Executive Summary: Enhanced Recovery After Surgery Best Practice Guideline for Care of Patients With a Fecal Diversion

CASTOMized project: a new comprehensive collaborative approach between case manager and stoma care nurse

BACKGROUND

The use of the Enhanced Recovery After Surgery (ERAS) care pathway is becoming more widespread in surgical specialties. However, the presence of an ostomy, and the patient's need to adapt quickly to living with a stoma, is described as the Achilles' heel of the ERAS pathways in colorectal surgery.

AIM

To investigate the efficacy of applying a new patient pathway within the ERAS protocol.

DESIGN

A retrospective observational study.

METHOD

The management of patients undergoing surgery for colorectal disease and stoma formation between January 2023 and December 2023 was reviewed. Two clinical nurse specialists collaborated to integrate interventions and pathways.

FINDINGS

Of the 99 colorectal cancer or inflammatory bowel disease patients included in the study, the stoma care and management for 96 (95.9%) of the group fully adhered to the pathway. A median hospital stay of 11 days was recorded, with an interquartile range of 9 days; 40% of patients were treated as emergency cases. Adherence to the ERAS protocol (nursing care items) was 98%. Most patients were discharged home (91%). Adherence to telephone follow-up decreased over time, but remained above 90%. In the immediate post-discharge period, the percentage of patients with a high-output stoma was established at 15%, with only 3 (3%) of these requiring re-admission.

CONCLUSION

The study highlights the benefits gained by entrusting advanced practice nurses with the integrated management of care pathways in ostomy patients.

Summary of Best Evidence for the Dietary Management in Patients with High-Output Ileostomy

Objective

This study aims to systematically search, screen, evaluate, and summarize the best evidence related to the dietary management of patients with high-output ileostomy, providing an evidence-based reference for the dietary management tailored to this specific demographic.

Methods

A comprehensive search was conducted across multiple databases, including BMJ best practice, Up to Date, Guidelines International Network, Medlive, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network, Registered Nurses Association of Ontario, JBI, Cochrane Library, PubMed, CNKI, Wanfang, and VIP databases. Additional searches included websites of professional organizations such as the European Society for Clinical Nutrition and Metabolism, Chinese Society for Parenteral and Enteral Nutrition, American Society for Parenteral and Enteral Nutrition, World Council of Enterostomal Therapists, United Ostomy Associations of America, and International Ostomy Association. Two researchers independently evaluated the quality of the included literature and extracted and summarized the evidence.

Results

Eighteen articles were included: 2 clinical decision documents, 5 guidelines, 3 expert consensus statements, 6 expert opinions, and 2 evidence summaries. Thirty pieces of evidence were synthesized, covering nutritional risk screening, dietary guidance, dietary behavior guidance, health education, and follow-up care.

Conclusion

The summarized best evidence is scientific and comprehensive, offering an evidence-based guide for healthcare professionals managing the dietary needs of patients with high-output ileostomy.

Characteristics of Interventional Trials for Patients Living With Intestinal Stoma Registered in ClinicalTrials.gov With a Focus on Inflammatory Bowel Disease

BACKGROUND

This systematic review was performed to characterize the landscape of research conducted in patients with intestinal stoma (IS) and highlight unmet needs for clinical research in Crohn's disease (CD) and IS.

METHODS

We searched ClinicalTrials.gov from inception to May 25, 2022, to identify clinical trials assessing interventions in patients with an IS, as well as those with an IS and CD. Studies were grouped according to type of intervention. We excluded observational studies with no treatment arm.

RESULTS

A total of 253 studies were included in the final analysis. Most studies investigated devices (n = 122 [48.2%]), or surgical procedures (n = 63 [24.9%]), followed by behavioral interventions (n = 30 [11.8%]), drugs (n = 20 [7.9%]), dietary interventions (n = 2 [0.8%]), skin care products (n = 2 0.8%]), and others (n = 14 [5.5%]). A total of 50.9% (n = 129) of studies had completed recruitment, enrolling 11 116 participants. Only 6 studies (surgery: n = 3; physiological studies: n = 2; drugs: n = 1) exclusively included patients with inflammatory bowel disease (IBD), and 16 studies commented that patients with IBD were excluded in their eligibility criteria. No study assessed efficacy of drugs in patients with CD and IS. Approximately one-quarter of studies (n = 65 of 253) included quality of life as an outcome measure.

CONCLUSION

There is a paucity of research in IBD patients with IS, with the majority focusing on devices and surgical procedures. There have been no drug trials evaluating efficacy in patients with CD and IS. There is an urgent need to identify barriers to enrollment and develop eligibility and outcome measures that enable the inclusion of patients with CD with stoma into clinical trials.

