European Wound, Ostomy and Continence Supplement, Volume 20

European Wound, Ostomy and Continence Supplement

Volume 20 | Supplement 4 | May 2022

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Ostomy patients and the challenge of digitalisation Renata Batas

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Time for a fresh start Werner Droste

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Clinical digest Renata Batas

S12 Caring during and after a pandemic Ana González Díaz and Concepción Capilla Díaz

S14 Coordinating roles in the stoma care pathway: practical recommendations from France Danièle Chaumier

S18 Transanal irrigation devices: an overview Gemma Harris

S24 A holistic view of the stoma care pathway in Italy: a nationwide learning survey Elena Toma, Filippo La Torre, Filippo Barone, Marcello Rovere, Maria Sole Ercolani, Paola Pocek, Lucia Filomeno and Giuseppe La Torre

S34 Factors predictive of optimal peristomal skin status in patients with an ostomy: a secondary analysis Eugenia Rodriguez González, Carmen del Pino Zurita, Gemma Arrontes Caballero, Araceli Hoyo Rodríguez, Eugenia Zapatero Rodríguez and Eduardo García Blázquez

In association with

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Tips Providing honest and accessible advice to your stoma patients PRACTICAL ADVICE AND INSPIRATION FOR A CONFIDENT, INDEPENDENT LIFE

Tips

The free source of stoma advice you can recommend and pass on to your patients

Getting back on your feet

Running free

PRACTICAL ADVICE AND INSPIRATION FOR A CONFIDENT, INDEPENDENT LIFE

Tips

Stoma Tips is the new, free biannual magazine full of practical information and inspiring stories to help ostomates live with comfort and confidence. As an independent magazine, we provide, clear, honest and unbiased advice on ostomy products—written and reviewed by qualified stoma care nurses—to help readers find the stoma routine that works best for them.

We also encourage people to open up about their stoma and break down the stigmas that can keep them silent.

Stoma Tips is a place for ostomates to share stories of things that have made them laugh and smile, as well as of how they overcame their more challenging moments. Our aim is to help ostomates of all ages and backgrounds live a life that’s as active, social and independent as before.

Troubleshooting your appliance Choosing the right appliances and accessories

What to wear Strengthening after stoma your coresurgery Stag with a stoma

Eating more of what you want

In association with:

In association with:

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Order your copy online now or get instant digital access www.stomatips.com GASTRO-Layout-Mar 2022.indd GASTRO-Layout-May 2022.indd 34 GASTRO-Layout-Feb 2022.indd 69 Untitled-1 2 JPrP_December layout.indd 23 49

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editorial

European Wound, Ostomy and Continence Supplement

EDITOR Benjamin Wakefield SUBEDITOR Shabnam Ali ADVERTISING MANAGER Nicholas Barlow CIRCULATION DIRECTOR Sally Boettcher PRODUCTION MANAGER Kyri Apostolou ASSOCIATE PUBLISHER Sophie Gardner PUBLISHING DIRECTOR Andrew Iafrati MANAGING DIRECTOR Anthony Kerr CHIEF EXECUTIVE OFFICER Ben Allen Editorial enquiries: benjamin.wakefield@markallengroup.com Commercial enquiries: nicholas.barlow@markallengroup.com

CONSULTANT EDITOR Renata Batas, Enterostomal Therapist, Community Health Centre Ljubljana, Slovenia EDITORIAL BOARD Ivanka Bencic, Clinical Nurse Specialist, Sisters of Charity Hospital, Zagreb, Croatia Dušica Biocanin, Head Nurse, First Surgical Clinic, Clinical Centre of Serbia, Belgrade Concepción Capilla Díaz, Assistant Professor, Faculty of Health Sciences, University of Granada, Spain Daniele Chaumier, Enterostomal Nurse, Hôpital Tenon, Paris, France Fiona Davidson, Nurse Manager, Hollister Ireland Danila Maculotti, Enterostomal Nurse, Poliambulanza Foundation Hospital, Brescia, Italy Vivien Nagy-Wikstedt, WOC Nurse and Sexual Counsellor, Helsinki University Hospital, Finland Susan Pridham, Ostomy Nurse Manager (Clinical Lead), Amcare Group, UK Margarete Anna Wieczorek, Independent Qualified WOC Nurse, Regensburg, Germany UK PERSONAL SUBSCRIPTION RATES Quarterly direct debit £25 Annual direct debit £100 Annual credit card £105 2-year credit card £179 3-year credit card £252 Subscribe online: www.magsubscriptions.com Subscribe by phone: +44 (0) 1722 716997 Institutional pricing: institutions@markallengroup.com

www.markallengroup.com Gastrointestinal Nursing is published by MA Healthcare Ltd, St Jude’s Church, Dulwich Road, London SE24 0PB Tel: +44 (0)20 7738 5454 Website: www.gastrointestinalnursing.co.uk

© MA Healthcare Ltd, 2022. All rights reserved. No part of the Gastrointestinal Nursing may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise without prior written permission of the Publishing Director.

The views expressed do not necessarily represent those of the editor or Gastrointestinal Nursing. Advertisements in the journal do not imply endorsement of the products or services advertised.

ISSN 1479-5248 Printed by Pensord Press Ltd, Blackwood, NP12 2YA

Ostomy patients and the challenge of digitalisation

T

he COVID-19 pandemic has had a particular impact on patients’ access to the healthcare system. Due to the pandemic, many patients could not or did not want to go to their GPs in person, making digital or telephone communications critical for urgent matters such as prescriptions. It has been reported that many patients now attend the hospital with exacerbations of underlying and chronic conditions, as well as advanced cancers, including bowel and bladder cancers.

According to Keller et al (2019), colorectal cancer (CRC) is the second most common cancer and cause of cancer-associated death in Europe. The incidence and prevalence of inflammatory bowel disease (IBD) is increasing worldwide, with approximately 2.5–3 million Europeans affected. In the EU, there are an estimated 176 000 new IBD cases annually (53 000 new diagnoses of Crohn’s disease (CD) and new diagnoses of 123 000 ulcerative colitis (UC)). The prevalence of CD in Europe ranges from 1522–21 312 cases/100 000 persons, and the prevalence of UC varies from 2422–2946 cases/100 000 persons (Keller et al, 2019). These conditions most often require surgery, where the final result may be a stoma, colostomy or ileostomy. Patients with a stoma face a new selfimage after surgery. They need to learn about and train in stoma self-care, with the goal of rehabilitation and living as normal a life as possible.

The enterostomal therapist has an important role in teaching patients about stoma care and resolving possible complications. The challenge is high output in patients with an ileostomy. High-output stomas, defined as an output in excess of 1 litre over a 24-hour period, can affect the psychological wellbeing of patients. There is a need for awareness among patients and health professionals of the signs and risks of high-output stomas.

High-output stoma management is complex. Discharges from the hospital require close collaboration between acute and community teams to ensure adequate planning, education and preparation (Goodey and Colman, 2016). Over time, a high-output stoma can result in dehydration, electrolyte depletion, acute kidney injury and malnutrition, and can potentially lead to chronic kidney disease. The stoma care nurse is in an ideal position to assist in the safe transition of the patient from hospital to the community. There is limited standardised practice for monitoring patients with high-output stomas in the community, but continued communication and a collaborative approach are essential for the patient’s safe discharge into the community (Smith and Boland, 2013).

During the pandemic, technology was helpful for healthcare workers and patients who were able and willing to use it. Digitalisation within healthcare has greatly advanced during the pandemic. Ostomy patients have started to use social media, such as Facebook, to find guidance about living with stoma. In many ways, this is a good way for patients to find useful information and make new connections. This can help them to adapt to their new way of life. In many countries, enterostomal therapists have started to communicate with patients through many different means, including email, phone, live chat via online platforms, and video calls. These are useful in situations where discussion between a patient and healthcare professional is enough to find a solution. However,

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in many cases where a stoma needs attention from a stoma therapist, remote means of consultation and communication are not enough.

We must not forget that many patients with a stoma are derived from an older population that is mostly unaccustomed to using modern technology. Many do not have computers and do not know how to use the internet. For these reasons, it is necessary for these patients to have access to well-established and more traditional ways of communication with healthcare professionals, in addition to remote consultations.

However, it is also necessary to prepare more online communications and content for more tech-savvy ostomy patients, offering advice on stoma care, problem-solving, signposting resources, and so on.

Digitalisation in heatlhcare helps patients and healthcare professionals by offering faster communication and solutions in cases where personal visitation of patients is not necessary. Advantages include the saving of time and travel costs. Online content and communication platforms also facilitate connection between healthcare providers for the purposes of education and training. The pandemic has provided an opportunity to radically change systems and processes in stoma care. The use of technology helps in establishing and maintaining interaction with patients, communicating with the wider multidisciplinary team and connecting with relatives or carers. With help of digital resources, we can enhance personal development, training and education.

GN Renata Batas, Consultant Editor Goodey A, Colman S. Safe management of ileostomates with high-output stomas. Br J Nurs. 2016; 25(S22):S4– S9. https://doi.org/10.12968/bjon.2016.25.22.S4 Keller DS, Windsor A, Cohen R, Chand M. Colorectal cancer in inflammatory bowel disease: review of the evidence. Techniques Coloproctol. 2019; 23:3–13. https://doi.org/10.1007/s10151-019-1926-2 Smith L, Boland L. High output stomas: ensuring safe discharge from hospital to home. Br J Nurs. 2013; 22(S5):S14–S18. https://doi.org/10.12968/bjon.2013.22.sup3.s14

Tips © 2021 MA Healthcare Ltd

the free magazine for ostomates practical advice and inspiration for a comfortable, independent life read and order online at www.stomatips.com

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ECET update

Time for a fresh start Werner Droste delivers news from the European Council of Enterostomal Therapy Werner Droste, Vice-President, European Council of Enterostomal Therapy, and Independent Specialist Wound, Ostomy and Continence Nurse, Germany (werner.droste@gmx.net)

I

German Deutsch m dritten Jahr der weltweiten SARS COV-2 Pandemie scheint in vielen Ländern eine vorsichtige Rückkehr zu einem Leben angestrebt zu werden, wie es vor der Pandemie zum gewohnten Lebensalltag zählte.

Schmerzlich vermißt haben wir als spezialisierte Pflegefachkräfte ganz besonders den direkten Austausch mit Kolleginnen und Kollegen aus vielen Ländern beispielsweise während der Kongresse und Fortbildungsveranstaltungen des ECET und anderen Organisationen der Pflege. Aktuell finden erste Veranstaltungen mit europäischer und internationaler Beteiligung wieder statt. So wird es innerhalb des EWMA-Kongresses in Paris am 25.05.2022 erstmalig wieder ein ECET-Seminar geben. Zu weiteren Veranstaltungen erfolgen aktuell die Gespräche mit den Beteiligten. Interessierte Kolleginnen und Kollegen können sich jederzeit über geplante Veranstaltungen auf der Website des ECET unter https://ecet-stomacare.eu informieren.

In der Zeit der Pandemie wurden viele Fachbeiträge zu den Themenfeldern Stomatherapie, Inkontinenzversorgung und Wundmanagement publiziert. Vieles davon mit direktem oder indirektem Bezug zur aktuellen Pandemie.

Trotz Pandemie ist aber die auch aus fachlicher Sicht die Zeit nicht stehen geblieben. Auch haben sich die Herausforderungen und Probleme der Menschen mit einem Pflege- und Versorgungsbedarf nicht von selbst erledigt. Ein Beispiel für einen besonders gravierenden und dringenden Handlungsbedarf stellt nach Ansicht des Autors die Prävention zur Entwicklung eines High-Output-Syndroms (HOS) bei Menschen mit einer Ileostomaanlage dar. Jüngere Publikationen haben aufgezeigt, dass für Menschen mit einem HOS die individuelle Hilfe und Unterstützung durch spezialisierte Pflegeexperten hilfreich ist und lebensbedrohende Eskalationen verhindert werden können.

I

© 2022 MA Healthcare Ltd

n the third year of the worldwide SARS COV-2 pandemic, many countries seem to be striving for a cautious return to a life that was part of everyday reality before the pandemic. As specialised nursing staff, we sorely missed direct exchanges with colleagues from many countries, for example, as happened during the congresses and training events of the European Council of Enterostomal Therapy (ECET) and other nursing organisations.

At last, events with European—and international— participation are again taking place. For example, there will be an ECET seminar for the first time within the European Wound Management Association (EWMA) Congress in Paris on 25 May 2022. Discussions are being held with those involved regarding taking part in further events. Interested colleagues can find out about planned events at any time on the ECET website at: https://ecet-stomacare.eu.

During the pandemic, many specialist articles were published on the topics of ostomy therapy, incontinence care and wound management, much of it with direct or indirect reference to the pandemic.

Despite the pandemic, time has not stood still from a professional point of view, nor have the challenges and problems of people with care and support needs resolved themselves. An example of a particularly serious and urgent need for action is the prevention of the development of highoutput stoma (HOS) syndrome in people with an ileostomy.

Recent publications have shown that people with HOS need individual help and support from specialised nursing experts, so that life-threatening escalations can be prevented. The

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ECET update

Die bestmögliche Beratung und Pflege mit dem Ziel der Vermeidung eines HOS zählt zu den wichtigen Aufgaben der spezialisierten Pflegeexperten. Dennoch müssen wir uns auch kritischen Fragen in diesem Kontext stellen. Fragen wie etwa: „Wie haben wir uns auf das rechtzeitige Erkennen eines drohenden HOS eingestellt? Welche Assessment-Instrumente werden in der Praxis tatsächlich regelhaft genutzt? Gibt es für jede Pflegefachkraft eine Standardprozedur bei Entdeckung eines Patienten mit einem HOS? „Mit welchen Inhalten und Methoden wird die Edukation der gefährdeten Menschen zur Prävention eines HOS erweitert?“. Auch aus Sicht des ECET als europäische Organisation der spezialisierten Pflege stellt sich die Frage nach der benötigten fachlichen Unterstützung aller Pflegeexperten in den europäischen Ländern. Wie können wir als europäische Organisation zur Verbesserung der Pflege und Versorgung dieser speziell gefährdeten Patienten beitragen?

Aus Sicht des Autors ist dieses Beispiel sehr gut geeignet, um auf anstehende, wichtige und dringliche Aufgaben für Pflegeexperten und deren Organisationen in der Zukunft aufmerksam zu machen.

Der ECET ist bereit diese Aufgaben aufzugreifen und zu bearbeiten.

Packen wir es gemeinsam an! GN

best possible advice and care to help with avoiding an HOS is an important task facing specialised care experts.

Nevertheless, we also have to ask ourselves critical questions in this context, including: How do we prepare for the timely detection of an impending HOS? Which assessment instruments are actually used regularly in practice? Is there a standard procedure for every nurse to follow to discover a patient with HOS? What content and methods could be used to educate people at risk to prevent HOS? From the point of view of ECET as a European specialised care organisation, the question arises as to the required professional support of care experts in European countries.

How can we as a European organisation contribute to improving the care and support of these particularly vulnerable patients?

From the author’s point of view, this example of HOS is well suited to drawing attention to upcoming, important and urgent tasks for nursing professionals and their organisations.

ECET is ready to take on these tasks and work on them.

Let’s tackle it together!

GN

WHY NOT WRITE FOR US? Gastrointestinal Nursing welcomes the submission of clinical and opinion articles on a range of GI issues including IBD, stoma, endoscopy, hepatology and policy and service development.

All manuscripts should be submitted via Editorial Manager, our online article submission system, via the link: editorialmanager.com/gasn/default.aspx.

© 2022 MA Healthcare Ltd

All published articles are subject to an external, double-blind peer review.

If you have any queries, contact the Editor, Benjamin Wakefield: gin@markallengroup.com Gastrointestinal Nursing European Wound, Ostomy and Continence Supplement

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clinical digest

Clinical digest A brief overview of recently published articles on wound, continence and stoma care

Complications and quality of life of ostomy support garment wearers Pittman J, Colwell K, Mulekar MS. Ostomy complications and quality of life of ostomy support belt/garment wearers: a web-based survey. Wound Ostomy Continence Nurs. 2022;49(1):60–68. https://doi. org/10.1097/WON.0000000000000843

Management of an ostomy involves the use of a pouching system that fits around the stoma in order to collect and contain the effluent. The goal for a person with a stoma is to find a pouching system that provides a reliable wear period without leakage and helps to maintain intact peristomal skin. Despite the availability of multiple pouching systems, many people living with an ostomy experience ostomy-related complications, which often impact their quality of life (QoL).

One of the numerous factors affecting QoL is leakage of effluent from an ostomy pouching system. Leakage can be defined as undermining of the pouch seal, which often occurs when fecal matter or urine comes into contact with the peristomal skin. Exposure of the peristomal skin to stoma effluent may cause irritant contact dermatitis, also referred to as peristomal moisture-associated skin damage (PMASD). In a study incorporating 200 participants with an ostomy, Ratliff (2014) found that 87% experienced problems with pouch leakage. Claessens et al (2015) examined 4138 persons with an ostomy and found that 76% experienced leakage over a 6-month period, and 91% were worried about leakage.

