Running head: POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
Post-Discharge Phone Call and Quality of Life for New Ostomy Patients
Debra S. Orr
East Carolina College of Nursing
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POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
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Student Name: Debra S. Orr
Project Title: Impact of Post-Discharge Telephone Calls by WOC Nurse on Quality of Life for
Adult Patients with New Ostomies
Project Proposal
Each year in the United States, approximately 100,000 people require surgical creation of
either a fecal or urinary ostomy. In a level one trauma center in Central North Carolina, over 100
patients required creation of a new ostomy in 2015. Most of these surgeries were not performed
electively precluding education prior to surgery. Abbreviated hospital stays after surgery limit
the amount of time for education by the specially trained wound ostomy continence (WOC)
nurse.
The quality of life (QOL) for ostomy patients has been well researched. There are
multiple validated tools for assessment of QOL, specifically for ostomy patients. A literature
search revealed that face-to-face patient visits after discharge improve QOL, however, there is
no literature that indicates whether QOL improves with WOC nurse-initiated phone calls. This
project will involve phone calls to ostomy patients after hospital discharge. There is currently no
routine contact initiated by the WOC nurse after discharge with new ostomy patients at the
practice change site. Patients over age 18 who perform most of their ostomy care will be
surveyed using the Stoma QOL survey administered through a phone interview. The thought is
that the shorter survey and direct phone contact will optimize participation. Patients who are
discharged from the hospital to skilled nursing facilities, rehabilitation facilities, and long term
acute care hospitals will be excluded as well as patients whose ostomy care is performed by a
caregiver.
The intervention will consist of a phone call to discharged ostomy patients initiated by
the WOC nurse. Patients in the quarter prior to the intervention will serve as the baseline group.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
3
Patients in the following quarter will receive an interventional phone call by the WOC nurse
followed by a QOL survey phone call. These patients will serve as the practice change group.
The interventional phone call will be scripted to provide consistency in questions asked and
information provided to each patient in the practice change group. The interventional phone calls
will be made 5-7 days after hospital discharge to allow sufficient time for the patient to have
experience with completing their ostomy care as pouches are changed every 3-5 days. The
project leader will complete phone calls to administer the QOL survey two weeks following the
interventional phone call to provide time for the patient to become acclimated to life with an
ostomy.
The QOL scores provided by the baseline group will be compared to the QOL scores
provided by the practice change group. Any differences in scores will be analyzed for
significance. If QOL scores are higher in the study group, the suggestion will be made to the
organization that post-discharge interventional phone calls initiated by the WOC nurse be
incorporated into their standard of care.
Committee Chair Approval:
Date 4-1-16
Mary Frances D. Pate PhD, CNS, RN
Assistant Professor
Date submitted to DNP Program Director: 4-1-16
Program Director Comments/Decision:
Approve:
Signature:
Return for additional information/revisions:
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
East Carolina University
College of Nursing
Doctor of Nursing Practice
Final Project Approval
Student Name: Dr. Debra Sigmon Orr
Project Title: Post-Discharge Phone Call and Quality of Life for New Ostomy Patients
Private Review Completed on 4/12/2017
Public Presentation Completed on April 13, 2017
Final Project/Final Paper Approval:
As the Chair of this student’s Doctor of Nursing Practice Project Committee, I have reviewed
and approved this student’s project and final paper and agree that he/she has met the project
expectations, including the DNP Essentials, and has completed the project.
DNP Committee Chair Signature:
Dr. Carol Ann King, DNP, FNP-BC, Clinical Associate Professor
Date: 4/18/2017
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POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
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Acknowledgements
The author would like to express her deepest gratitude to all those who have made the
project possible. Thank you to my parents Jack and Shirley Sigmon for believing in me. Thank
you to my wonderful husband, Bill and my terrific children William & Laura, Matthew, Julian,
and Natalie for all the times you fixed supper, did the dishes, walked the dogs, went to the
market, cleaned the house, and washed clothes for me over the past three years. I could not have
done this without you. Thank you to my sister and brother-in-law Sherry and Jeff Buterbaugh for
your support and listening ear. To my excellent WOC nurse co-workers, Leigh Ammons, Joanna
Burgess, Melanie Johnson, Marty Moore, Gloria Tabron, and Laura Zink, thank you for your
support while I completed this project. Thank you to the 6C and STICU case management and
nursing staff for their support and to Dr. Elizabeth Woodard for her help throughout the project.