Interventions for Adjunctive Care in Patients With Inflammatory Bowel Disease and Permanent Ileostomy: A Systematic Review

Background

The evidence for the management of patients with Crohn's disease (CD) and permanent ileostomy (PI) is limited. We aimed to summarize the interventional studies related to the provision of adjunctive ostomy care in this population.

Methods

MEDLINE, Embase, and Cochrane CENTRAL were searched from inception to January 5, 2024. Eligible studies were non-randomized or randomized controlled trials (RCTs), or comparative cohort studies predominantly recruiting participants with CD and/or ulcerative colitis (UC) with PI assessing interventions for the management of high stoma output, disease recurrence, peristomal skin care, pouching systems, behavioral interventions, mental health support, and diet.

Results

Out of 3217 records, 6 were eligible and all were RCTs (n = 95). Out of these, 5 adopted a crossover design, and 1 study was a double-blind parallel-group RCT. All except 1 were published more than 20 years ago (1976-2003). Two studies exclusively included patients with UC, one included CD, and the remaining included both UC and CD. Four studies assessed pharmacological interventions (loperamide, 5-aminosalysilate [5-ASA], azodisal sodium, and budesonide), one assessed oral supplement with different osmolarities, and one assessed dietary intervention (unrefined vs refined carbohydrate). A decrease in ileostomy output was the primary outcome of interest in 4 studies. None of the studies assessed interventions for peristomal skin care, quality of life, stoma pouching systems, behavioral interventions, mental health, or CD recurrence.

Conclusions

This study highlights that the evidence base to inform care for patients with IBD and PI is almost non-existent. There is an urgent need for focused research in this area to inform evidence-based treatment decisions.

Effect of Orem's self-care model on discharge readiness of patients undergoing enterostomy: A randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of Orem's self-care model in preparing hospitals for the discharge of patients with colorectal cancer who undergo enterostomy.

METHODS

92 patients with enterostomy were recruited between February 2022 and February 2023 from a general tertiary hospital. The participants were assigned to either the intervention group or the control group randomly. The intervention group received Orem's self-care program and a three-month follow-up, whereas the control group received only routine care and a three-month follow-up. Discharge readiness, self-care ability, and stoma-quality-of-life data were collected at hospital discharge (T1), 30 days (T2), and 90 days (T3) after discharge.

RESULTS

The intervention group had substantially higher discharge readiness (knowledge, p < 0.001; coping ability, p = 0.006; personal status, p = 0.001; expected support, p = 0.021; total score, p < 0.001), better self-care ability at T1 (self-care knowledge, p < 0.001; self-care skills, p = 0.010), better total quality of life (QoL) at T1, T2, and T3 (p < 0.001; p = 0.006; p = 0.014); better stoma management and daily routine at T1 (p = 0.004; p < 0.001); and better daily routine at T2 (p = 0.009) than the control group.

CONCLUSIONS

The designed discharge readiness program based on Orem's self-care could promote effective patient discharge readiness, self-care knowledge, self-care skills, and QoL.

TRIAL REGISTRATION

The trial number ChiCTR2200056302 registered on ClinicalTrials.gov.

Experience of providing care to a family member with Crohn's disease and a temporary stoma: A qualitative study

Objectives

The aim of this study is to understand the feelings and experiences of the main caregivers of temporary ostomy patien ts with Crohn's disease (CD). And explore the caregivers' inner feelings, to provide reference and basis for constructing the health education content of the main caregivers of CD patients with a temporary stoma.

Methods

A qualitative descriptive approach was used to conduct an unstructured interview among 11 primary caregivers of CD patients with temporary enterostomy from the gastroenterology department of The Second Hospital of Nanjing. Participants were selected using a purposive sampling technique. Data were collected between July 2021 and September 2021. The interviews were audio recorded and then transcribed for a qualitative thematic analysis.

Results

Five themes and accompanying subthemes were identified: (1) negative psychological experience (2) perceived caregiver burden (3) future uncertainty (4) disease benefit (5) insufficien support system.

Conclusions

Study findings suggest that caregivers of CD temporary enterostomy patients have problems such as negative psychology, heavy caregiver burden, uncertain future, lack of support system, etc., but they also have positive experience of feeling of benefit from the disease, and are eager to obtain more disease information from more channels.Therefore, medical staff should improve their professionalism and health education capabilities, carry out diversified and targeted health education activities to reduce the burden of care, stimulate positive caregiver responses and help caregivers respond to and deal with caregiving problems in a timely and accurate manner.

