Key stakeholders' perspectives: A gap analysis of hospital-acquired pressure injuries.

INTRODUCTION: Hospital-acquired pressure injuries (HAPIs) are a global high-stakes patient safety issue. Key stakeholder perspectives regarding their role and experiences with pressure injuries is critical as part of the solution to minimizing HAPI occurrence and attain sustainability. DESIGN: A qualitative, descriptive approach provided multiple perspectives of key stakeholders to support the complexity of HAPI care. The qualitative data are a part of a mixed method convergent research study examining pressure injury prevention and management practices. METHODS: Nursing system theory, mixed method convergent design, and participatory action research methodologies were chosen to address both the gap analysis development and results, achieve collaborative comprehensiveness, and enable key stakeholder involvement throughout this HAPI prevention and management initiative. Participants were recruited and enrolled from a large Level I trauma hospital and the key stakeholders. Demographic information were collected prior to the individual interview. Focused interviews were conducted virtually using zoom technology. Qualitative data were analyzed using NVivo software and thematic analysis was confirmed across the co-investigators for congruence and applicability to the research questions. RESULTS: Qualitative interviews with 26 key stakeholders provided data to support and integrate a link with gap analysis results on the complex health issue of HAPIs. Specific barrier and recommendation themes identified interventions that could be prioritized. The 52 barrier and 52 recommendation themes/sub-theme(s) respectively were organized by Donabedian (structure, process, and outcome) with structure elements the majority. The top three structure barrier themes involved equipment and standards for use, staff prevention education, and specialized health professionals. The top three structure recommendation themes involved specialized health professionals, equipment and standards for use, and an educational plan for those at risk or with HAPIs. CONCLUSION: The article provides findings from the qualitative portion of a mixed method study related to HAPIs. The qualitative findings associated with the gap analysis quantitative results, achieved the goal of the participatory action research key stakeholders' input into HAPI care and can be replicated internationally. CLINICAL RELEVANCE: The benefit of key stakeholder's involvement in solving a clinical problem is sustainability. A quantitative approach and integrating qualitative stakeholders' perspectives provide an in-depth solution that will advance nursing capacity toward health care delivery and HAPI nursing science and policy development on a global level.

Pressure Injury Prevention and Wound Management for the Patient Who Is Actively Dying: Evidence-Based Recommendations to Guide Care.

Preventing pressure injuries and wound deterioration can be challenging for the patient at the end of life. Pressure injuries are often deemed unavoidable when a patient is actively dying; however, the time frame for this process is variable. As the skin fails in an actively dying patient, interventions should align with the patient and family's goals. This integrative literature review defines essential concepts to pressure injury and wound management during this final stage of life including (1) actively dying, (2) end of life, (3) palliative care, and (4) comfort measures. We also provide clinically relevant, evidence-based recommendations for pressure injury prevention and wound management of the patient who is actively dying.

Lessons Learned About Peristomal Skin Complications: Secondary Analysis of the ADVOCATE Trial.

PURPOSE: The aims of this study were to (1) describe the demographic and clinical characteristics of the individuals with peristomal skin complications (PSCs); (2) describe the PSCs; (3) examine the relationship of PSC occurrence and severity with possible risk factors, and (4) describe how PSCs were managed clinically. DESIGN: Secondary analysis of data from randomized controlled study, the ADVOCATE trial. SUBJECTS AND SETTING: Study participants (n = 153) were divided into 2 groups: those who did not experience a PSC (n = 80) and those who did (n = 73). A participant was considered to have sustained a PSC during the original study if his or her Discoloration, Erosion, and Tissue score increased above the baseline score. METHODS: Demographic and pertinent characteristics of participants with and without PSCs were compared. In addition, data from the 73 participants who sustained PSCs were further analyzed to characterize and describe the PSCs, to investigate potential risk factors associated with the occurrence and severity of a PSC, and for clinical management. Group comparisons were made via t tests for continuous variables, χ test or Fisher exact test for categorical variables, and generalized linear models for identification of risk factors. RESULTS: The majority of the PSCs were mild or moderate in nature, and they were most commonly categorized by the investigators as irritant dermatitis. Two risk factors were associated with an increased likelihood of experiencing a PSC: stoma duration and peristomal skinfold or creases. Within the study period, the odds of sustaining a PSC increased over time and the presence of skinfolds or creases increased the likelihood of PSCs. Peristomal skin complication severity was likely to be worse with an ileostomy and less severe as stoma duration increased. Products used to manage PSCs consisted of barrier rings/seals, skin barrier powder, and paste or paste strips. CONCLUSIONS: Ileostomy is associated with higher risk of a severe PSC and peristomal skin creases or folds. Patient follow-up should be on a structured schedule beyond the first few weeks after surgery because the likelihood of getting a PSC increases over time. This approach may help improve outcomes, particularly for those with an ileostomy and challenging skin contours.

