Bibliographic Source(s)

• American Medical Directors Association (AMDA). Gastrointestinal disorders. Columbia (MD): American Medical Directors Association (AMDA); 2006. 28 p. [24 references]

Guideline Status

This is the current release of the guideline.

Guideline Category

Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Dietitians
Nurses
Pharmacists
Physician Assistants
Physicians
Social Workers

Guideline Objective(s)

• To improve the quality of care delivered to patients in long-term care settings
• To offer care providers and practitioners in long-term care facilities a systematic approach to recognizing assessing treating and monitoring patients with common gastrointestinal disorders

Target Population

Elderly individuals and/or residents of long-term care facilities with common gastrointestinal disorders

Interventions and Practices Considered

Recognition/Assessment

1. Identifying presence of gastrointestinal (GI) disorders by evaluating signs and symptoms and asking questions
2. Assessing risk factors for GI disorders
3. Determining the nature and severity of GI disorders using such tools as American Medical Directors Association (AMDA)'s Protocols for Physician Notification and the PQRST Mnemonic
4. Identifying the cause of GI disorder (comprehensive history physical examination and laboratory tests)
5. Determining if a referral for a specialty consultation is appropriate

Management/Treatment/Prevention

1. Managing the GI disorder and its underlying cause
2. Identifying and implementing measures to prevent or minimize the risk of GI disorders

Monitoring

1. Monitoring the patient's response to treatment and adjusting interventions as necessary
2. Monitoring the status and treatment of underlying causes of GI disorders and reviewing relevant medications
3. Monitoring the facility's management of GI disorders

Major Outcomes Considered

• Signs and symptoms of gastrointestinal (GI) disorders
• Risk factors for GI disorders
• Use of medications to treat GI disorders
• Number of specialist referrals and invasive testing
• Morbidity mortality and incidence of complications of GI disorders
• Incidence of GI disorders
• Quality of life

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

Not stated

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

This guideline was developed by an interdisciplinary workgroup using a process that combined evidence and consensus-based approaches. Workgroups include practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency association or organization such as the Agency for Healthcare Research and Quality (AHRQ) pertinent articles and information and a draft outline each group works to make a concise usable guideline that is tailored to the long-term care setting. Because scientific research in the long-term care population is limited many recommendations are based on the expert opinion of practitioners in the field.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Guideline revisions are completed under the direction of the Clinical Practice Guideline Steering Committee. The committee incorporates information published in peer-reviewed journals after the original guidelines appeared as well as comments and recommendations not only from experts in the field addressed by the guideline but also from "hands-on" long-term care practitioners and staff.

All American Medical Directors Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include AMDA physician members and independent physicians specialists and organizations that are knowledgeable of the guideline topic and the long-term care setting.

Major Recommendations

The algorithm Common Gastrointestinal Disorders in the Long-Term Care Setting is to be used in conjunction with the clinical practice guideline. The numbers next to the different components of the algorithm correspond with the steps in the text. Refer to the "Guideline Availability" field for information on obtaining the full text guideline.

Clinical Algorithm(s)

A clinical algorithm is provided for Common Gastrointestinal Disorders in the Long-Term Care Setting.

Type of Evidence supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based thinking.

Potential Benefits

Outcomes that may be expected from implementation of this clinical practice guideline include:

• Reduced incidence of some acute gastrointestinal (GI) disorders and greater stability of chronic GI disorders
• Appropriate use of medications to treat GI disorders
• Appropriate use of acute care facilities to assess and treat GI disorders if indicated
• Appropriate use of specialist referrals and invasive testing in the management of GI disorders
• Reduced morbidity mortality and incidence of complications (e.g. fecal impaction dehydration) of GI conditions
• Improved palliative care outcomes in residents with a poor prognosis

Potential Harms

Adverse Effects of Treatments and Medications

• Table 12 in the original guideline document lists adverse effects that should be monitored for.
• Both an increased relative risk for community-acquired pneumonia and an increased risk of community-acquired Clostridium difficile-associated disease have been reported in patients taking protein pump inhibitors (PPIs). It is uncertain whether the association with pneumonia is caused by the drug or is coincidental to increased use of PPIs in patients with chronic pulmonary conditions who are at increased risk for pneumonia.
• Prokinetic agents such as metoclopramide may cause excessive sedation depression and tardive dyskinesia.
• Any opioid can exacerbate ileus that is causing abdominal pain and should be used with caution.
• Both patients and dispensing staff are at some risk of allergy to psyllium.
• Because fiber can increase flatulence and fecal incontinence dosing should be individualized.
• Excessive long-term use of stimulant laxatives (e.g. senna bisacodyl) may be associated with the development of "cathartic colon" that is a poorly functioning colon caused by the chronic abuse of stimulant laxatives.
• The most common side effects of metronidazole are headache dizziness GI discomfort nausea and vomiting metallic taste diarrhea vaginitis pelvic discomfort a disulfiram-like reaction to alcohol seizures and peripheral neuropathy. An elevated white blood cell count has also been reported.
• Tetracycline may cause a photosensitivity reaction.
• Amoxicillin may cause diarrhea or allergy.

Contraindications

• Morphine is contraindicated to treat pain caused by cystic duct obstruction or spasm.
• Sucralfate is contraindicated if potential exists for significant drug-drug interactions (e.g. phenytoin thyroid hormone warfarin)

Qualifying Statements

• This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association and the American Health Care Association their heirs executors administrators successors and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use negligent or otherwise of this clinical practice guideline.
• The utilization of the American Medical Director Association's Clinical Practice Guideline does not preclude compliance with State and Federal regulation as well as facility policies and procedures. They are not substitutes for the experience and judgment of clinicians and care-givers. The Clinical Practice Guidelines are not to be considered as standards of care but are developed to enhance the clinician's ability to practice.

Description of Implementation Strategy

The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.

1. Recognition
   • Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG
2. Assessment
   • Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes
3. Implementation
   • Identify and document how each step of the CPG will be carried out and develop an implementation timetable
   • Identify individual responsible for each step of the CPG
   • Identify support systems that impact the direct care
   • Educate and train appropriate individuals in specific CPG implementation and then implement the CPG
4. Monitoring
   • Evaluate performance based on relevant indicators and identify areas for improvement
   • Evaluate the predefined performance measures and obtain and provide feedback

Implementation Tools

Audit Criteria/Indicators
Clinical Algorithm
Tool Kits

For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Getting Better
Staying Healthy

IOM Domain

Effectiveness

Bibliographic Source(s)

• American Medical Directors Association (AMDA). Gastrointestinal disorders. Columbia (MD): American Medical Directors Association (AMDA); 2006. 28 p. [24 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Guideline Developer Comment

Organizational participants included:

• American Association of Homes and Services for the Aging
• American College of Health Care Administrators
• American Geriatrics Society
• American Health Care Association
• American Society of Consultant Pharmacists
• National Association of Directors of Nursing Administration in Long-Term Care
• National Association of Geriatric Nursing Assistants
• National Conference of Gerontological Nurse Practitioners

Source(s) of Funding

Funding was supported by the following: Bristol-Myers Squibb Company Eisai Inc. Forest Laboratories Janssen Mallinckrodt Pharmaceuticals Novartis Pfizer Inc. Sanofi-Adventis Sepracor Inc. Wyeth

Guideline Committee

Steering Committee

Composition of Group that Authored the Guideline

Committee Members: Marjorie Berleth MSHA RNC FADONA; Lisa Cantrell RN C; Charles Cefalu MD MS; Sandra Fitzler RN; Joseph Gruber RPh FASCP CGP; Susan M. Levy MD CMD; Harlan Martin RPh. CCP FASCP; Evvie F. Munley; Jonathan Musher MD CMD; Mary Tellis-Nayak RN MSN; Barbara Resnick PhD CRNP; William Simonson PharmD. FASCP

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: None available

Print copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com

Availability of Companion Documents

The following are available:

• Guideline implementation: clinical practice guidelines. Columbia MD: American Medical Directors Association 1998 28 p.
• We care: implementing clinical practice guidelines tool kit. Columbia MD: American Medical Directors Association 2003

Electronic copies: None available

Print copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com

Additionally process and quality indicators can be found in Table 16 of the original guideline document.

Patient Resources

None available

NGC STATUS

This summary was completed by ECRI on June 23 2006.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline which is copyrighted by the American Medical Directors Association (AMDA) and the American Health Care Association. Written permission from AMDA must be obtained to duplicate or disseminate information from the original guideline. For more information contact AMDA at (410) 740-9743.

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