Prescription for Excellence: An Ostomy Clinic

   An ostomy clinic provides patients long-term accessibility to a Certified Ostomy Care Nurse (COCN) or Certified Wound, Ostomy and Continence Nurse (CWOCN) specialist, essential for people requiring ostomies. Preoperative visits for education and stoma site marking, postsurgical visits for follow-up or problem resolution, and guidance and suggestions for patients who have lived with an ostomy for years help promote holistic care. Developing a relationship between the CWOCN/COCN and the patient is of utmost importance, has a positive influence on the patient’s quality of life with the ostomy,¹ and allows individuals to gradually learn the skills necessary to manage the new ostomy, become independent in their care, and adapt successfully to this change in their lives.

   Education. Preoperative education regarding the physical care of a newly created ostomy and the psychosocial aspects of daily living offered in an outpatient setting helps allay patients’ fears and anxieties and provides an opportunity for answering their questions. Postoperatively, patients are often overwhelmed by the amount of information they need to learn while recuperating from a major surgical procedure, especially when hospital stays are only 4 or 5 days. Most individuals receive follow-up teaching, direct care, and support from the Visiting Nurse in their community for a limited period of time after discharge. Patients too sick or weak to return directly home are often discharged to a rehabilitation or skilled nursing facility. However, because these support resources are offered short term, follow-up care must be continued in the outpatient setting to facilitate support and education for these patients and provide opportunity for them to establish a long-term relationship with the CWOCN/COCN. Issues regarding resumption of work, school, social and recreational activities; intimacy; and the variety of products available from ostomy companies, as well as issues related to physical care, can be addressed in this environment.

   Stoma care. The size and shape of the stoma and abdominal contours change approximately 2 to 6 weeks post surgery, affecting appliance choice. A weight gain or loss of 10 lb or more also may affect the stoma and its topography. Modifications made in the appliance and care offered at timely visits help provide optimal peristomal skin protection to prevent any future complications while ensuring that individuals are using the best products to meet their circumstances. Analysis of data from the Montreux study,¹ where more than 600 enterostomal therapists collected quality-of-life information from more than 4,000 patients in 16 countries in Europe, provides evidence that the first 3 to 6 months after surgery is a critical time period — follow-up with an enterostomal therapist has a positive impact on an individual’s quality of life. This supports the idea that ostomy clinic visits should be an integral part of the comprehensive care provided to anyone who has ostomy surgery.

Establishing the Clinic

   Identifying need. The initial impetus for the establishment of an ostomy clinic often comes when the ostomy nurse identifies an unmet patient need. At the authors’ large urban acute care hospital, where a high volume of ostomy surgery is performed, discharged patients had no facility from which to receive follow-up care from a COCN/CWOCN. Before the ostomy clinic was established, the authors fielded telephone calls from Registered Nurses at various visiting nurse agencies that had no COCN/CWOCN, who pleaded with the authors to see their patients. In addition, patients called when their nurse was unable to achieve appliance adherence on weeping denuded skin. Because these patients often were upset and required the expert care of the CWOCN, patients were seen in a spare room to resolve the crisis. The CWOCNs were not comfortable with this practice for many reasons: no routine for follow-up care was in place, long-term needs of the patient were not being addressed, supplies and equipment in the room were inadequate, medical and secretarial support was lacking, and no formal patient scheduling or billing system existed. In addition, this practice was not an efficient use of the CWOCN’s time because of the many unpredictable, urgent appointments, the amount of time spent walking to a different building where the outpatient clinic was held, the disrupted planned inpatient visits and scheduled meetings, and the challenge to find a room that was available for 30 to 60 minutes. With the number of “informal visits” increasing, the CWOCNs in the authors’ facility initiated discussion with key people in their organization to explain the needs of patients and gain support for an ostomy clinic. Also noted was an important trend to consider — patients utilizing the emergency room for stoma and/or peristomal complications. These visits could occur 7 days per week at any time of day, including times when the WOC nurse was not available, possibly resulting in less-than-optimal patient care. This type of information, along with patient statistics, convinced hospital administration to grant approval for the CWOCNs to develop an ostomy clinic.

   Personnel. In the course of planning and designing the environment of an ostomy outpatient clinic, a physician with expertise in ostomy surgery should be named Medical Director. The specific role played by this physician may vary according to the hospital setting and state regulations. A secretary is also necessary to greet/check in patients, schedule routine appointments, cancel/reschedule requested appointments from outpatients or other healthcare providers, triage phone calls to the CWOCN as needed, and assist with arranging transportation for patients traveling to and from skilled nursing facilities or rehabilitation centers. Because of the variety of insurance company regulations, the secretary also can ensure receipt of the appropriate approvals and referrals before the patient’s visit.

   Billing/coding expertise. The complexities of working with different insurance companies and the intricacies of the healthcare reimbursement system, as well as different state codes, demand that someone with expertise in this area be contacted when first establishing the clinic to be certain that patient visit billing and coding is completed correctly. A specialist in healthcare finance also can be consulted to assist in negotiating the costs, charges, and reimbursement for each appointment. Additionally, the budget must factor in the cost of essential equipment and space requirements.

