To the Editor:
Goldberg M, Aukett LK, Carmel J, Fellows J, Pittman J; Ostomy Guidelines Task Force. Management of the patient with a fecal ostomy: best practice guideline for clinicians. J Wound Ostomy Continence Nurs. 2010;37(6):596-598.
Among the questions developed to guide evidence-based review of the literature, the ubiquitous one addressing stoma site marking is there, as it is in most of the articles devoted to exploring or explaining efficacy of stomal management outcomes. What is lacking is the twin adjunct to stoma site marking, namely, stomal construction. I rarely see this important point identified or explored alongside its rightful placement twin. What happened to the phrase stoma siting and construction as inseparable antecedents to better ostomy management outcomes? I strongly suspect that many WOC nurses would readily admit to the impacts, positive and negative, of stomal construction as a determinant for outcomes of ostomy lifestyle management. Why is this important determinant being overlooked?
On the matter of ostomy education, the article identifies pre- and postoperative time frames; however, there is no further delineation of how much time postoperatively should the key educational components be imparted. Furthermore, by grouping pre- and postoperative times within the discussion, there is an implicit understanding of the overall perioperative time frame being addressed. If we recognize that pre- and postoperative times are very much a changing concept, with increasingly shortened hospital stays and, hence, truncated perioperative time frames, when do we recharacterize the notion of postoperative time frame to something more in tune with the changing landscape of extended time frames? Put another way, just how long after the operation is the WOC nurse to take in order to successfully impart the education needed for effective ostomy management? Are there seamless processes in place to ensure these outcomes? The article does not address this notion of a seamless process. I know that the authors are aware of the persistent challenges facing ostomy patients as they transition from the acute (perioperative) to the postacute care arenas. No matter how well-intentioned the notion of evidence-based guidelines, if the teaching goals are not seamlessly and adequately met then what value do the guidelines really possess, and for whom?
Aronovitch SA, Sharp R, Harduar-Morano L. Quality of life for patients living with ostomies: influence of contact with an ostomy nurse. J Wound Ostomy Continence Nurs. 2010;37(6):649-653. I commend the authors for finally admitting to a potential cause for the mixed results of WOC nurse interventions reported elsewhere. Although the relevant sentence is revealed in the body of the text as an aside, it does, nevertheless, get to the heart of the problem of why WOC nurse intervention has not been conclusively shown to be beneficial to newly formed ostomates. To state, "It is likely that not all patients with an ostomy had received adequate pre- and postoperative teaching and counseling," is to affirm what has been a bone of contention bedeviling me, and I suspect many other observers of ostomy nursing practice for some time.
There may be some good that arises from such an admission. I can envision a study or 2 that finally asks the question: What kind of WOC patient contact positively affects ostomy management outcomes? Now, this is the kind of study that should put to the rest the ambiguity that persists about the impacts of current WOC nurse ostomy interventions.
Response:
We appreciate the interest in the article and the thoughtful inquiries regarding the content. It is worth noting that the guidelines are a review of the literature, in an effort to encourage evidence-based practice, and this article is a summary of the guideline, not the actual guideline itself.
First, about the questions regarding stomal construction as adjuvant to stomal site selection.
In the actual guideline, on page 5 there is a paragraph on stomal construction describing the surgical creation of the stoma. However, stoma construction is a surgical concern and not a modifiable characteristic. The WOC nurse develops strategies to manage the complications that may arise from the construction but not the construction itself. There was not any evidence that we found discussed stoma construction in conjunction with stoma site marking.
As for ostomy education, it is cited in the guidelines with a time frame of 3 to 4 postoperative education visits. Recommendations for the content of pre- and postoperative education are described. However, we did not state any timeframe for when the pre- or postoperative education should occur. We did not limit this education to the hospital stay; in fact, we described the shortened length of stay as a limitation that the patient faces. Therefore, this guideline links preoperative to postoperative education without defining any limitations of time. No evidence was identified that a time frame for education can be recommended as this is an individual issue depending on too many factors to be prescribed.
The article does not address "a seamless process," since the guidelines themselves are not a process, but rather a compilation of the current evidence.
Again, we appreciate the thoughtful comments relating to the guidelines and the opportunity to highlight some of the areas of interest.
Mike D'Orazio, ET
Broomall, Pennsylvania
-Margaret Goldberg, MSN, RN, CWOCN
Chair, WOCN Guidelines Task Force