In this mixed-methods descriptive study (Pittman et al, 2022), a web-based survey was provided to 1500 adults with an ostomy living in the community. The purpose of this study was to examine ostomy complications and health-related S8

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QoL in individuals with an ostomy who wear an ostomy support belt/garment. The quantitative and predefined qualitative results were reported in this study.

Descriptive analysis was conducted for all outcomes. Participants were separated into groups, depending on type of ostomy belt or belt/garment worn or whether they wore none at all.

Some 202 individuals responded to the survey (a 13.5% response rate). Of the 196 respondents who reported type of ostomy, 45% had an ileostomy (n=89), 26% had a colostomy (n=50), 14% had a urostomy (n=27), and 7% had multiple ostomies (n=13). Of the 173 respondents who answered a question on leakage, almost 91% (n=157) reported leakage, with 14% (n=22) having leakage at least weekly. In total, 78% (n=135) reported peristomal skin irritation, with approximately 20% (n=26/128) experiencing peristomal skin irritation at least weekly. Of participants, 69% (n=119) wore a type of ostomy belt.

Among respondents who wore a belt, 60% (n=71) wore an ostomy support belt/ garment and the remaining 40% (n=47) wore another type of belt. Meanwhile, 32% (n=55) did not wear any ostomy support belt/garment. The reasons for wearing a belt included concealment (n=7; 6%), increased confidence (n=45; 38%), prevention of leakage (n=6; 5%), and a combination of the aforementioned (n=51; 43%).

Participants were grouped according to their belt-wearing status: ostomy support belt/garment wearers, other type of belt wearers, and non–wearers.

Of the 174 participants who responded to the survey question on leakage, 157 (90%) reported experiencing leakage

and 135 (78%) reported rashes or skin irritation. Experiences of leakage event were not significantly different across groups (P=0.3663). Those who wore an ostomy support belt/garment reported leakage less often (less than once a month) versus respondents who wore other types of belts or no belt (n=49; 73% vs n=53; 60&; P=0.0388). Of the 174 participants who responded a question relating to peristomal skin, 135 (78%) reported peristomal skin complications.

Significantly fewer participants who wore an ostomy support belt/garment reported experiencing peristomal skin irritation compared to those who wore other types of belts or no belt (69% vs 84%; P=0.0080). The mean cumulative total City of Hope Quality of Life (COH QoL) Ostomy score for all participants was 6.45 ± 1.36 out of 10, with the psychosocial domain scoring the lowest at 5.67 ± 1.30 out of 10. No significant differences were observed in mean QoL domain and total scores by those who wore an ostomy support belt/garment, other type of belt/garment, and those who wore none. When comparing COH QoL mean scores and leakage frequency, those who reported leakage more often had significantly worse QoL scores in all four domains (physical (P=0.0008), psychological (P=0.0154), social (P=0.0056) and spiritual (P=0.0376)), as well as negatively impacted total COH QoL scores (P=0.0018).

Based on the results of this study, use of an ostomy support belt/garment may be of value as an additional intervention to decrease frequency of effluent leakage and peristomal skin irritation, and improve QoL.

Gastrointestinal Nursing European Wound, Ostomy and Continence Supplement

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Renata Batas, Enterostomal Therapist, Community Health Centre Ljubljana, Slovenia (renata.batas@gmail.com)

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Claessens I, Probert R, Tielemans C et al. The ostomy life study: the everyday challenges faced by people living with a stoma in a snapshot. Gastrointestinal Nursing. 2015; 13(5):18–25. https://doi. org/10.12968/gasn.2015.13.5.18 Ratliff CR. Factors related to ostomy leakage in the community setting. J Wound Ostomy Continence Nurs. 2014; 41(3):249–253. https://doi. org/10.1097/WON.0000000000000017

Ileostomy and quality of life

© 2022 MA Healthcare Ltd

Rud CL, Baunwall SMD, Bager P et al. Patientreported outcomes and health-related quality of life in people living with ileostomies: a populationbased, cross-sectional study. Dis Colon Rectum.

2021; epub ahead of print. https://doi.org/10.1097/ DCR.0000000000002100.

Having an ileostomy affects the patient’s daily life. Physical and psychosocial adaptation to a stoma is needed. To what degree an iIleostomy may impact on patients’ long-term health-related quality of life (HRQoL) is not clear, and further investigation is needed. The authors of this Danish study conducted a survey as part of a population-based, cross-sectional study, which included all patients who had been in contact with the Outpatient Stoma Clinic at Aarhus University Hospital, Denmark, between 2012 and 2017 and who had been coded for an ileostomy (DZ932) in the Danish version of the International Classification of Diseases (IDC-10) diagnostic database. Patients were invited to answer questionnaires related to stoma-specific and generic HRQoL evaluation tools (EQ-5D-5L and the Major Depression Inventory).

Of 621 identified patients (50% females), 412 (66%) responded to the survey. Among the respondents, 178 (43%) reported still having an ileostomy at the time of the survey and were, therefore, included in the analysis. Most participants reported that their stoma rarely reduced their general quality of life (Qol) (65%); however, 23% answered that it almost always reduced their HRQoL. Participants reported that fatigue was frequent: 68% (95% confidence interval: 60–75%) experienced feeling tired, and 26% (20–33%) answered that they were ‘always tired‘. Some 43% (36–51%) lacked energy, 62% (54–69%) reported poor sleep, and 59% (52–66%) needed to

rest during the day. Some 56% (48–63%) immediately needed to know the location of the nearest toilet, and 58% (51–66%) felt sexually unattractive because of their ileostomy. HRQoL scores, which were measured with generic questions, were 0.124 points below the the Danish norm (p<0.001), and 18% (13–25%) were scored as experiencing depression, which is a prevalence rate that is 2.6 times higher than in the general population (7%, 6–9%, p<0.001).

People living with an ileostomy may have low HRQoL, which, in this study, was attributed directly to the ileostomy in almost a fourth of participants. There have been limited prior studies on stomaspecific HRQoL in people living with ileostomies. The participants in the present study had a mean Stoma-QoL score of 58.8 points. For comparison, a Danish population of patients with an ileostomy or colostomy had a mean score of 62.6 points (Prieto et al, 2005), and Swedish patients with a sigmoidostomy had a score of 64.7 points (Kald et al, 20008).

This indicates that the type of stoma may affect the overall HRQoL. Limitations of the study were potential selection bias, and all participants did not answer all items.

Prieto L, Thorsen H, Juul K. Development and validation of a quality of life questionnaire for patients with colostomy or ileostomy. Health Qual Life Outcomes. 2005; 3:62. https://doi.org/ 10.1186/1477-7525-3-62 Kald A, Juul KN, Hjortsvang H, Sjödahl RI. Quality of life is impaired in patients with peristomal bulging of a sigmoid colostomy. Scand J Gastroenterol. 2008;43: 627–633. https://doi.org/ 10.1080/00365520701858470

Automated pulsating support system for pressure injury prevention and treatment Raepsaet C, Zwaenepoel E, Manderlier B et al. A fully automated pulsating support system for pressure injury prevention and treatment in 10 Belgium nursing homes: an observational study. Wound Ostomy Continence Nurs. 2021;48(2):115–123. https://doi. org/10.1097/WON.0000000000000746

A pressure injury (PI) is defined as a localised injury of the skin and/or underlying tissue, usually over a bony prominence as the result of prolonged

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pressure or a combination of shear stress and pressure. PIs cause discomfort to the patient and have a negative impact on the general health, activities of daily living, and quality of life. The most common symptom experienced by patients with any stage of PI is pain. PIs are associated with high treatment costs. Nurses play a pivotal role in promoting and maintaining their patients’ skin integrity, particularly for those who experience increased pressure risk from high mechanical loadings (inability to turn self) and those who are incontinent. Despite an increased knowledge concerning preventive strategies, PIs remain a common occurrence in nursing home residents.

Older people are particularly susceptible to PI development, due to impaired mobility and changes in skin condition.

In this multicentre cohort study, the cumulative incidence of varying PI stages (II–IV) and the changes of PI status in the sacral area of nursing home residents associated with the use of a fully automated pulsating support system air mattress, in use for 30 days, was assessed.

Caregivers’, residents’ and their family members’ experiences and perceptions of mattress comfort and other factors, such as pain, were also gathered.

This multicentre cohort study was conducted in a convenience sample of 40 residents (n=22 in the prevention group and n=18 in the treatment group) in 10 Belgian nursing homes between February 2019–October 2019. The Pressure Ulcer Scale for Healing (PUSH) tool was used to assess and measure PI status change.

A comfort assessment was performed at end of the study. Cumulative PI incidence of stages II–IV was calculated, and frequencies and percentages were used to describe the results of the comfort assessments.

Some 85% of residents participating in the study were women (n=34/40).

All 40 residents were at a high risk of PI development (assessed by their Braden Scale score and/or the presence of a PI).

The mean Braden Scale score was 12, indicating moderate risk. In the treatment

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group, 12 stage III PIs and 10 stage IV PIs were identified in 18 residents.

Most of the PIs occurred at the sacrum (n=17/22; 77%). Three PIs were located on the trochanters, and two at an ischial tuberosity. Two residents in the treatment group ceased participation during the study period, as one individual died on day 9 and another refused further participation on day 12 because of lower back pain.

However, data for all 40 residents were included for analysis.

It was demonstrated that the cumulative PI incidence was 5% (n=1/22) in the prevention group. In the treatment group, the mean score on the PUSH tool decreased from 9.36 to 7.70 during the observation period, indicating an overall improvement. Four of the existing PIs healed; 17 remained stable; and one deteriorated. The comfort questionnaires were completed by 76 nursing home caregivers, 21 family members, and 11 residents in the 10 participating nursing homes; mattress comfort was perceived as very good, and pain was noted to decrease with use of the mattress.

The overall cumulative PI incidence in the prevention group (n=1/22; 5%), including stages II–IV, was consistent with previously reported incidence rates, ranging between 5.1 and 5.2%, using static air overlay mattresses in a similar nursing home population.

In this study, only one stage II–IV PI (n=1/22; 4.5%) developed. In comparison to the study conducted by Serraes and Beeckman (2016), where the incidence rate of stage I–IV PIs was reported as 28.4%, of which 5.1% were stages II–IV (the majority of PIs were stage I), results were much better.

The results of this study indicate that most of the existing stage III or IV PIs did not deteriorate and some improved (defined as a decrease in PUSH score) while using the fully automated pulsating support system. Pulsating support systems have been associated with improved microcirculation and lymphatic flow, as well as pressure relief. These characteristics could have partly contributed to the S10

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favorable progress of PIs in this study.

Changes in PI status were also influenced by other factors, such as repositioning, proper positioning to enlarge contact area and reduce shearing forces, wound care and nutrition.

This study predominantly reported on one aspect of PI prevention and treatment—namely, the use of support surfaces.

However, strategies for preventing and treating PIs usually comprise a combination of pressurerelieving devices, skin/wound care, repositioning, and optimisation of the patient’s nutritional status. Treating PIs requires thorough consideration of many wound and patient characteristics. Due to this, the interplay between different prevention and treatment strategies of PIs should be taken into consideration.

Use of the mattress for the prevention of PIs was associated with low cumulative PI incidence rates and improvements in existing PIs. The mattress was evaluated as comfortable by the majority of the caregivers, residents and family members. Future research is needed to corroborate findings, in larger randomised clinical trials.

Serraes B, Beeckman D. Static Air Support Surfaces to Prevent Pressure Injuries: A Multicenter Cohort Study in Belgian Nursing Homes. J Wound Ostomy Continence Nurs. 2016;43(4):375-378. doi:10.1097/WON.0000000000000244

Autologous protein-based topical ointment for hard-to-heal skin wounds Muñoz V, Pino A, Martinez C et al. An autologous protein-based topical ointment for hard-to-heal skin wounds: a multiple case series. J Wound Ostomy Continence Nurs. 2021; 48(4):350–355. https://doi. org/ 10.1097/WON.0000000000000775

Normal healing is achieved through four programmed phases (haemostasis, inflammation, proliferation and remodeling). However, some wounds are difficult to heal even without underlying conditions, such as vascular disorders or diabetes mellitus. Several local causes (oedema ischaemia, tissue hypoxia, infection, necrosis and growth factor imbalance) and systemic causes (metabolic diseases, nutritional status, perfusion

disturbances or preexisting illness) also delay wound healing.

There is increasing evidence regarding the wound healing potential of plateletderived autologous byproducts. Plasma rich in growth factors (PRGF) is a specific treatment method based on plateletrich plasma therapy. It is a blood product containing concentrated levels of a patient’s own growth factors that facilitate wound healing. It uses autologous platelet-rich plasma to activate the patient’s own platelets and is designed to stimulate and accelerate tissue healing and regeneration.

A multiple case series has provided preliminary data regarding the use of a new autologous topical ointment derived from PRGF for the management of hardto-heal wounds. In this study, four patients experiencing difficult-to-heal wounds were included, who were treated with the PRGF-derived autologous ointment.

Within 2–8 weeks, all wounds healed completely, with no signs of infection or functional impairment of the affected limbs. No adverse events were reported.

This multiple case series adds to the literature suggesting that the PRGFderived autologous ointment is safe and effective for treatment of hard-to-heal wounds. Research indicated that PRGFderived autologous ointment possesses a high load of growth factors and physicochemical properties suitable for topical cutaneous application.

The use of topical administration of recombinant growth factors, such as PDGF or epidermal growth factor (EGF), as an alternative strategy has already been approved for wound healing by the US Food and Drug Administration.

These bioactive proteins have been shown to penetrate through the different layers of the skin and promote the cellular biosynthesis of key structural matrix proteins, such as collagen and hyaluronic acid. In this study (Muñoz et al, 2021), it was found that application of the PRGF-derived autologous ointment produced positive responses in terms of granulation tissue development and re-

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epithelialisation of wounds not responsive to other topical therapies. The results observed in the present case series report may reflect the wound healing potential of the endogenous topical formulation.

It is suggested that PRGF may reduce reactive oxygen species levels within the cutaneous tissue, increase skin metabolic activity, and reduce necrosis under oxidative stress conditions.

Randomised controlled trials are needed to determine the clinical efficacy of the autologous ointment.

Telemedicine in postoperative followup of stoma patients Augestad KM, Sneve AM, Lindsetmo RO. Telemedicine in postoperative follow-up of stoma patients: a randomized clinical trial (the STOMPA trial). BJS. 2020; 107:509–518. https://doi.org/10.1002/ bjs.11491

A stoma has a severe impact on a patient’s quality of life (QoL). The aim of this study was to prove that postoperative home community follow-up with teleconsultation (TC) by stoma nurses may reduce the burden of travel and improve QoL.

QoL of patients with a stoma, followed up in a hospital outpatient setting (controls) or by teleconsultation (intervention), was investigated. The researchers assessed healthcare resource use, organisation and patient satisfaction with the health service.

All patients were followed up for at least 12 months. Patients with a postsurgical stoma (ileostomy or colostomy) were included. Patients with a life expectancy of less than 2 years, with a mental illness or severe dementia, who were unable to provide informed consent, or those who had experienced stoma formation after palliative surgery (patients with disseminated cancer), were excluded from the study.

A university hospital and five district medical centres participated in the study.

Stoma nurses performed the clinical examination at the TC studio, aided remotely by hospital nurses and surgeons.

The primary assessment tool was the EQ-5 index score; secondary tools were the Stoma Quality-of-Life Scale, the OutPatient Experiences Questionnaire, and use of hospital resources.

Some 110 patients were included, who were randomly assigned to either hospital (58 patients) or TC (52) followup; 64 patients (hospital: 38; TC: 26) were followed up with for more than 12 months, and 246 consultations (hospital: 151; TC: 95) were performed. No difference in QoL was reported between the two follow-up methods (EQ-5D index score (P=0.301) and EQ-5D visual analogue scale (VAS) score (P=0.775); Work/Social Function (P=0.822); Sexuality/ Body Image (P=0.253) and Stoma Function (P=0.074)). Hospital follow-up performed better in terms of organisation of care (staff collaboration: P=0.004; continuance of care: P=0.003) and communication (surgeon was understandable: P<0.001; surgeon was caring: P=0.003). TC did not increase the number of hospital consultations (P=0.684) and reduced the number of journeys of more than 8 hours (P=0.007).

It was concluded that TC follow-up by stoma nurses did not improve the QoL of patients, but did decrease the readmission rate and burden of travel.

GN

So what if you’re a first-time writer?

So what if you’re a first-time writer?

Do you have the idea but don’t Do youhow have idea but don’t know tothe convert it into a know to convert it into a journalhow article? journal There’s noarticle? need to be disheartened.

There’s no need to be disheartened.

Members of the Editorial Board of Gastrointestinal NursingBoard will mentor authors Members of the Editorial of and guide them through Gastrointestinal Nursingthe willprocess mentor authors of writing high-quality journal articles. and guide them through the process © 2022 MA Healthcare Ltd

of writing high-quality journal articles.

