Evaluation of a real-life experience with a digital fluid balance monitoring technology.

BACKGROUND: Innovations in healthcare technologies have the potential to address challenges, including the monitoring of fluid balance. OBJECTIVE: This study aims to evaluate the functionality and accuracy of a digital technology compared to standard manual documentation in a real-life setting. METHODS: The digital technology, LICENSE, was designed to calculate fluid balance using data collected from devices measuring urine, oral and intravenous fluids. Participating patients were connected to the LICENSE system, which transmitted data wirelessly to a database. These data were compared to the nursing staff's manual measurements documented in the electronic patient record according to their usual practice. RESULTS: We included 55 patients in the Urology Department needing fluid balance charting and observed them for an average of 22.9 hours. We found a mean difference of -44.2 ml in total fluid balance between the two methods. Differences ranged from -2230 ml to 2695 ml, with a divergence exceeding 500 ml in 57.4% of cases. The primary source of error was inaccurate or omitted manual documentation. However, errors were also identified in the oral LICENSE device. CONCLUSIONS: When used correctly, the LICENSE system performs satisfactorily in measuring urine and intravenous fluids, although the oral device requires revision due to identified errors.

Digitizing fluid balance monitoring may offer a solution for optimizing patient care.

BACKGROUND: Precise fluid balance monitoring is essential for patient treatment, as incorrect fluid balance can lead to disorders. OBJECTIVE: This study aimed to assess the accuracy of the digital technology LICENSE (LIquid balanCE moNitoring SystEm) for fluid balance charting and compare it to the standard method (SM) to determine its usability in clinical practice. METHODS: This prospective study included 20 patients. The results from LICENSE were compared to those from SM and a reference measurement (manual weight of fluids, RM). Three LICENSE devices were used for urine output, intravenous fluids, and oral fluid intake. The accuracy of methods was evaluated using Bland Altman plots. RESULTS: The mean difference between LICENSE and RM was less than 2 millilitres (p= 0.031 and p= 0.047), whereas the mean difference between SM and RM was 6.6 ml and 10.8 ml (p< 0.0001). The range between the upper and lower limits of agreement was between 16.4 and 27.8 ml for LICENSE measurements and 25.2 and 52 ml for SM. CONCLUSION: LICENSE is comparable to or more accurate than the standard method for fluid balance monitoring. The use of LICENSE may improve the accuracy of fluid balance measurements. Further research is needed to evaluate its feasibility in daily clinical practice.

Quality of fluid balance charting and interventions to improve it: a systematic review.

INTRODUCTION: Fluid balance monitoring is pivotal to patients' health. Thus, fluid balance charting is an essential part of clinical nursing documentation. This systematic review aimed to investigate and describe the quality of fluid balance monitoring in medical, surgical and intensive care units, with an emphasis on the completeness of charting data, calculation errors and accuracy, and to evaluate methods used to improve fluid balance charting. MATERIALS AND METHODS: Quantitative studies involving adult patients and reporting data on fluid balance monitoring were included in the review. We searched MEDLINE, Embase, CINAHL and the Cochrane Library. The risk of bias in the included studies was assessed using tools developed by the Joanna Briggs Institute. RESULTS: We included a total of 23 studies, which involved 6649 participants. The studies were quasi-experimental, cohort or prevalence studies, and every third study was of low quality. Definitions of 'completeness' varied, as well as patient categories and time of evaluation. Eighteen studies reported the prevalence of patients with complete fluid balance charts; of those, 10 reported that not more than 50% of fluid balance charts were complete. Studies addressing calculation errors found them in 25%-35% of charts, including omissions of, for example, intravenous medications. The reported interventions consisted of various components such as policies, education, equipment, visual aids, surveillance and dissemination of results. Among studies evaluating interventions, only 38% (5 of 13) achieved compliance with at least 75% of complete fluid balance charts. Due to the heterogeneity of the studies, a meta-analysis was not possible. CONCLUSION: The quality of fluid balance charting is inadequate in most studies, and calculation errors influence quality. Interventions included several components, and the impact on the completion of fluid balance charts varied.

Understanding patients' perspectives when unprepared for the emergence of a parastomal bulge-a qualitative study.

