ORIGINAL ARTICLE
Constipation – prevalence and incidence among medical patients acutely admitted to hospital with a medical condition Eline Noiesen, Ingelise Trosborg, Louise Bager, Margrethe Herning, Christel Lyngby and Hanne Konradsen
Aims and objectives. To examine the prevalence and incidence of patient-reported symptoms of constipation in acutely hospitalised medical patients. Background. Constipation is a common medical problem with severe consequences, and most people suffer from constipation at some point in their lives. In the general population, constipation is one of the most common complaints and is a significant personal and public health burden. Alteration in patients’ patterns of elimination while in hospital has long been identified as either a potential or an actual problem that requires attention. Knowledge of the prevalence and incidence of constipation during hospitalisation is only sporadic. Design. The study was descriptive and a prospective cohort design was chosen. Methods. The Constipation Assessment Scale was translated into Danish and was used for the assessment of patient-reported bowel function. Five nurses made the assessments at admission to the acute medical ward and three days after admission. Three hundred and seventy-three patients participated in this study. Results. Thirty-nine percent of the patients showed symptoms of constipation at admission. Of the patients who did not have the symptoms at admission, 43% developed the symptoms during the first three days of their stay in hospital. Significantly more of the older patients developed symptoms of moderate constipation. The incidence rate was 143 new cases per 1000 patient days. Conclusions. In this study, symptoms of constipation were common among patients acutely admitted to hospital due to different medical conditions. Symptoms of constipation were also developed during the first three days of the stay in hospital. Relevance to clinical practice. The study highlights the need to develop both clinical guidelines towards treating constipation, and preventive measures to ensure that patients do not become constipated while staying in hospital.
Authors: Eline Noiesen, MA, RN, Clinical Nurse Specialist, Medical Department F, Gentofte University Hospital, Copenhagen; Ingelise Trosborg, MEd, HRD, RN, Clinical Nurse Specialist, Department of Pulmonary Medicine, Gentofte University Hospital, Copenhagen; Louise Bager, MScN, RN, Clinical Nurse Specialist, Department of Orthopedic Surgery, Gentofte University Hospital, Copenhagen; Margrethe Herning, MEd, RN, Clinical Nurse Specialist, Department of Cardiology, Gentofte University Hospital,
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2295–2302, doi: 10.1111/jocn.12511
What does this paper contribute to the wider global clinical community? Constipation is a clinical condition affecting a large number of people in the Western world when they are well as well as during illness. This paper • Illuminates a clinical condition that is often overlooked, when people are acutely hospitalised with mixed medical conditions. • Emphasises that as hospitalisation time decreases, constipation might be a condition that is not discovered at the hospital, but a condition patients are discharged with. • Highlights the importance of trans-sectional cooperation in order to treat the condition before, during and after illness.
Copenhagen; Christel Lyngby, MPH, RN, Quality Coordinator, Medical Department C, Gentofte University Hospital, Copenhagen; Hanne Konradsen, MScN, PhD, RN, Research Manager, Gentofte University Hospital, Copenhagen, Denmark Correspondence: Eline Noiesen, Clinical Nurse Specialist, Medical Department F, Gentofte University Hospital, Niels Andersens Vej 65, DK-2900 Hellerup, Denmark. Telephone: +45 39773469. E-mail: [email protected]
2295
E Noiesen et al.
Key words: acute medicine, constipation, Constipation Assessment Scale, incidence, nursing, prevalence Accepted for publication: 23 October 2013
Introduction In the general population, constipation is one of the most common complaints and is a significant personal and public health burden (Spinzi et al. 2009, Ueki et al. 2011). Most people suffer from the condition at some point in their lives. The symptoms are many, but straining to defecate, bloating, abdominal pain, nausea, decreased appetite and general discomfort seem to be the most frequent (Papatheodoridis et al. 2010, Rasmussen & Pedersen 2010). The severity of constipation varies and can be either an acute or chronic condition that often requires frequent interventions, with mixed or even unsatisfactory results (McGrea & Miaskowski 2009). Chronic constipation can lead to a variety of complications, including anal fissure, incontinence and, in the worst case, bowel perforation and death (Leung et al. 2011).
