Implementation of an easy in-hospital educational stoma pathway results in decrease of home nursing care services after discharge

How to dramatically reduce dehydration-related readmission in patients undergoing restorative surgery with diverting ileostomy for ulcerative colitis

BACKGROUND

Patients affected by ulcerative colitis (UC) often require surgery, involving two or three-stage procedures, including ileostomy creation. While ileostomy has some advantages, it can lead to complications, such as dehydration. The aim of this study was to evaluate the impact of a new individualized stoma-therapeutic-care-pathway (STCP) on dehydration-related readmissions. Secondary endpoints were stoma-related complications.

METHODS

The study compares two series of consecutive patients with UC undergoing diverting ileostomy during restorative ileo-pouch-anal-anastomosis. The STCP group consists of patients enrolled from January 2020 to December 2021 who followed the pathway. The older group was selected from 2015 to 2017 (control group). Clinical data were collected, including patient characteristics, hospital stay, complications, and readmissions. The study was approved by the local institutional review board.

RESULTS

Overall, 30-day dehydration-related readmission occurred in one (1.4%) versus nine (15.3%) patients in the STCP group versus control group, respectively (p = 0.005). In-hospital peristomal skin complications were significantly lower in STCP group (6 patients, 8.5%) versus control (35, 59.3%), as well as ostomy complications that occurred in 5 (7%) patients in the STCP group versus 8 (13.5%) in the control group (both p < 0.001). Ostomy complications reduced significantly in the STCP group after discharge (two patients, 2.8% versus eight, 13.5%), p = 0.001, and after 30-days (three patients, 4.2% versus five, 8.5%).

CONCLUSIONS

This study underscores the effectiveness of STCP in reducing dehydration-related readmissions and stoma-related complications in patients with UC undergoing stoma creation. It emphasizes the significance of patient education, close follow-up, and multidisciplinary care. Further research and standardized stoma education are essential.

Postoperative education and information-giving for the individual undergoing elective ostomy surgery

Postoperative stoma education is an essential aspect of care for all types of stoma formation because having a stoma impacts on every aspect of a person's life. This critical review of the literature explores stoma patients' needs and wants; postoperative education care guidelines; the role of ward link nurses; and care pathways. The findings from this review demonstrate that there is no national standard postoperative stoma care pathway, yet such pathways are a cost-effective means to improve patient outcomes and care. The review also identified that structured care pathways are not a new concept, but there is a lack of formal research to determine best practice in postoperative stoma education. In the UK, there is wide variation in practice and outcomes, which means that effectiveness cannot be accurately measured. The author has developed and implemented a multidisciplinary postoperative education pathway in line with a national need to further refine postoperative stoma care services to meet stoma patients' needs.

Effects of a perioperative educational pathway on ostomy self-care, level of independence and need for visiting nurse services: a comparative observational cohort study

AIM

Most new ostomy patients are not able to manage ostomy self-care when they are discharged and rely on visiting nurse services for ostomy care. The aim of this study was to determine if a perioperative ostomy educational pathway increases the level of independence and decreases the need for visiting nurse services in new ostomy patients.

METHOD

A prospective longitudinal study was conducted between July 2018 and February 2020. Patients who received a colostomy or ileostomy and were treated on the surgery ward were included. Patients who followed a perioperative ostomy educational pathway were compared to a historical control group. The primary outcome measure was the level of independence in ostomy care and the need for visiting nurse services.

RESULTS

After discharge, 67.6% of patients in the intervention group (n = 244) were able to independently perform ostomy care and were therefore not relying on visiting nurse services, compared to 15.2% of the patients in the control group (n = 33). The need for visiting nurse services was higher in patients aged ≥70 years (OR 3.20, P < 0.001), those who did not attend the preoperative practice session (OR 3.02, P = 0.002), those with a history of transient ischaemic attack (OR 10.22, P = 0.045) and those with mild cognitive impairment (OR 28.98, P = 0.002).

CONCLUSION

A perioperative ostomy educational pathway effectively increased the level of independence and decreased the need for visiting nurse services in new ostomy patients.

Restoration of intestinal continuity following emergency sigmoid colectomy for sigmoid volvulus: An American College of Surgeons National Surgical Quality Improvement Program analysis using coarsened exact matching

BACKGROUND

There is limited data to guide decision-making between performing a primary anastomosis and fashioning an end colostomy following emergency sigmoid colectomy for patients with sigmoid volvulus. The aim of this study was to compare the outcomes of these two approaches.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2021 was retrospectively analyzed. Missing data were multiply imputed, and coarsened exact matching was performed to generate matched cohorts. Rates of major complications and other postoperative outcomes were evaluated among patients who had a primary anastomosis as compared with matched controls who had an end colostomy following emergency sigmoid colectomy.

RESULTS

Overall, 4041 patients who had a primary anastomosis and 1240 who had an end colostomy met the inclusion criteria. After multiple imputation and coarsened exact matching, 895 patients who had a primary anastomosis had a matched control. The rate of major complications was lower in patients who had an end colostomy (33.2% vs. 36.7%), but this difference was not statistically significant (OR 0.86, 95% CI 0.70-1.05). Results were similar in subgroup analyses of higher-risk patients. There were no significant differences in overall complication rate, mortality, length of hospital stay, or readmission rate. Patients with a colostomy were more likely to be discharged to a care facility (OR 1.35, 95% CI 1.09-1.67).