For more information, write to the Editor, Benjamin Wakefield: gin@markallengroup.com For more information, write to the Editor, Benjamin Wakefield: gin@markallengroup.com Gastrointestinal Nursing European Wound, Ostomy and Continence Supplement

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Caring during and after a pandemic Ana González Díaz and Concepción Capilla Díaz explore how the internet has revolutionised healthcare, as well as the challenges it presents for communication among and between professionals and patients Ana González Díaz, Substitute Teaching Tutor, Faculty of Health Sciences, University of Granada, Ceuta Campus (agonzalezd@ugr.es); Concepción Capilla Díaz, Assistant Professor, Faculty of Health Sciences, University of Granada, Granada Campus

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ocurae_ostomia on Instagram). These offer a reliable source of information to train and support for people with a stoma. However, social media also presents potential problems for health professionals. Violations of professional behaviour online can include misrepresentation of qualifications, inappropriate communication with patients or misuse of the internet for improper practice, such as prescribing medication (O´Connor et al, 2021).

Webinars and podcasts (and to some extent social media) provide innovative opportunities for nurses and other clinicians to access specialist education in a convenient format that meets their professional needs (Moorley and Chinn, 2019). This can be a valuable resource for continuing professional development.

Health professionals have developed and evaluated new capacities to reach patients through remote consultations, which are valuable for overcoming geographical as well as pandemic-related restrictions.

Professionals doing this should ideally undertake training in virtual counselling first. Services can also offer online group sessions and training courses for families and caregivers of people with a stoma, and health professionals. Moreover, remote consultation raises the possibility of patients connecting with professionals anywhere in the world.

Before a remote consultation with an ostomate, the patient should first be asked to provide photographs of their

stoma from different positions, as well as other specific personal data. Then the professional should analyse these alongside the general status of the person, so that everything flows properly during the remote consultation.

However, innovative online environments require elaboration and adaption of care plans and proper followup, as well as training of new generations of nurses with sufficient skills so that care does not lose its essence. Likewise, provision of hospital-based stoma care, in-clinic follow up, home visits and faceto-face meetings remains essential to delivering an effective stoma service (Burch, 2021).

GN Burch J. Stoma care services during the COVID-19 pandemic. Br J Nurs. 2021; 30(S16):S40–S44 https://doi.org/10.12968/bjon.2021.30.16.S40 Capilla-Díaz C, Bonill-de-las-Nieves C, HernándezZambrano SM, Montoya-Juárez R, Morales-Asencio JM, Pérez-Marfil MN, Hueso-Montoro C. Living with an intestinal stoma: a qualitative systematic review. Qual Health Res. 2019; 29(9):1255–1265. https://doi.org/10.1177/1049732318820933 Maharani DA, El Tantawi M, Yoseph MG, Rahardjo A.. The use of internet platforms for oral health information and associated factors among adolescents from Jakarta: a cross sectional study.

BMC Oral Health. 2021; 21(1):22. https://doi. org/10.1186/s12903-020-01387-x Moorley C, Chinn T. Social media participatory CPD for nursing revalidation, professional development and beyond. Br J Nurs. 2019; 28(13):870–877. https://doi.org/10.12968/bjon.2019.28.13.870 O’Connor S, Zhang M, Honey M, Lee JJ. Digital professionalism on social media: a narrative review of the medical, nursing, and allied health education literature. Int J Med Inform.

2021; 153:104514. https://doi.org/10.1016/j. ijmedinf.2021.104514 © 2022 MA Healthcare Ltd

he internet has revolutionised healthcare in several ways, many of which have been accelerated by the COVID-19 pandemic.

For the public, the internet has become a major source of easily accessible information on health issues (Maharani et al, 2021). However, much of the available information is erroneous, poor quality or of doubtful origin (Capilla-Diaz et al, 2018).

Social networks, such as Instagram, Twitter and Tiktok, allow patients to connect with peers who have similar long-term conditions. This is certainly the case among people with a stoma, some of whom have become stoma influencers. Spanish-language examples include historiadeunaostomía, ostobag, lasexperienciasdedavid on Instagram and Lady Ostom on Youtube.

Stoma influencers in the UK include MrColitisCrohns on Instagram and Youtube, CharlotteAmyLouise on Instagram and Twitter, and Hannah Witton on Youtube. This exchange of information and experiences among peers can be educational and aid the emotional process of acceptance of the stoma. However, social media has also been linked to addictive behaviour, loss of privacy and abusive behaviour (O´Connor et al, 2021).

There are also specialist professionals who create informative stoma care content (Spanish-language examples include vivetubolsa, estomaterapeuta_ maria and the entrepreneurial project

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Coordinating roles in the stoma care pathway: practical recommendations from France Danièle Chaumier introduces recommendations for hospital discharge and community follow-up after ostomy formation, developed by the Strategic Healthcare Initiative for Easier Life Days (SHIELD)’s committee of multidisciplinary experts

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here are almost 100 000 people in France living with a stoma, and around 25 000 people have a stoma formed each year. These patients are often vulnerable, as their stoma has been created as a result of a serious pathology, most often cancer or inflammatory bowel disease (Crohn’s disease and ulcerative colitis). Stoma formation is often a lifedisrupting procedure. The resulting physical alterations can have nutritional, psychological and social consequences for the patient. The stigma associated with a stoma can make the social and professional reintegration of some patients particularly difficult.

The Strategic Healthcare Initiative for Easier Life Days (SHIELD) is the first public health initiative in France to address existing challenges in the ostomy patient care pathway. The initiative was

formed in 2019 to optimise stoma care management through the coordination of each health professional, especially in hospital discharge and follow-up in community. It was conceived in line with the work led by the French government since 2017, particularly My Health 2022 and the Ségur of Health). Its work became increasingly urgent when the COVID-19 crisis destabilised the normal functioning of hospitals.

Since 2020, SHIELD’s committee of multidisciplinary experts (Box 1) have been working to produce a set of recommendations to optimise the management of stoma care, specifically regarding hospital discharge and community follow-up. On World Ostomy Day 2021, SHIELD published its ‘Practical recommendations: role and coordination of each health actor involved in the

Box 1. Expert panel • Guillaume Bonnaud, President, Hepato-Gastroenterology Cabinets and Groups Reflection Club • Gilles Bonnefond, Presidential Advisor, Union of Community Pharmacists • Danièle Chaumier, President, French Association of Enterostomal Therapists • Magali Corbet, General Manager, Lilial (distributor) • Cécile Dupas, Head of Nursing, Private Hospital of the East Lyonnais • Brigitte Lecointre, Director, French National Association of Nurses and Graduated Nurses and Students • Guillaume Meurette, President, French National Society of Coloproctology • Alain Olympie, Director, afa Crohn RCH France (patient association) • Cristina Romao, Senior Director of Health Economy, Regulation and Public Affairs, Coloplast France Note: Public disclosures of potential conflicts of interests for each committee member are available at https://dpi.sante.gouv.fr

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ostomy patient’s care pathway’. This guide is supported by Coloplast France and is available at pro.coloplast.fr.

The development of this guide was based on bibliographic research and expert opinion. It drew on data available from reports and qualitative surveys on the stoma care pathway and management of these patients in hospital and in the community. Opinions were drawn from a multidisciplinary expert committee representing the different healthcare professionals involved in the stoma care pathway, as well as representatives of patient associations. The committee met five times to elaborate these recommendations. During the meetings, the opinions and proposals of each expert were collected before the final validation of the recommendations.

The committee’s work followed four defined phases: 1. Description of the current state of patient care at each stage of the pathway 2. Identification of the major hurdles at each stage of the pathway, particularly on hospital discharge and community follow-up 3. Definition of the most important areas for improvement and recommendations for practice 4. Drafting of practical recommendations.

The possible care management strategies in this guide are not exhaustive, as it was not possible to consider all the specific cases, comorbidities and hospital care

Gastrointestinal Nursing European Wound, Ostomy and Continence Supplement

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Danièle Chaumier, President, French Association of Enterostomal Therapists (daniele.chaumier@gmail.com)

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Conference Week 2022

Nursing and Nutritional Care – complex, diverse, essential

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SAVE THE DATE

The NNNG are delighted to be hosting an event this year that covers the diverse and complex world of nutrition and nutrition support, with award winning experienced speakers from across the spectrum of Healthcare.

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Box 2. Three main areas for improvement 1. Better coordination between healthcare providers in hospital discharge and community follow-up 2. Better access to appliances and accessories that have demonstrated a significant improvement in patients’ quality of life 3. Personalised care and community follow-up in agreement with patient preference and professional regulations

protocols. Therefore, individual healthcare professionals remain responsible for determining the appropriate course of action for each patient on a case-bycase basis.

The committee highlighted several hurdles faced by ostomates that can prevent optimal care: • Poor co-ordination between health professionals, especially on hospital discharge • Lack of training in stoma care among nurses in hospitals and the community, making the management care and coordination difficult • Insufficient of material and human resources for health professionals trying to perform their tasks • Limited information for patients and professionals on different pathologies,

treatments and available appliances and accessories.

The committee then identified three main areas for improvement, each with the central objective of putting the patient at the heart of their care (Box 2) This guide aims to offer practical and concrete recommendations for each health professional involved in the stoma care pathway at hospital or in the community.

This should help to optimise the holistic management of patient care through description of an optimised care pathway

that clarifies roles of the different actors along this pathway and spells out the essential contacts to provide to patients.

It also emphasises the importance of training and therapeutic education, as well as use of specialist equipment.

Based on feedback from the field, the current system for managing care has shortcomings that need to be corrected in order to improve the quality of life of ostomy patients. These recommendations are intended to raise awareness and mobilise health professionals, healthcare providers, associations and patients around concrete proposals. The SHIELD committee strongly hopes for the support of all ostomy patient associations and relevant professional societies in sharing this guide, as well as the concrete implementation of its recommendations.

GN

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Transanal irrigation devices: an overview Abstract Transanal irrigation (TAI) is a safe and effective treatment but should not be carried out before less invasive treatment options have been trialled. A thorough assessment of the patient and consideration of their preferences and tolerance should determine TAI suitability and system choice. The range of available TAI) equipment can be overwhelming. Therefore, to aid health professionals, this article presents a summary of the latest available TAI devices on the market, as well as guidance on how to select a suitable device. TAI devices can be categorised into low- or high-volume; cones, catheters or balloon inflating devices; manual, electric pump or gravity-fed systems; and bed systems. Determining whether a low or high volume of water is required is a good starting point for device selection. Nurses should be aware of available devices and select one most suitable for a patient, as well as adequately train them in its usage and provide followup support. Nurses should communicate the potential improvement to quality of life TAI can offer and encourage adherence to avoid premature discontinuation.

gk.harris11@gmail.com

Key words Constipation Faecal incontinence Neurogenic bowel dysfunction Rectal irrigation Transanal irrigation This article has been subject to double-blind peer review Submitted 20 December 2021 Accepted 25 January 2022

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ransanal irrigation (TAI) involves instilling water into the lower bowel via the anus using either a rectal catheter or a cone, and is usually performed over a toilet. When the catheter or cone is removed, the water is expelled along with the contents of the rectum, sigmoid colon and possibly descending colon (Nursing Times, 2007). Following sufficient training, TAI can be performed by the patient, a carer or a health professional (Yates, 2020).

Some 6.5 million adults in the UK suffer from a bowel problem, with one in 10 of the population being affected by faecal incontinence (NHS England, 2018). TAI is widely used in the UK to effectively manage neurogenic bowel dysfunction (NBD) and has recently been approved by the National Institute for Health and Care Excellence (NICE) (2018) as a treatment for constipation and faecal incontinence. It is a maintenance therapy, rather than a cure (Emmett et al, 2017).

Henderson et al (2018) previously noted that warm tap water (36–38°C) is typically used; however, frequency of TAI and the volume of water used can vary depending on the patient’s tolerance, response and requirements. Individuals are advised to irrigate daily initially for the first 2–3 months (Emmanuel et al, 2019a), and then alternate days thereafter (Yates, 2020). Patients

should set realistic expectations when beginning TAI, as it can take up to 12 weeks to establish an effective and suitable routine (Wilson, 2017).

Efficacy, safety and patient benefits Firstly, it is essential to note that TAI should not be carried out before less invasive advice and treatment options have been explored (Wilson, 2017).

TAI is generally regarded as a safe treatment.

There are risks involved with TAI, such as the formation of a hole in the wall of the rectum or colon, otherwise known as bowel perforation.

While this is extremely serious and usually requires corrective surgery, bowel perforation is very rare (Sheffield Teaching Hospitals, 2020). Latest data reports the risk of bowel perforation due to TAI as two per one million irrigations (Christensen et al, 2016). It is advised that patients weigh up the risks against the potential benefits (Sheffield Teaching Hospitals, 2020). Further, forewarning patients about potential common side effects of TAI, including abdominal cramping, dizziness, nausea and minor rectal or anal bleeding (University Hospitals Birmingham, 2017), is vital to prevent them from stopping TAI prematurely.

Despite this, if patients are instructed correctly, TAI can provide myriad benefits for both

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Gemma Harris, Freelance Journalist and Health Writer, Birmingham, UK

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patients and health professionals. These include (Emmanual et al, 2013; NICE, 2018): Consistent bowel routine, with regular bowel movements Individuals can select time/place of evacuation Reduction in time to achieve bowel care Improvement of symptoms and reduction in the severity of chronic constipation Potential prevention and reduction of frequency of faecal incontinence Psychological improvement and enhanced quality of life for patients Reduction in stoma surgery rates Reduction in incidence, frequency and cost of urinary tract infections Reduction in hospital admissions in people with NBD and associated treatment costs.

The nursing role Nurses should undertake a full assessment before beginning TAI, to determine patient suitability.

If there is any doubt regarding suitability, nurses should seek further medical advice before commencing treatment (Shaw, 2018). In addition, there are numerous TAI devices available, which may cause confusion. It is the nurse’s responsibility to be aware of all devices and discuss which would be most beneficial for the patient (Yates, 2019).

As devices are typically used by the individual at home, following individual manufacturers’ instructions and providing adequate training to the patient is crucial for safe and efficient longterm use of TAI (Emmanuel et al, 2013). There is evidence that TAI has a high discontinuation rate: between 19–57% after 1 year (Mekhael, 2021). Therefore, just as communicating potential side effects to and training patients is vital in encouraging continuation of TAI, a nurse’s ability to effectively communicate the proven improvement in quality-adjusted life years (Emmanuel et al, 2016) and encourage adherence during follow-up is also critical.

Able to get to the toilet?

Yes

No Qufora IrriSedo Bed

Electric or manual pump?

Electric

MANUAL High or low volume?

Cone or catheter?

CONE IryPump S Navina Smart

CATHETER

HIGH

LOW Aquaflush Compact Qufora IrriSedo Mini

Navina Smart

Cone or catheter?

CONE Gravity-fed system required?

© 2022 MA Healthcare Ltd

Yes

Aquaflush Actif/Lite Qufora IrriSedo Cone

No Aquaflush Actif/Lite Navina Classic Qufora IrriSedo Cone

CATHETER Gravity-fed system required?

Yes

Qufora IrriSedo Balloon/Klick

No Navina Classic Peristeen Qufora IrriSedo Balloon/Klick

Figure 1. Flowchart to help select an appropriate transanal irrigation system (Bardsley, 2020) Gastrointestinal Nursing European Wound, Ostomy and Continence Supplement

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MacGregor Healthcare and Renew Medical

Patients’ capabilities and patient/carer preferences should remain at the forefront when selecting the most suitable TAI equipment (Shaw, 2018) (Figure 1), but there are additional, important factors to consider. A good starting point would be to determine whether a low or high volume of water is required (Henderson et al, 2018). Collins and Norton (2013) note that lowvolume irrigation is typically used successfully in patients with passive faecal incontinence or postdefaecation soiling. Meanwhile, high-volume irrigation may be more appropriate for patients with neurogenic dysfunction, constipationpredominant irritable bowel syndrome, idiopathic constipation, obstructive defaecation syndrome or faecal incontinence.

A patient should also choose whether they would prefer to use a rectal catheter or cone.

While most patients can use any system, a person with reduced mobility may be more suited to a rectal catheter, and patients with anal pain may also find these more comfortable. A catheterbased system may be more convenient for those who have TAI delivered via carers (Henderson et al, 2018). In addition, health professionals should consider whether a patient has a latex allergy and avoid prescribing equipment that could trigger this (Emmanuel et al, 2013).

Cone

Cone Integrated manual pump and reservoir

Figure 2. Qufora IrriSedo Mini (above) and Aquaflush Compact+ (below) are compact, low-volume transanal irrigation systems S20

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Types of systems Despite the wide choice, TAI devices can be categorised into low (less than 250 ml) or high (more than 250 ml) volume; cones, catheters or balloon inflating devices; manual, electric pump or gravity-fed systems (Bardsley, 2020); and bed systems (Shaw, 2018).

Low- and high-volume systems The maximum volume of fluid that a TAI system can deliver varies, depending on the system. For instance, low-volume systems can typically deliver up to 250 ml of fluid per irrigation (Shaw, 2018).