Background The number of people affected by constipation varies. Previous research has shown that constipation is present in 2– 28% of the North American population, with an average frequency of 15% (Higgins & Johanson 2004), and that the prevalence of constipation recorded in Europe is within the same range (Peppas et al. 2008, Papatheodoridis et al. 2010). This wide range is most likely the result of differing definitions, the population studied and the varied methods to determine constipation (Chatoor & Emmnauel 2009). Nonetheless, epidemiological studies have shown that constipation is highly prevalent and may affect up to 20% of the population at any given time (Spinzi et al. 2009). Constipation has been defined in many different ways, one of them being unduly infrequent and difficult evacuation of the bowels (Miles et al. 2009). It is known to cause some degree of symptom distress and has a deleterious effect on the patients’ overall quality of life (McMillan 2002, Tack et al. 2011). It is reported that most patients suffering from chronic constipation consider their constipation to be either a very severe or an extremely severe medical condition (Hart et al. 2012). Constipation may result in substantial suffering from symptoms, such as gas, bloating, abdominal pain and discomfort (Sweeney 1997, Miles et al.
2296
2009, Spinzi et al. 2009) – symptoms that can have a considerable impact on daily life, negatively affect the patients’ social and professional life and affect their health-related quality of life (Dennison et al. 2005, Bouras & Tangalos 2009, Tack et al. 2011, Hart et al. 2012). Constipation may occur as a consequence of various predisposing disorders caused by metabolic, endocrinological, neuromuscular or hormonal effects of the intestine, or due to anatomical abnormalities (Richmond & Devlin 2003, Chatoor & Emmnauel 2009). In addition to these clinical diseases and conditions, a wide range of physical, psychological and social factors have been shown to be related to constipation. Alteration in patients’ patterns of elimination while in hospital has long been identified as either a potential or an actual nursing diagnosis that requires attention (Richmond & Devlin 2003, Kyle 2007). In hospital settings, it is well understood that constipation confers an additional risk of poor health outcomes, increased disability and increased healthcare costs (McMillan 2002). It often prolongs the patients’ hospital stay and causes pain and distress, with a significant impairment of the patients’ overall well-being (Harari et al. 2007, Rasmussen & Pedersen 2010). A recent study has identified the use of laxatives at home as the only risk factor for objective constipation during hospitalisation when patients have been bedridden for more than two weeks (Cardin et al. 2010). Knowledge of the incidence and prevalence of constipation during hospitalisation is only sporadic. Kinnunen reported that as many as 79% of the patients admitted to a geriatric long-term hospital were constipated (Kinnunen 1991). Among 123 patients who had undergone thoracic surgery, 50% developed constipation during the first postoperative period, and it took an average of 17 days after discharge before normal bowel habits were re-established (Rasmussen & Pedersen 2010). Besides the patient-related side effects of constipation, the financial cost of constipation is also high, due to an increasing laxative consumption and overall use of nursing care (Sanchez & Bercik 2011). Constipation is a common medical problem with severe consequences. In order to effectively treat the condition and its symptoms, knowledge is needed of its frequency. The aim of this study was to examine the prevalence and
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2295–2302
Constipation – prevalence and incidence
Original article
incidence of patient-reported symptoms of constipation in acutely hospitalised medical patients.
Methods Design This study was conducted at a medium-sized university hospital in the Capital Region of Denmark. A prospective cohort design was chosen with a view to examining the consequences of exposure (being hospitalised) and because the occurrence of constipation was expected to be relatively high. Patients who were acutely hospitalised due to a medical condition and admitted to the acute medical ward were included. Exclusion criteria were inability to give written consent due to the patients’ mental or physical status, inability to understand Danish, transferal from another hospital, diagnosis with inflammatory bowel disease, colostomy or ileostomy or being placed in isolation as data collection material was not permitted to take into or out from these special patient rooms. The patients were admitted from their own homes or from nursing homes.
