Patient Held Stoma Diary Today I am going to present our patient held diary and the results of the small pilot study. Anne Haston, Isla Ramsay, SHEENA LESLIE, LOUISE HOOLIGHAN

I would like to give you a background to our service in Lothian This is just to show you the area we cover

Our Service Our team consists of four nurses (Band 7, Band 6 and two Band 5s). There are 13 Colorectal Surgeons and 5 Urology Consultants. Annually, we see 300 new colorectal and 50 new Urostomy patients Our working hours at present are Monday to Friday and do not include weekends or on call cover. Having gone through various changes we are now a team of 4 with thanks to Anne Donaldson, Catherine Crombie and Catriona Rostron

What we do Cover NHS Lothian 4 clinics weekly WGH Cover NRIE Monthly clinics – St John’s Hospital Bonnyrigg Community Hospital Roodlands Hospital Community Visits Wards Lecturing/training Surgical siting This is what we do that others don’t see. Staff in the wards don’t realise that we don’t just visit ward patients.

A stoma is a surgically created opening of the intestinal or urinary tract on to the body surface. I thought for those of you who don’t know what a stoma is I would briefly show you

Stomas TEMPORARY – May be a loop stoma PERMANENT – Will be an end stoma UROSTOMY WILL ALWAYS BE AN END STOMA We look after patients who have a Colostomy, Ileostomy and a Urostomy For those of you who don’t know what a stoma looks like .....

Colostomy Colostomy nearly always on the left hand side

Ileostomy Nearly always on the right hand side

Urostomy Nearly always sited on the left hand side, but if the patient golf's we often site on the other side!

Stoma Problems This shows some of the problems we encounter with patients and we attempt to manage. These can often be extremely time consuming.

Stoma patients often feel: Embarrassment Shame Anger Disgust Depressed Unacceptance Changes in body image Grief from lowered self esteem Fear of leakage Rejection and being naked And what about the patients feelings? Spending time with patients is vital to their recovery, as they can feel a whole range of conditions

Ward Patients The stoma team were often seen to be the reason for delayed discharge due to patients not being able to manage their own stoma care. Staff not always confident to undertake routine stoma care Early discharges – ERAS Laparoscopic patients The reason for the patient held diary

Patient Held Diary Encourage patients to take ownership of their stoma Evaluation tool to enable outcomes to be audited SO we decided to develop a patient held diary We thought if we empower the patient to take ownership of their stoma It encourages them to participate in their stoma care early, and research shows the earlier a patient is involved in this then the quicker their acceptance of their stoma It would prompt staff to assist with stoma care

Pilot Study 10 Elective Laparoscopic colorectal stoma patients 10 Elective laparotomy colorectal stoma patients We chose a small trial sample

What did we want to achieve? To see how many patients manage their own stoma care by Day 3-4. To see if there was any difference between the two different groups, Laparoscopic and Open surgery. Was the reason for surgery an influencing factor to discharge date? Was the age of the patient an influencing factor to discharge date? Would ward staff be encouraged by the patient being more actively involved in their stoma care due to the diary? Literature does show that the quicker a patient participates in their own stoma care encourages acceptance

Method The diary is explained preoperatively and given to the patient postoperatively on Day 1. If referred in time, we see all elective patients prior to surgery, the diary is mentioned to them and given to them on admission.

Our stoma team designed a patient held diary, with daily goals, to encourage patients to take ownership of their stoma. This is also used as an evaluation tool to enable outcomes to be audited. By using the patient care diaries, we have achieved 40% patients within our group being discharged from our service by 4 days post op. A further 35% patients discharged by 5 days. This left 25% patient being discharged at 6 days or more post op.

Was the reason for surgery an influencing factor to discharge date? Was the reason for surgery an influencing factor to discharge date? These results also show on average a faster discharge date for Ulcerative Colitis patients as opposed to those with Colorectal Cancers.  

Although a small data set, these results show that overall the discharge date was earlier for patients with laparoscopic bowel resection for colorectal cancers than for the patients having open laparotomy. Similarly, laparoscopic bowel resection for Ulcerative Colitis had a quicker discharge date compared to those having open laparotomy

  Was the age of the patient an influencing factor to discharge date? From the data collected we also found that the there was little correlation between age/sex of the group and discharge.

Main conclusions Laparoscopic patients were discharged from the service much quicker. With both laparoscopic and open patients, there was a correlation between the patient’s diagnosis and the speed at which they were discharged from the stoma service. The Ulcerative Colitis patients had much faster discharge than those with procedures for Colorectal Cancers.

SERVICE COMPARISON Following the implementation of the patient held diary, we wanted to compare our current service to other Stoma services in Scotland to see where we can improve. Anecdotal evidence from the diaries, suggested that patients were asking for Staff to observe their stoma care however did not always receive the support they required

We asked Scottish Stoma Nurses… Do ward staff routinely carry out stoma care? 15% Always 70% Sometimes 15% Rarely

Do you visit all stoma patients Day 1 post operatively 90% Yes 10% No Of note only 1 of these nurses work weekends Interestingly 90% say yes, although only 1 of these nurses work weekends

In our unit, we are still finding variation in Stoma care delivery to support patients at the weekends, this is supported by anecdotal evidence from the patient diaries. Furthermore, patients often felt guilty asking ward staff for support and made minimal demands. Due to stoma care nurses taking responsibility for stoma care, it could be said that this may have allowed ward nurses to less confident in delivering Stoma Care. As a Stoma team, we firmly believe that to facilitate early discharge and to encourage patients to take ownership of their stoma, it is important to educate the patient pre- operatively and prepare them as much as is possible. Furthermore, providing support and encouragement on day one is crucial for the start of their postoperative journey.

Recommendations for future practice Need for further studies into where we can improve our practice. Requirement of 7 day working Continue to roll out competencies for staff Training the Trainer ( ongoing programme) The aim will be to have the majority of our patients participating in their stoma care between day one and day three postoperatively supported by confident ward staff. Our sample size was small, we will continue to continuously audit these. Of note, we developed the staff competencies and started Training the Trainer Another, recommendation for future practice is to look at developing an e-learning module for all staff.

Thanks for listening!