Thank you to my church family at Hollands United Methodist in Raleigh especially to my
WINGS circle who have encouraged me and kept me in prayer.
My gratitude to the faculty at East Carolina University College of Nursing including my
academic advisor, Dr. Michelle Skipper; my chair, Dr. Ann King, and committee member Dr.
Deb Kosko. Additional faculty who were instrumental in guiding this project includes Dr.
Tracey Robertson Bell, Dr. Robin Webb Corbett, Dr. Candace Harrington, Dr. Nanette LavoieVaughan, Dr. Mary Francis Pate, and Dr. Jan Tillman. The support and encouragement of my
classmates Dr. Brittany Canaday, Dr. BethAnn Guevara and Dr. Sharry Malpass was invaluable.
Lastly, my utmost gratitude to my patients. I count it a profound privilege to be allowed
into your lives during this challenging and intensely personal time. You have each taught me
more than you will ever know.
DO
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
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Abstract
Over 100,000 ostomy surgeries are performed yearly in the United States. Quality of life (QOL)
for colostomy, ileostomy, and urostomy patients has been extensively researched. A member of
the wound ostomy continence (WOC) nurse department served as the leader of the quality
improvement project. Patients with new ostomy formation at the practice change site completed
a QOL survey. Some patients received a supportive phone call from the project leader before
completing the QOL survey. QOL scores did not improve in this small patient population (n =
3) after the supportive phone call. QOL scores at the practice change site were lower for
younger patients, ileostomy patients, and patients with less social support. The project leader
developed a QOL risk assessment tool for use in identifying patients with potential for lower
QOL. Challenges with the project included number of patients meeting inclusion criteria and
inability to contact patients after discharge.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
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Table of Contents
I.
Introduction
8
II.
Research Based Evidence
10
III.
Methodology
14
IV.
Results
18
V.
Discussion
19
VI.
Recommendations
23
VII.
References
26
VIII.
Appendices
31
Running head: POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
8
Introduction
Approximately 100,000 ostomy surgeries are performed yearly in the United States
(Erwin-Toth, Thompson, & Davis, 2012). At a level one trauma center in central North Carolina
(practice change site), over 100 ostomy surgeries were performed in 2015. Most of these ostomy
creation surgeries were performed because of a medical emergency precluding patient teaching
pre-operatively. Grant, McCorkle, Hornbrook, Wendel, & Krouse (2012) note that pressures to
decrease length of stay resulted in reduced time for ostomy teaching prior to discharge. This
resulted in patients being discharged with abbreviated ostomy care preparation and can cause
decreased quality of life (QOL) for patients with newly formed ostomies.
Without some knowledge of ostomy surgery, one may not grasp the impact on QOL for
ostomy patients and their families. An ostomy is a surgically created opening in the body for
waste elimination, either fecal or urinary. For a fecal ostomy, either the small or large intestine
is brought up through the abdomen creating an outlet for stool. An ileostomy results from use of
small intestine while a colostomy indicates use of the large intestine for stoma creation. The
quality and quantity of effluent is impacted by the location of the diversion within the digestive
system with ileostomy output being higher in volume and acidity. Common reasons for fecal
ostomy creation are cancer, Crohn’s disease, intestinal rupture, and trauma. Depending on the
disease process and rectal preservation, both ileostomies and colostomies can be reversed
through an additional surgery to reconnect the bowel and rectum thereby restoring traditional
elimination patterns.
Urinary ostomies are created by isolating a small piece of bowel which is brought
through the abdomen to form the stoma. The ureters are brought from the kidneys to this newly
formed pouch creating a conduit for urinary output. During the ostomy creation surgery, the
bladder is removed resulting in a permanent change in the urinary elimination process. The
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
9
primary reason for a urinary ostomy is bladder cancer. After any ostomy surgery, the patient is
not only coping with a new pattern of elimination, but also with the underlying causative injury
or disease process.
In all the previously discussed ostomy types, there is no sphincter to control waste
outflow. Waste is continually expelled from the body into a special pouch worn on the abdomen.
Creation of an ostomy results in loss of continence, alteration in daily routine, and altered body
image (Indrebø, Anderson, & Natvig, 2014). The ostomate’s adjustment to life with an ostomy
improved when they received pre-operative ostomy site marking and teaching from a specially
trained wound ostomy continence (WOC) nurse (Hu et al., 2014). Shortened hospital stays, lack
of preoperative teaching, and abbreviated postoperative teaching resulted in inadequate
preparation for self-care. Inadequate preparation for self-care in patients with newly formed
ostomies had the potential to not only decrease QOL but also increase use of hospital resources.