AIM: The aim was to investigate patients' experiences of being prepared for the development of a parastomal bulge in relation to a stoma. METHODS: The paper draws on a qualitative interview study conducted with 20 Danish patients participating in five focus groups. Analysis was performed using a phenomenological-hermeneutic approach. RESULTS: We identified three themes. The first theme is 'The unforeseen bulge gives rise to increasing concern and a search for an explanation'. Patients searched for explanations in their own life and suspected that their behaviour or previous illness induced the bulge. The second theme is 'Missing or confusing information leads to counterproductive behaviour'. Patients lacked information on the prevention and treatment of parastomal bulging which led to disappointment with healthcare professionals. The third theme is 'Weighing the pros and cons of life with the bulge against the gamble of surgical repair'. Some patients came to terms with their situation, but for others a deadlocked situation arose when surgical repair was not an option. CONCLUSION: Healthcare communication directly impacts on patients' experiences and outcomes. When unprepared for the emergence of a parastomal bulge, patients' emotional and psychological well-being are affected and likewise patients' possibility of using their own health beliefs as a preventive strategy. To preserve patient autonomy, satisfaction and well-being, surgeons and stoma nurses should provide patients with tailored information bearing in mind the current lack of clear evidence on the prevention and treatment of parastomal bulging.

Treatment of incisional and parastomal hernias in Denmark.

Incisional and parastomal hernias are frequent complications after abdominal surgery. Patients with relevant symptoms should be referred to the local surgical department for diagnosis and indication for surgery. Patients with giant and parastomal hernias are referred to one of the five Danish regional hernia centres. Patients with parastomal hernias often benefit from being referred to a stoma nurse. The most frequent complications after hernia repair are wound complications and recurrence. In case of severe wound infection, incarceration, or strangulation the patient must always be referred acutely, as argued in this review.

Management of treatment-related sequelae following colorectal cancer.

AIM: Colorectal cancer survivors are one of the most rapidly growing groups of patients living with and beyond cancer. In a national multidisciplinary setting, we have examined the extent of late treatment-related sequelae in colorectal cancer survivors and present the scientific evidence for management of these conditions in this patient category with the aim of facilitating identification and treatment. METHOD: A systematic search for existing guidelines and relevant studies was performed across 16 and 4 databases, respectively, from inception to 2021. This yielded 13 guidelines and 886 abstracts, of which 188 were included in the finalized guideline (231 included for full text review). Secondarily, bibliographies were cross-referenced and 53 additional articles were included. RESULTS: Symptoms have been divided into overall categories including psychosocial, bowel-related, urinary, sexual (male and female), pain/neuropathy and fatigue symptoms or complaints that are examined individually. Merging and grading of data resulted in 22 recommendations and 42 management strategies across categories. Recommendations are of a more general character, whereas management strategies provide more practical advice suited for initiation on site before referral to specialized units. CONCLUSION: Treatment-related sequelae in colorectal cancer survivors are common and attention needs to be focused on identifying patients with unmet treatment needs and the development of evidence-based treatment algorithms.

Update Systematic Review, Meta-Analysis and GRADE Assessment of the Evidence on Parastomal Hernia Prevention-A EHS, ESCP and EAES Collaborative Project.

Objective: To perform a systematic review and meta-analysis on the effectiveness of prophylactic mesh for the prevention of parastomal hernia in end colostomy, with the ultimate objective to summarize the evidence for an interdisciplinary, European rapid guideline. Methods: We updated a previous systematic review with de novo evidence search of PubMed from inception up to June 2022. Primary outcome was quality of life (QoL). Secondary outcomes were clinical diagnosis of parastomal hernia, surgery for parastomal hernia, and 30 day or in-hospital complications Clavien-Dindo ≥3. We utilised the revised Cochrane Tool for randomised trials (RoB 2 tool) for risk of bias assessment in the included studies. Minimally important differences were set a priori through voting of the panel members. We appraised the evidence using GRADE and we developed GRADE evidence tables. Results: We included 12 randomized trials. Meta-analysis suggested no difference in QoL between prophylactic mesh and no mesh for primary stoma construction (SMD = 0.03, 95% CI [-0.14 to 0.2], I2 = 0%, low certainty of evidence). With regard to parastomal hernia, the use of prophylactic synthetic mesh resulted in a significant risk reduction of the incidence of the event, according to data from all available randomized trials, irrespective of the follow-up period (OR = 0.33, 95% CI [0.18-0.62], I2 = 74%, moderate certainty of evidence). Sensitivity analyses according to follow-up period were in line with the primary analysis. Little to no difference in surgery for parastomal hernia was encountered after pooled analysis of 10 randomised trials (OR = 0.52, 95% CI [0.25-1.09], I2 = 14%). Finally, no significant difference was found in Clavien-Dindo grade 3 and 4 adverse events after surgery with or without the use of a prophylactic mesh (OR = 0.77, 95% CI [0.45-1.30], I2 = 0%, low certainty of evidence). Conclusion: Prophylactic synthetic mesh placement at the time of permanent end colostomy construction is likely associated with a reduced risk for parastomal hernia and may confer similar risk of peri-operative major morbidity compared to no mesh placement. There may be no difference in quality of life and surgical repair of parastomal hernia with the use of either approach.