Data collection The Constipation Assessment Scale (CAS) was used to assess the patients’ bowel function (McMillan & Williams 1989). The scale consists of eight characteristics that were developed on the basis of a literature search and are considered to be universally related to constipation. These are abdominal distension or bloating, change in the amount of gas passed rectally, less frequent bowel movements, oozing liquid stool, rectal fullness or pressure, rectal pain with bowel movement, small volume of stool and unable to pass stool. Each of the characteristics was given a three-point rating scale (‘no problem’, ‘some problem’, and ‘severe problem’), scored 0, 1 or 2, respectively. The scores were summed to create a range from 0 for no constipation to 16 for the most severe constipation. A score of 2 or more indicates some degree of constipation, while a score of 7 or more indicates severe constipation (McMillan 2002). The validity and reliability of the CAS has been psychometrically evaluated to differentiate between subjects with and without constipation and moderate/severe symptoms, as tested among patients with cancer and healthy individuals (p < 00001) (McMillan & Williams 1989). An acceptable degree of internal consistency has been found (r = 098) in relation to test–retest reliability (McMillan & Williams 1989, Coffin & Causse 2011). © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2295–2302
Permission to translate the CAS into Danish was obtained from the original author. The research group translated the scale from English into Danish. In case of differences of opinion on the correct translation, the original author and healthcare professionals with experience in the medical specialty were consulted, and the final translation was decided by consensus. Two persons, proficient in both languages, independently back-translated the scale into English. The back-translations were accepted by the original author. The Danish version was tested by eight patients for understanding and appropriateness of questions, and the ability to remember bowel function. Data were collected over a seven and half-week period in October and November 2012. All patients admitted to the acute medical ward within the previous 24 hours were considered for inclusion. Each day, a nurse visited the acute medical ward and recorded all patients admitted that day and on the previous evening and night. If the patient gave written consent to participate, the nurse would then collect demographics data (including the use of laxatives) and ask the patient the questions. Patients were admitted with a wide range of medical conditions, most often related to infections, cancer or heart and lung diseases. Six experienced nurses performed the assessment. In order to calibrate the data collection, the nurses discussed the answers of the first five patients and agreed on how to document the answers, followed by a consensus decision on how to document the findings when patients were unsure about which answer to give. Subsequently, each patient who had previously been included in the study, had scored 0 or 1 on CAS and was still admitted to hospital three days after the first assessment was tracked in the patient administration system and asked to attend a second assessment. At that time these patients were transferred to other medical wards at the hospital. Data on admission length were obtained from patients’ electronic journals. As the aim of this study was to calculate the incidence rate, patients scoring 2 and above on the CAS were not asked to attend.
Ethical considerations Permission was obtained from the Danish Data Protection Agency. The Ethics Committee of the Capital Region of Denmark approved the study.
Analysis Statistical analyses were performed using SPSS, version 19.0 for Windows (SPSS, Chicago, IL, USA). Comparison of two
2297
E Noiesen et al.
proportions was made using a chi-squared test, with 005 as the level of significance. Standard deviation and a confidence interval (CI) of 95% were calculated to further describe the data. The sample was divided at the median to compare younger (
Constipation – prevalence and incidence among medical patients acutely admitted to hospital with a medical condition Eline Noiesen, Ingelise Trosborg, Louise Bager, Margrethe Herning, Christel Lyngby and Hanne Konradsen
Aims and objectives. To examine the prevalence and incidence of patient-reported symptoms of constipation in acutely hospitalised medical patients. Background. Constipation is a common medical problem with severe consequences, and most people suffer from constipation at some point in their lives. In the general population, constipation is one of the most common complaints and is a significant personal and public health burden. Alteration in patients’ patterns of elimination while in hospital has long been identified as either a potential or an actual problem that requires attention. Knowledge of the prevalence and incidence of constipation during hospitalisation is only sporadic. Design. The study was descriptive and a prospective cohort design was chosen. Methods. The Constipation Assessment Scale was translated into Danish and was used for the assessment of patient-reported bowel function. Five nurses made the assessments at admission to the acute medical ward and three days after admission. Three hundred and seventy-three patients participated in this study. Results. Thirty-nine percent of the patients showed symptoms of constipation at admission. Of the patients who did not have the symptoms at admission, 43% developed the symptoms during the first three days of their stay in hospital. Significantly more of the older patients developed symptoms of moderate constipation. The incidence rate was 143 new cases per 1000 patient days. Conclusions. In this study, symptoms of constipation were common among patients acutely admitted to hospital due to different medical conditions. Symptoms of constipation were also developed during the first three days of the stay in hospital. Relevance to clinical practice. The study highlights the need to develop both clinical guidelines towards treating constipation, and preventive measures to ensure that patients do not become constipated while staying in hospital.
Authors: Eline Noiesen, MA, RN, Clinical Nurse Specialist, Medical Department F, Gentofte University Hospital, Copenhagen; Ingelise Trosborg, MEd, HRD, RN, Clinical Nurse Specialist, Department of Pulmonary Medicine, Gentofte University Hospital, Copenhagen; Louise Bager, MScN, RN, Clinical Nurse Specialist, Department of Orthopedic Surgery, Gentofte University Hospital, Copenhagen; Margrethe Herning, MEd, RN, Clinical Nurse Specialist, Department of Cardiology, Gentofte University Hospital,
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2295–2302, doi: 10.1111/jocn.12511
What does this paper contribute to the wider global clinical community? Constipation is a clinical condition affecting a large number of people in the Western world when they are well as well as during illness. This paper • Illuminates a clinical condition that is often overlooked, when people are acutely hospitalised with mixed medical conditions. • Emphasises that as hospitalisation time decreases, constipation might be a condition that is not discovered at the hospital, but a condition patients are discharged with. • Highlights the importance of trans-sectional cooperation in order to treat the condition before, during and after illness.
