher risk of proctitis and clotting disorders, its use must be sanctioned by the patient’s consultant. • Rectal examination and flexiseals should be avoided in neutropenic patients due to the risk of introducing bacteria, please discuss with the consultant (ideally in conjunction with gastroenterologist/haematology)
Factors to consider before using the FMS: Before using the FMS in patients with diarrhoea persisting beyond 48hours you should to check for correctable factors and address these as per hospital policy, see insertion and maintenance checklist.
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Insertion of a FMS Tube> Equipment required: • I x convatec flexiseal signal kit • Non sterile gloves x 2 pairs • Incontinence pad • Lubricant • Disposable non sterile bowl • Apron • A proactive stool management plan should be commenced prior to insertion of the FMS. • Insertion should only be done when approved by a consultant and by a member of staff trained in using the FMS system. They must have attended a teaching session on FMS use. • If the patient is awake, consent should be obtained and they should be informed that the tube is to be inserted, the reason why, and what the procedure involves. • If the patient appears overly anxious they may require some sedation prior to the FMS being inserted please discuss with medical staff. • Insertion and maintenance of the FMS should be using the guidelines given in the instruction booklet in each pack. • Irrigation fluid should be prescribed on the drug chart. All care should be documented as normal in the nursing care plan. NB the Flexiseal Signal Faecal Management System is not intended for use for longer than 29 days Insertion Procedure: 1. Explain the procedure to the patient and gain consent. 2. Assemble equipment including gloves, water-soluble lubricant and 45 ml of tap water in a clean container. 3. Place the patient in the left lateral position with knees drawn up towards the chest. 4. The rectum should be free from stool prior to insertion of the FMS; a PR examination should be done before tube insertion to check that there is no solid stool in the rectum that might block the tube. If type 6–7 stools are present, or if rectum is empty, proceed with insertion of the Flexi-Seal. 5. Insertion of the FMS should be using the guidelines for insertion given in the instruction booklet in each pack. 6. Open kit, securely snap the collection bag to the connector at the end of the catheter ensuring the hole on the collection bag is 7
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attached to the white prong on the catheter then label it with the date and time. 7. Unfold the length of the catheter to lay flat on the bed, extending the collection bag towards the foot of the bed. 8. Using the syringe provided, remove any residual air from the balloon by attaching to syringe to the inflation / white port and withdrawing the plunger. Disconnect then expel any air from the syringe. Fill same syringe with 45mls of tap water at room temperature and attach the syringe to the inflation / white port. 9. Lubricate the balloon end of the catheter and anus in lubricating jelly. 10. Insert a gloved index finger into the blue retention balloon cuff finger pocket.
11. Grasp the catheter and gently insert the balloon end through the anal sphincter until the balloon is beyond the external orifice and well inside the rectal vault i.e the black line is inside the rectum.
Inflated Balloon Anal Sphincter
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12. Keep finger insitu and inflate the balloon with 5 ml water by slowly depressing the syringe plunger. 13. Remove finger and inflate with the remaining water until the balloon pressure indicator pops up. Average volume required is between 37 ml and 42 ml. Never exceed 45 ml. • If the balloon pressure indicator does not “pop” the balloon is under filled. Use the syringe to withdraw fluid from the retention balloon and re-inject until the pressure indicator balloon “pops” or 45mils has been injected. • If the balloon pressure indicator “pops” or expands significantly at less then 30mls, with draw the water and reposition the balloon in the rectal vault. After repositioning repeat from step 8. 14. Remove the syringe from the inflation port and gently pull on the soft silicone catheter to ensure the balloon is secure. You should now see the black line reappear from the rectum. 15. Remove gloves and apron, and wash hands. 16. Position the length of the flexible silicone catheter along patient’s leg avoiding kinks and obstruction. Take note of the position indicator line (black line) relevant to the patients anus. 17. Hang the bag by the strap at a convenient location at the bedside. 18. Record in the appropriate documents that the Flexi-Seal has been inserted and record all output. 19. Reassure patient and inform them of the outcome. Troubleshooting: • If leakage occurs the device should be inspected to ascertain that there is no external obstruction. • If no obstruction can be found, attempt deflating the balloon by withdrawing up to 10 ml from the inflation port and reassess/reintroduce. • If the silicone device becomes blocked with solid particles, irrigate by filling a syringe with 30 mls of tap water then attach to the irrigation port, and insert. Repeat this procedure as often as necessary to maintain function of the device. • If repeated flushing with water does not return the flow of stool through the catheter the device should be inspected to ascertain that there is no external obstruction e.g. pressure from body parts, piece of equipment or resolution of diarrhoea. • If this fails to rectify the problem then the use of the device should be discontinued. 9
Flexiseal signal FMS
Maintenance: The FMS should be managed as recommended in the FMS Pocket Guide to Maintenance and Irrigation. Irrigation fluid should be prescribed on the drug chart. All care should be documented as normal in the nursing care plan • Every 2 hours check that the patient is not experiencing pain or discomfort from the BMS, if they do consult medical staff and consider removal • Every 2 hours confirm Catheter is not occluded due to twisting or patient lying on tube or faecal particles. • Every 2 hours inspect Catheter near anus to ensure there is no column of irrigant and / or faeces is sitting in Catheter. If irrigant or faeces is present, milk into Collection Bag. • 2 hourly check patient’s skin integrity and perianal region for perianal mucous or faeces leakage. Manage accordingly as per tissue viability policy and document findings on care plan. • Record faecal output at least every 6 hours on fluid balance chart • Change collection bag as required - Wash hands, Ensure personal protective equipment is worn, place new collection bag by catheter. Remove used bag and snap the cap onto each used bag to seal contents. Dispose as per waste management policy. Affix new bag as per insertion procedure. Do not reuse bags once detached • Weekly verification of retention cuff volume: Aspirate all fluid from retention cuff and disconnect syringe Verify deflated state by observing collapsed balloon pressure device. Re-fill retention cuff with up to 45mls of water.
Stool Sampling: If a stool sample is required it should be taken from the tubing of the system rather than the bag. Disconnect the bag and obtain sample, connect a new bag and dispose of used bag. Potential Complications: • Loss of anal sphincter muscle tone • Pressure necrosis of rectal or anal mucosa • Infection • Bowel obstruction • Perforation of the bowel • Persistent rectal pain 10
Flexiseal signal FMS
• Rectal bleeding • Abdominal distension • Unable to open bowels for more than 48 hours. If any of the above adverse events occur, remove device and inform consultant. Removal of FMS: The FMS should not be removed without discussion with the ward team. The tube should not be removed immediately the diarrhoea seems to have stopped. One consideration is that this might be a temporary ‘lull’, another that it might be appropriate in some cases to leave the tube in. 1. Wash hands with soap and water prior to commencing procedure. 2. Ensure personal protective equipment is worn prior to any risk of exposure to bodily fluids. 3. Deflate retention balloon by attaching the syringe to the inflation port and withdraw all the water. 4. Disconnect the syringe and dispose safely. 5. Grasp the catheter as close to the patient as possible and slowly slide it out of the anus. 6. Dispose of the device, gloves and apron in accordance with waste management policy. 7. Wash hands following removal of personal protective equipment with soap and water.
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References • • • •
• • • • • • • • • • •
All Wales Guidelines for Faecal Management Systems Guidelines for Best Practice (2010) Beldon P (2008) Faecal incontinence and its impact on wound care. Continence Essentials Journal 1: 22–7 Estrada O, Martinez I, Del Bas M, Salvans S, Hidalgo LA (2009). Rectal diversion without colostomy in Fournier’s gangrene. Tech Coloproctology 13(2): 157–9 European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) Prevention and treatment of pressure ulcers: quick reference guide. www.npuap.org/Final_Quick_Prevention_for_web_2010. Healthcare Associated Infections (HCAI) Technology Innovation Programme (2009) Showcase Hospitals Report number 5, The Flexi-Seal® Faecal Management System. HCAI Technology Innovation Programme, London Health Protection Agency (2010) Summary Points on Clostridium difficile Infection. http://tinyurl.com/36ezs6k Johnston A (2005) Evaluating Flexi-seal FMS: A faecal management system. Wounds UK 1(3): 110–4 Lewis SJ, Heaton KW (1997) Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology 32(9): 920–4 National Institute for Health and Clinical Excellence (2007) Faecal Incontinence: The Management of faecal incontinence in Adults. www.nice.org.uk/CG049 Nursing and Midwifery Council (2008) The Code . Nursing and Midwifery Council, London Ousey K, Gillibrand W, Lui S (2010) Effective management of acute faecal incontinence in hospital: review of continence management systems, Frontline Gastroenterol 1: 94–7 Ousey K, Gillibrand W (2010) Using faecal collectors to reduce wound contamination. Wounds UK 6(1): 86–91 Padmanabhan A, Stern M, Wishin J et al (2007) Clinical evaluation of a flexible faecal incontinence system. Am J Crit Care 16(4): 384– 93 Royal College of Physicians (1995) Incontinence: causes, management and provision of services. A working party of the Royal College of Physicians. Journal of Royal College of Physicians 29: 272–4 12
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Insert patient label Patient Name Date of Birth NHS/Hsp Number
Flexiseal Insertion and Maintenance Checklist Clinical Area ………………………Date ………………………………… Medical Staff Approval Print Name ……….……………Signature ……..………..…….……. Yes
No
1. Has a rectal tube/rectal bag been tried? 2. Can the patient be prescribed any anti diarrhoeal medication e.g. loperamide 3. Has the stool been tested for CDT. 4. Check that diarrhoea is not due to overflow. Do a PR exam and if rectum full, give enema to clear it. 5. Consider elemental enteral feed, if malabsorption is suspected If NO has been ticked for any of the above please correct these before proceeding • Patient aged 18 years or over • Patients at risk or already has tissue/skin breakdown due to faecal incontinence (Bristol Stool score 6-7) • Diarrhoea persisting for >48h where all correctable factors have been addressed • Laboratory confirmation of C. Difficle or VRE patients • Wounds in or near the sacral or perineal area likely to be contaminated with stool. • Patient has adequate anal sphincter tone • No evidence of massive persistent malaena • Patient does not have faecal impaction • No Known sensitivity/allergy to silicone • No known rectal or anal injury • No confirmed rectal/ anal pathology / tumour or stricture or stenosis • No suspected or confirmed rectal mucosal impairment / inflammation of the rectum • No haemorrhoids of significant size and/ or symptoms • No spinal cord injury above T5 because of the risk of autonomic dysreflexia. • No Inflammation in the rectum • No lower bowel surgery / rectal surgery / bowel trauma within the last year including anal sphincter reconstruction • No evidence of compromised rectal wall integrity • Patient does not require medication via rectal route Checklist completed by ………………………….. Signature ……………………………
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Maintenance Checklist for the BMS Date ……….
Black Line Position Checked
0200 0400 0600 0800 1000 1200 1400 1600 1800 2000 2200 2400
Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
Date
Black Line Position Checked
………. 0200 0400 0600 0800 1000 1200 1400 1600 1800 2000 2200 2400
Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
Bristol stool score 12 hourly
Skin Integrity SKKIN Code
Clinical Area …………………………….. Patient Tube pain free Position and Correct comfortable Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
Bristol stool score 12 hourly
Skin Integrity SKKIN Code
Patient Tube pain free Position and Correct comfortable Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
no kinks or blocks in system
Retention cuff inflated (weekly volume check
Actions taken / Comments
Initials
Retention cuff inflated (weekly volume check
Actions taken / Comments
Initials
Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
no kinks or blocks in system Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
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Maintenance Checklist for the BMS Date ……….
Black Line Position Checked
0200 0400 0600 0800 1000 1200 1400 1600 1800 2000 2200 2400
Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
Date
Black Line Position Checked
………. 0200 0400 0600 0800 1000 1200 1400 1600 1800 2000 2200 2400
Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
Bristol stool score 12 hourly
Skin Integrity SKKIN Code
Clinical Area …………………………….. Patient Tube pain free Position and Correct comfortable Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
Bristol stool score 12 hourly
Skin Integrity SKKIN Code
Patient Tube pain free Position and Correct comfortable Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
no kinks or blocks in system
Retention cuff inflated (weekly volume check
Actions taken / Comments
Initials
Retention cuff inflated (weekly volume check
Actions taken / Comments
Initials
Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
no kinks or blocks in system Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
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Maintenance Checklist for the BMS Date ……….
Black Line Position Checked
0200 0400 0600 0800 1000 1200 1400 1600 1800 2000 2200 2400
Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
Date
Black Line Position Checked
………. 0200 0400 0600 0800 1000 1200 1400 1600 1800 2000 2200 2400
Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
Bristol stool score 12 hourly
Skin Integrity SKKIN Code
Clinical Area …………………………….. Patient Tube pain free Position and Correct comfortable Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
Bristol stool score 12 hourly
Skin Integrity SKKIN Code
Patient Tube pain free Position and Correct comfortable Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
no kinks or blocks in system
Retention cuff inflated (weekly volume check
Actions taken / Comments
Initials
Retention cuff inflated (weekly volume check
Actions taken / Comments
Initials
Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
no kinks or blocks in system Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N Y/ N
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Flexiseal Care and Management
ASSESSMENT OF PRACTICE CLINICAL COMPETENCY DOCUMENT PRINT NAME ..................................................…
SIGNATURE ..............................................……
DATE COMMENCED ..........................………..
EXPECTED COMPLETION DATE …………….
ACTUAL COMPLETION DATE ………………………………………………………………. VERIFIER……………………………………….. SIGNATURE ……………..........INITIALS.....…… VERIFIER……………………………………….. SIGNATURE ……………..........INITIALS.....……
OUTLINE This Competency document is designed to be used by all staff being assessed in practice, irrespective of experience. The assessment of clinical ability comprises of a series of competencies. The timescale for completion of competencies will vary according to grade and relevant experience. However, as a guideline, expected completion time will be following discussion with your verifier/Senior Manager, as per the Standards for Managers and Registered Practitioners (Practitioners) And Non-Registered Nursing Staff and Allied Health Professional Undertaking Working in New Ways Packages AIMS • • • •
To demonstrate an increase in competence To develop self and others To achieve quality care through evaluation and research To provide a profile of evidence
PROCESS • The verifier will be co-jointly responsible, with the practitioner for ensuring any necessary documentation is completed. Time should be set aside for the verifiers to assist the practitioner in addressing any other personal objectives, further meetings to be arranged as required. • Verifiers should work with their practitioners at least 3 times per month. • Practitioners, Non-Registered Nursing Staff And Allied Health Professional should self assess all aspects in the initial (formative) category within two weeks of commencing the specified competencies • Practitioners, Non-Registered Nursing Staff And Allied Health Professional must provide evidence for the compulsory category in each competency and should indicate in the box provided which additional method is used and the page number in their profile where this evidence can be found • Ideally practitioners, Non-Registered Nursing Staff and Allied Health Professional should provide 2 forms of evidence for each competency. • The verifiers should sign and date the document when the competencies are assessed (as per rating criteria). • The practitioner will be responsible for arranging a mutually agreed time with an experienced member of staff, mentor or clinical educator to perform their assessments NB
Self-assessments must be completed before mentor/verifier ratings. Each practitioner, Non-Registered Nursing Staff and Allied Health Professional must have both an initial (formative) and a final (summative) assessment OUTCOMES • The practitioner will complete all pre-set competencies. • Patient care will improve with practitioners increased competence and confidence • Practitioner theory practice gap reduction • A portfolio of evidence will be produced to demonstrate competence
GUIDELINES FOR USING THE COMPETENCY MEASUREMENT TOOL The framework describes four levels of competence. Competence is defined as “the skills, knowledge, experience, attributes and behaviours required by an individual in order to perform the job effectively” (Royal College of Nursing 2002) The criteria for achievement are divided into three areas:• STANDARD • QUALITY OF PERFORMANCE • ADVICE ASSISTANCE CUES Each of these 3 areas must be considered to determine the level of competence (level). The level that is awarded will relate to the lowest of the 3 areas achieved. TERMINOLOGY USED IN ASSESSMENT OF COMPETENCE • • • • •
Safety - Performance includes both physical and psychological aspects. The criterion for safety is that behaviour does not cause harm by action or omission. Accuracy is assessed by the extent to which the knowledge base is used during the performance. Effectiveness refers to the achievement of stated objective. Affectiveness refers to the manner with which the behaviour is performed. Cues. This refers to the amount and type of assistance required. Cues can be directive or supportive and may be verbal or practical. They refer to what is necessary to maintain or promote the performance.
EVIDENCE REQUIRED Evidence should be collected using one of the evidence methods identified in the table below At least one form of evidence should be used for assessment of practice, ideally two Evidence should then be put into the practitioner’s portfolio this will allow for verification of competence during the Appraisal process and provide the practitioner with evidence of learning .
NUH ASSESSMENT OF PRACTICE / COMPETENCY MEASUREMENT TOOL SCALE/ LEVEL OF ACHIEVEMENT
STANDARD
QUALITY OF PERFORMANCE
Proficient (PRO)
Safe, accurate and effective with appropriate affective manner. Applies theory to practice and judges its appropriateness
Performance demonstrates expertise. Pro-active and flexible approach. Acts as a role model for practice, stimulates and informs others. Client/patient centred.
Freely offers cues to others
Independent (I)
Safe, accurate and effective at all times. Applies theory to practice
Skilful and co-ordinated performance. Confident and economical use of time. Able to focus primarily on the client/patient.
Self-directing
Supervised (S)
Safe, accurate and effective performance. Some potential for omissions or inaccuracies. Can relate theory to practice most of the time
Skilful and co-ordinated performance in some key aspects. Some degree of confidence but spends excess time in achieving objectives. Focuses on the client/patient but is distracted when the skill is more complex.
Frequent directive and supportive cues.
Unskilled (U)
Unsafe practice when unsupervised. Some potential for omissions or inaccuracies. Limited ability to relate theory to practice
Unskilled in some aspects. Lacks confidence. Spends considerable time in achieving objectives. Unable to focus on the client/patient, but concentrates on the skill.
Continuous directive and supportive cues.
Adapted from K. N Bondy (1983) Criterion-Referenced definitions for rating scales in clinical evaluation Journal of nursing Education 22 (9) 376-382
ADVICE ASSISTANCE CUES
EVIDENCE METHOD: O =Naturalistic Observation Observation of the candidate by the assessor at work WT = Witness Testimony As the named assessor cannot always be present and /or available to for assessment, the written testimonies of others are valuable. The candidate or an approved mentor/assessor/other may write a witness testimony. It is an account of the candidates’ performance that is signed by an approved assessor with the relevant skills and knowledge e.g. a physio may sign for respiratory competencies. WP = Work Product Various products of the candidates work may be used as supporting evidence towards a competency. These may include competency documents, care plans, observation charts, WINW packages, reflective diaries, study days, portfolios and teaching packages. PA = Project or Assignment In depth exploration / learning contract of a specific area related to work, this may be of any length providing that sufficient evidence is shown to achieve the actual competency, it should contain evidence and/or research. Examples include literature reviews, essay, projects and assignments (undertaken within last 5 years) providing that the candidate can show clear evidence of up- to- date knowledge and /or skills. WQ = Written questions Assessors may wish to give the candidate a list of written questions to answer to assist them in achieving the competency; the candidate and assessor should then go through the questions to ensure they are accurate and both should sign. S = Simulation Occasionally it may be necessary for the assessor to watch a simulation when a situation is unlikely to happen regularly in real life. For an example, resuscitation skills are often assessed in this way using a manikin and a basic scenario. When a simulation is used, the candidate is required to reflect on the simulation; outlining what skills and learning have been demonstrated. This is then signed by the assessor and submitted as evidence. CE = Candidate Explanation The assessor and candidate discuss/ and demonstrate the competency. The candidate explains their understanding of the competency and gives work related examples of their knowledge and skills being used in practice. The assessor may clarify the candidates understanding and abilities by asking questions about the subject, probing for additional information. Please note whichever method is used the evidence must be signed and dated by both the candidate and the verifier Regulatory Standards:
Where significant links exist between a competency and a specific regulatory standard, this is highlighted in the document. 1) Care Quality Commission (2012) The Essential Standards. http://www.cqc.org.uk/organisations-we-regulate/registering-firsttime/essential-standards. [accessed 4th June 2012] 2) All Wales Guidelines for Faecal Management Systems Guidelines for Best Practice (2010 3) NHS Institute for Innovation and Improvement (2009) High Impact Actions for Nursing and Midwifery. NHS Institute, Coventry 4) NHS Litigation Authority (2012) NHSLA Risk Management Standards 2012-13. London 5) Nottingham University Hospitals NHS Trust (2010) Behavioural Standards – For Everyone at NUH. Nottingham
Consent: Valid consent to treatment is absolutely essential for all forms of health care, from providing personal care to undertaking major surgery. Seeking consent is also a matter of common courtesy between health care professionals and patients. .. When performing clinical observations patients must be provided with sufficient information to ensure they understand the nature of the proposed treatment … before they give their consent to it. Refer to NUH Consent to Examination or Treatment Policy (2010) - CL/CGP/020
Medical Device Competency: All users of Medical Devices are responsible for ensuring that they acquire, maintain and disseminate knowledge and skills in the use of medical devices. This will include the completion of competency statements signed by an Authorised Trainer (as defined by the Authorised Trainers List) for appropriate medical devices and ensuring copies of these statements are passed to their line manager. Refer to NUH Medical Devices Training Procedure - CL/CGP/028 (2011) For medical device competency statements access: http://nuhnet/diagnostics_clinical_support/clinical_engineering/medical_devices_training/Pages/Competency_Statements.aspx
Aim: - The learner is able to safely and competently insert the flexiseal signal bowel management system (BMS) COMPETENCY / OUTCOME
EVIDENCE METHOD USED
Criteria for practice assessment
PAGE NUMBER IN PROFILE/
MIN LEVEL TO ACHIEVE
KSF
WQ/O
1.1
1. Demonstrate the ability to accurately
The practitioner will be able to demonstrate relevant knowledge and understanding of the rational for insertion of the BMS and associated complications
2. 3. 4. 1.2
The practitioner will be able to insert the BMS in a safe and effective manner
O
1. 2. 3. 4. 5. 6.
assess the patient and complete the appropriate documentation prior to insertion of BMS a. Ask about medical history, previous operations, investigations b. Ask about general health and use the information appropriately Describe the common bowel conditions that are contraindicated for BMS use Correctly utilise the Bristol Stool Chart Correctly follow the checklist for insertion of the BMS Ensure the responsible Consultant is aware and has approved insertion of the BMS Demonstrate the ability to explain the procedure and obtain verbal informed consent. Demonstrate the correct and comfortable positioning of the patient Demonstrate the ability to perform the procedure safely Outline the hazards associated with the BMS Ensure the responsible Consultant is called immediately if a complication occurs
I
INITIAL
LEVEL
FINAL
LEVEL
SELF RATING DATE & SIGN
VERIFIER RATING DATE & SIGN
SELF RATING DATE & SIGN
VERIFIER RATING DATE & SIGN
Regulatory Standard
CQC Reg 1, 11, 12 14, NHSLA: 1.8, 2.8, 4.6, 5.2, 5.5, 6.4 V&B 1-10
I
CQC Reg 1, 2, 8, 11, 12, 14, NHSLA: 4.6, 5.2, 5.5,
V&B 1-10
COMPETENCY / OUTCOME
EVIDENCE METHOD USED
Criteria for practice assessment
PAGE NUMBER IN PROFILE/
MIN LEVEL TO ACHIEVE
KSF
1.3
The practitioner will be able to care holistically for the patient who has a BMS insitu
O
2. 3.
4. 5. 6.
LEVEL
FINAL
LEVEL
SELF RATING DATE & SIGN
VERIFIER RATING DATE & SIGN
SELF RATING DATE & SIGN
VERIFIER RATING DATE & SIGN
Regulatory Standard
CQC Reg 1, 7, 8, 9 12, 14, 21
1. Demonstrate the ability to complete accurately the 2 hourly checklist to include a. Black line check b. Bristol stool score c. Skin integrity d. Tube position check e. Patient comfort f. Drainage g. Retention cuff volume h. Irrigation fluid prescribed if needed i. Is the BMS still required Document loss Demonstrate the ability to explain the plan of care to the patient, discuss any concerns the patient may have and offer the opportunity to discuss their treatment with the doctor Is able to explain what to do and who to contact if any complications arise Can explain or demonstrate correct stool sampling technique Demonstrate correct removal of the BMS when no longer required or if BMS has been insitu longer than 28days
INITIAL
I
NHSLA: 1.8, 4.6, 4.9, 5.2, 5.4, 5.10 V&B 1-10
RECORD OF SUPERVISED / ASSESSED PRACTICE Developing my Competence Practitioner Name ……………………………………
Date
Objective
Strengths
Development Areas Identified
Actions Agreed
Practitioner/ Learner Initials
Mentor/ Verifier Initials