As a senior specialist nurse in colorectal nursing, I have occasionally been asked for advice on the antegrade continence enema (ACE) procedure. My knowledge base in this area was limited, as no adult patients were known to have had this procedure in my trust and children who had undergone it were nursed and advised by paediatric gastroenterology nurses. When these patients were transitioning from children to adult services, they would contact my department if they had any concerns. Invariably, I referred these concerns to other health professionals, as I did not feel sufficiently knowledgeable to answer them.
A poster seemed to be an appropriate resource as it can be a powerful tool to encourage people to find out more about a topic (Erren and Bourne, 2007). It would be a useful tool to encourage fellow nurses to talk about why they needed to know more about this little-known topic in adult nursing.
Erren and Bourne (2007) discussed why it is important for the title to attract people, so keeping it short and clear seemed appropriate to convey my message. I called it ‘The ACE procedure: An information poster’.
What is an antegrade continence enema?
An antegrade continence enema is a method used to clean and empty the bowel in children and adults who have constipation or faecal incontinence. A catheter is inserted into a surgically created ACE stoma, which has been formed using the appendix or intestine. Generally, saline or water is used to clean the colon. This is performed every 1–2 days and takes about 30–60 minutes.
Research and literature
The ACE procedure, also known as the Malone procedure or MACE procedure, is not well documented as a nursing subject. Databases yielded minimal results on specific nursing care. It was apparent that there was little instruction on the nursing management of these patients, so it seemed pertinent to use experiential knowledge and apply this, alongside evidence-based research, to formulate an educational poster.
I wanted to discover what problems these patients would experience but could not find a handbook that answered all of my questions. Therefore, I decided to design a poster, which would be evidence based and draw on collaborative sources (Hyde et al, 2008; Sharrard, 2015).
Some information differed. For example, at one centre, water (rather than saline) was recommended for irrigation (Sharrard, 2015). I contacted the author to discuss the rationale for this and discovered both could be used, but a saline mix would sometimes prove more effective because of its osmolality and would reduce electrolyte loss from the body (Larowe, 2013; Ayub et al, 2019). There have been comparative studies about other flushes, such as saline versus glycerine but, from discussions with an experienced paediatric gastroenterology nurse at my trust, it seems trial and error is used to determine which flush suits each individual.
Target group: why did I choose them? What was the clinical need?
The target readership of the poster is predominantly health professionals. It gives them an indication of the ACE procedure, the nursing care involved and a section on troubleshooting. There is a clear clinical need. I have spoken to other stoma care nurses who admit to having little experience in this area, and embraced the opportunity to improve their learning from my study of the ACE procedure.
A poster being presented should be eye-catching and clear (Erren and Bourne, 2007). I presented my poster at a paediatric stoma course and at the ASCN conference. It was well received in peer review and was considered suitable for parents and carers as well. Common themes of the feedback included ‘an easy read that related to practice’.
I am pleased to have looked at this area of nursing as it has increased my confidence.
Evidence on care and assessment
Cullum et al (2008: 2) described evidence-based nursing as the ‘application of valid, relevant, research-based information in nurse decision-making’. They said it should be considered alongside experience and existing knowledge to aid decision making in best practice.
In this situation, with limited evidence available, it was essential to draw on what evidence there was and apply it to practice. For example, there was no specific evidence-based guidance regarding the management of the skin around the ACE stoma, apart from keeping it clean and dry, so it was pertinent to consider similar situations where there was excellent evidence-based experience, as in the management of the peristomal area, and apply this to practice (Association of Stoma Care Nurses UK (ASCN, 2015). The Nursing and Midwifery code (2018) stipulates that nurses must practise using the best available evidence, which implies that, even if there is no evidence directly related to the topic, the bigger picture should be considered and explored to deliver best practice.
In the future, if a similar situation arose because of poor knowledge in a particular subject and I felt ill equipped to deliver holistic care, I would ensure I looked at the literature that was available to deliver best practice.
Benefits of ACE procedure
The ACE procedure can be useful for patients with congenital abnormalities of the anus and rectum and neuropathic bowel disorders and for the treatment of severe constipation (Great Ormond Street Hospital (GOSH), 2019). It is not a firstline treatment and other methods, such as bowel training, change in diet, oral and rectal medications and colonic (retrograde) irrigation, are considered first (GOSH, 2019).
A study on the long-term outcomes by Ayub et al (2019) found there were benefits for the children concerned as having the procedure reduced soiling, constipation and the need for manual evacuation. Of their study group, 79% experienced an improvement in their bowel regime. Sturkenboom et al (2018) suggested that it is useful for patients who wish to avoid more major surgery and a faecal stoma.
Transition to adult services
An article by Patel et al (2015), which examined 15 studies on a total of 374 patients, suggests full continence is achieved in 33–100% of patients. However, the authors discuss the poor quality of the research examined and the need for larger studies in adults to properly assess the role ACE may have in the adult population.
Transition from child to adult services is another area that requires further development. It is pertinent to suggest that transitioning should be planned early if the child has ongoing health concerns, which could be anticipated in patients who have an ACE stoma.
A recent example in my practice of how transitioning would have been beneficial was the case of a 21-year-old woman who was having problems with her ACE stoma. She had never been transitioned into adult care, so had no surgeon responsible for her care, which made care difficult during an acute phase.
There appears to be no set age when transitioning should start (Rosen et al, 2003). However, the frustration of being faced with a complex health situation where transitioning has not occurred makes it difficult for the young person and the healthcare provider. Transition is often poorly managed, which can be detrimental to health (Reiss et al, 2005; Crowley et al, 2011).
Complications of an ACE stoma
Stenosis is frequently discussed in the literature. Rensing et al (2017) examined risk factors with ACE stoma stenosis, and found that obesity posed a significant risk factor for this. In their study group, 49% experienced stenosis regardless of the body material used for the ACE channel. Nurses should be promoting healthy eating and warning patients of the increased risk factors if they develop a high BMI. It is advisable to use a silicone stoma stopper to keep the tract adequately open, which should be worn all the time between washouts. Patients should be advised to look for signs of infection and to call their GP if concerned (University Health Network, 2018).
Implications for adult stoma care
I was delighted that my poster on the ACE procedure won the Best Poster Award at the ASCN national conference in 2019. It highlighted the interest that adult stoma care nurses have in this area and a desire to learn more about it in order to improve the nursing care of this specific group.
As the children who have had ACE procedures are entering adulthood, adult stoma care nurses will become more familiar with the concept and management of this group, and gradually develop the confidence and expertise to adequately support them.