Although ostomy patients received information about contacting a member of the WOC team
after discharge, very few patients at the practice change site availed themselves of this resource.
This resulted in crisis situations and presentation to the emergency department. Within the five
years prior to the quality improvement project, the nurses of the WOC department noted an
increase in patient visits to the emergency department for care related to ostomy pouching. For
some patients, these emergency department visits resulted in hospital-based acute care.
Patients lacking the necessary ostomy care skills presented to the emergency department
with abdominal wall cellulitis, dehydration, bowel obstruction, or difficulty obtaining supplies in
the weeks immediately following ostomy surgery. For some patients, this resulted in additional
hospitalizations. Kulaylat, Dillon, Hollenbeak, & Stewart (2015) found that ileostomy creation
and emergent surgical situations resulted in higher incidence of readmission within 30 days. The
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
10
number of patients with readmission, especially among those with ileostomy formation,
contributed to the quality improvement project at the practice change site. In their study of
health care utilization after ileostomy surgery, Tyler et al. (2014) found ileostomy patients to be
twice as likely to have readmission with a median hospitalization cost of $33,363 and a five-day
median length of stay. In addition, they stated that colostomy patients had higher incidences of
readmission than patients whose gastrointestinal surgery did not result in an ostomy. These
statistics illustrated the financial impact to both the patient and the organization along with the
need to avoid hospital-based acute care for this patient population. While the cost to the patient
and the organization was measurable, the emotional and psychological impact on the patient and
their family cannot be quantified. The cost to the patient and organization as well as the patient
suffering were large factors for initiating the practice change.
A member of the WOC nurse team at the practice change site implemented the quality
improvement project. The nursing administration team made themselves available for
development of the project as well as assistance with the Institutional Review Board (IRB)
process. The other members of the WOC nurse team were supportive of the project and were
receptive to the results. The project leader carried out the quality improvement project over a
six-month period.
Research Based Evidence
Pertinent published articles were gathered using PubMed search with the search terms
“quality of life”, “colostomy”, “ileostomy”, and “urostomy”. Filters included articles related
only to human subjects over the age of 18 published in English within five years. The initial
search produced 1,341 results. Title review resulted in elimination of irrelevant articles. Review
of the abstracts of the remaining 71 articles resulted in 29 fully reviewed articles (see Appendix
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
11
A). Articles previously reviewed by the project leader were used, as well as pertinent articles
gleaned from references of the fully reviewed articles.
Of the studies reviewed, none investigated the use of post-discharge phone calls and
relationship to patient reported QOL. One study by Zheng, Zhang, Qin, Fang, and Wu (2012)
sought to examine the experience and perceptions of both patients and WOC nurses when
telephone follow-up was performed. The investigators found that both the patients and WOC
nurses found the intervention convenient, effective, and meaningful. The investigators did not
perform any QOL assessment related to the phone calls. This study validates the lived
experience of the practice change site’s WOC nurse team by stating that the involved nurses
could “profoundly understand the stoma patients’ practical problems” as well as “reflect
positively on their jobs” (Zheng et al., 2012, p. 187). Caring for patients during readmission
provided impetus for the project leader to consider how the WOC nurse team might change their
routine patient care pattern to provide support, improve QOL, and decrease readmissions.
Personal conversations with ostomy patients and their families during readmission at the practice
change site highlighted their perceived lack of post-discharge support. The findings of Zheng et
al. (2012) supported this perceived lack of post-discharge support. Lack of support and difficulty
with pouching for patients with new ostomies greatly impacts their QOL.
QOL survey validation and translation was documented by Gao et al. (2013), Canova,
Giorato, Roveron, Turrini, & Zanotti (2013), and Indrebø, Andersen, & Natvig (2014). Pereira,
Cesarino, Martins, Pinto, & Netinho (2012), Person et al. (2012), Tal et al. (2012) supported preoperative teaching for improved QOL. Ratliff (2014) stated that women were more likely to
have problems with pouch leakage than men resulting in lower QOL scores. Yang et al. (2014)
suggest that QOL challenges are higher in the first month after ostomy formation surgery. A
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
12
study by Kement et al. (2014) suggested that younger patients had lower QOL scores and were
more embarrassed by their stoma regardless of their income level and educational background.
