Promising practices are strategies or approaches shown to produce positive results and to effectively prevent and/or delay untoward outcomes. The policies, procedures, and documentation practices outlined below are based upon Justice Center investigations and corrective action plan audits. These promising practices are offered to support the health of people receiving services and reduce the occurrence of health-related problems such as constipation or intestinal obstruction. The information is offered as a prevention resource and not meant as medical or professional advice. The suggested preventive measures may not be appropriate for all people receiving services or all treatment environments. (A printable copy of this page can be found below.)
People who have compromised health conditions and/or use certain medications may be at higher risk of intestinal obstructions. An intestinal obstruction is a potentially serious condition in which the intestines are blocked. The blockage maybe either partial or complete, occurring at one or more locations in the intestines. Both the small intestine and large intestine, called the colon, can be affected. When a
blockage occurs, food and drink cannot pass through the body. Untreated intestinal obstructions can result in serious harm to a person’s health, including death. The conditions that contribute to intestinal obstruction, early detection and intervention strategies are provided in the downloadable documents below. With an increased understanding of this condition, people in care, providers and family members can play a key role in the prevention and timely response to signs and symptoms of intestinal obstruction.
These case studies, involving fictitious victims, represent a collection of facts identified from multiple Justice Center investigations and are used for illustrative purposes only to aid in staff training. The case studies present a variety of examples of problems and suggested solutions which can guide agencies in a critical examination of their own operations and actions which may be needed to ensure that the individuals they serve receive appropriate care in a timely manner.
Sarah is an adolescent dually diagnosed with intellectual and psychiatric disabilities. She was admitted to an inpatient psychiatric facility and has a history of constipation, which previously required hospitalizations and a nasogastric tube. She is also prescribed Clozapine.
On the third evening of her inpatient stay, Sarah begins vomiting and experiencing painful cramps and complains of not having a bowel movement. The nausea and vomiting continue through the night and into the following morning when she is evaluated by a pediatrician who recommends reassessment if vomiting continues or symptoms worsen. Later in the day, Sarah refuses to allow her vital signs to be checked and stays in bed most of the day which are not normal behaviors for her. At shift change, not all oncoming staff are informed of Sarah's situation. That evening staff found Sarah unresponsive with vomit in her bed. The Charge Nurse was contacted, who in turn contacted the on-call doctor. However, the Charge Nurse did not tell the doctor about Sarah's elevated pulse or lethargy. The doctor advised continued monitoring. 15 minutes later, the Nurse Administrator called the on-call doctor again, requesting an in-person assessment. The doctor found Sarah's pulse weak and had an ambulance called.
Paramedics were not provided with Sarah's medical history of constipation, bowel obstruction, and Clozaril therapy. They were also told her distended abdomen was normal. She was taken to a local hospital where she died the following day from complications of an intestinal obstruction.
- History of constipation
- Prescribed Clozapine
- Displayed signs/symptoms of constipation
- Lack of awareness of constipation and intestinal obstruction symptoms
- Failure to notify pediatrician
- Lack of communication between staff
- Unfamiliarity with and failure to follow policies and practices
- Insufficient information provided to emergency responders
Additional case studies are available for download in the Toolkit below. Look for Could This Happen In Your Program.
What You Can Do
Partners in Prevention
Establish policies and procedures to address the following:
- Detecting signs and symptoms of illness
- Medical follow up
- Emergency practices
- Bowel movement monitoring protocol
- Communication practices
- Administrative oversight
Create documentation protocol for:
- Assessments for detecting signs and symptoms of illness
- Using a bowel movement tracking form
- Checklist to ensure specific aspects of care monitoring are implemented
- Food/fluid intake log
- Exercise log
Regular Training on the following:
- Policies and procedures
- Person-specific treatment and care plans
- Documentation requirements
- Non-verbal cues that may indicate constipation
More information on these recommendations can be found in the Promising Practices document.
Intestinal Obstruction Toolkit Resources
Case studies involving fictitious victims used to aid in staff training and the development of prevention strategies.
Specific medications and other individual risk factors that may contribute to constipation.