Meanwhile, high-volume systems can deliver between 250 ml and 4000 ml (Yates, 2019). Shaw (2018) recommends a starting volume of 500 ml, gradually increasing by 100 ml until successful evacuation is achieved without leakage between irrigations.

Low-volume systems (Figure 2), which usually clean out the rectum only, consist of a small reservoir attached to a cone. Therefore, they are a compact system that can be easier to transport (Wilson, 2017), making these a more convenient option than a high-volume system should they provide sufficient symptom relief. Henderson et al (2018) stated that low-volume systems can be a good introduction for patients who are nervous about TAI. High-volume devices empty the rectum, descending colon and part of the transverse colon (Yates, 2020), and consist of a larger irrigation bag connected to a tube (Emmett et al, 2017) (Figure 3). It is worth noting that highvolume systems can also be used for low-volume irrigation (Yates, 2020). In a systematic review of TAI as a treatment for chronic functional constipation, Emmett et al (2015) identified seven small studies using high-volume irrigation, with patient-reported satisfaction (subjective or visual-analogue scale) being the most reported outcome. While it appears that high-volume devices are more effective in managing/providing symptom relief in patients with certain conditions, it remains unclear whether high-or low-volume devices are generally better. As was the case in 2020 (Bardsley, 2020), the results from the only randomised controlled trial protocol to directly compare low- and high-volume systems used by adults with chronic constipation had not been published (Emmett et al, 2017).

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Cones, catheters and balloons TAI using a cone (Figure 2) involves the user holding the cone manually in place. The flexibility and dexterity of the patient should be assessed to determine their capability. The requirement of the patient to possess adequate core strength to help them balance sufficiently while completing the installation process and maintaining the position of the cone (Holroyd, 2017) should be considered.

Some low-volume cone systems can be used with an extension tube to make the installation process easier (Bardsley, 2020). Catheter systems usually include a balloon that creates a seal and helps retain irrigation fluid by inflating inside the rectum. Therefore, patients are not required to hold the catheter in place (Holroyd, 2017).

While this can make catheters a more convenient option, the inflation process can cause reflex rectal contractions that expel the catheter (Yates, 2020). The balloon can be filled with either air or water, but Henderson et al (2018) have previously suggested that water may be more suitable for patients who experience either leakage during instillation or expulsion of the catheter after the balloon has been inflated. On the other hand, cones may have an advantage over catheters in terms of ease of setting up, procedure time and low risk of complications (Emmanuel et al, 2019b).

Cone systems also have a conical tip, which can be less invasive than a catheter (Bardsley, 2020).

Further, an audit of 48 female and two male patients with evacuation difficulties and/or passive faecal incontinence, who used the Qufora Mini Irrigation System (now known as Qufora IrriSedo Mini system) (Figure 2), demonstrated that 70% found the cone comfortable, while 74% rated its performance as ‘good’ or ‘acceptable.’ Two-thirds of participants experienced improved symptoms and wanted to continue using it (Collins and Norton, 2013). Despite this, there is insufficient evidence to suggest whether one system outperforms another.

Manual, electric and gravity-fed During TAI, the water is propelled by an electric or manual pump or a gravity-fed system. To determine which is best suited to a patient, it is important to consider whether they have sufficient hand strength to pump up the device (Yates, 2020).

In manual pumps, water instillation is delivered by manual squeezing. Low-volume systems use manual pumps that double up as

Coloplast

clinical

Free-standing reservoir bag

Constant-flow manual pump

Balloon catheter Figure 3. Peristeen uses a constant-flow manual pump

the reservoir. Many high-volume systems also feature manual pumps, but these are usually connected to a separate reservoir bag (Bardsley, 2020). Peristeen (Figure 3) is an example of this: it uses a constant-flow pump that does not rely on gravity to maintain regular pressure during instillation. Much of the published evidence on TAI focuses on this device and indicates that it improves bowel-related outcomes (NICE, 2018).

Some high-volume systems are designed to be suspended above the user at a distance sufficient to exert enough gravitational force to propel the water into the colon without the use of a pump.

Alternatively, some high-volume systems use an electric pump to propel the water. These systems usually have either an integrated reservoir or are connected to a floor bag; they can be placed on the ground and require minimal manual effort from the user (Bardsley, 2020).

One of the latest TAI systems on the market is the Navina Smart (Figure 4), which consists of a catheter with an in/deflatable balloon, a water container and an electric pump, and is designed to be used with an app that can be downloaded onto a smartphone to track progress (Emmanuel et al, 2021). In a study of the IryPump R Set— another relatively new TAI device similar to the Peristeen but which enables finer adjustment of the irrigation rate and has a balloon catheter with two interconnected, inflatable sections intended to minimise leakage during TAI—levels of patient

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Manual air pump

Electric pump

Manual water pump Figure 4. Navina Smart uses an electric pump and Navina Classic a manual pump

satisfaction were high, and the TAI success rate was 72.4% (Charvier et al, 2020).

Anecdotal evidence shows that electric pumps can be more cumbersome, but easier to use (Yates, 2021). Currently, there is no evidence to suggest whether manual, electric or gravityfed systems are more effective, so patient assessment and preference, along with specialist nurse advice, availability of funding and local formularies, are most likely to influence device selection (Woodward, 2017).

Bed system Bed systems, such as the Qufora Irresido, are designed for bedbound patients, those who are receiving terminal care and those who cannot make it to the toilet (MacGregor Healthcare Ltd, 2016 in Wilson, 2017). This is a closed system, where water is pumped from a suspended water bag into the rectum through a non-ballooned rectal catheter, and waste is collected in a drainage bag (Wilson, 2017).

CPD reflective questions If performed correctly, what benefits can patients and health professionals expect from transanal irrigation (TAI)?

What is the maximum volume of water low- and high-volume TAI devices can deliver?

Consider which type of device might be most suitable for a patient with reduced flexibility and dexterity Reflect on the advantages and disadvantages of catheters compared with cones

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TAI is considered a safe and effective treatment, but should only be carried out after less invasive treatment options have been explored. Nurses should be aware of the range of available devices and consult the Bladder, Bowel and Stoma Handbook (MA Healthcare, 2021), an annually updated product selection guide, alongside NICE (2018) guidance, to stay up to date with the latest developments. A thorough assessment of the patient and consideration of their preferences and tolerance should influence system choice.

Nurses not only need to help patients select a suitable device, but also adequately train them in its usage and provide ongoing follow-up support, so patients can successfully implement and continue with TAI. Emmanuel et al’s (2019a) Decision Guide is also a useful tool to consult throughout the TAI process.

GN Declaration of interest None Bardsley A. Transanal irrigation systems for managing bowel dysfunction: a review. Gastrointest Nurs. 2020; 18(5). https://doi.org/10.12968/gasn.2020.18.5.18 Charvier K, Bonniaud V, Waz D et al. Use of a new transanal irrigation device for bowel disorder management by patients familiar with the irrigation technique: a prospective, interventional, multicenter pilot study. Tech Coloproctol. 2020; 24(46):1–10. https://doi.org/10.1007/s10151-020-02212-x Christensen P, Krogh K, Perrouin-Verbe B et al. Global audit on bowel perforations related to transanal irrigation. Tech Coloproctol. 2016; 20(2):109–115. https://doi.org/10.1007/ s10151-015-1400-8 Collins B, Norton C. Managing passive incontinence and incomplete evacuation. Br J Nurs. 2013; 22(10). https://doi. org/10.12968/bjon.2013.22.10.575 Emmanuel A, Kurze I, Krogh K et al. An open prospective study on the efficacy of Navina Smart, an electronic system for transanal irrigation, in neurogenic bowel dysfunction. PLOS ONE. 2021. https://doi.org/10.1371/journal.pone.0245453 Emmanuel AV, Krogh K, Bazzocchi G et al. Consensus review of best practice of transoral irrigation in adults. Spinal Cord.

2013; 51:732–738. https://doi.org/10.1038/sc.2013.86 Emmanuel A, Collins B, Hendersen M et al. Development of a decision guide for transanal irrigation in bowel disorders.

Gastrointest Nurs. 2019a; 17(7). https://doi.org/10.12968/ gasn.2019.17.7.24 Emmanuel A, Kumar G, Christensen P et al. Long-term cost-effectiveness of transanal irrigation in patients with neurogenic bowel dysfunction. PLOS ONE. 2016; 11(8):e0159394. https://doi.org/10.1371/journal. pone.0159394 Emmanuel A, Storrie J, Bambury L et al. Transanal irrigation using a cone system in patients with lower motor neurone spinal cord injury. University College London. 2019b.https:// tinyurl.com/2p9h7xde (accessed 4 May 2022) Emmett C, Close H, Mason J et al. Low-volume versus highvolume initiated trans-anal irrigation therapy in adults with chronic constipation: study protocol for a randomised controlled trial. Trials. 2017; 151. https://doi.org/10.1186/ s13063-017-1882-y

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Wellspect Healthcare

Conclusion

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Emmett CD, Close HJ, Yiannakou Y, Mason JM. Transanal irrigation therapy to treat adult chronic functional constipation: systematic review and meta-analysis. BMC Gastroenterol. 2015; 15. https://doi.org/10.1186/s12876015-0354-7 Henderson M, Tinkler L, Yiannakou Y. Transanal irrigation as a treatment for bowel dysfunction. Gastrointest Nurs. 2018; 16(4). https://doi.org/10.12968/gasn.2018.16.4.26 Holroyd S. Latest developments in transanal irrigation therapy.

J Community Nurs. 2017; 31(2):51–56 MA Healthcare. Bladder, bowel and stoma handbook. 2021.

London; MA Healthcare Mekhael M, Kristensen H, Larsen HM et al. Transanal irrigation for neurogenic bowel disease, low anterior resection syndrome, faecal incontinence and chronic constipation: a systematic review. J Clin Med. 2021; 10(4):753. https://doi. org/10.3390/jcm10040753 National Institute for Health and Care Excellence. Peristeen transanal irrigation system for managing bowel dysfunction: Medical technologies guidance [MTG36]. 2018. www.nice. org.uk/guidance/mtg36 (accessed 4 May 2022) NHS England. Excellence in continence care: practical guidance for commissioners, and leaders in health and social care.

2018. www.england.nhs.uk/wp-content/uploads/2018/07/ excellence-in-continence-care.pdf (accessed 4 May 2022) Nursing Times. Transanal irrigation for bowel management.

2007. www.nursingtimes.net/archive/transanal-irrigationfor-bowel-management-26-08-2007 (accessed 16 December 2021)

Shaw L. Transanal irrigation for bowel dysfunction: the role of the nurse. Br J Nurs. 2018; 27(21). https://doi.org/10.12968/ bjon.2018.27.21.1226 Sheffield Teaching Hospitals. Transanal irrigation: toolbox for neurogenic bowel management. 2020. https:// publicdocuments.sth.nhs.uk/pil3732.pdf (accessed 4 May 2022) University Hospitals Birmingham. Guideline for rectal irrigation for adults. 2017. www.acpgbi.org.uk/_userfiles/ import/2017/02/Guidelines-for-rectal-Irrigation-for-adultsNHS.pdf (accessed 4 May 2022) Wilson M. A review of transanal irrigation in adults.

Br J Nurs. 2017; 26(15). https://doi.org/10.12968/ bjon.2017.26.15.846 Woodward S. Treating chronic constipation and faecal incontinence using transanal irrigation. Br J Nurs. 2017; 26(22). https://doi.org/10.12968/bjon.2017.26.22.1220 Yates A. Transanal irrigation: an alternative therapy for bowel dysfunction? Br J Nurs. 2019; 28(7). https://doi. org/10.12968/bjon.2019.28.7.426 Yates A. Transanal irrigation: is it the magic intervention for bowel management in individuals with bowel dysfunction?

Br J Nurs. 2020; 29(7). https://doi.org/10.12968/ bjon.2020.29.7.393 Yates A. Transanal irrigation to treat bowel dysfunction: an update on practice. Gastrointestinal Nursing. 2021; 19(Sup9). https://doi.org/10.12968/gasn.2021.19.Sup9.S20

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A holistic view of the stoma care pathway in Italy: a nationwide learning survey Abstract Background: The therapeutic care pathway for a patient with a stoma starts with a preoperative diagnosis and the decision to form an ostomy, followed by postoperative education, and it continues for as long as the stoma is in place. Clinical studies in this area are often limited to analysing a specific stage in this process, and less attention has been given to how each stage influences the rest of the pathway.

Aim: This study aimed to provide a holistic assessment of the entire stoma care pathway, encompassing professional management of emerging complications, as well as the patient’s perceptions of care and capacity for self-management, to determine how one management stage might affect another.

Method: The study consisted of an anonymous questionnaire with 96 items divided into nine sections. It enrolled people with one or more urinary and/or intestinal stoma/s and lasted from September 2017 to December 2019.

Findings: In the sample of 403 ostomates, 52% were female and 48% male, while 74% had an intestinal stoma, 19% a urinary stoma and 7% both. Of all respondents, 52% presented with peristomal lesions. Preoperatively, a lack of training (76%), stoma siting (70%) and psychological support (92%) were observed.

After discharge, 75% had peristomal lesions, 47% had professional care. At the time of the study, 60% were self-sufficient in ostomy care, 52% had lesions, while 38% were unsatisfied with the device used.

Elena Toma, Independent Consultant Clinical Nurse Specialist in Wound, Ostomy Care, and Tissue Viability, Rome, Italy; Filippo La Torre, Professor in General Surgery, Sapienza University of Rome, Italy; Filippo Barone, Clinical Nurse Specialist in Ostomy Care, Regional General Hospital Francesco Miulli, Bari, Italy; Marcello Rovere, Clinical Nurse Specialist in Ostomy Care, Azienda Sanitaria Locale Roma 2, Rome, Italy; Maria Sole Ercolani, Clinical Nurse Specialist in

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T

he therapeutic care pathway for a stoma patient encompasses various stages.

It starts at the time of a preoperative diagnosis, when the choice to form an ostomy is made. It continues with postoperative inpatient care and education, when the patient physically recovers from surgery and is taught to be selfsufficient in day-to-day stoma care. Discharge is followed by a period of rehabilitation, when the patient is helped to reach psychological acceptance and overcome emerging physical complications. Even once these are achieved, the pathway continues with follow-up support for as long as the patient has a stoma. At each of these stages, a patient is likely to have different daily

needs and face various physical and psychical challenges, while being cared for by a different team of health professionals.

Each team is usually only responsible for the stage in which they have been specifically trained.

Therefore, when moving the patient to the next stage, there are often gaps in interprofessional communication. This can be disorientating and uncomfortable for the patient, who may feel abandoned and resent the feeling that they are starting over again (Taneja et al, 2019). In Italy at present, stoma care professionals are not expected to follow a patient along a holistic home–hospital– home pathway, although case managers may be provided for some stages of therapeutic care. If

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Conclusion: Detailed discussion is given to peristomal skin care, self-sufficiency, ongoing support and the needs of people with both a urinary and an intestinal stoma. Patient education, psychological support and access to a stoma care specialist all likely affect acceptance and quality of life.

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these practices remain unchanged, ostomates and their families and/or caregivers can be left unguided through a quick succession of events that are difficult to cope with.

The literature on stoma care includes many studies that analyse specific aspects of care, such as the presence of complications (Guzmán-García et al, 2019; Toma et al, 2019; Boyd-Carson et al, 2020; Del Missier et al, 2019; Levine, 2020; Pearson et al, 2020), stoma wound management (Colwell et al, 2017; LeBlanc et al, 2019a; Toma et al, 2019a; Toma et al, 2019b; Cardoso et al, 2020; Dalgleish et al, 2020), nutrition (Migdanis et al, 2018; Lee et al, 2019; Yang et al, 2019), therapeutic education (Mohamed et al, 2017; Huang et al, 2018; Zhou et al, 2019), quality of life (Indrebø et al, 2016; Harputlu and Özsoy, 2018; Dudfield et al, 2019; Goldstine et al, 2019) and the economic impact (Adler and Ziglio, 1996; Neil et al, 2016; LeBlanc et al, 2019b). However, there are not as many studies analysing the complete patient pathway; and so this study was designed to analyse this through a learning survey, using a purpose-built anonymous questionnaire aimed at patients with a urinary and/or intestinal stoma.

Aims This study intended to analyse the professional care and self-management undertaken at each stage of the stoma care pathway, as well as to determine whether any complications or other adverse events occurring along the pathway could have originated in a previous stage.

Moreover, the study focused on the patient’s quality of life, including their satisfaction with their care, their relationship with their stoma and their social relationships.

© 2022 MA Healthcare Ltd

Methods The learning survey was undertaken from September 2017 to December 2019. This included a preliminary pilot survey that was reviewed and reworked into the final survey.

A working group was established, comprising specialist physicians and stoma care nurses (SCNs) from across Italy. The questionnaires were designed following the Delphi guidelines, which allowed working group members to express and share their opinions in an aggregated and anonymous format (Dalkey and Helmer, 1963; Adler and Ziglio, 1996).

