CASE STUDY

A Patient-Centered Remote Care Pathway To Manage Postoperative Complications In Ostomates

Introduction

Patients that undergo surgery resulting in a stoma (ileostomy or colostomy) suffer a significant burden of morbidity in terms of increased length of stay, increased hospital readmissions for dehydration and acute kidney injury, skin complications and impaired quality of life (1). There is a wide variation in both the patient education and perioperative support offered. We aimed to design a patient-centered care pathway, incorporating remote patient monitoring and telehealth technologies and focused on the outcomes that matter most to patients.

Methods

An extensive literature search identified perioperative interventions most likely to improve outcomes in stoma patients. An advisory group was convened consisting of current and previous stoma patients (n=25) and senior clinicians experienced in managing stoma patients(n=13). Further surveys were conducted at the American Society of Colorectal Surgeons annual conference (Nashville, 2018 n=78) and the World Ostomy and Continence Nurse Society meeting (Reading, 2018 n=51). A structured qualitative process identified the most important features to each group. A clinical pathway was proposed, and a team of engineers and developers assessed the technical feasibility before starting development. Individual aspects of the pathway were prototyped and rapidly iterated in consultation with the advisory group.

Results

A literature review identified that educational interventions and peer support programs are effective in empowering stoma patients to self-manage and improved monitoring of patient hydration status can reduce complications including readmissions and improve quality of life. (2) (3) (4). These interventions are also highly acceptable to patients.

Issues most frequently raised by patients as intrusive to their quality of life were skin irritation (83%), detecting and minimizing leakage (40%), frequency of bag changes (17%), and the ability to differentiate fluid output from gas (19%). Clinicians were overwhelmingly concerned about the cumulative volume of stoma output (100%). 59% reported they had recommended admission purely to monitor stoma output. and indicated that the ability to remotely monitor this would shorten length of stay and prevent readmission (99%).

Conclusions

A novel model of care was developed using remote monitoring, peer support, telehealth nursing and home healthcare components. Remote monitoring is provided through a ‘smart’ stoma bag and base-plate system (11 Health and Technologies Inc.), an FDA approved product which utilizes capacitive and thermal data to map stoma output and saturation of the base-plate in real time. Patient-level alerts inform a patient of a full bag or of an impending leak. All patients are paired with a peer who is a current or previous stoma patient, trained as a health coach to provide education and support. Ongoing health concerns including dehydration or skin issues can be escalated to a telehealth nurse who has access to telemetry from the platform. If features of dehydration are present, IV rehydration can be arranged in the patient's own home. The impact of this pathway on readmissions and other complications is currently being assessed.

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11 Health and Technologies

References

1. Kwiatt M, Kawata M. Avoidance and management of stomal complications. Clin Colon Rectal Surg. 2013;26(2):112-21.

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):1266-72.

3. Hardiman KM, Reames CD, McLeod MC, Regenbogen SE. Patient autonomy-centered self-care checklist reduces hospital readmissions after ileostomy creation. Surgery. 2016.

4. Thorpe G, McArthur M, Richardson B. Healthcare experiences of patients following faecal output stoma-forming surgery: a qualitative exploration. Int J Nurs Stud. 2014;51(3):379-89.