   Setting. The location and milieu of the clinic must feel welcoming to patients. The waiting room should feature comfortable chairs, easy access to a bathroom, space for wheelchairs and stretchers, and adequate lighting. It also may include a phone, computers with access to the internet, teaching materials from ostomy companies, informative magazines/brochures/pamphlets, announcements of local ostomy support group meetings, supply catalogs from medical equipment companies that provide ostomy equipment, and business cards of the clinic’s providers.

   The examining room should have an exam table, chairs, a sink, a bio-hazardous materials trash container, a needle box for scissors and other sharps, and storage space for ostomy supplies, tissues, washcloths, disposable underpads, gloves, and dressing supplies. In addition, storage space for product samples and materials is needed. Patients often have a support person accompany them to the ostomy visit whose presence is desired in the room. Because the accompanying person may not need or want to observe physical care, having a privacy curtain is helpful.

   Emergency equipment and a code cart must be easily accessible, especially because many patients are recovering from surgery or have a variety of medical problems. The COCN/CWOCN and secretary should know the institution’s procedure for sending a patient to the emergency department and the name and phone number of the physician to contact for questions and/or emergencies must be readily available. All clinic policies and procedures should meet requirements mandated by the facility as well as those regulated by state and federal agencies.

   Visit intervals. The COCN/CWOCN must determine the clinic hours and the amount of time spent with each person. Depending on patient volume, clinic times may be offered from once a week in the morning or afternoon to daily. Nurses should be aware that clinic can be an intense experience where individuals may present with challenging physical and/or psychological issues one after another, necessitating a visit from 30 minutes to 1 hour. The patient deserves the full attention of the provider and scheduling four patients per morning and/or afternoon session may have to suffice.

   Marketing clinic services. Once the ostomy clinic is established, it should be publicized. Strategies include:
  • mailing letters to physicians, patients with ostomies, visiting nurse agencies, skilled nursing facilities, and rehabilitation centers
  • placing a notification in a facility’s publications and newsletters
  • advertising in community newspapers
  • distributing a comprehensive brochure to diverse settings. The brochure should include information on the healthcare providers, services provided, appointment scheduling, and health insurance coverage
  • listing the ostomy clinic in the outpatient clinic directory.

   As knowledge of the ostomy clinic grows and referrals increase, additional days and personnel may need to be added.

   Types of visits. In the authors’ practice, the ostomy clinic was available for 48 weeks from January 2004 through December 2004, during which time approximately 400 patient visits occurred (averaging 33 visits per month). Quarterly summaries from 2004 are presented in Figure 1. These numbers are expected to grow as postoperative visits at 1, 3, and 6 months after surgery and yearly follow-up appointments become more routine in the CWOCN’s practice.

   Patients with temporary ostomies were not routinely seen in the clinic due to space and time limitations. Some of these patients and their nurses in home care agencies, rehabilitation centers, and skilled nursing facilities without a CWOCN/COCN telephoned the clinic asking questions regarding sizing, irritant skin dermatitis, leakage, and other ostomy care issues. In some instances, clinic clinicians addressed incorrect advice given by healthcare providers who are not ostomy specialists — eg, one patient received bacitracin ointment to treat peristomal skin irritation when the etiology of the problem was a poorly fitting appliance with subsequent leakage of effluent under the seal. Because of observed need for closer follow-up of patients with temporary ostomies and the improved quality of life outcomes reported in the Montreux study, the authors’ clinic added hours in 2005. Additional hours will help meet the needs of all patients who have had ostomy surgery at this hospital and will allow better accommodation of referrals for patients who have had surgery at facilities without an ostomy clinic and for patients whose surgery was performed while they were away from home and now need follow-up care.

   The extensive and diverse issues addressed in an ostomy clinic include:
  • Pre-operative consulting for stoma site marking, counseling, and education
  • Resizing the template due to changes in the stoma and abdominal contours after discharge from the hospital
  • Identifying the correct size and type of ostomy appliances that best suit each individual — ie, one-piece, two-piece, flat versus convex, drainable pouch, closed end pouch, transparent versus opaque pouch, type of pouch closure, and where to obtain products
  • Instructing patients on how to manage skin folds and creases around a stoma as well as stoma changes (eg, from protruding to flush or retracted)
  • Addressing mechanical injury, such as skin tears, skin stripping, pressure, or suture granulomas
  • Assessing and treating any chemical injury, such as irritant or contact dermatitis, pseudoverrucous lesions, or alkaline encrustation
  • Providing care for any infection, such as peristomal candidiasis, folliculitis, pyoderma gangrenosum, or bacterial processes
  • Recommending care for parastomal hernias or stomal prolapses
  • Offering suggestions regarding clothing, bathing, diet, odor and flatus control, resumption of lifestyle and activities, intimacy and sexual function, and decisions about sharing knowledge of one’s ostomy with other people.

   Figure 2 shows the varied diagnoses of patients seen in the authors’ ostomy clinic at the time of admission to the hospital in 2004.