Question formation was guided by a literature

review (using MEDLINE, PubMed, CINAHL, and Cochrane). This returned 200 observational scientific articles on the stoma care pathway, which had a sample size of 30 or more and were published between 2005 and 2017, in Italian, English and Spanish.

The study was conducted in accordance with the Helsinki Declaration of 2013. Participants were sent an introductory letter explaining that the questionnaires were anonymous, and no sensitive data would be collected. The questionnaires avoided potentially sensitive economic or spiritual questions or anything that might suggest bias towards a particular product or manufacturer. Two Italian ostomy associations, Associazione Italiana Stomizzati (AISTOM) and Pazienti Liberi dalle Neoplasie Uroteliali (PALINURO), formally endorsed the survey and published it on their websites.

Questionnaire development A preliminary survey was piloted. The questions were ordered according to the chronological sequence of a typical patient pathway, and they were phrased to be as a clear, simple and accessible as possible. The questionnaires were distributed both digitally and in person. This initial version consisted of two parts: a clinical assessment, completed by a health professional (44 items over three sections), and a selfassessment, completed by the patient (65 items over six sections). Both parts asked many of the same questions about the stoma and general wellbeing. The CNSs provided the participants with the self-assessment questions at the same time as carrying out their own clinical assessment.

The 87 preliminary questionnaires that were returned showed a 95% match between the clinical assessment and the self-assessment parts on these questions. Therefore, the clinical assessment was deemed unnecessary and left out of the final version of the questionnaire. The order and phrasing of the self-assessment questions were reviewed to improve consistency and clarity and to eliminate any recall bias (caused by the difficulty of remembering answers to earlier questions). It was also noticed that patients who were accompanied by a relative, despite being told that their answers would be anonymous, were reluctant to answer questions about compliance, quality of care, social relationships and quality of life (Toma and La Torre, 2017). Thus, the final version was distributed digitally only, to allow

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Wound and Ostomy Care, San Giovanni Addolorata Hospital, Rome, Italy; Paola Pocek, Clinical Translator and English Language Consultant, Lecco, Italy; Lucia Filomeno*, Registered Nurse in the Human Neuroscience Department, Sapienza University of Rome, Italy; Giuseppe La Torre, Professor in the Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy *l.filomeno@ policlinicoumberto1.it

Key words Ostomy assessment Stoma care pathway Peristomal skin complication Peristomal lesion Stoma evaluation This article has been subject to double-blind peer review Submitted 13 April 2021 Accepted 3 June 2021

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Sample The sample was drawn from patients, accessing any of the stoma care services in which the authors worked, who consented to participate.

To achieve a high response rate, the inclusion criteria were set at any adult (over 18 years) with an intestinal stoma, urinary stoma or both. This was considered particularly important for such a lengthy and potentially emotionally challenging survey, which would require respondents to recall potentially traumatic experiences.

To ensure only those enrolled could participate, access to the questionnaire was sent to participants via direct private communication by the researchers to their patients or by AISTOM and PALINURO to registered members only.

The questionnaire was created on Google S26

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Forms, and statistical analysis was performed using the software Statistical Package for Social Science (SPSS) version 25.0.

Results Sample The sample comprised 403 participants, which was a high number considering the demanding length of the questionnaire (Table 1). Of these 52.4% were women. By age group in years, 4.5% were under 30, 12.2% 31–40, 33.5% 41– 60, 35.0% 61–80 and 14.9% over 80.

Three-quarters (74.7%) had a permanent rather than temporary ostomy, while 73.9% had an intestinal stoma, 19.4% a urinary stoma and 6.7% both. The procedure was an emergency for 34.7% and planned for 64.8%. The majority of the participants had had a stoma for more than a year, with 40.0% having theirs for 1–5 years and 25.8% for more than 5 years. In terms of selfsufficiency, 10.2% were dependent on carers, 41.7% partially self-sufficient and 47.9% totally self-sufficient. However, 52.1% had peristomal lesions at the time of the study. As for the clinical condition that precipitated stoma formation, the prevailing diseases recorded were neoplasms (30.3%), followed by Crohn’s disease (9.7%).

Among the 28.0% who felt pain caused by the ostomy, the intensity on the Numeric Rating Scale was 1–3 (moderate) for 31.9%, 4–6 (high) for 48.7% and 7–10 (very high) for 19.5%.

There were participants representing 17 of Italy’s 20 regions; divided into four areas, there were 44% from the north, 28% from the centre, 23% from the south and 6% from the islands.

Of participants, 31% had their stoma-forming procedure in a different province from their residence, and 14% had it in a different region, which was more common among residents of northern regions.

Preoperative care Preoperatively, 23.8% received patient education and 8.2% received psychological care. Among the 289 (71.7%) who received a preoperative interview, this was usually done by a doctor alone (77.2%). The remaining 28.3% were largely included among those who had to undergo an emergency (rather than planned) procedure.

Among the 345 (85.6%) who received preoperative information, this was felt to be insufficient by 35.4%, sufficient by 55.4% and

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respondents take the time they needed to answer independently and in privacy.

Therefore, in the final version, a single questionnaire was developed. In it, the questions were deliberately grouped in blocks. The complex and structured questionnaire was well accepted by the patients, who understood the focus. During this stage, the authors verified the questions’ comprehensibility and logical structure, and they checked all the relevant topics and updated the references. The final questionnaire comprised 96 questions over nine sections: Personal information (4) General assessment and sample characteristics (16) Stoma assessment (4) Preoperative care (7) Postoperative care (9) Current ostomy management (25) Peristomal hygiene (7) Nutrition (7) Quality of life (17).

Most of the questions were closed, except one under stoma assessment and three under general assessment and sample characteristics The questions on quality of life covered many aspects of holistic wellbeing, including physical activity, emotional acceptance, body image and social relationships. The final questionnaire was piloted by 10 people who had already completed the previous version, and they provided with very positive feedback. It was approved by the panel, although, for the sake of time, it was not validated.

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Table 1. Sample characteristics Category Sex

Age (years)

Characteristic

%

Female

52.4

Male

47.6

<30

4.5

31–40

12.2

41–60

33.5

61–80 >80

Characteristic

%

No

28.3

Yes

71.7

Generalist nurse

2.8

Specialist nurse

6.2

Doctor

77.2

35.0

Doctor and generalist nurse

3.8

14.9

Doctor and specialist nurse

10.7

Dependent on carers

10.2

Partially self-sufficient

41.7

Totally self-sufficient

47.9

No answer

0.2

None Neoplasm Diabetes

6.5

Crohn’s disease

9.7

Ulcerative colitis

6.7

Other conditions

6.7

<2 months

9.9

3–11 months

24.3

1–5 years

40.0

>5 years

25.8

Neoplasm

51.9

Inflammatory bowel disease

25.3

Accident

2.5

Other

20.3

Emergency

34.7

Planned

64.8

No answer

0.5

Permanent

74.7

Temporary

25.3

Intestinal

73.9

Urinary Intestinal and urinary

Self-sufficiency in stoma care

No

40.4

Yes

59.6

Presence of pain caused by the ostomy

No

72.0

Yes

28.0

Intensity of pain (Numeric Rating Scale)

1–3 (moderate)

31.9

4–6 (high)

48.7

7–10 (very high)

19.5

Healthy

39.2

Macerated

8.7

Lesions present

52.1

Self-sufficiency

Comorbidities

Time with stoma

Indication for stoma

Type of procedure Intended duration of ostomy Type of ostomy

© 2022 MA Healthcare Ltd

Table 2. Preoperative care

Peristomal skin condition at present

Category Preoperative interview

Preoperative interviewer

Preoperative information

14.4 85.6

Insufficient

35.4

Sufficient

55.4

21.3

Exhaustive

9.3

30.3

No

69.7

Yes

30.3

Generalist nurse

8.2

Specialist nurse

41.8

Doctor

50.0

Level of preoperative information

Whether stoma siting was performed

Stoma sited by

Preoperative education

No

76.2

Yes

23.8

No

91.8

Yes

8.2

Characteristic

%

No

76.2

Yes

23.8

No

81.6

Yes

18.4

No

51.6

Yes

48.4

No

53.8

Yes

46.2

19.4

Hospital stoma/outpatient clinic

31.2

6.7

Community stoma/outpatient clinic

11.3

Psychological care

Table 3. Postoperative care Category Postoperative education Self-sufficiency in stoma care on discharge Independent mobility on discharge Home care support on discharge

Provision of postoperative assistance

Peristomal lesions in the first month after discharge Frequency of peristomal lesions

Postoperative information

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No Yes

Private care

20.4

National Home Care Service

37.1

No

24.6

Yes

75.4

Rarely

25.3

Often

74.7

No

7.9

Yes

92.1

Insufficient

39.6

Sufficient

50.1

Exhaustive

10.2

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Postoperative care That only 18.4% were self-sufficient in stoma care on discharge was likely related to the fact that only 23.8% had received postoperative training, as well as that only 48.4% were independently mobile. Among the 186 (46.2%) who received support on discharge, this was provided by a hospital stoma/outpatient clinic for 31.2%, community stoma/outpatient clinic for 11.3%, private care for 20.4% and national home care service for 37.1%. Among the 304 (75.4%) who had peristomal lesions in the first month after discharge, 25.3% had them infrequently and 74.7% often. Among the 371 (92.1%) who received postoperative information, this was felt to be insufficient by 39.6%, sufficient by 50.1% and exhaustive by 10.2% (Table 3).

Current management Among the 239 who were self-sufficient in stoma care at the time of completing the survey, this was <6 months for 66.5%, 6 months–1 year for 20.5% and >1 year for 13.0%. Daily time spent in stoma care was <1 hour for 69.2%, 1–2 hours for 27.0% and >2 hours for 3.7%.

Appliances were changed several times per day for 24.8%, once a day for 33.0%, every 2 days for 28.3% and every 3 or more days for 13.9%. At this time, 67.0% used a two-piece rather than one-piece appliance, 68.5% used an open rather than closed pouch and 17.1% used a support belt.

Only 5.2% never had peristomal irritation/ lesions, while 58.8% had them rarely, 27.5% often and 8.4% always. Among the 381 who had to treat peristomal skin problems, the primary caregiver was usually a specialist nurse (42.8%) or the patient themselves (33.6%). The primary professional contact for stoma care was most commonly a specialist nurse (50.6%), but 24.3% had no such contact.

In terms of satisfaction, 62.5% were satisfied with their stoma appliance, and 55.3% felt the correct quantity of devices were being supplied, while this was too few for 42.4% and too many for 2.2%. Satisfaction with nursing care was ‘not at all’ for 28.5%, ‘sufficiently’ for 43.9% S28

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and ‘totally’ for 27.5%, while satisfaction with medical care was not at all for 38.0%, sufficiently for 51.1% and totally for 10.9%.

Among the 323 who used a peristomal hygiene product, 48.6%, used the same products they used for their body, 29.7% stoma-specific products and 21.7% Marseille soap. Stoma care product choice was mainly determined by advice received for 28.0%, most convenient cost for 24.3%, advertisements for 6.0%, perceived quality for 16.6% and ingredients for 5.2%. Advice on received peristomal hygiene products was generic for 30.0%, specific for 24.8% and absent for 45.2%. The main source of advice on peristomal hygeine products was a specialist nurse for 24.3%, a generalist nurse for 9.7%, a pharmacist for 6.2% and a doctor for 6.0%, although 53.8% mainly relied on their own research.

Among participants, 77.7% were satisfied with their nutrition, and 65.0% were self-sufficient in nutrition management, although 48.1% had reduced eating and 29.5% had reduced drinking since stoma formation. Among the 312 (77.4%) who received nutrition advice, 55.8% were sufficiently and 9.3% completely satisfied, while 34.9% were not. Most (71.0%) had no primary professional contact for nutrition care, but this was a stomatherapy nurse for 10.7%, nutritionist for 8.4% doctor for 6.5% and generalist nurse for 3.5% (Table 4).

Quality of life In terms of quality of life since stoma formation, self-sufficiency in housework and domestic activities was as before for 29.3%, reduced for 53.6% and halted for 17.1%, while ability to carry out work activities was as before for 17.6%, less than before for 19.4% and halted for 63.0%.

Participants who could perform activities outside the home were as before for 28.0% and less than before for 61.3%, while 10.7% no longer left the house. Meanwhile, 58.8% had a changed quality of night rest since stoma formation. Of the 208 (61.3%) who had reduced mobility since stoma formation, 62.5% could use a wheelchair and were not confined to bed.

Regarding acceptance of the ostomy, 16.6% felt they would never get used to it, 39.2% that they had no choice, 13.9% that it would soon be closed and 30.3% that they had become used to it. Of participants, 76.9% felt their ostomy saved

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exhaustive by 9.3%. Among the 122 (30.3%) whose stoma was sited, this was usually done by a doctor (50.0%) or specialist nurse (41.8%) or sometimes a generalist nurse (8.2%) (Table 2).

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Table 4. Current management (continued)

Table 4. Current management Category

Characteristic

%

Self-sufficiency in stoma care

No

40.7

Time to achieving selfsufficiency in stoma care Daily time spent in stoma care Type of stoma appliance used Type of pouch

Frequency of appliance change Satisfaction with stoma appliance Quantity of devices supplied Use of support belt Presence of peristomal irritation/lesions

Primary source of peristomal skin care

Primary professional contact for stoma care

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Satisfaction with nursing care

Satisfaction with medical care

Yes

59.3

No self-management

68.6

<6 months

66.5

6 months–1 year

20.5

Category

Characteristic

%

Type of advice on peristomal hygiene products

I received generic advice

30.0

I received specific advice

24.8

I received no indications

45.2

Same products as I use for my body

48.6

I use specific products

29.7

Marseille soap

21.7

Pharmacist

6.2

Generalist nurse

9.7

Specialist nurse

24.3

Preferred peristomal hygiene product

>1 year

13.0

<1 hour

69.2

1–2 hours

27.0

>2 hours

3.7

Two-piece

67.0

Doctor

6.0

One-piece

33.0

Self

53.8

Open

68.5

No answer

19.9

Closed

31.5

Advice received

28.0

Several times per day

24.8

Most convenient cost

24.3

Once a day

33.0

Advertisement that I heard/saw

6.0

Every 2 days

28.3

The quality I suppose the product has

16.6

Every 3 or more days

13.9

The ingredients in the product

5.2

No

37.5

No

22.6

Yes

62.5

Yes

77.4

Correct

55.3

Insufficient

34.9

Too few

42.4

Sufficient

55.8

Too many

2.2

Exhaustive

9.3

No

82.9

No

22.3

Yes

17.1

Yes

77.7

Never

5.2

Nurse

3.5

Rarely

58.8

Stomatherapy nurse

10.7

Doctor

6.5

Main source of advice on peristomal hygeine products

Main determiner of stoma care product choice

Nutrition advice received

Satisfaction with nutrition advice

Satisfaction with nutrition

Primary professional contact for nutrition care

Often

27.5

Always

8.4

Nutritionist

8.4

Generalist nurse

12.6

No-one

71.0

Specialist nurse

42.8

Self-sufficiency in nutrition management

No

35.0

Yes

65.0

Reduced eating since stoma formation

No

51.9

Yes

48.1

Reduced drinking since stoma formation

No

70.5

Yes

29.5

Reduced mobility since stoma formation

No

38.7

Yes

61.3

Generalist doctor

6.0

Specialist doctor

5.0

I treat them myself

33.6

Generalist nurse

10.7

Specialist nurse

50.6

Generalist doctor

5.2

Specialist doctor

9.2

No reference

24.3

Not at all

28.5

Sufficient

43.9

Totally

27.5

Not at all

38.0

Sufficient

51.1

Totally

10.9

their life, 10.7% felt it was a transitional state and felt it could have been avoided 12.4%.

In terms of patients’ relationship with their ostomy, while 60.8% of participants had no problems looking at their stoma, 25.6% found it upsetting, 6.2% found it scary and 7.4% refused to do so. While 56.8% had no problems in touching their stoma, 25.1% found it upsetting,

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Table 5. Quality of life

and not at all for 7.4%. When asked if they had feelings of loneliness, the answer was a lot for 19.1%, sufficient for 31.8% and not at all for 49.1% (Table 5).

Discussion Peristomal skin care Peristomal lesions were common, especially in the first month after the procedure (75.4%), but also at the time of the study. Their presence is often a cause of pain and anxiety for the patient (Collier, 2019; Goldstine et al, 2019; Sun et al, 2020), as well as increased costs (Neil et al, 2016; LeBlanc et al, 2019a; Taneja et al, 2019) and more complicated ostomy management.

Peristomal lesions can occur throughout the period the stoma is present (LeBlanc et al, 2019b; Toma et al, 2019; Dalgleish et al, 2020; Sun et al, 2020). They can be caused by unsuitable management (Mitchell and Hill, 2020), postoperative complications (Guzmán-García et al, 2019; Cardoso et al, 2020; Gachabayov et al, 2020; Pearson et al, 2020) or existing diseases (Toh et al, 2017; Nagano et al, 2019; Flynn et al, 2019; Mitchell and Hill, 2020; Sun et al, 2020).