Knowles et al. (2013), and Kulaylat, Dillon, Hollenbeak, & Stewart (2015) reported lower QOL
scores in patients with emergency surgeries and those with ileostomy creation.
Practices to increase QOL included pre-discharge teaching to address specific social
interactions (Danielsen, Soerensen, Burcharth, & Rosenberg, 2013), increasing ability to perform
self-care (Cheng, Meng, Yang, & Zhang, 2013; Hu et al., 2014), and follow up with the WOC
nurse during the six months after surgery (Gomez, Barbera, Lombraña, Izquierdo, & Baños,
2014). Hu et al. (2014) suggested that patients with increased social support systems had better
adjustment to ostomy formation and higher self-care abilities, which can be postulated, would
improve QOL. Likewise, Zhang, Hu, Xu, Zheng, & Liang (2013) stated that increased family
and social support resulted in improved QOL. Neuman, Park, Fuzesi, & Temple (2012) found
that patients with rectal cancer had ostomy management difficulties consistent with other ostomy
patients but reported QOL comparable the patients without an ostomy. They suggest that this
perspective shift is attributable to the diagnosis of cancer as well as the temporary nature of the
ostomy.
Hayden et al. (2013), Kulaylat, Dillon, Hollenbeak, & Stewart (2015), Nagle et al.
(2012), Lindholm et al. (2013), Paquette, Solan, Rafferty, Ferguson, & Davis (2013), and Tyler
et al. (2014) focused on post-discharge hospital-based acute care (HBAC) and post-operative
complications. Hayden et al. postulated that patients with high output ileostomies had higher
rate of readmission. Kulaylat et al. found that patients with ostomies created emergently and
ileostomies had higher 30-day readmission rates. Lindholm et al. found that patients with loop
ileostomies had more complications. Nagle et al. and Paquette et al. reported higher readmission
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
13
rates related to dehydration for ileostomy patients. Additionally, Tyler et al. stated that
ileostomy patients had higher 30-day readmission rates than did colostomy patients.
The project leader based the practice change on evidence indicating that teaching and
support from the WOC nurse improved QOL for patients with newly formed ostomies.
Obstacles to face-to-face support after discharge at the practice change site included staffing
patterns, geographic challenges, and scope of practice. Members of the WOC nursing
department are employed by the practice change site to provide hospital-based care rather than
out-patient care with two or three nurses providing care throughout the 500+ bed facility. The
primary practice change site was one location of a multi-location organization. After discharge,
patient follow up appointments occurred at any of the organizations locations meaning that the
ostomy patient might not return to the practice change site for follow up. Lastly, no one in the
department held an advance practice certification which would allow provision of billable care to
ambulatory patients. The WOC nursing staff discussed the practice change during multiple staff
meetings prior to implementation. The project leader and the WOC nursing department decided
that a scripted phone call would offer support for the patient population while being within the
scope of practice and staffing patterns.
The theoretical framework used for the practice change was the American Association of
Critical-Care Nurses (AACN) Synergy Model for patient care. The core concepts identify the
characteristics of the patient and correlate these with the competencies of the nurse. Patient
characteristics include resiliency, vulnerability, stability, complexity, availability of resources,
participation in care, participation in decision-making, and predictability and are scored as either
one, three, or five (American Association of Critical-Care Nurses, 2016). While resiliency of
ostomy patients varies, most are either highly or moderately vulnerable. The underlying disease
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
14
process can classify the patient as minimally or moderately stable with moderate or high
complexity. Adding to the complexity of the ostomy patient population is the large number of
uninsured patients. Using this model, an uninsured patient with a new ostomy creation for a
diagnosis of cancer without family support would be classified as highly vulnerable, moderately
stable, and highly complex with few resources. These patient characteristics are then matched
with nurse competencies.
The nurse characteristics identified by the AACN are clinical judgment, advocacy, caring
practices, collaboration, systems thinking, response to diversity, facilitation of learning, and
clinical inquiry (American Association of Critical-Care Nurses, 2016). The WOC nurse can be
seen having a high level of each of these characteristics because of their specialized training and
certification. The WOC nurse must be an RN prepared at the Bachelor of Science level with five
years of nursing experience before completing the course of study necessary for certification.
After completion of the didactic program, the WOC nurse candidate must complete required
clinical hours with an approved preceptor before seeking certification. Once certification is
achieved, credentials must be renewed every five years either through examination or portfolio
submission (Wound Ostomy Continence Nursing Certification Board, 2014).