   Patient scheduling. The frequency of return visits depends on whether the visit was “routine” or problem-focused. Observations in the authors’ practice suggest that patients benefit from a follow-up appointments in the ostomy clinic approximately 1 month, 3 to 4 months, and 6 months after surgery, and yearly thereafter. Even persons who have lived with an ostomy for years understand the importance of these visits, which afford them the opportunity to learn new tips for living with an ostomy or about new appliances that were developed over the year. For problem-focused visits, the frequency of follow-up visits must be determined on an individual basis. The secretary may book the appointments when the patient is leaving the visit to find the most convenient available opening for both patient and provider. A reminder phone call from the secretary a few days before the scheduled visit is appreciated by most patients.

The Clinic Visit

   Obtaining and maintaining medical records. Before the patient is brought in to the examining room, the clinician must review the patient’s medical record to become familiar with his/her medical history. The ostomy clinic secretary can request the medical record ahead of time to ensure its availability the day of the visit. Some healthcare facilities have an electronic medical record that allows for quick and easy access to a patient’s health history, medications, and current treatments.

   In the authors’ clinic, keeping cards with brief notes on all the patients seen in the inpatient or outpatient setting has proven helpful as a quick reference guide for summaries of patient/clinician interactions. The cards are filed in the clinic office and are easily retrieved before a visit or to obtain information before returning a patient phone call (see Figure 3). The appropriate sections are circled (eg, inpatient versus outpatient, stoma site marked, stoma site used, shape of stoma, type of stoma, irregularities near stoma, and peristomal skin condition). Demographic information, medical record number, and other objective information are recorded, including the name of the primary care physician, the surgeon, the gastroenterologist, or any other key providers that the CWOCN may want to readily identify. The space in other sections allows for additional specific data (eg, sigmoid versus transverse colostomy for “type of colostomy,” pyoderma gangrenosum under “peristomal skin,” or 1,000 cc of tap water daily to irrigate a colostomy for “solution used and amount”). The back of the note card is used for abbreviated notes on patient visits in the inpatient or outpatient setting, including appliance type and manufacturer, appliance change frequency, accessory products, adaptation issues, results of modifications in treatment plans, and other information the clinician deems important.

   Communication. Each patient visit must be documented in the medical record and communicated by mail or email with the surgeon and/or primary care physician. Ideally, the nurse dictates the contents of the letter and a secretary or service transcribes the dictation. After the nurse proofreads the letter, the secretary is responsible for mailing or emailing it to the appropriate physician. It is helpful if the letter includes the name and order numbers of currently used ostomy products because the physician may have to write prescriptions for these items. Transmitting digital pictures of the ostomy and/or peristomal skin via email may be beneficial for the physician or other healthcare providers to illustrate a condition. Copies of these communications also can be kept with the patient’s medical record. Clinicians must be familiar with their facilities’ policies and knowledgeable about the privacy issues when using any form of technology.

Provider Satisfaction

   Assisting patients during their journey toward restoration of health and meeting their personal goals are part of a rewarding and satisfying experience for the COCN/CWOCN. Stories patients have shared and letters they have written reinforce how initial fears can be overcome and a state of wellness achieved. Patients talk about feeling confident at a son’s wedding, overcoming the fear of hugging a 2-year-old child, experiencing a successful pregnancy because the mother-to-be was knowledgeable about the stoma changes to expect and how to modify care, going scuba diving and happily not seeing the pouch “blow up” from pressure changes, and being able to maintain a sense of control while dying as in the case of a young woman who was encouraged in the ostomy clinic to care for her own colostomy because she was dependent on others for almost everything else.

Conclusion

   Thus far, literature on ostomy clinics has been scarce, yet the importance of this ambulatory service for this patient population is obvious. The concept of improved quality of life related to this outpatient service is supported by the Montreux study where 3 to 6 months following ostomy surgery, patients’ quality of life improved when they had access to a nurse who specialized in ostomy care. Patient adaptation to and successful integration of this change in their life is facilitated in an ostomy clinic — individual physical and psychosocial needs can be addressed in a private, calm environment. The clinic setting fosters the development of a long-term relationship, and decreases fragmentation and sustains the continuity of care between the COCN/CWOCN and the patient. This strengthens trust, a key component of nursing care. The ostomy clinic is a source of many tales of patients showing great courage. Although clearly ostomy clinics are extremely valuable, future studies that further demonstrate their importance are warranted.

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

Additional Resources

1. Boarini J, Colwell JC, McNichol, LL, et al. Roles of the ostomy nurse specialist: historical perspective, role potential. In: Colwell, JC, Goldberg MT, Carmel JE, eds. Fecal and Urinary Diversions Management Principles. St. Louis, Mo.: Mosby;2004.

2. The Wound, Ostomy Continence Nursing Society. Professional practice fact sheet. Establishment of wound ostomy continence clinics. JWOCN. 1998;25(5):22A, 24A,26A passim.

3. The Wound, Ostomy Continence Nursing Society Regulatory/Reimbursement Task Force. Professional practice fact sheet: reimbursement options for WOC(ET) nurses in ambulatory care. JWOCN. 1999;26(6):25A–31A.