title: Evaluation of the implementation of a bowel management protocol in intensive care: effect on clinician practices and patient outcomes.
abstract: OBJECTIVE
  To evaluate the effect of a multifaceted implementation of a bowel management protocol on outcomes for intensive care patients, in particular the incidence of constipation and diarrhoea, and on clinicians' bowel management practices.
  
  
  BACKGROUND
  Complications associated with poor bowel management for critically ill patients result in adverse outcomes. Implementation of protocols requires strategies proven to change clinician behaviour.
  
  
  METHODS
  Before and after study.
  
  
  METHODS
  Our bowel management protocol was implemented using three evidence-based elements: education sessions, printed educational materials in the form of a fact sheet and reminders. We retrospectively collected data from patients' medical records admitted at two time points within three Sydney metropolitan intensive care units (preimplementation, n = 101; postimplementation, n = 107).
  
  
  RESULTS
  No significant difference was found in the incidence of constipation and diarrhoea pre and postimplementation of the protocol. Seventy-two per cent (n = 73) of patients preimplementation and 70% (n = 75) of patients postimplementation experienced one or more episodes of constipation (bowels not open for 72 hours or greater), and 16% (n = 16) of patients preimplementation and 20% (n = 21) of patients postimplementation experienced one or more episodes of diarrhoea. There was a slight nonsignificant increase in bowel assessment on admission by medical officers postimplementation (pre, 47%, n = 48; post, 60%, n = 64).
  
  
  CONCLUSIONS
  Targeted multifaceted implementation of a bowel management protocol did not have an impact on the incidence of constipation or diarrhoea for intensive care patients or on clinician practices. The lack of impact on patient outcomes may be due to clinicians' nonadherence to our bowel management protocol. Reasons clinicians' practices did not change may include the influences of clinical decision-making on behaviour.
  
  
  CONCLUSIONS
  This study highlights difficulties inherent in changing clinician behaviour and practices to improve patient outcomes despite using an evidence-based multifaceted implementation strategy. Further research is required to ascertain the most effective implementation strategies.
authors.affiliation: School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia; Intensive Care Service, St. Vincent's Hospital, Sydney, NSW, Australia.
authors.forename: Serena
authors.initials: S
authors.lastname: Knowles
authors.forename: Elizabeth
authors.initials: E
authors.lastname: McInnes
authors.forename: Doug
authors.initials: D
authors.lastname: Elliott
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hardy
authors.forename: Sandy
authors.initials: S
authors.lastname: Middleton
mesh_terms: D003248:Constipation / Q000628:therapy; D003422:Critical Care; D003967:Diarrhea / Q000628:therapy; D006801:Humans; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: bowel management; clinician practices; constipation; diarrhoea; intensive care; medical record audit; protocol