Methodology
The project leader, a member of the WOC team at the practice change site, developed the
quality improvement (QI) project. Before submission of the project to the practice change site’s
Institutional Review Board (IRB) for approval, the details of the quality improvement project
were established, scripts for phone calls were written (see Appendixes B and C), the QOL survey
was selected (see Appendix D), and data collection tools were developed (see Appendix E). The
project leader developed the script for the supportive phone call with input from the project team
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
15
and the WOC nursing department. The supportive phone call script contained elements from the
domains of physical, emotional, and social dimensions, which are measured by questions in QOL
surveys (Knowles et al., 2017). The project team reviewed, revised, and approved the supportive
phone call script. No validation process was deemed necessary by the project team. The director
of nursing research and best practice at the practice change site granted organizational support
(see Appendix F).
After review and consideration of several QOL surveys, the project team selected the
Stoma QOL survey with completion of the survey via phone call (Canova, Giorato, Roveron,
Turrini, & Zanotti, 2013). After careful consideration of multiple survey options, the shorter
survey and direct phone contact were selected to optimize participation. Distribution of surveys
by mail was considered and felt to be problematic due to time restraints. Following submission
to IRB, the project required expedited approval rather than exempt status. The project leader
added additional documents to the IRB package and the project was given expedited approval
(see appendix G). Subsequently, East Carolina University and the practice change site signed a
collaborative IRB agreement (see Appendix H).
At the beginning of all phone calls, the project leader identified herself, the purpose of
the phone call, and requested patient permission to continue. The project leader thanked any
patient who did not consent to continuation of the phone call and removed their names from the
baseline or practice change group. No financial or other compensation was provided to the
patient. The project leader offered each patient a copy of the information sheet (see Appendix I).
Participants in the retrospective portion of the project had the information sheet reviewed with
them during the phone call and a copy was sent via United States postal service if they desired.
Patients in the practice change group had the information sheet reviewed with them prior to
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
16
hospital discharge and were provided a copy if they desired. The practice change site IRB
required only verbal consent therefore no signed consent forms were gathered. The project
leader confirmed this with the IRB representative at the practice change site.
The Stoma QOL was developed by Prieto, Thorsen, & Juul (2005) to assess QOL in the
specific ostomy patient population and includes twenty questions in the domains of family and
friend relationships, sexual activity, sleep, and social relationships. See Appendix A for the
QOL survey used. The project leader selected the Stoma QOL survey based on evidencesupported validity, lack of restrictions on usage, and ease of administration.
The project leader, through her role as an ostomy nurse, had personal knowledge of each
member of the organically occurring patient population at the quality improvement site.
Placement of participants in the retrospective and practice change groups was based on the time
of their discharge in relation to IRB approval. Using the inclusion and exclusion criteria, the
project leader reviewed each patient with ostomy creation surgery at the practice change site.
The population included patients over 18 years of age considered able to participate with English
as their primary language. Patients discharged from the hospital to another facility such as
skilled nursing facilities, rehabilitation facilities, and long term acute care hospitals were
excluded as well as patients deemed unable to complete the survey due to cognitive impairment.
Determination of cognitive impairment occurred through personal interaction by the project
leader and the WOC nurse team at the practice change site. Contacting patients discharged from
the hospital to another facility via telephone was felt to be an insurmountable obstacle excluding
this portion of the patient population from the practice change. As a small, ancillary department
in the organization, the WOC nurses lacked experience with use of outpatient translation
services. Historically, the number of patients in the practice change site who do not have English
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
17
as their primary language was very small. For these reasons, patients who do not have English
as their primary language were excluded.
After obtaining all IRB documents, the project leader reviewed the patients with newly
created ostomies at the practice change site in the quarter prior to the practice change. The
baseline group included patients discharged home and cognitively able to complete the QOL
survey. The maximum number of participants was 25. The number of participants was based on
historical data, which indicated that approximately 100 ostomy surgeries were performed at the
practice change site yearly. Each potential participant was assigned a numeric identifier between
1 and 25. The project leader initiated phone calls to patients for completion of the QOL survey.
