Helping Patients Postop: Adjusting to Life With an Ostomy

When caring for a patient who has recently underwent ostomy surgery, there are multiple needs that clinicians should be addressing simultaneously, for example the psychological adjustment to a new body image and a new method of bodily elimination. I remind patients that they only need to tell who they want about their ostomy—and briefly explain to the other person that they had surgery—until the patient is more comfortable discussing it.

The most critical need in the postoperative period is being able to manage the new physical tasks of caring for the ostomy. First, the patient needs to know the who, what, when, and where of emptying the pouch and changing the appliance. Patients recovering from anesthesia often have cognitive deficits,¹ including memory loss and impaired recall. These deficits are compounded by the busy hospital atmosphere and concurrent patient psychological adjustment. To compensate for these issues, there is a lot of repetition in postoperative education. Patients are seen as often as possible in the immediate postoperative period by a certified ostomy nurse for teaching. The goal is that, prior to discharge, the patient is able to empty the pouch independently. Depending on patient comfort, acceptance of the ostomy, and dexterity, they should also be beginning to assist with changing the appliance. Patients are encouraged to participate in the appliance changing process as often as possible, incorporating a “see one, do one” style and using verbal cues as needed, and resorting to hand-over-hand assisting in portions of the appliance change, only if necessary.

No one person can help a patient transition to life postop. It is important to direct new ostomates to other resources, such as online education, ostomy support groups (like those through the United Ostomy Associations of America), programs through manufacturers, home healthcare providers, and, of course, teaching family to help care for and support the patient.

Creating this network of support allows the patient and healthcare team to better triage when issues do arise. We created an outpatient triage tool that has been distributed to health care areas, including registered nurses in the outpatient ostomy clinic that triage phone calls, the emergency department, pharmacies, primary care offices, and urgent cares. Staff at these locations may be less familiar with caring for an ostomy or changing an appliance and can reference the sheet for common patient concerns. The two most commonly encountered problems for newer ostomates are supply related and pouch adherence related.

The outpatient ostomy triage tool addresses these two main issues by first listing several triage questions to assist clinicians. These questions include whether the patient has supplies and where they come from, if the patient is established with the outpatient ostomy clinic and/or home health, if they are enrolled in a manufacturer support program, and whether they can keep an appliance on for at least 24 hours.

Patients who cannot keep the appliance on for at least 24 hours will need to have either an urgent home health visit or an urgent follow-up visit scheduled in the outpatient ostomy clinic. The triage tool includes troubleshooting tips for appliance changes that address common issues preventing appliances from staying in place:

1. Has the stoma been measured recently and is the opening cut to the appropriate size?
2. Is the pouch being emptied prior to being too full?
3. Is the wafer removed gently, or is it ripped off and causing medical adhesive-related skin injuries (MARSI)?
4. Is the skin open AND weeping? Instructions on crusting technique are included.
5. Are they cleaning with warm water only?
6. Is the skin completely dry before applying the appliance?
7. Is there a crease, fold, or scar around the stoma? Instructions on use of stoma ring are included.  

Patients who are in immediate need of supplies are directed to purchase supplies out of pocket from a limited stock of commonly used ostomy products, available at our pharmacies, until durable medical equipment (DME) orders can be created and received. The stock we have made available includes appliances, stoma rings, paste, powder, and skin protectant. Patients who have enough supplies at home can then be directed to manufacturer programs depending on what product they are currently using. These programs allow access to certified ostomy nurses that can also triage other ostomy issues, connect patients with insurance-approved DME suppliers, and typically can ship the patient a few sets of sample supplies. They are a valuable, ongoing resource for the ostomate.  

We know that postoperative educational programs are associated with fewer complications, and lower re-admission rates.^2-4 Health care providers and clinicians receive very little education in ostomy care, and they may not be aware of the myriad of resources available for patients with ostomies who are experiencing issues. An ostomy triage tool is a brief, easy-to-use document that point of contacts can use to direct patients to the correct resources as they adjust to their new normal after surgery.

References

1. Zurek AA, Yu J, Wang DS, et al. Sustained increase in α5GABAA receptor function impairs memory after anesthesia. J Clin Invest. 2014;124(12):5437-5441. doi:10.1172/JCI76669
2. Nagle D, Pare T, Keenan E, Marcet K, Tizio S, Poylin V. Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates. Dis Colon Rectum. 2012;55(12):1266-1272. doi:10.1097/DCR.0b013e31827080c1
3. Hardiman KM, Reames CD, McLeod MC, Regenbogen SE. Patient autonomy-centered self-care checklist reduces hospital readmissions after ileostomy creation. Surgery. 2016;160(5):1302-1308. doi:10.1016/j.surg.2016.05.007
4. American College of Surgeons. Skills programs. Accessed September 20, 2017. https://www.facs.org/education/patient-education/skills-programs.