Copenhagen; Christel Lyngby, MPH, RN, Quality Coordinator, Medical Department C, Gentofte University Hospital, Copenhagen; Hanne Konradsen, MScN, PhD, RN, Research Manager, Gentofte University Hospital, Copenhagen, Denmark Correspondence: Eline Noiesen, Clinical Nurse Specialist, Medical Department F, Gentofte University Hospital, Niels Andersens Vej 65, DK-2900 Hellerup, Denmark. Telephone: +45 39773469. E-mail: [email protected]
2295
E Noiesen et al.
Key words: acute medicine, constipation, Constipation Assessment Scale, incidence, nursing, prevalence Accepted for publication: 23 October 2013
Introduction In the general population, constipation is one of the most common complaints and is a significant personal and public health burden (Spinzi et al. 2009, Ueki et al. 2011). Most people suffer from the condition at some point in their lives. The symptoms are many, but straining to defecate, bloating, abdominal pain, nausea, decreased appetite and general discomfort seem to be the most frequent (Papatheodoridis et al. 2010, Rasmussen & Pedersen 2010). The severity of constipation varies and can be either an acute or chronic condition that often requires frequent interventions, with mixed or even unsatisfactory results (McGrea & Miaskowski 2009). Chronic constipation can lead to a variety of complications, including anal fissure, incontinence and, in the worst case, bowel perforation and death (Leung et al. 2011).
Background The number of people affected by constipation varies. Previous research has shown that constipation is present in 2– 28% of the North American population, with an average frequency of 15% (Higgins & Johanson 2004), and that the prevalence of constipation recorded in Europe is within the same range (Peppas et al. 2008, Papatheodoridis et al. 2010). This wide range is most likely the result of differing definitions, the population studied and the varied methods to determine constipation (Chatoor & Emmnauel 2009). Nonetheless, epidemiological studies have shown that constipation is highly prevalent and may affect up to 20% of the population at any given time (Spinzi et al. 2009). Constipation has been defined in many different ways, one of them being unduly infrequent and difficult evacuation of the bowels (Miles et al. 2009). It is known to cause some degree of symptom distress and has a deleterious effect on the patients’ overall quality of life (McMillan 2002, Tack et al. 2011). It is reported that most patients suffering from chronic constipation consider their constipation to be either a very severe or an extremely severe medical condition (Hart et al. 2012). Constipation may result in substantial suffering from symptoms, such as gas, bloating, abdominal pain and discomfort (Sweeney 1997, Miles et al.
2296
2009, Spinzi et al. 2009) – symptoms that can have a considerable impact on daily life, negatively affect the patients’ social and professional life and affect their health-related quality of life (Dennison et al. 2005, Bouras & Tangalos 2009, Tack et al. 2011, Hart et al. 2012). Constipation may occur as a consequence of various predisposing disorders caused by metabolic, endocrinological, neuromuscular or hormonal effects of the intestine, or due to anatomical abnormalities (Richmond & Devlin 2003, Chatoor & Emmnauel 2009). In addition to these clinical diseases and conditions, a wide range of physical, psychological and social factors have been shown to be related to constipation. Alteration in patients’ patterns of elimination while in hospital has long been identified as either a potential or an actual nursing diagnosis that requires attention (Richmond & Devlin 2003, Kyle 2007). In hospital settings, it is well understood that constipation confers an additional risk of poor health outcomes, increased disability and increased healthcare costs (McMillan 2002). It often prolongs the patients’ hospital stay and causes pain and distress, with a significant impairment of the patients’ overall well-being (Harari et al. 2007, Rasmussen & Pedersen 2010). A recent study has identified the use of laxatives at home as the only risk factor for objective constipation during hospitalisation when patients have been bedridden for more than two weeks (Cardin et al. 2010). Knowledge of the incidence and prevalence of constipation during hospitalisation is only sporadic. Kinnunen reported that as many as 79% of the patients admitted to a geriatric long-term hospital were constipated (Kinnunen 1991). Among 123 patients who had undergone thoracic surgery, 50% developed constipation during the first postoperative period, and it took an average of 17 days after discharge before normal bowel habits were re-established (Rasmussen & Pedersen 2010). Besides the patient-related side effects of constipation, the financial cost of constipation is also high, due to an increasing laxative consumption and overall use of nursing care (Sanchez & Bercik 2011). Constipation is a common medical problem with severe consequences. In order to effectively treat the condition and its symptoms, knowledge is needed of its frequency. The aim of this study was to examine the prevalence and
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2295–2302
Constipation – prevalence and incidence
Original article
incidence of patient-reported symptoms of constipation in acutely hospitalised medical patients.