If the project leader was unable to reach the patient after three phone calls, the patient was
removed from the baseline group. Remaining patients were called until all patients with ostomy
surgery in the quarter before the practice change were reached or removed from the baseline
group. Any patient who had been discharged within one week of IRB approval and initiation of
phone calls was moved to the practice change group rather than the baseline group. The project
leader recorded the QOL survey scores, the number of patients excluded, the number of patients
reached, and the number of patients removed due to inability to reach. The project leader
recorded this on the data presentation tool.
The project leader screened patients with newly created ostomies discharged from the
organization during the practice change. Cognitively competent patients discharged home were
included in the pool for practice change group with a maximum number of participants set at 25.
Patients were assigned a numeric identifier from 26-50. The practice change supportive phone
call script was used during the phone call one week after discharge. Approximately two weeks
later, the patient was called again and the QOL survey was completed. As with the baseline
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
18
group, the project leader attempted to reach the patient three times before removing them from
the list of potential participants. The project leader recorded QOL scores in the data presentation
tool. The project leader removed all patient identifiers from information presented. Information
gathering tools were always kept in a locked cabinet at the quality improvement site when not in
the immediate possession of the project leader. The number of patients excluded, reached, and
removed were recorded for reference. The QOL scores from the baseline group and practice
change group were recorded using IBM® Statistic Package for the Social Sciences (SPSS®)
version 22. Given the low number of recorded responses in the practice change group, no
statistical analysis testing was performed.
Results
The project leader identified and evaluated twenty patients for inclusion in the baseline
group. Of those, seven were excluded based on the predetermined criteria, two declined to
participate, and two were not reached within three phone calls leaving nine completed QOL
surveys (see Appendix J). The age of the baseline ranged from thirty-three to eighty-nine years
with an average age of sixty-six years. Three respondents were female and six were male. Three
patients had ileostomies and six had colostomies. The QOL scores ranged from 48 to 75 on an
80-point scale with an average of 61.89.
The project leader identified and evaluated twenty-four patients for inclusion in the
practice change group. Of those, thirteen were excluded based on the predetermined criteria, one
declined to participate, and five were not reached within three phone calls. A total of five
patients received the supportive phone call. However, of those, two were lost to follow up due to
inability to reach via phone on three occasions resulting in three completed questionnaires (see
Appendix K). The age of the three participants who received the interventional phone call and
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
19
provided QOL data ranged from twenty-four to fifty-eight years. The average age of was thirtyeight years. Two participants were male and one female. Two participants had colostomies and
one had an ileostomy. The QOL scores ranged from 47 to 60 on an 80-point scale with an
average of 53.67. The analysis did not show an increase in QOL scores for the practice change
group.
Case studies of the three patients in the quality improvement group provide guidance for
identification of patients at risk for lower QOL. The patient with the highest QOL score of 60
was male, age 58, married, and had a colostomy. This patient had a budded stoma which is
generally considered easier to manage. The patient requested that the QOL survey be sent to him
via email due to holiday travel out of state. This is significant because the remainder of the
surveys were completed via phone call. The patient with the lowest QOL score of 47 in the
practice change group was female, age 34, single, and had a colostomy. This patient had an
extremely challenging stoma to pouch as it was not budded and in a significant skin fold. The
patient not only received the supportive phone call but also called the WOC nursing department
for assistance with pouching after discharge. The final patient in the practice change group had a
QOL score of 54, was male, age 24, in a relationship, and had a budded ileostomy. He had the
highest number of days between surgery and survey because he had a stay in the rehabilitation
hospital that is part of the practice change site.
Discussion
Limitations included time constraints, number of available participants, and successful
contact with participants. The time constraint included the length of time between ostomy
surgery and completion of the questionnaire. Elapsed time between surgery and questionnaire
completion ranged from twenty-four to one hundred forty-four days. In comparison, elapsed
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
20
time between surgery and QOL survey for the practice change group ranged from twenty-nine to
one hundred five days. The average number of days between surgery and QOL scores for the
baseline group was eighty-nine while the average number of days between surgery and QOL
scores for the practice change group was sixty. Lastly, the average number of days between
hospital discharge and survey for the baseline group was seventy-three and only thirty-two for
the practice change group. As seen in Figure 1 (Appendix L), there was very modest increase in
QOL score with increased days between surgery and QOL survey.
While the analysis did not show an increase in the QOL scores, the data for all completed
QOL surveys was evaluated for trends that could be used by the WOC nurse department to target
patient populations which had lower scores. In alignment with other published studies, the
participants with ileostomies in the quality improvement project had a lower average QOL score
(58) than those with colostomies (60.75). Ileostomy patients also had a smaller range of scores
(7) than did colostomy patients (28). When comparing the average QOL scores between women
and men, the average score for women was 53.75 and the average score for men was 62.875.
