My Scope of Practice: Evolution of an Ostomy Clinic

This month, Ostomy Wound Management highlights the scope of practice of an ostomy clinic and the individuals dedicated to providing quality care to a previously underserved community.

 Patients must have access to an ostomy nurse specialist when facing a fecal or urinary diversion. Preoperative visits for educational and stoma site marking, postsurgical visits for follow-up maintenance, and ongoing need to address pouching concerns are essential for a patient’s successful adaptation to life with a hole in his/her abdomen. A 2007 proposal to the Duke Raleigh Hospital (Raleigh, NC) Nurse Executive Board and Finance Committee resulted in development of a clinic that continues to grow and enhance the care of persons with ostomies in Raleigh/Durham and the surrounding communities.   Wound ostomy and continence nurses (WOCN) are skilled in many areas of patient care and education, including the ability to provide care recommendations that are evidence-based, cost-effective, and individualized for specific patient situations. Duke Raleigh Hospital is a 186-bed acute care facility serving Raleigh and Wake County. It has been part of the Duke University Health System since 1998 and has received Magnet designation for the American Nurses Credentialing Center. WOCN areas of responsibility and percent of time spent with each type of patient within the hospital include wound care (60%), ostomy care (30%), continence care (5%), and professional practice (5%) to ensure adherence with required regulations to provide the highest standard of care, coordinating monthly skin care audits, precepting WOCN students, and conducting regular wound, ostomy, and skin care education. WOC consults have focused primarily on wound care due to the type of patient population encountered. The addition of both the colorectal oncology service to the Duke Cancer Center and a comprehensive adult urology surgical team have gradually increased the WOC census to include more ostomy and continent diversion patients. 

  Preoperative stoma siting may help reduce postoperative problems such as leakage, fitting challenges, need for expensive custom pouches, skin irritation, and pain and clothing concerns. Poor placement can cause undue hardship and affect psychological and emotional health. Preoperative counseling and education enhances the likelihood of patient independence in stoma care and resumption of normal activities. A 2003 quality-of-life study¹ found the first 3 to 6 months post-surgery is a critical time where follow-up with an ostomy certified nurse has a positive impact on patient quality of life. In the Raleigh/Durham area, ostomy patients did not have an opportunity to receive essential presurgical ostomy counseling and postoperative care. Before the Ostomy Clinic was established, only one surgical group provided ostomy patients postoperative care and counseling. A WOCN was not compensated for time or travel to the surgeon’s office, and new ostomy patients were lost to follow-up care. If a surgeon asked for WOCN input, it often was weeks or months after surgery when patients have difficulty with pouching or skin irritations. Many patients were told to see a dermatologist for skin irritations and lesions resulting from inappropriate pouching systems or application. Not all ostomy patients have access to computers to access support groups or the United Ostomy Association of America website and in some cases were not aware of these organizations. Ostomy patients did not have the benefit of a stoma nurse in their small community hospitals and were discharged with little or no information; they learned to care for their stomas using their own creativeness and initiative.

  The Outpatient Hospital Services Department was established in 2007, allowing the opportunity to develop the Ostomy Clinic. Over a 9-month period, the WOC nurse working with the financial analysis team developed a clinical pathway and the necessary patient charge codes for reimbursement. Task analysis of procedures provided data for service billing codes. This was a new contribution to the hospital outpatient service; WOC nurses do not charge for inpatient services and some hospitals may not see the value of hiring WOC nurses in difficult economic times. Reimbursement for outpatient services would provide a revenue stream for the hospital and promote the value of employing WOC nurses.

  The first ostomy clinic patients were seen in Fall 2008. The Ostomy Clinic is located on the third floor of the hospital as part of the Outpatient Hospital Services department. An examination room complete with sink, table, and chairs is allocated for ostomy patients within the department. Once a physician faxes an order for Ostomy Evaluation and Treatment to the clinic, the patient is contacted by the WOCN to make an appointment. Initially, patients were seen one afternoon a week; over time, patients were seen between 9 am and 4 pm Monday through Friday. Patients register as outpatients before their visit with the WOCN. Referring physicians receive a faxed consult note after the patient visit and if the patient needs more complex care, the physician is contacted directly.

  Physician offices were given information on the Ostomy Clinic services for existing ostomy patients. Marketing involved creating a brochure for distribution throughout the medical community; information about the clinic was added to the Duke Raleigh Hospital website in 2010. Outpatient consults increased monthly. Clinic traffic increased 75% when the colorectal and urology specialists became part of the hospital. Ostomy and continent diversion patients could now be scheduled for counseling, preoperative stoma siting, and postoperative care. Initial goals of reimbursement for service and follow-up care in a clinical environment were realized within the first year of operation. More business necessitated staff increases. In 2010, an additional full-time WOC position was requested and filled within 6 months of posting.

  With the provision of adequate funding and resources, the Duke Raleigh Ostomy Clinic seeks to 1) continue to grow to meet the needs of the community, 2) become a leading center for education and management of urinary and fecal diversions and a training center for local and national WOC students, and 3) participate in research activities. The Ostomy Clinic, in association with various community outreach programs such as the Open Door Clinic and Public Health services, has the potential to become the major provider of ostomy care for underserved rural populations in North Carolina.

 This article was not subject to the Ostomy Wound Management peer-review process.

1. Marquis P, Marrel A, Jambon B. Quality of life in patients with stomas: the Montreaux Study. Ostomy Wound Manage. 2003;49(2):48-55.