Benefits of a Single-Session, In-Hospital Preoperative Education Program for Patients Undergoing Ostomy Surgery: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to compare the effects of a 45-minute session of video-based preoperative ostomy education on self-care knowledge, self-care proficiency, anxiety, depression, length of hospital stay, and ostomy-related complications to a control group who received 3 postoperative educational sessions.

DESIGN

This was a randomized controlled trial.

SAMPLE AND SETTING

The sample comprised 47 patients scheduled to undergo ostomy surgery for colon or rectal cancer surgery at a tertiary referral hospital in Seoul, South Korea, from November 2018 to May 2019. However, 2 participants in the intervention group and 4 in the control group withdrew from the study and data analysis is based on 41 participants who completed study procedures.

METHODS

Participants were randomly allocated to an intervention group (n = 21) or a control group (n = 20). The intervention group received a single 45-minute session of video-based preoperative ostomy education along with stoma site marking and postoperative education. The control group underwent stoma site marking and 3 postoperative education sessions Self-care knowledge, anxiety, and depression were assessed by validated instruments. Self-care proficiency was assessed via direct observation using a checklist. Ostomy-related complications were evaluated by a WOC nurse. Length of hospital stay and disease-related characteristics were collected from medical records.

RESULTS

Compared with the control group, the intervention group showed significant improvements in self-care knowledge (P = .001) and self-care proficiency scores (P = .001). Intervention group participants also had lower anxiety scores (P = .025), depression scores (P = .014), shorter hospital stays (P = .008), and fewer ostomy-related complications (P = .001).

CONCLUSIONS

In patients undergoing ostomy surgery, a single 45-minute session of preoperative video-based ostomy education improved self-care knowledge and proficiency. This intervention also reduced depression, anxiety, and ostomy-related complications.

Enhancing Self-Management of Percutaneous Endoscopic Gastrostomy Tubes Through the Implementation of a Standardized Education and Assessment Pathway: A Quality Improvement Initiative

Intraduodenal infusion of levodopa-carbidopa intestinal gel by percutaneous endoscopic gastrostomy tube with jejunal extension is a treatment option to reduce motor and nonmotor complications in patients with advanced Parkinson's disease when oral therapy no longer provides sufficient benefit. Medication management is of central focus; however, there was no standardized patient education on stoma-site care and tube maintenance, leading to the development of stoma-site complications. As a quality improvement (QI) initiative, a standardized education and assessment pathway was developed and implemented in an urban academic outpatient clinic to enhance patient self-management and reduce stoma-site complications. A retrospective chart review was conducted to establish baseline incidence of cutaneous stoma-site complications. QI interventions were implemented using a rapid-cycle improvement model. Routine stoma assessments by a nurse who specializes in wound, ostomy, and continence care were implemented at set points, and patient education on PEG tube care and maintenance was reinforced at each session. Results demonstrated a significant reduction in moderate-to-severe tube and stoma-site-related complication. Implementation of a similar standardized education and assessment pathway in patients with percutaneous endoscopic gastrostomy tubes may lead to a decrease in stoma-site-related complications and overall better patient self-management.

Family caregivers' experiences of caring for neonates undergoing enterostomy in China: A qualitative study

AIM

To describe the nursing experiences and care needs of family caregivers caring for neonates with enterostomies in China.

DESIGN

A qualitative study.

METHODS

We conducted semi-structured interviews with family caregivers who care for neonates undergoing enterostomy. Family caregivers were selected using a purposive sampling method from three children's hospitals until no new data were generated (N = 26). Data analysis applied the thematic analysis method. The caregivers' experiences were described using qualitative content analysis.

RESULTS

The experience of family caregivers was described as growing in adaptation, where five main themes emerged: (1) complex emotional responses; (2) uncertainty about everything; (3) lack of confidence, anxiety and helplessness; (4) eagerness for professional support; (5) active adaptation, gain-harvest and gain-growth. These findings increased understanding and added knowledge on this topic that is rarely studied in China. Healthcare authorities and professionals should recognize and understand the lives and situations of family caregivers (whose neonates undergo enterostomy) to better identify their difficulties and needs.

The Quality and Clinical Applicability of Recommendations in Ostomy Guidelines: A Systematic Review

Aim

To systematically search ostomy clinical practice guidelines, critically assess their quality and clinical applicability of recommendations, and summarize the recommendations.

Design

Systematic review.

Data Sources

The PubMed, ProQuest and CINAHL databases, eight guideline databases, and three ostomy institution websites were searched on September 3, 2021.

Review Methods

Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE Recommendation EXcellence (AGREE-REX) were used to assess the guideline.

