The Ostomy Files: Strategies for Improving Ostomy Outcomes

   T he convergence of several immense and divergent changes in healthcare delivery and payment have caused providers to make changes in the processes and structure of care provision, especially as it relates to ostomy care. Along with these changes comes today's reality that achieving financial efficiency and clinical effectiveness is wholly dependent on the outcomes of the care actually provided. Wasteful or highly variable practices, historically inherent in ostomy care, not only hamper an organization's survival and escalate cost, but also impede the individual patient's rehabilitation.

    Clinicians caring for ostomy patients, regardless of the care setting, frequently feel isolated and hampered in their attempts to respond to patient and employer needs - often the two seem completely contradictory. Without relatively straightforward mechanisms in place that develop and maintain collaborative and contiguous care, positive clinical and financial outcomes can rapidly disappear under the stress of today's work environment.

   Ostomy surgery easily lends itself to an analysis of outcomes because surgical cases are much more likely than medical cases to follow a standard path. Nurses caring for patients with ostomies are at the crossroads where the system and the patient meet face-to-face; therefore, they need to create a sound collaborative structure that works for both entities while benefiting the patient.

   Today, clinical and financial outcomes and quality are the "products" of care. If healthcare organizations are at financial risk or cannot meet the array of regulations and accreditation standards, they will fail - the ostomy patient paying the ultimate price in expensive and prolonged rehabilitation and the burden of needless additional emotional and psychological (and sometimes physical) trauma.

   The first step toward improving ostomy outcomes is to understand the organization's current practice patterns (physicians, nurses, management, financial, and purchasing), the subset of ostomy patients most frequently treated, and the current resources being used to provide ostomy care. Inefficient and poor quality care occurs whenever additional cost, evaluation, or treatment provides no measurable improvement in outcomes. A typical scenario is the repetitive selection of inappropriate ostomy supplies that neither solve a management problem nor satisfy the patient.¹

   The process of care delivery, and subsequently its outcomes, depends on information. Currently, information on every aspect of ostomy care is fragmented within organizations and across referring institutions. Often, nonspecialized clinicians simply do not know the right way to care for a particular problem or do not have enough information to make an appropriate care decision.

   Knowledge about basic ostomy care, establishing an ostomy product formulary, and standardizing care plans can help clinicians predict and prevent complications and provide appropriate care; therefore, decreasing costs and hastening rehabilitation.

   The cost per case should be analyzed by ostomy type (eg, ileostomy, urostomy, J-pouch, and colostomy) and include all the resources ordered by the physician as well as the services rendered by nursing and other non-chargeable departments. Some patients require more concentrated coordination of care throughout some or all of their episode of care, while others require support coordination and management of care needs for long periods of time. Ostomy patients fall into the latter category, as their needs are life-long. The care of ostomy patients can and should be coordinated across an episode of care and across an entire continuum.

   If ostomy self-care is the most important variable in predicting a positive adjustment,² mechanisms must be in place to improve and accelerate the patient's ability to do so. These mechanisms include standardized pre- and postoperative teaching programs for the patient and family that are fully integrated by clinicians and consistent across care settings.
Clinicians should examine the outcomes of ostomy care from a variety of perspectives in order to grasp the impact of an organization's current practice on cost, quality, and rehabilitation. Below are strategies that may be worth investigating in the process of evaluating an organization's ostomy outcomes:
  * Create a map of current ostomy care practice by surgery type.
  * Develop a cost model aligned to map of current ostomy care practice.
  * Determine the cost of supplies by surgery type (ie, ileostomy, colostomy, urostomy; temporary versus permanent).
  * Assess the cost of ostomy care provided by a WOC nurse versus a nonspecialized clinician.
  * Examine the outcome of hospital (or other) discharge for new surgery (eg, level of self-care achieved, coordination of care between referring institutions, length of stay).
  * Assess the outcome of home teaching (ie, number of home visits; difference between teaching provided by a single consistent clinician versus teaching provided by a variety of clinicians).
  * Assess the outcome of a standardized teaching plan across settings.
  * Compare the outcome of preoperative stoma site marking to stomas not marked preoperatively.
  * Compare the outcome of the postoperative use of one-piece to using two-piece systems.
  * Compare the outcome of using standard versus using extended-wear wafers in hospital/home by surgery type.
  * Consider the outcome of telemedicine on ostomy patient teaching.
  * Determine per case resource utilization (costs) (eg, ileostomy, J-pouch, colostomy, urostomy).
  * Assess length of stay (or number of home health episodes) per case type.
  * Quantify patient satisfaction with care delivery.

   The answer to improving ostomy outcomes is to improve quality and to establish solid, evidence-based standardized care plans and processes into which the analysis of the current practice patterns and increased knowledge and education have been integrated. All vested parties - the organization, the physician, the clinician, and most of all, the patient -will benefit.

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

1. Turnbull GB. Quality of life: healing the brain and the body. Ostomy/Wound Management. 2002;48(6):10-12.

2 . Piwonka MA, Merino JM. A multidimensional modeling of predictors influencing the adjustment to a colostomy. J WOCN. 1999;26:298-305.