The average score for single patients was 60 and the average score for patients in a relationship
was 59.5.
The amount of time between surgery, discharge, and survey could be mitigated if given a
longer period for performing the quality improvement project. Constructing the project as
ongoing would provide more data as the project leader would be able to evaluate each patient
prospectively and alternate placing them in the control and practice change group. The project
could be constructed to conclude after a predetermined number of respondents in the practice
change and baseline group were contacted.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
21
Younger patients that completed the project survey had a slightly lower QOL score when
compared to older patients as seen in Figure 2 (Appendix M). Although patients of all ages face
the same alteration in their elimination pattern, why do younger patients have lower QOL
scores? Based on Maslow’s hierarchy, younger patients are less likely to be in the selfactualization phase of development (Butts & Rich, 2015). The vulnerability of surgery,
alteration in elimination pattern, and need for help can be postulated to impact self-esteem more
in younger patients.
As previously stated, the QOL scores were lower in patients with ileostomy than in
patients with colostomy. The score range was smaller in the ileostomy group (7) than in the
colostomy group (28). This suggests that the scores are more generalizable to the entire patient
population for ileostomies. A higher variance of scores was noted in patients with colostomies.
The number of available and reachable participants proved to be a larger obstacle than
anticipated by the project leader. Historically, between 100 and 125 ostomy surgeries occur at
the practice change site per year. The pre-practice change group included 20 patients. Five were
removed from the list due to discharge to another facility, one was removed due to being unable
to complete the questionnaire, and one was removed due to language barrier leaving 13. Two of
the patients reached by phone declined to participate. Two patients were not reached within the
predetermined number of phone calls resulting in nine completed questionnaires.
In the practice change group, 24 ostomy surgeries occurred during the time allotted for
the project. Thirteen of these 24 patients did not meet the predetermined inclusion criteria. Five
of the remaining 11 were reached for the practice change phone call. Five patients received the
practice change phone call. The project leader did not reach two of these to complete the QOL
questionnaire despite three phone calls and an additional attempt via email. The remaining three
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
22
QOL questionnaires were completed and recorded. Of note, each of the 12 patients included in
the practice change group were visited during their hospital stay by the project leader and agreed
to participate in the project, yet were not reachable after discharge. This information was shared
with the WOC nursing department as it sheds light on the difficulty the organization experienced
with less than anticipated patient traffic in a recently established out-patient ostomy clinic.
Successful contact with project change participants was perhaps the biggest frustration
faced by the project leader. As previously stated, each potential practice change participant was
interviewed by the project leader during their hospital stay and verbally agreed to participate.
Two of the patients had full voicemail boxes resulting in an inability to leave a message. The
project leader did not reach two patients who received the supportive phone call for the QOL
survey despite phone and email contact. Four of the patients included in the practice change
group but not reached were known by the project leader to have returned to work. This raises the
question of whether the patients who were not reached would have reported higher QOL scores
than those reached.
When evaluating the challenges faced with reaching all the ostomy patients for both the
baseline and practice change groups, there were 44 total patients. Twenty of these were
excluded based on the predetermined criteria, three refused to participate, and nine were not
reached. See Figure 3 (Appendix N) for visual presentation of these statistics. Of the 44 total
participants, there were 12 completed QOL surveys, nine in the baseline group and three in the
practice change group.
Unfortunately, the quality improvement project concluded with more questions than
answers. Why were patients not reachable? Were unreachable patients more self-sufficient and
would they have reported higher QOL scores? As reported by Zheng, Zhang, Qin, Fang, and Wu
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
23
(2012), the project leader found post-discharge interaction with the patients to be very
meaningful and fulfilling. Despite the lack of increased QOL scores, all the patients reached
expressed gratitude for the telephone interaction with the WOC nurse.
Plans for dissemination of the quality improvement project results at the practice change
site included presentation to the WOC nursing department and the surgery trauma
interprofessional team. Dissemination at the university level included poster presentation along
with placement of the scholarly project paper in the DNP repository. The poster will be
submitted for consideration to the local, state, and national WOC nurse conventions.