CONCLUSION

Differences in rates of major complications and many other outcomes after primary anastomosis as compared with end colostomy were not statistically significant following emergency sigmoid colectomy for sigmoid volvulus.

Management of adult intestinal stomas: The 2023 French guidelines

AIM

Digestive stoma are frequently performed. The last French guidelines have been published twenty years ago. Our aim was to update French clinical practice guidelines for the perioperative management of digestive stoma and stoma-related complications.

METHODS

A systematic literature review of French and English articles published between January 2000 and May 2022 was performed. Only digestive stoma for fecal evacuation in adults were considered. Stoma in children, urinary stoma, digestive stoma for enteral nutrition, and rare stoma (Koch, perineal) were not included.

RESULTS

Guidelines include the surgical landmarks to create digestive stoma (ideal location, mucocutaneous anastomosis, utility of support rods, use of prophylactic mesh), the perioperative clinical practice guidelines (patient education, preoperative ostomy site marking, postoperative equipment, prescriptions, and follow-up), the management of early stoma-related complications (difficulties for nursing, high output, stoma necrosis, retraction, abscess and peristomal skin complications), and the management of late stoma-related complications (stoma prolapse, parastomal hernia, stoma stenosis, late stoma retraction). A level of evidence was assigned to each statement.

CONCLUSION

These guidelines will be very useful in clinical practice, and allow to delete some outdated dogma.

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.

Nursing interventions for the promotion of tracheostomy self-care: A scoping review

AIMS AND OBJECTIVES

To map nursing interventions, their characteristics, and outcomes, in promoting self-care of the person with a tracheostomy.

BACKGROUND

The development of competencies in self-care of a person with a tracheostomy is recognised as one of the most significant nursing intervention areas for the promotion of autonomy, prevention of complications and adaptation. Identifying nursing interventions for the promotion of self-care of the person with a tracheostomy enables enhanced clinical practice knowledge within different care contexts and the identification of gaps in the available evidence.

DESIGN

The Joanna Briggs Institute (JBI) methodology was used to perform this scoping review.

METHOD

A search was conducted on the CINAHL, Scopus, Web of Science, PubMed, JBI Database of Systematic Reviews and Implementation Reports, and Cochrane Database of Systematic Reviews. The search for grey literature included Portugal´s Open Access Scientific Repository, OpenGrey, and ProQuest Dissertations and Theses. Studies published in Portuguese, English, Spanish and French were included. The PRISMA-ScR checklist was used.

RESULTS

From a total of 4,224 identified articles, 31 were included in this review. Multiple nursing interventions were identified and grouped into four types of action: informing, managing, determining and attending. Although most interventions are implemented with the face-to-face method, there is a growing interest in using technologies for this purpose. The dose is the characteristic most poorly described in interventions. Various results were obtained; however, valid assessment tools were not always used.

CONCLUSIONS

Designing and testing intervention programmes for the promotion of self-care of the person with a tracheostomy is necessary, based on available and robust evidence to guide clinical practice.

RELEVANCE TO CLINICAL PRACTICE

This review allowed to systematise nursing interventions to promote self-care of the person with a tracheostomy. The use of combined interventions and methodologies is likely to be more effective in care delivery.

Primary Anastomosis Versus End-Ostomy in Left-Sided Colonic and Proximal Rectal Cancer Surgery in the Elderly Dutch Population: A Propensity Score Matched Analysis

Background

Primary anastomosis (PA) in left-sided colorectal cancer (CRC) surgery in elderly patients is disputed. The aim of our study was to evaluate the differences in postoperative outcomes after left-sided CRC surgery in elderly patients in The Netherlands, comparing patients with PA and those who underwent end-ostomy (EO).

Method

Patients aged ≥ 75 years with stage I–III left-sided CRC, diagnosed and surgically treated in 2015–2017 were selected from the Netherlands Cancer Registry (n = 3286). Postoperative outcomes, short-term (30-, 60-, and 90-day) mortality and 3-year overall and relative survival were analyzed, stratified by surgical resection with PA versus EO. Propensity score matching (PSM) and multivariable logistic regression analysis were conducted.

Results

Patients with higher age, higher American Society of Anesthesiologists classification and higher tumor stage, a perforation, ileus or tumor located in the proximal rectum, and after open or converted surgery were more likely to receive EO. No difference in anastomotic leakage was seen in PA patients with or without defunctioning stoma (6.2% vs. 7.0%, p = 0.680). Postoperative hospital stay was longer (7.0 vs. 6.0 days, p < 0.0001) and more often prolonged (19% vs. 13%, p = 0.03) in EO patients. Sixty-day mortality (2.9% vs. 6.4%, p < 0.0001), 90-day mortality (3.4% vs. 7.7%, p < 0.0001), and crude 3-year survival (81.2% vs. 58.7%, p < 0.0001) were significantly higher in EO patients, remaining significant after multivariable and PSM analysis.

Conclusion

There are significant differences between elderly patients after left-sided CRC surgery with PA versus EO in terms of postoperative length of stay, short-term survival, 3-year overall survival, and relative survival at disadvantage of EO patients. This information could be important for decision making regarding surgical treatment in the elderly.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-09976-y.