EHS Rapid Guideline: Evidence-Informed European Recommendations on Parastomal Hernia Prevention-With ESCP and EAES Participation.

Background: Growing evidence on the use of mesh as a prophylactic measure to prevent parastomal hernia and advances in guideline development methods prompted an update of a previous guideline on parastomal hernia prevention. Objective: To develop evidence-based, trustworthy recommendations, informed by an interdisciplinary panel of stakeholders. Methods: We updated a previous systematic review on the use of a prophylactic mesh for end colostomy, and we synthesized evidence using pairwise meta-analysis. A European panel of surgeons, stoma care nurses, and patients developed an evidence-to-decision framework in line with GRADE and Guidelines International Network standards, moderated by a certified guideline methodologist. The framework considered benefits and harms, the certainty of the evidence, patients' preferences and values, cost and resources considerations, acceptability, equity and feasibility. Results: The certainty of the evidence was moderate for parastomal hernia and low for major morbidity, surgery for parastomal hernia, and quality of life. There was unanimous consensus among panel members for a conditional recommendation for the use of a prophylactic mesh in patients with an end colostomy and fair life expectancy, and a strong recommendation for the use of a prophylactic mesh in patients at high risk to develop a parastomal hernia. Conclusion: This rapid guideline provides evidence-informed, interdisciplinary recommendations on the use of prophylactic mesh in patients with an end colostomy. Further, it identifies research gaps, and discusses implications for stakeholders, including overcoming barriers to implementation and specific considerations regarding validity.

Life with a stoma across five European countries-a cross-sectional study on long-term rectal cancer survivors.

PURPOSE: Stoma-related problems are known to be important to patients and potentially affect everyday life. The prevalence of stoma-related problems in rectal cancer survivors remains undetermined. This study aimed to examine aspects of life with a long-term stoma, stoma management, and stoma-related problems and explore the impact of stoma-related problems on daily life. METHODS: In total, 2262 patients from 5 European countries completed a multidimensional survey. Stoma-related problems were assessed using the Colostomy Impact score. Multivariable regression analysis, after adjusting for potential confounding factors, provided odds ratio (OR) and 95% confidence intervals (CI) for stoma-related problems' association with restrictions in daily life. RESULTS: The 2262 rectal cancer survivors completed the questionnaire at a median of 5.4 years (interquartile range 3.8-7.6) after stoma formation. In the total sample, leakage (58%) and troublesome odour (55%) were most prevalent followed by skin problems (27%) and pain (21%). Stoma-related problems were more prevalent in patients with parastomal bulging. A total of 431 (19%) reported feeling restricted in daily activities in life with a stoma. Leakage, odour, skin problems, stool consistency, and frequent appliance changes were significantly associated with restrictions in daily life. The highest risk of experiencing restrictions was seen for patients having odour (OR 2.74 [95% CI: 1.99-3.78]) more than once a week and skin problems (OR 1.77 [95% CI: 1.38-2.27]). CONCLUSION: In this large cohort with rectal cancer, stoma-related problems were highly prevalent and impacted daily life. Supportive care strategies should entail outreach to patients with a long-term stoma.

Assessment of a support garment in parastomal bulging from a patient perspective: a qualitative study.

AIM: To investigate patients' experiences of the assessment of support garments in relation to a parastomal bulge. METHODS: We conducted a qualitative study with semi-structured interviews preceded by field observations. The 11 in-dept interviews were analysed using interpretative phenomenological analysis. RESULTS: In the assessment process patients lacked information from professionals on the advantages, disadvantages as well as criteria for choosing between garments.Garments had to fit patients' needs and personal preferences; being comfortable, flexible and user-friendly. The garment created new possibilities and challenges; well-assessed garments reduced symptoms while poorly assessed worsened or induced symptoms and ended up unworn. When comorbidities were not accounted for, garments were unmanageable to patients. Patients needed guidance on how to apply and use the garment. Lack of hands-on-guidance left patients confused and helpless with unworn garments. Re-assessment of a garment before it could be worn was time consuming, stressful and required patients' physical and mental resources. CONCLUSION: Exploring patients' expectations, symptoms, needs and comorbidity was vital for patients' subsequent use and benefit of garments. Tailor-made information, hands-on-guidance and professional assistance are important in the assessment process. Interventions to support a patient centred, individual and systematic approach is warranted.

Patients' experiences of abdominal exercises after stoma surgery: a qualitative study.