Methods Design This study was conducted at a medium-sized university hospital in the Capital Region of Denmark. A prospective cohort design was chosen with a view to examining the consequences of exposure (being hospitalised) and because the occurrence of constipation was expected to be relatively high. Patients who were acutely hospitalised due to a medical condition and admitted to the acute medical ward were included. Exclusion criteria were inability to give written consent due to the patients’ mental or physical status, inability to understand Danish, transferal from another hospital, diagnosis with inflammatory bowel disease, colostomy or ileostomy or being placed in isolation as data collection material was not permitted to take into or out from these special patient rooms. The patients were admitted from their own homes or from nursing homes.
Data collection The Constipation Assessment Scale (CAS) was used to assess the patients’ bowel function (McMillan & Williams 1989). The scale consists of eight characteristics that were developed on the basis of a literature search and are considered to be universally related to constipation. These are abdominal distension or bloating, change in the amount of gas passed rectally, less frequent bowel movements, oozing liquid stool, rectal fullness or pressure, rectal pain with bowel movement, small volume of stool and unable to pass stool. Each of the characteristics was given a three-point rating scale (‘no problem’, ‘some problem’, and ‘severe problem’), scored 0, 1 or 2, respectively. The scores were summed to create a range from 0 for no constipation to 16 for the most severe constipation. A score of 2 or more indicates some degree of constipation, while a score of 7 or more indicates severe constipation (McMillan 2002). The validity and reliability of the CAS has been psychometrically evaluated to differentiate between subjects with and without constipation and moderate/severe symptoms, as tested among patients with cancer and healthy individuals (p < 00001) (McMillan & Williams 1989). An acceptable degree of internal consistency has been found (r = 098) in relation to test–retest reliability (McMillan & Williams 1989, Coffin & Causse 2011). © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2295–2302
Permission to translate the CAS into Danish was obtained from the original author. The research group translated the scale from English into Danish. In case of differences of opinion on the correct translation, the original author and healthcare professionals with experience in the medical specialty were consulted, and the final translation was decided by consensus. Two persons, proficient in both languages, independently back-translated the scale into English. The back-translations were accepted by the original author. The Danish version was tested by eight patients for understanding and appropriateness of questions, and the ability to remember bowel function. Data were collected over a seven and half-week period in October and November 2012. All patients admitted to the acute medical ward within the previous 24 hours were considered for inclusion. Each day, a nurse visited the acute medical ward and recorded all patients admitted that day and on the previous evening and night. If the patient gave written consent to participate, the nurse would then collect demographics data (including the use of laxatives) and ask the patient the questions. Patients were admitted with a wide range of medical conditions, most often related to infections, cancer or heart and lung diseases. Six experienced nurses performed the assessment. In order to calibrate the data collection, the nurses discussed the answers of the first five patients and agreed on how to document the answers, followed by a consensus decision on how to document the findings when patients were unsure about which answer to give. Subsequently, each patient who had previously been included in the study, had scored 0 or 1 on CAS and was still admitted to hospital three days after the first assessment was tracked in the patient administration system and asked to attend a second assessment. At that time these patients were transferred to other medical wards at the hospital. Data on admission length were obtained from patients’ electronic journals. As the aim of this study was to calculate the incidence rate, patients scoring 2 and above on the CAS were not asked to attend.
Ethical considerations Permission was obtained from the Danish Data Protection Agency. The Ethics Committee of the Capital Region of Denmark approved the study.
Analysis Statistical analyses were performed using SPSS, version 19.0 for Windows (SPSS, Chicago, IL, USA). Comparison of two
2297
E Noiesen et al.
proportions was made using a chi-squared test, with 005 as the level of significance. Standard deviation and a confidence interval (CI) of 95% were calculated to further describe the data. The sample was divided at the median to compare younger (