Results

The initial search identified 1475 documents. Of these, 27 full-text documents were reviewed. Finally, 10 guidelines were included. Among these, the 2019 Registered Nurses’ Association of Ontario (RNAO) guidelines had the highest total scores using AGREE II and AGREE-REX. The 2019 National Institute for Health and Care Excellence (NICE) and 2018 European Hernia Society (EHS) were also ranked as high-quality and evaluated as “recommended.” The median of the “applicability” domain was the lowest (45%) among the six AGREE II domains. The median of the “values and preferences” domain was the lowest (38%) among the three AGREE-REX domains. In total, 172 recommendations were summarized and parastomal hernia received the most attention among the recommendations.

Conclusion

The quality of the 10 clinical practice guidelines varied widely. The three identified high-quality guidelines might be appropriate first choices in daily ostomy care and management practice and can be tailored to the local context. Ostomy guidelines require further improvement in the “applicability” and “values and preferences” domains.

No Patient or Public Contribution

This review only searched and evaluated relevant documents, so such details do not apply to this review.

A close adherence to a stoma-therapeutic pathway improves immediate stoma-related outcomes and reduces the length of hospital stay

PURPOSE

New stoma creation is related to a wide range of implications and stoma-related complications could occur frequently. The aim was to assess the impact of a close stoma-therapeutic-care pathway (STCP) in terms of length of stay, autonomy in the management of the pouch, readmission rate, and stoma-related complications.

METHODS

Patients undergoing surgery for colorectal disease and first stoma creation from January 2017 to December 2020 were analyzed. All patients enrolled had joined the Enhanced Recovery after Surgery (ERAS) protocol.

RESULTS

Among 143 enrolled, 56 (40%) did not completely follow the STCP (group A), whereas 87 (60%) demonstrated strict compliance (group B). The hospital stay lasted 8 days in group B and 11.5 in group A (p = 0.001). The first look at the stoma needed 1 day in group B and 3 days in group A (p < 0.001), emptying the pouch 2 days in group B and 5 days in group A (p < 0.001). Finally, the ability to change the pouch was 3 days in group B and 6 days in group A (p < 0.001). Nine (16.1%) stoma-related complications were counted in group A and 16 (18.4%) in group B, and 30-day readmission was 10.1% in group B and 11.5% in group A (p = 0.82 and p = 1, respectively, not significant).

CONCLUSIONS

The STCP has been shown to reduce the hospital stay and to have a protective role making the patient autonomous in the management of the stoma.

Ostomy and Continent Diversion Patient Bill of Rights: Research Validation of Standards of Care

An estimated 725,000 to 1 million people are living with an ostomy or continent diversion in the United States, and approximately 100,000 ostomy surgeries are performed each year in the United States. As a result of ostomy surgery, bodily waste is rerouted from its usual path because of malfunctioning parts of the urinary or digestive system. An ostomy can be temporary or permanent. The ostomy community is an underserved population of patients. United Ostomy Associations of America, Inc (UOAA), is a nonprofit organization dedicated to promoting quality of life for people with ostomies and continent diversions through information, support, advocacy, and collaboration. Over the years, UOAA has received hundreds of stories from people who have received inadequate care. In the United States, patients receiving medical care have certain health rights. For ostomy and continent diversion patients, these rights are known as the "You Matter! Know What to Expect and Know Your Rights-Ostomy and Continent Diversion Patient Bill of Rights" (PBOR). These rights define and provide a guide to patients and health care professionals as to what the best practices are when receiving and providing high-quality ostomy care during all phases of the surgical experience. This includes preoperative to postoperative care and throughout the life span when living with an ostomy or continent diversion. In 2020, the National Quality Forum released "The Care We Need: Driving Better Health Outcomes for People and Communities," a National Quality Task Force report that provides a road map where every person in every community can expect to consistently and predictably receive high-quality care by 2030 (thecareweneed.org). One of the core strategic objectives this report stated is to ensure appropriate, safe, and accessible care. Actionable opportunities to drive change include accelerating adoption of leading practices. The adoption of the PBOR best practices will drive the health care quality improvement change needed for the ostomy and continent diversion population. There are concerns in the ostomy and continent diversion communities among patients and health care professionals that the standards of care outlined in the PBOR are not occurring across the United States in all health care settings. There are further concerns stated by health care professionals that the patient-centered recommendations outlined in the PBOR need to be strengthened by being supported with available published health care evidence. The work of this task force was to bring together members of UOAA's Advocacy Committee, members of the Wound, Ostomy, and Continence Nurses Society (WOCN Society) Public Policy and Advocacy Committee, and representatives from surgical organizations and industry to create a systemic change by validating through evidence the Ostomy and Continent Diversion PBOR. Through the work of the task force, each component of the PBOR has been substantiated as evidence-based. Thus, this article validates the PBOR as a guideline for high-quality standards of ostomy care. We show that when patients receive the standards of care as outlined in the PBOR, there is improved quality of care. We can now recognize that until every ostomy or continent diversion patient receives these health care rights, in all health care settings, will they truly be realized and respected as human rights in the United States and thus people living with an ostomy or continent diversion will receive "the care they need."