Evaluation of Web-Based Ostomy Patient Support Resources.

PURPOSE: To evaluate currently available, no-cost, Web-based patient support resources designed for those who have recently undergone ostomy surgery. DESIGN: Descriptive, correlational study using telephone survey. SAMPLE AND SETTING: The sample comprised 202 adults who had ostomy surgery within the previous 24 months in 1 of 5 hospitals within a large healthcare organization in the Midwestern United States. Two of the hospitals were academic teaching hospitals, and 3 were community hospitals. METHODS: The study was divided into 2 phases: (1) gap analysis of 4 Web sites (labeled A-D) based on specific criteria; and (2) telephone survey of individuals with an ostomy. In phase 1, a comprehensive checklist based on best practice standards was developed to conduct the gap analysis. In phase 2, data were collected from 202 participants by trained interviewers via 1-time structured telephone interviews that required approximately 30 minutes to complete. Descriptive analyses were performed, along with correlational analysis of relationships among Web site usage, acceptability and satisfaction, demographic characteristics, and medical history. RESULTS: Gap analysis revealed that Web site D, managed by a patient advocacy group, received the highest total content score of 155/176 (88%) and the highest usability score of 31.7/35 (91%). Two hundred two participants completed the telephone interview, with 96 (48%) reporting that they used the Internet as a source of information. Sixty participants (30%) reported that friends or family member had searched the Internet for ostomy information on their behalf, and 148 (75%) indicated they were confident they could get information about ostomies on the Internet. Of the 90 participants (45%) who reported using the Internet to locate ostomy information, 73 (82%) found the information on the Web easy to understand, 28 (31%) reported being frustrated during their search for information, 24 (27%) indicated it took a lot of effort to get the information they needed, and 39 (43%) were concerned about the quality of the information. CONCLUSION: Web-based patient support resources may be a cost-effective approach to providing essential ostomy information, self-management training, and support. Additional research is needed to examine the efficacy of Web-based patient support interventions to improve ostomy self-management knowledge, skills, and outcomes for patients.

WOCN Society and AUA Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Urostomy Surgery.

Marking the optimal location for a stoma preoperatively enhances the likelihood of a patient's independence in stoma care, predictable pouching system wear times, and resumption of normal activities. Urologists and certified ostomy nurses are the optimal clinicians to select and mark stoma sites, as this skill is a part of their education, practice, and training. However, these providers are not always available, particularly in emergency situations. The purpose of this position statement, developed by the Wound, Ostomy and Continence Nurses Society in collaboration with the American Urological Association and the American Society of Colon and Rectal Surgeons, is to provide a guideline to assist clinicians (especially those who are not surgeons or WOC nurses) in selecting an effective stoma site.

WOCN Society and ASCRS Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Colostomy or Ileostomy Surgery.

Marking the optimal location for a stoma preoperatively enhances the likelihood of a patient's independence in stoma care, predictable pouching system wear times, and resumption of normal activities. Colon and rectal surgeons and certified ostomy nurses are the optimal clinicians to select and mark stoma sites, as this skill is a part of their education, practice, and training. However, these providers are not always available, particularly in emergency situations. The purpose of this position statement, developed by the Wound, Ostomy and Continence Nurses Society in collaboration with the American Society of Colon and Rectal Surgeons and the American Urological Association, is to provide a guideline to assist clinicians (especially those who are not surgeons or WOC nurses) in selecting an effective stoma site.

Psychometric evaluation of the ostomy complication severity index.