PURPOSE: Abdominal exercises are being advocated after stoma surgery and investigated in clinical research. Little is known about the patients' perspective of doing abdominal exercises in the first three months after getting a stoma. The aim of this study was to explore patients' experiences with and attitudes toward abdominal exercises after stoma surgery. MATERIALS AND METHODS: Patients with a new ileostomy or colostomy were invited to participate in an interview after having performed a set of abdominal exercises one time as part of a preceding study. Semi-structured interviews were conducted at inpatient wards and outpatient clinics at two hospitals. Audio recordings were transcribed to text verbatim and analyzed with inductive content analysis. RESULTS: Analysis of 14 interviews resulted in four categories: "The attitude toward abdominal exercises is positive"; "Treatment and illness form barriers to abdominal exercises"; "Wish for help with abdominal exercises after stoma surgery"; and "Abdominal exercises are experienced as being easy". CONCLUSIONS: Participants with a new stoma wished for guidance in abdominal exercises. Health professionals should be aware of potential barriers to participation in abdominal exercise in patients with a stoma. Abdominal exercises were easy to perform with a stoma in a supervised setting.Implications for rehabilitationParticipants were positive toward abdominal exercises, and the stoma was rarely in the way.Help and guidance with abdominal exercises is important after stoma surgery.Health professionals should consider possible barriers and concerns to exercise.

Physical activity after colorectal cancer surgery-a cross sectional study of patients with a long-term stoma.

PURPOSE: Physical activity is recommended to cancer survivors by the World Health Organisation (WHO) and is associated with improved survival after colorectal cancer. It remains unclear whether having a stoma is a barrier for an active lifestyle. We examined the level of physical activity and explored factors impacting physical activity in survivors with a stoma. METHODS: A total of 1265 (65%) patients in the Danish Stoma Database completed a multidimensional survey. Physical activity of moderate- and vigorous-intensity was assessed using two validated questions. Based on WHO guidelines, physical activity was categorised into 'Meeting' or 'Not Meeting' recommendations. Multivariate regression analysis, adjusting for potential confounders, provided odds ratio (OR) and 95% confidence intervals (CI) for factors' association with'Not Meeting' guideline recommendations. RESULTS: In total, 571 patients with colorectal cancer reported on physical activity at a median of 4.3 years (interquartile range 3.1-5.8) after stoma surgery. Two hundred ninety-three patients (51%) were 'Meeting recommendations' and 63% of them were 'Highly active'. Two hundred seventy-eight were 'Not meeting' recommendations (49%). Of the factors analysed, patients without support garment were more likely (OR 1.72 [95% CI 1.16; 2.54] not to meet guideline recommendations. We found no association between stoma type, surgical procedure, parastomal bulging and 'problematic stoma' and level of physical activity, respectively. CONCLUSION: In this large sample of survivors with a stoma half of patients met or exceeded guideline recommendations. Of patients not meeting recommendations some could potentially meet the recommendations by modest increases in either moderate or vigorous activity.

On the frontline treating COVID-19: A pendulum experience-from meaningful to overwhelming-for Danish healthcare professionals.

OBJECTIVES: In the current study, we aimed to explore the experiences and attitudes among healthcare professionals as they transitioned from their familiar disciplines to respiratory medicine, intensive care or other departments during the first wave of the COVID-19 pandemic. BACKGROUND: In preparation for the increasing number of patients suspected of having or who would be severely ill from COVID-19, a major reconstruction of the Danish Healthcare System was initiated. The capacity of the healthcare system to respond to the unprecedented situation was dependent on healthcare professionals' willingness and ability to engage in these new circumstances. For some, this may have resulted in uncertainty, anxiety and fear. DESIGN: The study was a descriptive study using semi-structured focus group interviews. Healthcare professionals (n = 62) from seven departments were included, and 11 focus group interviews were conducted. The focus group interviews took place during June 2020. Analyses was conducted using thematic analysis. The current study was reported using the consolidated criteria for reporting Qualitative research (COREQ). RESULTS: Healthcare professionals experiences was described by five themes: 1) Voluntary involvement, 2) Changes within the organisation, 3) Risks, 4) Professional identity and 5) Personal investment. Common to all five themes was the feeling of being on a pendulum from a meaningful experience to an experience of mental overload, when situations and decisions no longer seemed to be worthwhile. CONCLUSIONS: Healthcare professionals experienced a pendulum between a meaningful experience and one of mental overload during the COVID-19 pandemic. The swinging was conditioned by the prevailing context and was unavoidable. RELEVANCE TO CLINICAL PRACTICE: To balance the continuous pendulum swing, leaders must consider involvement, and to be supportive and appreciative in their leader style. This is consistent with a person-centred leadership that facilitates a well-adjusted work-life balance and may help prevent mental overload developing into burnout.