Recommendations
The project did identify opportunities for improvement in caring for patients with newly
formed ostomies. One factor in poor QOL scores in the literature was emergent stoma formation
surgery instead of planned stoma formation surgery. As most patients at the practice change site
have emergent stoma formation, this factor applies to most of the patient population. The data
supports the generalized presumption that patients with ileostomies have the possibility of a
more HBAC and lower QOL warranting additional time with the WOC nurse. The trend of
higher QOL scores in the older patient population suggests that additional resources should be
invested in the younger members of the patient population and those lacking strong support
systems. Lastly, patients with stomas that are difficult to pouch related to stoma size, shape, or
location are at a higher risk for lower QOL and should receive additional time with the WOC
nurse.
Based on the findings from this project, the author recommends integrating a formal QOL
risk analysis for each ostomy patient at the study change site (see Appendix L). This would
assist the WOC department and the practice site interdisciplinary team to identify patients who
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
24
need more bedside time with a WOC nurse before discharge as well as those that would benefit
from a follow up phone call or video call. When educating a patient with multiple QOL risk
factors, the WOC nurse would be equipped to discuss delay of discharge and use of postdischarge resources with the interdisciplinary team. This process of identifying patients at risk
for lower QOL scores and providing them with increased resources prior to discharge correlates
with the Synergy Model used to design the project (American Association of Critical-Care
Nurses, 2016). The Synergy Model seeks to match patient characteristics such as vulnerability,
resiliency, and participation in care with the competencies of the nurse.
The project leader shared these recommendations were shared with the WOC nursing
department during a staff meeting. The project leader provided any requested project materials
and information should the organization chose to carry the project forward. The project leader
could share suggestions for improved project design if the department wished to carry the
practice change project forward at a future time. The project leader also shared information with
the interdisciplinary team of the surgical nursing unit at the practice change site. The relative
low cost for completion of this project of $50 for office supplies and $350 (10 hours of RN
salary @ $35/hour) would be considered by the organization when deciding whether to continue
the project.
In summary, the project leader sought to improve the quality of life for patients with
newly formed ostomies at the practice change site. The quality improvement project involved
placement of a supportive phone call after discharge. QOL scores did not improve with the
supportive phone call. The project leader noted shared attributes of age, social support, ostomy
type, and abdominal contours among patients with lower QOL scores. These attributes are also
associated with lower QOL scores in the reviewed literature. Using these attributes, the project
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
25
leader developed a risk assessment tool for staff at the practice change site to utilize for
identification of patients with potential lower QOL scores. The project leader noted difficulty
reaching patients and number of patients meeting inclusion criteria as the largest obstacles for the
project.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
26
References
American Association of Critical-Care Nurses. (2016). The AACN Synergy Model for Patient
Care. Retrieved May 15, 2016, from
http://www.aacn.org/wd/certifications/content/synmodel.pcms?menu=certification#Basic
Butts, J. B., & Rich, K. L. (2015). Philosophies and Theories for Advanced Nursing Practice (2nd
ed.). Burlington, MA: Jones & Bartlett Learning.
Canova, C., Giorato, E., Roveron, G., Turrini, P., & Zanotti, R. (2013). Validation of a stomaspecific quality of life questionnaire in a sample of patients with colostomy or ileostomy.
Colorectal Disease, 15(11), e692-e698. doi: 10.1111/codi.12324
Cheng, F., Meng, A. F., Yang, L. F., & Zhang, Y. N. (2013). The correlation between ostomy
knowledge and self-care ability with psychosocial adjustment in Chinese patients with a
permanent colostomy: A descriptive study. Ostomy Wound Management, 59(7), 35-38.
Danielsen, A. K., Soerensen, E. E., Burcharth, K., & Rosenberg, J. (2013). Learning to live with
a permanent intestinal ostomy: impact on everyday life and educational needs. Journal of
Wound Ostomy Continence Nursing, 40(4), 407-412. doi:
10.1097/WON.0b013e3182987e0e
Erwin-Toth, P., Thompson, S. J., & Davis, J. S. (2012). Factors impacting the quality of life of
people with an ostomy in North America. Journal of Wound, Ostomy and Continence
Nursing, 39(4), 417-422. doi:10.1097/WON.0b013e318259c441
Gao, W., Yuan, C., Wang, J., Du, J., Wu, H., Qian, X., & Hinds, P. S. (2013). A Chinese version
of the City of Hope quality of life-ostomy questionnaire [Abstract]. Cancer Nursing,
36(1), 41-51. doi:10.1097/NCC.0b013e3182479c59
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
27
Gomez, A., