# Improving Constipation in Critical Care Patients: A Single-Centre Prospective Cohort Closed-Loop Clinical Audit

## TL;DR

This study evaluates how educational interventions affect adherence to bowel protocols in ICU patients, finding some improvement in medical patients but limited change in surgical patients.

## Contribution

The study provides insights into the effectiveness of educational interventions on protocol adherence for preventing constipation in ICU patients.

## Key findings

- Educational interventions improved protocol adherence in medical ICU patients but not in surgical patients.
- Medical patients had a higher rate of bowel movements within 48 hours after the intervention compared to surgical patients.
- No significant improvement was observed in surgical patients due to post-operative care plans.

## Abstract

Background

Constipation affects many critically ill patients and may lead to discomfort, prolonged hospital stay, or mortality. Standardised bowel protocols are recommended to improve patient care. This audit evaluates the adherence to the bowel protocol at the Intensive Care Unit (ICU) at Royal Liverpool University Hospital, before and after educational interventions.

Methods

Adult ICU patients aged 18 and above were included. Patients who had post-gastroenterological surgery, hepatic encephalopathy, bowel obstruction/ischaemia, or spinal cord injury were excluded from this study. Data were collected from paper charts and the internal hospital electronic system. Two four-week cycles of data were collected (20/05/2024-16/06/2024, 10/07/2024-07/08/2024), with the intervention of the delivery of educational sessions and posters implemented between the two cycles.

Results

In the first cycle, 50 patients were assessed: 14 medical and 36 surgical. Enteral feeding within 48 hours occurred in 100% of medical and 88.9% of surgical patients. Senna and docusate were prescribed in 50% of medical and 25% of surgical patients on admission. Bowel movements within 48 hours occurred in 64.3% of medical and 36.1% of surgical patients (p=0.113 when comparing within the first cycle). In the second cycle, 48 patients were included: 10 medical and 38 surgical. Senna and docusate were prescribed in 90% of medical patients, with 90% achieving bowel movements within 48 hours. Surgical patients showed lower adherence, with 13.2% prescribed senna and docusate and 21.1% opening bowels within 48 hours. Within the second cycle, the difference in the onset of bowel motion between medical and surgical patients was statistically significant (p=0.0001). However, no statistical changes were found comparing the first and second cycles in medical and surgical patients prospectively.

Conclusion

The outcome of this audit suggests, but does not confirm, that educational interventions may positively impact the adherence to bowel protocol in ICU patients. Surgical patients demonstrated limited change due to post-operative care plans determined by parent teams. Ongoing education is essential for optimising the compliance of bowel protocol in the ICU.