PURPOSE: The purpose of this study was to evaluate the psychometric properties of a new instrument to measure incidence and severity of ostomy complications early in the postoperative period. SUBJECTS AND SETTINGS: 71 participants were enrolled, most were men (52%), white (96%), and married or partnered (55%). The mean age of participants was 57 ± 15.09 years (mean ± SD). Fifty-two participants (84%) experienced at least 1 ostomy complication in the 60-day postoperative period. The research setting was 3 acute care settings within a large healthcare system in the Midwestern United States. INSTRUMENT: We developed an evidence-based conceptual model to guide development and evaluation of a new instrument, the Pittman Ostomy Complication Severity Index (OCSI). The OCSI format includes Likert-like scale with 9 individual items scored 0 to 3 and a total score computed by summing the individual items. Higher scores indicate more severe ostomy complications. METHOD: This study consisted of 2 phases: (1) an expert review, conducted to establish content validity; and (2) a prospective, longitudinal study design, to examine psychometric properties of the instrument. A convenience sample of 71 adult patients who underwent surgery to create a new fecal ostomy was recruited from 3 hospitals. Descriptive analyses, content validity indices, interrater reliability testing, and construct validity testing were employed. RESULTS: Common complications included leakage (60%), peristomal moisture-associated dermatitis (50%), stomal pain (42%), retraction (39%), and bleeding (32%). The OCSI demonstrated acceptable evidence of content validity index (CVI = 0.9) and interrater reliability for individual items (k = 0.71-1.0), as well as almost perfect agreement for total scores among raters (ICC = 0.991, P ≤ .001). Construct validity of the OCSI was supported by significant correlations among variables in the conceptual model (complications, risk factors, stoma care self-efficacy, and ostomy adjustment). CONCLUSION: OCSI demonstrated acceptable validity and reliability and can be used to assess incidence and severity of ostomy complications in the early postoperative period. We found the OCSI to be brief, easy-to-use, and clinically practical. It can be used to (a) identify priority areas for nursing intervention related to the ostomy, (b) determine appropriate interventions to prevent or treat complications, and (c) evaluate the effects of nursing interventions designed to improve outcomes for patients with ostomies.

Characteristics of the patient with an ostomy.

BACKGROUND: Complications following intestinal and urinary diversion (OSTOMY) surgery are a significant problem for many individuals. Patient characteristics or risk factors have been associated with the development of ostomy complications, but research in this area is limited. PURPOSE: To examine the demographic and clinical characteristics of new ostomy patients. DESIGN: Descriptive, cross-sectional study. SUBJECTS AND SETTING: A convenience sample of 144 new ostomy patients was recruited from a large midwest urban level i trauma teaching hospital system. METHODS: A descriptive, cross-sectional design was used to examine the demographic and clinical characteristics in persons with a new ostomy. demographic and clinical characteristics included were age, gender, disposition, diagnosis, ostomy type, type of procedure (emergent or elective), stoma type (temporary or permanent), technique of stoma creation (loop or end), stoma site marked preoperatively, body type, stoma height, and complicating factors. Data were collected through a medical record review and direct observation by the WOC nurse. RESULTS: Significant differences were found among demographic and clinical characteristics and ostomy type and disposition. Age, type of procedure, reason for surgery, stoma type, stoma site marking, and complicating factors were significantly different by ostomy type. The majority of stomas were not marked preoperatively (67%). Sixty-eight percent of persons with a stoma above skin level versus 38% with a stoma below skin level were discharged to their home. Statistically significant relationships were found among disposition and type of procedure (P = .036), stoma height (P = .003), reason for surgery (P = .000), and age (P = .005). CONCLUSION: This study provides additional information regarding specific patient characteristics (demographic and clinical) and their relationship to ostomy type and disposition.

Should WOC nurses measure health-related quality of life in patients undergoing intestinal ostomy surgery?

