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The Ostomy Files: Who is Really Providing Ostomy Care Today?
"The WOC Nurse is only there 2 days a month."
"The home care agency didn't have an ET Nurse."
"I never saw an ostomy nurse."
So say the ostomy patients - those who are newly operated or those with long-standing ostomies who develop problems. The burden of their concerns is not the direct responsibility of the WOC nurse - it is simply a result of current circumstances and basic arithmetic.
The numbers don't add up.
The biggest problem is an imbalance between supply and demand. The number of WOC nurses (just under 4,000 nationwide1) is insufficient to care for the growing number of patients within the profession's range of practice. This is compounded by the fact that registered nurses can become certified by the WOCN (Wound Ostomy Continence Nurses Society) in one, two, or all three of the specialties within the scope of WOCN practice. It is fair to assume that there are fewer COCNs (certified ostomy care nurse) than CWCNs (certified wound care nurse) because of the size of the population of patients with wounds and their drastic need for care. Or, perhaps, the expertise of CWOCNs (certified wound ostomy continence care nurse) is used primarily for wound care.
A Multifaceted Problem
Recent advances in technology and increases in public and private payor cost controls, as well as shortened hospital stays, have shifted higher acuity patients, such as those with ostomies, into alternative care settings faster. Today, the majority of pre- and postoperative ostomy teaching and rehabilitation takes place in these settings. Therefore, the bulk of ostomy care today is likely provided by nonspecialized clinicians who lack 1) current knowledge of state-of-the-art ostomy care, 2) appropriate use of modern ostomy products, and 3) an understanding of what comprises cost-effective ostomy care.
This situation is the result of many factors, including the small percentage of nurses specially trained in ostomy care and the fact that the majority of today's nurses are older than 40 - meaning that their nursing education and training was completed many years ago. Through no fault of their own, many of these staff nurses may have an inadequate understanding of their role in caring for patients with stomas as well as limited problem-solving expertise regarding the frequent skin and stomal complications presented to them.
Local and national payor regulations that restrict access through prior-approval requirements (eg, referrals from a primary care physician) or price setting (ie, prospective payment systems - PPS) can result in underuse of appropriate resources2 required for optimal ostomy rehabilitation (eg, adequate supply of appropriate ostomy supplies or WOC nurse visits). Implementation of PPS in Medicare-certified home health care agencies has spurred a decline of nearly one-third the number of such facilities since 1997.3 Previously viewed as revenue by home care agencies, Medicare skilled nursing visits are now considered to be an expense, further increasing the potential of distancing an ostomy patient from appropriate and adequate care.
Impact on Patients
Over the years, great strides have been made in the surgical techniques involved in creating stomas and the ostomy products used to manage them. Unfortunately, however, today's problems (inadequate, inconsistent care and teaching or little-to-no access to specialized ostomy care nurses) are not new. In an era where patients are being asked to assume more of a financial responsibility for their medical care, this situation not only exacerbates the emotional turmoil inherent in ostomy surgery as it lengthens rehabilitation time, but it also unnecessarily increases the overall costs of care.
What can be done?
Healthcare providers are eagerly searching for ways to improve their financial and clinical outcomes and minimize their exposure to legal liability. Due to the current overwhelming nursing shortage and the small number of certified ostomy nurses, savvy administrators are searching for nurses with specific skills who can have a positive affect on their business.
WOC nurses with a working knowledge of state-of-the-art ostomy care and modern ostomy products can become a valuable asset to any healthcare organization - not just by providing all the hands-on ostomy care, but also by taking a step back from the bedside and serving proactively as resource and teacher for non-specialized staff. This individual should be responsible for establishing standards of care, teaching protocols, providing staff education, evaluating ostomy products, and determining cost-effective ostomy care that matches the organization's patient population.
The burden is on the WOC nurse to recognize and clearly demonstrate the value of ostomy care services through the establishment of a standardized approach throughout an organization and across referring institutions. It's a win-win situation. The healthcare organization wins. The staff nurses win. The WOC nurse wins. And most importantly, the patient wins.
1. Wound Ostomy Continence Nurses Society. Available at: www.wocn.org. Cited: July 22, 2002.
2. McNeil BJ. Shattuck lecture: hidden barriers to improvement in the quality of care. New Engl J Med. 2001;345(22):1612-1620.
3. Department of Health and Human Services. Office of Inspector General. Access to Home Health Care After Hospital Discharge 2001. July 2001. OEI-02-01-00180. Available at: www.oig.hhs.gov. Cited: February 26, 2002.