Nursing Interventions to Promote Self-Care in a Candidate for a Bowel Elimination Ostomy: Scoping Review

Objectives: To identify nursing interventions, their characteristics, and outcomes for promoting self-care in candidates for a bowel elimination ostomy. Materials and methods: A scoping review was carried out based on the Joanna Briggs Institute’s recommendations. For this, studies published in Portuguese, English, and Spanish on the Web of Science, CINAHL, and Scopus databases and without a time limit were selected on November 9, 2020. Results: Of 2248 articles identified, 41 were included in this review. We identified 20 nursing interventions associated with the self-care of patients with an ostomy; most of them have gaps in their content, method, and frequency or dosing. More than 30 indicators were identified to assess the impact of nursing interventions; however, most of them were indirect assessments. Conclusion: There is scarce evidence regarding the different aspects that must be involved in nursing interventions for patients with a stoma. Moreover, there is no standardization in methods, frequency, or dosing of intervention. It is urgent to define the content, method, and frequency of nursing interventions necessary to promote self-care in patients with a bowel elimination ostomy and to use assessment tools that directly measure stoma self-care competence.

Algorithmic approaches to ostomy management: An integrative review

Objective

The aim of this review is to describe approaches to ostomy management utilizing algorithmic approaches found within the literature.

Design

An integrative review approach was used based on a modified Cooper's five‐stage research review framework.

Data Sources

Systematic searches occurred using the CINAHL and MEDLINE databases searching for peer‐reviewed, English publications.

Review Methods

There were 640 articles identified through the review process, 608 of which were excluded based on title and abstract review. The remaining 12 articles were assessed in full text after which two studies were removed as duplicates and six studies were excluded based on inclusion/exclusion criteria. Four studies were included in this synthesis. Studies were critically analysed using a critical appraisal tool developed for both qualitative and quantitative study assessments.

Results

Utilizing inductive content analysis, included literature was presented within two categories: validation of ostomy algorithms and implementation of ostomy algorithms in practice. Four themes emerged from these categories including the following: algorithm validation, identifying underlying causes, focus on accessories and large‐scale implementation.

Conclusion

No currently available validated algorithms published in full were found during this literature review. Current literature demonstrates the potential benefit for ostomy management algorithms to standardize and improve ostomy patient care.

Impact

This study sought to determine the availability and supporting research of ostomy management algorithms which may assist in standardizing and improving ostomy care. This review has demonstrated a lack of available ostomy management algorithms. Given the potential benefit of ostomy algorithms identified within the literature, further studies should be completed to develop, validate and test new ostomy management algorithms.

Practice Implications from the WCET® International Ostomy Guideline 2020

GENERAL PURPOSE

To introduce the 15 recommendations of the International Ostomy Guideline (IOG) 2020, covering the four key arenas of education, holistic aspects, and pre- and postoperative care; and to summarize key concepts for clinicians to customize for translation into their practice.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Analyze supporting evidence for the education recommendations in the IOG 2020.2. Identify a benefit of the International Charter of Ostomate Rights.3. Distinguish concepts related to pre- and postoperative ostomy-related care.4. Select a potential barrier to IOG 2020 guideline implementation.

Self-care of people with intestinal ostomy: beyond the procedural towards rehabilitation

OBJECTIVES

to interpret the self-care experience of people with intestinal ostomy registered in an ostomy program, based on the framework of the Social Model of Disability.

METHODS

qualitative exploratory research, with the participation of nine people with intestinal ostomy, based on the Social Model of Disability.

RESULTS

majority were elderly, married, male with colostomy due to colorectal neoplasia. The self-care of these people was analyzed in two thematic groups: "Interdisciplinary assistance needed for people with intestinal ostomy" and "Self-care for the rehabilitation of the person with intestinal ostomy". It was proved that there was a need for a specialized health team, offering information on disabilities, teaching self-care and perioperative follow-up.

FINAL CONSIDERATIONS

when the social barriers of physical disabilities are overcome in the context of assistance for health and life, self-care will go beyond the reductionist vision of procedural care, towards comprehensive care, favoring the achievement of rehabilitation and the quality of survival.