The Ostomy Files: Managing Oversight of Colostomy Irrigation in Long Term-Care

   Today's nursing homes are under constant and ever-increasing scrutiny by federal and state regulators, payors, and consumers. The bar is continuously ratcheted up for improved quality of care and better financial and clinical outcomes. The shortage of nurses, along with resource constraints, attrition, and staff turnover (especially for Certified Nursing Assistants [CNA]), compound the problem and make consistency and continuity of care an even greater challenge.

   Postoperative colostomy patients are frequently referred to skilled nursing facilities for instruction on colostomy irrigation and ostomy self-care. Patients with long-standing colostomies often become long-term nursing home residents in their later years due to health problems unrelated to the colostomy. Regardless of the reason for admission, the goal of routine irrigation of a descending or sigmoid colostomy is to maintain normal bowel function by evacuating the bowel on a consistent basis. This can be achieved by using the proper colostomy irrigation technique and involving the patient in the process to his or her maximum physical and mental capabilities.¹

   In the absence of a staff WOC nurse, responsibility for colostomy care is usually assigned to a specific staff member or level of caregiver - a treatment nurse (LPN, RN), a staff RN or LPN, or a CNA. Due to turnover and other internal staffing issues, different staff commonly perform colostomy irrigation on different days. Documentation can be sketchy (ie, "colostomy irrigation performed") or even absent in terms of what was done, how the patient reacted to the procedure, and the results of the irrigation. Under these circumstances, evaluating whether the irrigation is achieving its desired outcome - that is, maintaining normal bowel function by bowel evacuation via the colostomy - is difficult.

   Because nursing home residents are often elderly, fragile, bedbound, malnourished, and have multiple health problems, they are particularly vulnerable to dehydration and constipation. The Centers for Medicare and Medicaid Services (CMS) has given surveyors tools to improve identification of specific deficiencies, investigate whether a deficiency is the result of poor care, and document the level of harm resulting from a home's identified deficient care practice.² Resource shortages alone make meeting federal standards for nursing homes a challenge. Thus, the elderly nursing home patient with a descending or sigmoid colostomy who meets the criteria for colostomy irrigation requires meticulous attention to the process and outcome of daily colostomy irrigations in order to demonstrate data-driven clinical outcomes and compliance to federal and state standards.

   Achieving consistency among caregivers and adequately documenting the procedure to help communicate the current status of the patient's bowel function are important steps to take. Accomplishing these goals requires: 1) proper colostomy irrigation supplies; 2) a trained staff; and 3) documentation that clearly demonstrates who performed the procedure, when it was performed, and its outcome. These steps can help provide the patient with a proper irrigation technique and serve as a communication tool for other staff members, federal and state surveyors, physicians, and referral organizations (hospital, home health agency).

   A practical solution would be to establish a chart to document (see Chart) the results of colostomy irrigation on a regular basis. Providing a central location for tracking the procedure offers care providers an accessible source from which the patient's pattern of bowel function can be tracked and eliminates the need to search through pages of nursing or progress reports to find the same information. This system provides additional assurance that appropriate amounts of irrigant are used, orders are followed consistently, and results of the irrigation are adequately documented.

   In a time when CMS is being urged to strengthen the nursing home survey process,² long-term care providers must be diligent in their efforts to follow orders correctly and provide a sequential written portrait of the care provided to their residents. 

   The Ostomy Files is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.

1 . Erwin-Toth P, Doughty DB. Principles and procedures of stomal management. In: Hampton BG, Bryant RA, eds. Ostomies and Continent Nursing Management. St. Louis, Mo.: Mosby Year Book;1992:75-79.

2. United States General Accounting Office. Nursing home quality: prevalence of serious problems, while declining, reinforces importance of enhanced oversight. GAO-03-561. July 2003. Available at: www.gao.gov/cgi-bin/getrpt?GAO-03-561. Accessed August 15, 2003.