This study revealed a lack of both preoperative and postoperative patient education, which makes it harder for the patient to gain self-

Category

Characteristic

%

Ability to use a wheelchair to aid mobility

Yes

62.5

Bedridden

37.5

Changed quality of night rest since stoma formation

No

41.2

Yes

58.8

As before

29.3

Reduced

53.6

Halted

17.1

As before

17.6

Less than before

19.4

I no longer carry them out

63.0

As before

28.0

Table 5. Quality of life (continued)

Less than before

61.3

Category

Characteristic

%

I no longer leave the house

10.7

30.0

Saved your life

76.9

Decreased social activity since stoma formation

Yes No

70.0

It’s a transitional state

10.7

11.9

Could have been avoided

12.4

Sense of being avoided since stoma formation

Yes No

88.1

I will never get used to it

16.6

Relationships with friends since stoma formation

Worse

17.1

The same

79.4

Better

3.5

Relationships with relatives since stoma formation

Worse

11.7

The same

83.4

Better

5.0

Relationship with partner since stoma formation

Worse

34.2

The same

58.3

Better

7.4

Feeling of being supported by loved ones since stoma formation

A lot

42.4

Enough

50.1

Self-sufficiency in housework and domestic activities

Ability to carry out work activities since stoma formation

Activities outside the home

Do you believe that the fitting of the ostomy

Acceptance of ostomy

Willingness to touch the stoma

Looking at the ostomy

Talking about the ostomy

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I have no choice

39.2

I hope that it will soon be closed

13.9

I got used to it

30.3

I refuse to touch it

12.7

I touch it, but it upsets me

25.1

I touch it, but it scares me

5.5

I have no problems in touching it

56.8

I refuse to look at it

7.4

I look at it, but it upsets me

25.6

I look at it, but it scares me

6.2

I have no problems in looking at it

60.8

I refuse to talk about it

18.4

It upsets me to talk about it

27.8

I have no problems talking about it

53.8

Feelings of loneliness since stoma formation

Not at all

7.4

A lot

19.1

Sufficient

31.8

Not at all

49.1

Gastrointestinal Nursing European Wound, Ostomy and Continence Supplement

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5.5% found it scary and 12.7% refused to do so.

There were 53.8% who had no problems talking about their stoma, 27.8% who found it upsetting and 18.4% who refused to talk about it.

In terms of social life and relationships since stoma formation, 30.0% had decreased their social activity and 11.9% felt others avoided them. Relationships with friends were worse for 17.1%, the same for 79.4% and better for 3.5%; with relatives, they were were worse for 11.7%, the same for 83.4% and better for 5.0%; and with partners worse for 34.2%, the same for 58.3% and better for 7.4%. When asked if they felt supported by loved ones, the answer was a lot for 42.4%, sufficient for 50.1%

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sufficiency stoma care and a satisfactory quality of life (Saunders and Brunet, 2019; Harris et al, 2020).

Peristomal skin care is fundamental in the prevention of peristomal lesions, but it is often underestimated by patients and professionals alike (Toma et al, 2019). However, without clear guidelines, even the aspects that may appear simple to professionals can present problems for patients (Toma et al, 2019). Moreover, ostomates may not understand how their peristomal skin should look and may assume a peristomal lesion is a normal occurrence. For example, they may not be able to distinguish between the stoma and a lesion at the mucocutaneous junction. This shows the importance of monitoring patients throughout their care pathway and ensuring that they are supported by specialist professionals, which may require more widespread training in peristomal wound care. This could be addressed through better therapeutic training and more consistent healthcare support services.

© 2022 MA Healthcare Ltd

Self-sufficiency In this study, 41% of the sample could not manage their ostomy in a self-sufficient way.

This could be related to how more than half of participants were over 60 years old and 52% had a stoma due to cancer, as well as the lack of preand postoperative patient education. Patients who were not self-sufficient entrusted their ostomy management to their spouse (49%) or children (26%). Patients with an intestinal stoma were more self-sufficient (68%) than those with urinary stoma (35%) or with double stoma (41%), and women were significantly more selfsufficient (69%) than men (49%).

In Italy, patients who lose physical selfsufficiency following an operation are not automatically assigned home care, as the national health service relies on regional management.

In this study, 52% of the sample was unable to move independently and only 18% were able to manage their stoma after discharge. however, only 17% had access to a free regional home care service, which is consistent with the 18% of bedridden patients at the time of discharge.

Support and self care In this study, those who did not have a professional contact for stoma care were more likely to have peristomal lesions at the time of

the study (30%), self-manage these (72%) and be unhappy with their appliance (60%), which compares to 21% of those who had a stoma nurse as a main contact.

Consequently, only 42% of participants adhered to manufacturer’s recommendations to replace two-piece devices every 2 or more days, with 25% of the sample managing two-piece devices incorrectly or using an inadequate device.

A quarter of the sample changed their appliance several times per day. This could be a reason why 38% of participants were not satisfied with their appliance and 42% felt they received an insufficient quantity.

Patients who had had a stoma for over 5 years were less likely to have a professional stoma care contact (37%). Those who relied on self-care gave their reasons for doing so as: did not know who to ask (58%); did not trust the advice received (20%), could not reach the specialist service point due to mobility or economic restrictions (22%).

Ongoing psychological support is also of the utmost importance (Indrebø et al, 2016; Harputlu and Özsoy, 2018; Dudfield et al, 2019; Goldstine et al, 2019). Accepting an ostomy is an important stage for a patient’s quality of life, as it allows them to reach a positive attitude to themselves and others and thus lead a fulfilling social life and form positive relationships.

Double stomas This study revealed the often greater challenges faced by people with both an intestinal and urinary stoma. Compared with people with a single stoma, they are more likely to have peristomal lesions (74%) and greater difficulties in their management (7%). They were also more likely to lack a professional contact for stoma care (52%), feel they had received sufficient information (19%) and rely on self-treatment rather than professional support (41%), and they showed the lowest adherence to advice received.

The needs of people with a double stoma are evidently important to address. However, this is one of the few studies to investigate these patients (Toma et al, 2019), and the literature is lacking in this area, perhaps due to the challenge of finding statistically significant samples. Further research is needed to fully understand the needs of people with two stomas and so provide these patients with the necessary care to guarantee the best possible quality of life.

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How can stoma care teams improve patient education in both the preoperative and postoperative stages?

How can stoma patients be helped to understand what their peristomal skin should look like?

What additional challenges might be faced by patients with two stomas?

How can healthcare teams improve interprofessional communication to minimise feelings of discomfort and abandonment among patients?

Conclusion This study benefitted from a large sample size that included patients from both private and public services. However, the questionnaire was limited in flexibility and depth for collecting data.

The data from this learning survey reveal gaps in patient education and professional care for people with a stoma in Italy. This information should be used to drive improvements in these areas at all stages of the patient pathway, supporting them to self-manage and to accept their ostomy.

GN Acknowledgments The authors wish to thank the Associazione Italiana Stomizzati (AISTOM) and Pazienti Liberi dalle Neoplasie Uroteliali (PALINURO) for their important contributions in the creation of the learning survey. The authors also wish to thank stoma care specialists Giovanna Nubile, Maria Antonietta Campioni and Alexandra Del Missier for their cooperation in the preliminary phase of the study.

Declaration of interest None Adler M, Ziglio E (eds). Gazing into the oracle: the Delphi method and its application to social policy and public health. London: Jessica Kingsley; 1996 Boyd-Carson H, Gana T, Lockwood S, Murray D, Tierney GM. A review of surgical and peri‐operative factors to consider in emergency laparotomy care. Anaesthesia. 2020; 75(S1):e75–e82. https://doi.org/10.1111/anae.14821 Cardoso IA, Salomé GM, Miranda FD, Alves JR, Leão JPP, Leão AS, Mendonça ARA. A new APP for prevention and treatment of complications of intestinal peristomal skin.

J Coloproctol (Rio J). 2020; 40(02):120–128. https://doi. org/10.1016/j.jcol.2019.10.011 Collier M. Minimising pain and medical adhesive related skin injuries in vulnerable patients. Br J Nurs. 2019; 28(15):S26– S32. https://doi.org/10.12968/bjon.2019.28.15.S26 Colwell JC, McNichol L, Boarini J. North America wound, ostomy, and continence and enterostomal therapy nurses current ostomy care practice related to peristomal skin issues. J Wound Ostomy Continence Nurs. 2017; 44(3):257–261. https://doi.org/10.1097/ WON.0000000000000324 Dalgleish L, Campbell J, Finlayson K, Coyer F. Acute skin failure in the critically ill adult population: a systematic review.

Adv Skin Wound Care. 2020; 33(2):76–83. https://doi. org/10.1097/01.ASW.0000617844.69248.92 Dalkey N, Helmer O. An experimental application of the DELPHI method to the use of experts. Manage Sci. 1963; 9(3):458–467. https://doi.org/10.1287/mnsc.9.3.458

S32

056_GASN_20_S4_24_33_Stoma pathway.indd 32

Del Missier A, La Torre F, Toma E. Treatment of peristomal granulomatosis with a neem and red hypericum oil application: case studies. Clin Ter. 2019; 170(2):e86–e92. https://doi.org/10.7417/CT.2019.2115 Dudfield L, Upton P, Upton D. Personality and wellbeing in people living with a chronic wound. Wounds International.

2019; 10(4):12–16 Gachabayov M, Tulina I, Tsarkov P, Weber J, Lee H, Kajmolli A, Bergamaschi R. Does an ileostomy rod prevent stoma retraction? A meta-analysis of randomized controlled trials. Wound Manag Prev. 2020; 66(1):24–29. https://doi. org/10.25270/wmp.2020.1.2429 Goldstine J, van Hees R, van de Vorst D, Skountrianos G, Nichols T. Factors influencing health-related quality of life of those in the Netherlands living with an ostomy. Br J Nurs. 2019; 28(22):S10–S17. https://doi.org/10.12968/ bjon.2019.28.22.S10 Guzmán-García C, Flores-Barrientos OI, Juárez-Rojop IE et al. Abdominal surgical site infection incidence and risk factors in a Mexican population. Adv Skin Wound Care. 2019; 32(6):1–6. https://doi.org/10.1097/01.

ASW.0000557833.80431.00 Harputlu D, Özsoy S. A prospective, experimental study to assess the effectiveness of home care nursing on the healing of peristomal skin complications and quality of life.

Ostomy Wound Manage. 2018; 64(10):18–30. https://doi. org/10.25270/owm.2018.10.1830 Harris MS, Kelly K, Parise C. Does preoperative ostomy education decrease anxiety in the new ostomy patient? A quantitative comparison cohort study. J Wound Ostomy Continence Nurs. 2020; 47(2):137–139. https://doi. org/10.1097/WON.0000000000000623 Huang L, Yu H, Sun A, Xu F, Xia C, Gao D, Wang D. Effects of continuing nursing on stomal complications, self-care ability and life quality after Miles’ operation for colorectal carcinoma. Gastroenterology Nursing. 2018; 41(4):1. https://doi.org/10.1097/SGA.0000000000000290 Indrebø KL, Natvig GK, Andersen JR. A cross-sectional study to determine whether adjustment to an ostomy can predict health-related and/or overall quality of life. Ostomy Wound Manage. 2016; 62(10):50–59 LeBlanc K, Heerschap C, Martins L, Butt B, Wiesenfeld S, Woo K. The financial impact of living in Canada with an ostomy. J Wound Ostomy Continence Nurs.

2019a; 46(6):505–512. https://doi.org/10.1097/ WON.0000000000000590 LeBlanc K, Whiteley I, McNichol L, Salvadalena G, Gray M. Peristomal medical adhesive-related skin injury. J Wound Ostomy Continence Nurs. 2019b; 46(2):125–136. https:// doi.org/10.1097/WON.0000000000000513 Lee YJ, Kweon M, Park M. Nutritional management of a patient with a high-output stoma after extensive small bowel resection to treat Crohn’s disease. Clin Nutr Res. 2019; 8(3):247–253. https://doi.org/10.7762/ cnr.2019.8.3.247 Levine JM. Clinical aspects of aging skin: considerations for the wound care practitioner. Adv Skin Wound Care. 2020; 33(1):12–19. https://doi.org/10.1097/01.

ASW.0000613532.25408.8b Migdanis A, Koukoulis G, Mamaloudis I et al. Administration of an oral hydration solution prevents electrolyte and fluid disturbances and reduces readmissions in patients with a diverting ileostomy after colorectal surgery: a prospective, randomized, controlled trial. Dis Colon Rectum. 2018; 61(7):840–846. https://doi.org/10.1097/ DCR.0000000000001082

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CPD reflective questions

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Mitchell A, Hill B. Moisture-associated skin damage: an overview of its diagnosis and management. Br J Community Nurs. 2020; 25(3):S12–S18. https://doi.org/10.12968/ bjcn.2020.25.Sup3.S12 Mohamed SS, Salem GMM, Mohamed HA. Effect of self-care management program on self-efficacy among patients with colostomy. Am J Nurs Res. 2017; 5(5):191–199. https://doi. org/10.12691/ajnr-5-5-5 Nagano M, Ogata Y, Ikeda M, Tsukada K, Tokunaga K, Iida S. Peristomal moisture-associated skin damage and independence in pouching system changes in persons with new fecal ostomies. J Wound Ostomy Continence Nurs. 2019; 46(2):137–142. https://doi.org/10.1097/ WON.0000000000000491 Neil N, Inglese G, Manson A, Townshend A. A cost-utility model of care for peristomal skin complications. J Wound Ostomy Continence Nurs. 2016; 43(1):62–68. https://doi. org/10.1097/WON.0000000000000194 Pearson R, Knight SR, Ng JCK, Robertson I, McKenzie C, Macdonald AM. Stoma-related complications following ostomy surgery in 3 acute care hospitals. J Wound Ostomy Continence Nurs. 2020; 47(1):32–38. https://doi. org/10.1097/WON.0000000000000605 Flynn RL, Chowdhury MH, Rudolph J, Einstein S. Rare presentation of postsurgical pyoderma gangrenosum presenting as necrotizing soft tissue infection. Adv Skin Wound Care. 2019; 32(11):507–511. https:// doi.org/10.1097/01.ASW.0000579692.74662. bbve&db=PubMed&list_uids=31498172&dopt=Abstract Saunders S, Brunet J. A qualitative study exploring what it takes to be physically active with a stoma after surgery for rectal cancer. Support Care Cancer. 2019; 27(4):1481– 1489. https://doi.org/10.1007/s00520-018-4516-3 Sun V, Bojorquez O, Grant M, Wendel CS, Weinstein R, Krouse RS. Cancer survivors’ challenges with ostomy appliances and self-management: a qualitative analysis. Support Care

Cancer. 2020; 28(4):1551–1554. https://doi.org/10.1007/ s00520-019-05156-7 Taneja C, Netsch D, Rolstad BS, Inglese G, Eaves D, Oster G. Risk and economic burden of peristomal skin complications following ostomy surgery. J Wound Ostomy Continence Nurs. 2019; 46(2):143–149. https://doi.org/10.1097/ WON.0000000000000509 Toh JWT, Shedden K, Pathma-Nathan N, Ctercteko G, El Khoury T, Gaveghan F. A rare case of peristomal cutaneous B cell lymphoma. Int J Colorectal Dis. 2017; 32(9):1365– 1366. https://doi.org/10.1007/s00384-017-2841-5 Toma E, La Torre F, Ercolani MS, La Torre G, Pocek P. 2019.

Healing of peristomal lesions through application of a hygiene protocol respecting the skin’s physiological pH and natural moisturizing factor: a clinical study. Senses Sci. 2019(3):781–804.

Toma E, La Torre F. Il percorso gestionale del paziente stomizzato – learning survey. Master Thesis. Rome: Sapienza University of Rome; 2017 Toma E, Sole Ercolani M, Missier A Del, Barone F, La Torre G. 2019. Clinical research on stoma patients: validation of TOR Form for evaluation and monitoring. Senses Sci. 2019a; (1):713–724. https://doi.org/10.14616/ sands-2019-6-713724.

Toma E, Veneziano ML, Filomeno L. The evaluation of skin lesions, according to the Toven Method – an interprofessional communication tool. Clin Ter. 2019b; 170(3):e177–180. https://doi.org/10.7417/CT.2019.2129 Yang Y, Liu Y, Zheng W et al. A literature review and case report of severe and refractory post-colectomy enteritis.

BMC Gastroenterol. 2019; 19(1):1–7. https://doi. org/10.1186/s12876-019-0974-4Zhou H, Ye Y, Qu H, Zhou H, Gu S, Wang T. Effect of ostomy care team intervention on patients with ileal conduit. J Wound Ostomy Continence Nurs. 2019; 46(5):413–417. https://doi.org/10.1097/ WON.0000000000000574

WHY NOT WRITE FOR US? Gastrointestinal Nursing welcomes the submission of clinical and opinion articles on a range of GI issues including IBD, stoma, endoscopy, hepatology and policy and service development.

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All manuscripts should be submitted via Editorial Manager, our online article submission system, via the link: editorialmanager.com/gasn/default.aspx.