Impact of a Parastomal Bulge on Quality of Life - A Cross-sectional Study of Patients From the Danish Stoma Database.

OBJECTIVE: To investigate stoma specific and generic HRQoL in patients with and without a parastomal bulge. BACKGROUND: Most patients have to live with their stoma complicated by a parastomal bulge. How this affects quality of life remains unclear. METHODS: Patients in the Danish Stoma Database completed the Short-form 36 health survey and the stoma-QOL questionnaire. Linear regression analysis, adjusted for potential confounding factors, provided mean and mean score differences and 95% confidence intervals for each HRQoL scale and item. Cohens d provided estimates of effect size. RESULTS: A total of 1265 patients (65%) completed the questionnaire 4.4 (interquartile range 3.1-6.0) years after stoma surgery. Of these, 693 (55%) patients with a parastomal bulge had significantly impaired (P < 0.01) HRQoL across all stoma specific and generic health domains compared to patients without a parastomal bulge. In patients with a benign diagnosis or an ileostomy, a parastomal bulge impacted significantly on Social Functioning and Mental Health resulting in a worse Mental Component Summary. A large bulge >10 cm impaired HRQoL (P < 0.01) across all stoma specific and generic domains. The impact on HRQoL was independent of time with the bulge. CONCLUSIONS: A novel finding in this large, unselected sample from high-quality regional registries was that parastomal bulging was associated with substantial and sustained impairment of HRQoL.

Living with a parastomal bulge - patients' experiences of symptoms.

AIMS AND OBJECTIVES: To investigate experienced symptoms of parastomal bulging in relation to an ileostomy or colostomy. BACKGROUND: Parastomal bulging is a common complication of stoma formation that can affect patients' physical, psychological and social function. Symptom burdens reported by health professionals vary from asymptomatic to high symptom load; however, patients' experiences of symptoms are lacking. DESIGN AND METHOD: A qualitative design with focus group interviews was chosen for data collection. Twenty patients participated in five semi-structured interviews. Analysis was performed using a phenomenological-hermeneutic approach. FINDINGS: The bulge caused different unfamiliar bodily sensations that interacted with patients' everyday lives. Some but not all of these sensations were modifiable. As the bulge and the ostomy changed size and shape, patients had to adjust and readjust stoma care continuously. The physical change called for patients' awareness and posed a threat to patients' control of the ostomy and challenged stoma self-care. The bulge caused a bodily asymmetry that deformed the patients' bodies in a way that exceeded the perceived alteration already caused by the stoma. To cover the physical disfigurement, new clothing solutions, garment wear and creativity were essential in everyday life. Patients gradually adapted to the bulge over time. Easy access to professional help was crucial in order to find the best appliance and garment solution in relation to the bulge. CONCLUSIONS: Various symptoms related to the parastomal bulge affected patients' everyday lives in different ways and underpinned that an individualised approach is important when addressing patients' problems and complaints. Research into nonsurgical treatments and patient perspectives is limited and highly warranted to improve clinical outcome. RELEVANCE TO CLINICAL PRACTICE: The ever-changing bulge posed a threat to patients' control of the ostomy and required specific care from the stoma therapist. Needs-based access to counselling, advice and supplementary materials is important.

Post-discharge symptoms following fast-track colonic cancer surgery: a phenomenological hermeneutic study.

OBJECTIVE: To obtain knowledge of patients' experiences of postoperative symptoms during the initial two weeks following fast-track colonic cancer surgery. METHOD: Semi-structured in-depth interviews with seven colonic cancer patients two weeks post hospital discharge. Analysis was performed using a phenomenological hermeneutical approach. RESULTS: During the first two weeks after discharge the patients experienced unfamiliar symptoms that affected their everyday lives. Despite distressing symptoms, they applied a "wait-and-see" strategy, and only reacted when symptoms became intolerable. The patients failed to report their unfamiliar symptoms during hospital nurse follow-up telephone call. While waiting for the final histology patients suffered loss of sleep and chaotic thinking, and experienced ambiguity of hoping for the best and expecting the worst. CONCLUSION: Although fast-track surgery programmes lead to shorter hospitalisation and improved physical performance, post-colonic surgery patients experience various symptoms after discharge. Healthcare professionals need to address symptoms that might have immediate and long-term consequences on patients' everyday life. Follow-up studies are encouraged to explore the patient perspective to identify the needs of individual patients after hospital discharge.