BACKGROUND: Ostomy surgery requires significant reconstruction of the gastrointestinal tract, resulting in uncontrolled passage of fecal effluent from a stoma in the abdominal wall. Concerns about creation of an ostomy often supersede all other concerns. Ostomy-related concerns include impaired body image; fear of incontinence; fear of odor; limitations affecting social, travel-related, and leisure activities; and impaired sexual function. Because the creation of an ostomy affects multiple domains within the construct of health-related quality of life (HRQOL), it is not surprising that quality of life is a frequent outcome measure in ostomy-related research. OBJECTIVES: We reviewed existing research in order to identify the influence of intestinal ostomy surgery on HRQOL. We sought to identify clinical evidence documenting the influence of nursing interventions on HRQOL in patients with an intestinal ostomy. In addition, we systematically reviewed the literature to evaluate the validity and reliability of condition-specific instruments for measuring HRQOL in this patient population. SEARCH STRATEGY: We completed an integrative review using the key terms "quality of life" and "ostomy" in order to identify sufficient evidence to determine the influence of intestinal ostomy surgery on HRQOL. A systematic review using the key terms "ostomy" and "nursing" was completed to identify the effect of specific nursing interventions on HRQOL in patients with intestinal ostomies. Only randomized clinical trials were included in this review. A systematic review using the key terms "quality of life" and "ostomy" was used to review and identify condition-specific HRQOL instruments and evidence of their validity and reliability. MEDLINE and CINAHL databases were used to address all 3 aims of this Evidence-Based Report Card. Searches were limited to studies published between 1980 and January 2009. Hand searches of the ancestry of studies and review articles were completed to identify additional studies. RESULTS: An integrative literature review revealed sufficient research to conclude that intestinal stoma surgery impairs HRQOL. Multiple factors, including the underlying reason for an ostomy, presence and severity of ostomy complications, presence and severity of comorbid conditions, sexual function, age, and ability to pay for ostomy supplies influence the magnitude of this effect. HRQOL tends to be most severely impaired during the immediate postoperative period. It usually improves most dramatically by the third postoperative month, and it continues to improve more gradually over the first postoperative year. A systematic review revealed 2 randomized clinical trials demonstrating that at least 2 nursing interventions improve HRQOL in persons with intestinal ostomies. A separate systematic review identified 4 instruments for measuring HRQOL in the research setting. IMPLICATIONS FOR PRACTICE: There is sufficient research-based evidence to conclude that intestinal ostomy surgery exerts a clinically relevant impact on HRQOL, and that nursing interventions can ameliorate this effect. While a small number of instruments exist, including several that have proved valid and reliable in the research setting, no instrument has yet been adapted for routine in the clinical setting.

Demographic and clinical factors related to ostomy complications and quality of life in veterans with an ostomy.

PURPOSE: The purpose of this study is to describe demographic, clinical, and quality-of-life variables related to ostomy complications (skin irritation, leakage, and difficulty adjusting to an ostomy) in a veteran population in the United States. DESIGN: The original study employed a descriptive crosssectional study using a mixed method design. This secondary analysis used the quantitative data collected. SAMPLE AND SETTING: Two hundred thirty-nine veterans with intestinal ostomies from 3 Veteran's Administration hospitals participated in the study. METHODS: Instruments used for this investigation included the City of Hope Quality of Life: Ostomy Instrument. Demographic and medical history data were collected from the survey, the Veteran's Administration health information system, and the Tumor Registry database. A self-administered survey questionnaire (mCOH-QOL-Ostomy) was mailed to each participant. RESULTS: The severity of skin irritation, problems with leakage, and difficulty adjusting were significantly related to demographic, clinical, and quality-of-life domains. Univariate analyses showed that age, income, employment, preoperative care (stoma site marking and education), having a partner, ostomy type, reason for ostomy, time since surgery, total quality-of-life scores and scores on all 4 domains of quality of life were related to the severity of these ostomy complications. Age was inversely related to severity of all 3 ostomy complications (skin irritation, leakage, and difficulty adjusting). Having an ileostomy, rather than a colostomy, was associated with higher severity of skin irritation. Having had the stoma site marked preoperatively was associated with less difficulty adjusting to an ostomy, and having had preoperative ostomy education was associated with less severe problems with skin irritation and leakage. Severity of each ostomy complication predicted total quality-of-life scores. Difficulty adjusting to the ostomy was related to all 4 quality-of-life domains (physical, psychological, social, and spiritual). CONCLUSIONS: This study found important relationships between demographic and clinical factors and ostomy complications. Skin problems, leakage, and difficulty adjusting predicted total quality of life scores and domains. Establishing relationships among ostomy complications and demographic, clinical factors, and quality of life can enhance identification of patients at risk for the development of complications and is an important first step in identifying the development of effective interventions to reduce the negative impact of complications for people with ostomies. Further study of predictors and outcomes of ostomy complications is needed to improve care.

Effect of aging on wound healing: current concepts.

The population is aging, and advanced age is commonly identified as a risk factor for delayed wound healing. Therefore, it is important for WOC nurses to be knowledgeable about how aging affects the wound healing and repair process, and strategies they can use to promote healing in the elderly population. Impaired wound healing in the aged is due partly to comorbidities common among the elderly, but evidence also suggests that inherent differences in cellular structure and function may impair tissue repair and regeneration as well. This article will address the effect of aging on wound healing, with a particular focus on processes of cellular senescence and related factors hypothesized to result in slowed or impaired wound healing in the elderly.