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Factors predictive of optimal peristomal skin status in patients with an ostomy: a secondary analysis Abstract

Eugenia Rodriguez González, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain; Carmen del Pino Zurita, Consorci Corporació Sanitària Parc Taulí de Sabadell, Sabadell, Spain; Gemma Arrontes Caballero, Hospital Universitario Puerta de Hier-ro, Majadahonda, Madrid, Spain; Araceli Hoyo Rodríguez, Hospital Universitario Reina Sofía, Córdoba, Spain; Eugenia Zapatero Rodríguez, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain; Eduardo García Blázquez, Coloplast Productos Médicos, Spain esegb@coloplast.com

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T

he need to create and maintain an artificial opening to the skin for elimination of stool or urine after gastrointestinal and/ or genitourinary surgery is a critical matter for both patients and healthcare providers (Nichols et al, 2019). Specialised postoperative nursing care helps patients, who are often cancer survivors, face the reality of their new condition.

Continuous innovation in ostomy appliance design and technology is needed for successful management of ostomy care. Greater knowledge of the factors involved in negatively impacting patients’ perception of their quality of life will also ease the social and psychological burden of living with an ostomy (Sun et al, 2020).

Most patients with an ostomy reported ostomy-related self-care challenges, with the majority experiencing problems across multiple domains of ostomy self-care (Bulkley et al, 2018).

Additional work is needed to understand and reduce unmet needs and improve wellbeing in these patients. Peristomal skin irritation is to be expected in the immediate period after surgery.

However, in the population with an established ostomy, effluent leakage of varying severity often produces skin disturbances, meaning that issues with skincare must be continuously addressed, despite the patient education provided (Goldstine et al, 2019).

In their study, entitled Uses and Attitudes in Ostomy (U&A Ostomy), Bueno Cruz et al (2021) analysed a sample of 871 patients to describe the clinical reality of patients with an ostomy in Spain. The type of ostomy and devices used, the practice of preoperative stoma marking, the frequency of leakage, the complications present and the degree of self-perceived quality of life were analysed (Bueno Cruz et al, 2021).

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Peristomal skin problems are common in ostomy patients and are connected to decreased quality of life and patient independence, as well as increased treatment costs. This study analysed the factors related to peristomal skin changes in order to better define the clinical profile of patients with optimal peristomal skin status. Secondary analysis of data from a nationwide, cross-sectional, retrospective, multicentre study performed in Spain (Uses and Attitudes in Ostomy) (Bueno Cruz et al, 2021) evaluated clinical data, including demographics, preoperative stoma site marking, type of ostomy, device used, frequency of leakage and scores from the Ostomy Skin Tool (OST) and quality of life (QoL) questionnaires. Risk factors for peristomal skin changes were analysed using multivariate analysis, and a predictive nomogram to anticipate optimal peristomal skin status (defined here as discolouration (D), erosion (E), and tissue overgrowth (T) (DET) score of 0) was developed. Some 871 patients with an ostomy using different commercial devices in Spain were evaluated. Multivariate analysis to predict optimal peristomal skin status revealed leakage frequency, patient age, type of ostomy, preoperative siting and type of baseplate used were independent predictors of peristomal skin status. Optimal peristomal skin care should be a treatment goal for nurse specialists in stomal therapy, and its individual influencing variables should be taken into account by nurses specialising in ostomy care.

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In addition, assessment of nursing professionals during hospital admission and in specialised consultation was also performed with this cohort (Lado Teso et al, 2019) as part of the U&A Ostomy study. Bueno Cruz et al’s study (2021) offered an excellent opportunity to analyse peristomal skin care in a wide population of patients with an ostomy and define the factors influencing peristomal skin care.

Aims Using this study as a foundation, our aim was to build a nomogram to more easily identify patients with a higher chance of optimal peristomal skin status. This information will be relevant for stoma care nursing specialists providing support to this patient population.

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Methods Study population A retrospective, cross-sectional and observational multicentre study was performed with patients with an ostomy who were cared for by specialist stoma care nurses (Bueno Cruz et al, 2021). The intention of the present study was to identify patterns relating to skin health and integrity following an ostomy across Spain, incorporating the specialist nurse’s perspective. Inclusion criteria were: adult patients (over 18 years) who had had an ostomy for more than 6 months, who were able to understand and complete the questionnaires used and who gave informed, signed consent to participate in the study. The exclusion criteria were multiple ostomies or re-operation for complications; pregnancy or breastfeeding; and simultaneous participation in other studies. The nurse specialist involved in this study recruited the patient after verifying inclusion criteria were met and signed consent was obtained, including all information in an electronic case report form. The researchers, practitioners and stoma care units involved covered the entirety of Spain. Peristomal skin condition was evaluated by the participant nurse specialist, who is trained in the use of the Ostomy Skin Tool (OST), a standardised instrument for assessing the extent and severity of peristomal skin change in terms of discolouration (D), erosion (E), and tissue overgrowth (T) (DET). Health-related quality of life (HRQoL) was assessed and reported by the patient using the global wellbeing (Likert scale from 0–10) and Stoma-QoL scales to avoid researcher and study bias.

Variables evaluated The OST, a standardised tool for assessing peristomal skin, as described above, was used by a stoma care nurse specialist during consultation. This validated tool provides a simple assessment scheme for ostomy care nurses, with demonstrated intra- and internurse reliability (Martins et al, 2010; Jemec et al, 2011). It is based on a standardised description of three characteristics of abnormal peristomal skin: discoloration (D), erosion (E) and tissue overgrowth (T). Within each domain, both the area of peristomal skin affected (the percentage of the area under the adhesive barrier) and the severity of the skin changes is taken into account.

The area affected is assigned a score between 0 and 3, and the severity is scored between 0 and 2.

Therefore, each of the three domains contributes a score between 0 and 5; consequently, the total DET score can fall between 0 and 15. HRQoL was evaluated using a 10-item Likert scale for wellbeing and the Stoma-QoL scale, which is composed of 20 questions, answered qualitatively from 0 to 4 (with a maximum score of 80, which is extrapolated to a total of 100).

Other variables evaluated were patient age; sex; body mass index (BMI); time of and reason for ostomy; type of ostomy; type and brand of appliance used; frequency of leakage; if surgery was scheduled or emergency; and whether preoperative stoma marking was performed or not. Intention to treat was considered to evaluate the role of stoma siting (ie preoperative site marking by the nurse specialist, whether it was implemented or not by the surgeon at the time of surgery). Frequency of leakage was evaluated per week. Those classed as patients without leakage were those with no or only sporadic leakage, as compared to patients with frequent leakage (once or several times per week).

Ostomy Peristomal skin care Nomogram Ostomy Skin Tool Stoma care This article has been subject to double-blind peer review Submitted ??

Accepted November 2021

Statistical analysis Categorical variables were described by frequency distribution and bar chart. Ordinal variables were described by mean, standard deviation (SD) if the distribution was parametrical, and by median and interquartile ranges when non-parametrical.

Mean DET score was compared using the t-test for different categories for the variables evaluated, including preoperative stoma siting, frequency of effluent leakage and Stoma-QoL data. Chi-square contingency tests were also used

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Key words

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to evaluate association between DET score and other variables categorically expressed, including self-perceived treatment satisfaction and StomaQoL scores. All contrasts were performed in two tails, and a value below 5% was used to consider a test statistically significant.

Factors that were likely determinant of a DET score of 0 on the OST were evaluated by logistic regression analysis using odds ratio estimates and 95% Wald confidence limits for the variables investigated. All the variables with significant impact in univariate analyses were then evaluated in a multivariate logistic regression model (stepwise selection with a threshold entry of p=.15 and stay of criterium p=.1). Odds ratios were defined with their respective 95% confidence intervals for each variable analysed, detecting those which independently predicted a DET score of 0.

The association of predicted probabilities and observed responses was evaluated, and the area under receiver operating characteristic (ROC) curve for the selected model was calculated.

The apparent and expected optimism-corrected performances of the model were calculated with internal (1000 bootstrap iterations) validation.

Finally, a nomogram predicting optimal peristomal skin status (defined as a DET score of 0) was proposed. A nomogram, or alignment chart, is a graphical calculating device, a twodimensional diagram designed to allow the approximate graphical computation of a mathematical function. A nomogram consists of a set of n scales, one for each variable in an equation. Knowing the values of n-1 variables, the value of the unknown variable can be found. The result is obtained by laying a straight edge across the known values on the scales and reading the unknown value from where it crosses the scale for that variable. The virtual line created by the straight edge is called an index line. Nomograms are typically used in applications for which the level of accuracy they provide is sufficient and useful.The statistical analysis was performed by using Statistical Analysis System (SAS), version 9.4 (developed by SAS Institute Inc, Cary, NY, US).

Results A total 871 patients with an ostomy were included in this observational nationwide study performed by specialist nurses in stoma care from 148 institutions in Spain between February 2017 S36

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and April 2018, regardless of the commercial appliance that the patient was using. The maleto-female ratio was 1.78. Mean age was 66.1 ± 13 (range 19–92), and mean BMI was 26.5 ± 11.1 (range 25–31). The ostomy was permanent in 68.5% and temporary in 31.5%. The types of ostomy were colostomy (57.5%), ileostomy (28.6%) and urostomy (13.9%). The main reason for ostomy was neoplasia (75%), followed by inflammatory bowel disease (13.2%).

The main parameters investigated to describe self-evaluated HRQoL were global wellbeing and Stoma-QoL scores. Mean ± SD was 7.4 ± 1.9 (range 1–10) for global wellbeing scores and 57.8 ± 10.3 (range 11.5–100) for Stoma-QoL scores.

Stoma-related complications at the time of evaluation were present in 569 patients (65.3%), which led to specialist clinical consultation in 211 of these (37.1%). Some degree of peristomal skin disorder was identified in 263 patients (30.2%); in 203 of these (23.3%), chemical irritation by effluent contact was considered the most likely aetiological factor. Other complications described were parastomal hernia in 144 patients (16.5%), flush stoma in 100 (11.5%), retracted stoma in 69 (7.9%), scar folds in 50 (5.7%) and stomal stenosis in 24 (2.8%). The frequency of effluent leakage at the time of inclusion in the study was registered in 811 patients (96.4%). It was reported as absent in 395 cases (45.4%), sporadic in 174 (20%) and repetitive in 242 (27.8%); in 60 cases (6.9%), this information could not be obtained. Among those with repeated leakage, the frequency was once per week in 138 patients (15.8%), twice per week in 56 (6.4%), three times per week in 28 (3.2%) and four times or more per week in 20 (2.3%). For further analysis, patients with repetitive leakage (once or more per week) were grouped together.

The status of peristomal skin using the OST was evaluated by a specialist nurse at the time of inclusion in 841 patients (96.6%). DET score was equal to 0 (ie no discolouration, no erosion and no tissue overgrowth) in 511 (60.8%) and other than 0 in 330 (39.2%). Figure 1 shows that the patients with a DET score of 0 rated their self-perceived satisfaction more highly, both in terms of the global wellbeing scale (p<.0001) and Stoma-QoL scoring (p<.0001).

Mean ± SD value for DET score was 1.72 ± 2.7 (range 0-13). Table 1 shows the distribution of mean DET score values for the different

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variables evaluated, according to patient and ostomy characteristics. Differences in mean DET score were identified according to type of ostomy (p<.0001), duration of ostomy (p=.002), character of surgery (p=.047), stoma siting (p=.004), ostomy appliance (p<.0001), baseplate convexity (p<.0001) and frequency of leakage (p<.0001). The proportion of patients with a DET score of 0 was lower in the population aged 50– 60 years of age than patients in other age groups (Chi-x2, p=.013).

Univariate analysis revealed frequency of leakage (none, sporadic, repetitive), patient age (≤50, 51–60, >60 years), type of ostomy (ileostomy, colostomy, urostomy), duration of ostomy (permanent or temporary), type of device (one-piece, two-piece or three-piece), type of surgery (planned or emergency), preoperative stoma siting (marked or not), type of appliance (open, closed or urostomy) and type of baseplate (flat, convex) predicted a DET score of 0 in the OST. In multivariate analysis, the duration of ostomy, type of device used, type of surgery and type of appliance used were not independent predictors. Leakage severity (repetitive vs not; odds ratio (OR) 3.09 (95% CI 1.97–4.85), and repetitive vs sporadic; OR 5.21 (95% CI 3.54– 7.66)), patient age (50 years or less vs 51-60 years; OR 2.1 (95% CI 1.14-3.87)); type of ostomy (colostomy vs ileostomy; OR 2.51 (95% CI 1.693.71)), preoperative stoma marking (sited vs not sited; OR 1.84 (95% CI 1.32–2.57)) and type of baseplate (flat vs convex; OR 2.05 (95% CI 1.46–

3.90)) are determinants of optimal peristomal skin status (Table 2).

Figure 2 shows the logistic regression model presented to predict optimal peristomal skin status. The accuracy of the ROC-curve model was 76.7% (Figure 2). This model was internally validated by bootstrapping with 77.1% (95% CI 76.9–77.3) apparent performance and 20.5% (95% CI 20.1–20.8) expected optimism.

Considering the aforementioned variables, a nomogram is proposed to predict patients with a greater chance of a DET score of 0 in the OST (Figure 2), which is associated, as previously stated, with higher scoring in patient-reported outcomes on both the global wellbeing and Stoma-QoL scales.

Discussion Healthy peristomal skin is essential to support optimal performance of the ostomy appliance, which can be compromised when irritant effluent makes contact with the peristomal skin. Leakage and irritation may lead to increased problems with the fit and security of the ostomy appliance, negatively impacting HRQoL (Erwin-Toth et al, 2012), challenging health professionals and resulting in increased costs (Meisner, 2012).

Adaptation of patients to their new life following an ostomy largely depends on the preservation of peristomal skin integrity (Salvadalena, 2008; Goldstine et al, 2019). Specialists in ostomy care play a prominent role in managing peristomal skin disorders in patients and prevent more serious

10 Percent

30 20 10 0

Other

30

6 Percent

Wellbeing scale (0–10)

8

DET = 0

4

20 10 0

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2

DET = 0

Other

0

A. Ostomy Skin Tool

20

40

60

80

100

B. Stoma-QoL Scale (0–100)

Figure 1. Patients with a DET score of 0 rate their self-perceived satisfaction higher in both scales used in this analysis Gastrointestinal Nursing European Wound, Ostomy and Continence Supplement

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complications (Almutairi et al, 2018; Burch, 2019). Preventive measures and early intervention are needed to avoid peristomal skin deterioration, but it is important to identify the factors implicated in the process of such deterioration. However, the elements underlying skin injury depend on a varying array of the individual risk factors involved in producing skin tears and deterioration. In this

sense, this research has been designed to propose and validate a nomogram that could help nurse specialists to anticipate and promote optimal peristomal skin care.

The OST is a resource that has been used to grade the severity of skin changes in ostomy patients. It is recognised as reliable and valid in evaluating peristomal skin changes and

Table 1. Discolouration (D), erosion (E) and tissue overgrowth (T) (DET) scale mean values for the categories evaluated (n=841) Variable

Number (%)

DET scale (mean ± SD)

p-value*

Sex Male

536 (62.7)

1.66 ± 2.60

Female

305 (36.3)

1.83 ± 2.87

111 (13.2)

1.44 ± 2.25

.768

Age < 50 years 51–60 years

192 (22.8)

1.83 ± 2.41

>60 years

538 (64)

1.75 ± 2.89

485 (57.7)

1.38 ± 2.49

.096

Type of ostomy Colostomy Ileostomy

245 (29.1)

2.41 ± 2.92

Urostomy

111 (13.2)

1.65 ± 2.65

Permanent

570 (67.8)

1.60 ± 2.72

Temporary

271 (32.2)

1.99 ± 2.65

<.0001

Duration of ostomy .002

Type of surgery Planned

646 (76.8)

1.63 ± 2.66

Emergency

195 (23.2)

1.97 ± 2.78

446 (53)

1.43 ± 2.57

.047

Preoperative stoma siting Performed and respected Performed and non-respected

18 (2.2)

2.61 ± 2.43

Not performed

377 (44.8)

2.00 ± 2.83

One-piece

227 (27)

1.11 ± 2.40

Two- or three-piece

614 (73)

1.95 ± 2.77

.004

Number of pieces <.0001

Type of baseplate** Flat

514 (64.2)

1.38 ± 2.46

Convex

287 (35.8)

2.41 ± 3.01

395 (48.7)

1.04 ± 2.36

<.0001

Frequency of leakage*** None Sporadic

174 (21.5)

1.36 ± 2.28

Repetitive

242 (29.8)

3.20 ± 3.01

176 (21.3)

2.39 ± 3.02

<.0001

< 50 50–69

316 (38.1)

1.90 ± 2.79

70 or more

336 (40.6)

1.19 ± 2.29

© 2022 MA Healthcare Ltd

Stoma-QoL score**** <.0001

Note: *t-test; **most regularly used type of baseplate data available in 801 cases; ***frequency of leakage data available in 811 cases; ****Stoma-QoL scoring data available in 828 cases

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Table 2. Logistic regression model to predict a DET score of 0 on the Ostomy Skin Tool Univariate analysis variable

β estimate

Odds ratio estimate (point)

Odds ratio estimate (95% Wald confidence limits)

p-value

Repetitive vs no leakage

1.282

3.60

2.35

5.53

<.0001

Repetitive vs sporadic leakage

1.776

5.91

4.09

8.54

<.0001

More than 60 vs 51–60 years

.488

1.63

1.14

2.33

.007

50 or less vs 51–60 years

.536

1.71

1.01

2.90

.048

Colostomy vs ileostomy

.966

2.63

1.88

3.68

<.0001

Urostomy vs ileostomy

.511

1.67

1.05

2.66

.032

Permanent vs temporary ostomy

.531

1.70

1.24

2.33

.0009

One-piece vs multi-piece device

.80

2.22

1.52

3.26

<.0001

Planned vs emergency

.406

1.50

1.06

2.12

.021

Preoperative stoma siting vs not

.641

1.90

1.41

2.56

<.0001

Closed vs open appliance

1.269

3.56

2.55

4.96

<.0001

Urostomy vs open appliance

.655

1.93

1.21

3.06

.0055

3.46

<.0001

Flat vs convex baseplate

.933

2.54

1.87

Multivariate analysis variable

β estimate

Odds ratio estimate (point)

Odds ratio estimate (95% Wald confidence limits)

p-value

Repetitive vs no leakage

1.128

3.09

1.97

4.85

<.0001

Repetitive vs sporadic leakage

1.650

5.21

3.54

7.66

<.0001

More than 60 vs 51–60 years

.360

1.45

.97

2.16

.074

50 or less vs 51–60 years

.742

2.10

1.14

3.87

.017

Colostomy vs ileostomy

.919

2.51

1.69

3.71

<.0001

Urostomy vs ileostomy

.403

1.50

.89

2.53

.133

Preoperative stoma siting vs not

.610

1.84

1.32

2.57

.0003

Flat vs convex baseplate

.718

2.05

1.46

3.90

<.0001

Points

Sting

0.75 Sensitivity

Ostomy

0.5 Age

0.25

Leakage

Total points

0 0

0.25

0.5

0.75

1

Risk

44

Convex

Flat

0

37

No

Yes

0

24 Urostomy

Baseplate

0 20 40 60 80 100 0

IIoestomy

1

0

22

56 Colostomy

AUC = 0.767

45

51–60 >60 <51 0

68

Repetitive

100

Sporadic

None

0

52

85

112 136 161

188

220

281

0.1

0.2

0.3

0.4

0.7

0.8

0.92

0.5

0.6

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Specificity

Figure 2. Logistic regression model for optimal peristomal skin status and nomogram with variables to predict optimal skin status

contributing to the clinical decision-making process (Martins et al, 2010; Jemec et al, 2011). Different measures taken to enhance

peristomal skin care in difficult cases, such as convex pouching systems and barrier rings to protect peristomal skin by providing a safe seal

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around the stoma, have also been tested using this tool (Rat et al, 2018). Several other tools for the assessment of peristomal skin complications have been developed (Haugen and Ratliff, 2013).

However, the researchers preferred the OST, as it is widely used in Spain, and its capacity to identify optimal skin status (DET score = 0) means that it can be used to develop a multivariate model.

Another recently developed scale, the Peristomal Lesion Scale (PLS), was not used, as this tool is helpful in terms of identifying the severity of skin damage but is not capable of defining a normal or default skin status (Menin et al, 2019). Similarly, another tool with recently demonstrated internal consistency and reliability is the Ostomy Leak Impact (OLI) instrument (Nafees et al, 2018); however, this is more appropriate for measuring how the burden of leakage affects ostomy users across different domains, rather than assessing the integrity of peristomal skin itself. Therefore, we preferred to use the OST and measure the number of leakage episodes reported.

The present article is a post-hoc analysis of a nationwide retrospective sample evaluated in Spain, performed with the intention to outline how professionals manage stoma care and reveal the attitude of patients towards their condition. This study, absent of commercial interest, revealed many findings in relation to the clinical reality of ostomy patients and the diffusion of preoperative stoma marking and its relationship with postoperative complications (Lado Teso et al, 2019; Bueno Cruz et al, 2021).

A previous evaluation confirmed preoperative stoma siting and the type of ostomy predicted optimal peristomal skin status (Bueno Cruz et al, 2021). In this paper, we have assessed many other variables involved in peristomal skin health and propose that other independent factors, such as frequency of leakage, patient age and the type of baseplate used, are also significant in maintaining optimal peristomal skin. The researchers also confirmed the importance of leakage on both skin integrity and self-reported patient QoL (Colwell et al, 2017; Colwell et al, 2018).

The Dialogue Study (Andersen et al, 2011) also demonstrated that patient age, type of ostomy, time since surgery, leakage and the choice of appliance were factors affecting peristomal skin status. This study revealed that the use of a double-layer adhesive, together with evidenceS40

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based nursing practices, improved peristomal skin condition (Andersen et al, 2011; Martins et al, 2011). The present study was intended as only descriptive, rather than interventional. However, as discussed, we found interesting results regarding preoperative stoma siting, patient age and type of device used, and these findings were complementary to those of the Dialogue Study (Andersen et al, 2011).

The type of ostomy is a definite major determinant of skin health, associated with chemical dermatitis caused by ileostomy output and the absorbency of the hydrocolloid material used in ostomy appliances (Kelleher et al, 2019).

We also confirmed that repetitive leakage was most harmful to the skin, but sporadic leakage was also injurious to a lesser degree. Preoperative stoma siting is not only a simple practice to reduce stoma-related complications (Arolfo et al, 2018; Hsu et al, 2020), but also an independent prognosticator of optimal skin condition, and it should be a standard of care. Planned, rather than emergency, surgery was a predictor in univariate analysis, but not independent, as it could be substituted by stoma marking itself.

Patient age was another significant factor. In this study, it appears that patients aged 50 years or less and over 60 years are at less risk of skin deterioration. In other words, peristomal skin status is worse in the intermediate population (ie between 51 and 60 years of age). It is possible that this group lacks the greater health status afforded by a younger age, and the increased social activity of this age group makes them more vulnerable than older patients. This observation merits further evaluation in future studies. We did not observe a relation between sex and peristomal skin status.

Regarding ostomy appliances, we observed patients regularly using flat baseplates, as opposed to convex baseplates, were more prone to optimal skin integrity. This is an apparent paradox, because it is well-known that use of a one-piece soft convex baseplate can prevent leakage and protect peristomal skin by providing a safer seal around the stoma (Hoeflok et al, 2017; Rat et al, 2018). However, the population using flat baseplates in our descriptive analysis was not necessarily the demographic requiring the use of a convex baseplate, as there was an absence of significant peristomal skin disorders and limited effluent leakage; therefore, they were presenting

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optimal skin status. Similarly, one-piece and closed devices, which have previously been reported to prevent or lessen leakage (Ratliff, 2014; Fellows et al, 2017; Rat et al, 2018), were not independent predictors of optimal peristomal skin in the multivariate analysis.

The main limitations of this study were its retrospective condition, the absence of specific nursing interventions evaluated, such as the use of resins and modelling rings, adhesives or belts, and the variance between observers in determining DET score in the absence of a centralised evaluation system for the OST. However, this study reflects common daily practice and provides robust assessment of the different factors involved in preserving skin integrity, providing nurse specialists with an evidence base to improve their practice and reinforce patient education. Interventional studies regarding the use of innovative design with a soft convex appliance to provide a safe seal around the stoma are needed.

Skin irritation and injury to peristomal skin is much more than a dermatological issue and is deeply connected to patient wellbeing. Factors that contribute to reducing effluent leakage can be implemented in perioperative care, enhancing preoperative stoma marking and diminishing the chances of leakage. Assessing the impact of damage to peristomal skin is a first-line option in patients with an ostomy and could serve to improve quality of life in these patients. Patients, clinicians and caregivers share the responsibility to enhance skin health through variable intervention strategies. This nomogram could guide nurses to identify the factors implicated in skin health and optimise the skincare of patients with an ostomy.

GN

© 2022 MA Healthcare Ltd

Note This article was first published in the December 2021 issue of The British Journal of Community Nursing’s Community Wound Care supplement Ethics statements The study was approved by Independent Review Board (Burgos, Spain). All subjects gave informed consent to participate in this clinical study and all procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was endorsed by Sociedad Española de Estomaterapia (SEDE), Asociación Española de Coloproctología (FAECP) and Consejo General de Enfermería y Sociedad Española de Enfermería en Cirugía (SEECIR).

Financial disclosure The study was supported by Coloplast Productos Médicos, S.A. (Madrid, Spain) Statement of interest The authors declare no conflict of interest associated to the publication of this manuscript

CPD reflective questions When treating or consulting with a patient with ostomy, how would a prediction of their future peristomal skin status be beneficial to your practice?

What is the relative weight of the numerous variables involved in peristomal skin health? Which factor do you think is most significant when treating a patient with an ostomy?

Will the nomogram presented in the study aid in your clinical practice? Why or why not?

Almutairi D, LeBlanc K, Alavi A. Peristomal skin complications: what dermatologists need to know. Int J Dermatol. 2018; 57(3):257–264. https://doi.org/10.1111/ijd.13710 Andersen BD, Keizerswaard P, Castro MM, English E, Carter D. Introduction to the DialogueStudy: methods and baseline demographic findings. Gastrointest Nurs. 2011; 9(S2):4–8. https://doi.org/10.12968/gasn.2011.9.Sup2.4 Arolfo S, Borgiotto C, Bosio G, Mistrangelo M, Allaix ME, Morino M. Preoperative stoma site marking: a simple practice to reduce stoma-related complications. Tech Coloproctol. 2018; 22(9):683–687. https://doi.org/10.1007/ s10151-018-1857-3 Bueno Cruz B, Jiménez López I, Mera Soto A et al. The effect of preoperative stoma site marking on peristomal skin status and quality of life. Gastrointest Nurs. 2021; 19(S4):S34–S41. https://doi.org/10.12968/gasn.2021.19.Sup4a.S34 Bulkley JE, McMullen CK, Grant M, Wendel C, Hornbrook MC, Krouse RS. Ongoing ostomy self-care challenges of long-term rectal cancer survivors. Support Care Cancer.

2018; 26(11):3933–3939. https://doi.org/10.1007/s00520018-4268-0 Burch J. Peristomal skin care considerations for community nurses. Br J Community Nurs. 2019; 24(9):414–418. https:// doi.org/10.12968/bjcn.2019.24.9.414 Colwell JC, McNichol L, Boarini J. North America wound, ostomy, and continence and enterostomal therapy nurses current ostomy care practice related to peristomal skin issues. J Wound Ostomy Continence Nurs. 2017; 44(3):257– 261. https://doi.org/10.1097/WON.0000000000000324 Colwell JC, Pittman J, Raizman R, Salvadalena G. A randomized controlled trial determining variances in ostomy skin conditions and the economic impact (ADVOCATE Trial).

J Wound Ostomy Continence Nurs. 2018; 45(1):37–42. https://doi.org/10.1097/WON.0000000000000389 Erwin-Toth P, Thompson SJ, Davis JS. Factors impacting the quality of life of people with an ostomy in North America: results from the Dialogue Study. J Wound Ostomy Continence Nurs. 2012; 39(4):417–422. https://doi. org/10.1097/WON.0b013e318259c441 Fellows J, Forest Lalande L, Martins L, Steen A, Størling ZM. Differences in ostomy pouch seal leakage occurrences between North American and European residents. J Wound Ostomy Continence Nurs. 2017; 44(2):155–159. https://doi. org/10.1097/WON.0000000000000312 Goldstine J, van Hees R, van de Vorst D, Skountrianos G, Nichols T. Factors influencing health-related quality of life of those in the Netherlands living with an ostomy. Br J Nurs. 2019; 28(22):S10–S17. https://doi.org/10.12968/ bjon.2019.28.22.S10 Haugen V, Ratliff CR. Tools for assessing peristomal skin complications. J Wound Ostomy Continence Nurs.

2013; 40(2):131–134. https://doi.org/10.1097/WON. 0b013e31828001a7 Hoeflok J, Salvadalena G, Pridham S, Droste W, McNichol L, Gray M. Use of convexity in ostomy care: results of

Gastrointestinal Nursing European Wound, Ostomy and Continence Supplement

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research

an international consensus meeting. J Wound Ostomy Continence Nurs. 2017; 44(1):55–62. https://doi. org/10.1097/WON.0000000000000291 Hsu MY, Lin JP, Hsu HH, Lai HL, Wu YL. Preoperative stoma site marking decreases stoma and peristomal complications: A meta-analysis. J Wound Ostomy Continence Nurs.

2020; 47(3):249–256. https://doi.org/10.1097/ WON.0000000000000634 Jemec GB, Martins L, Claessens I, Ayello EA, Hansen AS, Poulsen LH, Sibbald RG. Assessing peristomal skin changes in ostomy patients: validation of the Ostomy Skin Tool. Br J Dermatol. 2011; 164(2):330–335. https://doi.org/10.1111/ j.1365-2133.2010.10093.x Kelleher K, Hunt R, Hannigan A, Coffey JC, Moloney MC, Ahern M, Conway E, O’Sullivan L. A single-arm, practical application assessment of user experience and peristomal skin condition among persons with an ileostomy using a new barrier seal with assisted flow. Wound Manag Prev.

2019; 65(1):14–19 Lado Teso A, Fabeiro Mouriño MJ, Bueno Cruz B, Vázquez García MC, Jiménez López I, Mera Soto A. Usos y actitudes de los pacientes ostomizados en España (Estudio U&A en Ostomía). Metas Enferm. 2019; 22(4):19–27 Martins L, Ayello EA, Claessens I, Steen Hansen A, Hentze Poulsen L, Sibbald RG, Jemec GB. The ostomy skin tool: tracking peristomal skin changes. Br J Nurs.

2010; 19(15):960–964. https://doi.org/10.12968/ bjon.2010.19.15.77691 Martins L, Samai O, Fernández A, Urquhart M, Hansen AS. Maintaining healthy skin around an ostomy: peristomal skin disorders and self-assessment. Gastrointest Nurs.

2011;9(suppl 2):9–13. https://doi.org/10.12968/ gasn.2011.9.Sup2.9 Meisner S, Lehur PA, Moran B, Martins L, Jemec GBE, Meisner S1. Peristomal skin complications are common,

expensive, and difficult to manage: a population based cost modeling study. PLoS One. 2012; 7(5):e37813. https://doi. org/10.1371/journal.pone.0037813 Menin G, Roveron G, Barbierato M, Peghetti A, Zanotti R. Design and validation of a ‘Peristomal Lesion Scale’ for peristomal skin assessment. Int Wound J. 2019; 16(2):433– 441. https://doi.org/10.1111/iwj.13052 Nafees B, Størling ZM, Hindsberger C, Lloyd A. The ostomy leak impact tool: development and validation of a new patient-reported tool to measure the burden of leakage in ostomy device users. Health Qual Life Outcomes. 2018; 16(1):231. https://doi.org/10.1186/s12955-018-1054-0 Nichols T, Goldstine J, Inglese G. A multinational evaluation assessing the relationship between peristomal skin health and health utility. Br J Nurs. 2019; 28(5):S14–S19. https:// doi.org/10.12968/bjon.2019.28.5.S14 Rat P, Robert N, Fernandes I, Edmond D, Mauvais F. Evaluation of a one-piece soft convex ostomy appliance: a prospective, multicentre, open-label pilot study. Br J Nurs. 2018; 27(16):S20–S28. https://doi.org/10.12968/bjon.2018.27.16.

S20 Ratliff CR. Factors related to ostomy leakage in the community setting. J Wound Ostomy Continence Nurs. 2014; 41(3):249–253. https://doi.org/10.1097/ WON.0000000000000017 Salvadalena G. Incidence of complications of the stoma and peristomal skin among individuals with colostomy, ileostomy, and urostomy: a systematic review. J Wound Ostomy Continence Nurs. 2008; 35(6):596–607. https://doi. org/10.1097/01.WON.0000341473. 86932.89.

Sun V, Bojorquez O, Grant M, Wendel CS, Weinstein R, Krouse RS. Cancer survivors’ challenges with ostomy appliances and self-management: a qualitative analysis. Support Care Cancer. 2020; 28(4):1551–1554. https://doi.org/10.1007/ s00520-019-05156-7

WHY NOT WRITE FOR US? Gastrointestinal Nursing welcomes the submission of clinical and opinion articles on a range of GI issues including IBD, stoma, endoscopy, hepatology and policy and service development.

© 2022 MA Healthcare Ltd

All manuscripts should be submitted via Editorial Manager, our online article submission system, via the link: http://www.editorialmanager.com/gasn/ default.aspx. All published articles are subject to an external, double-blind peer review.

If you have any queries, feel free to contact the Editor at benjamin.wakefield@markallengroup.com.

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Webinar Series

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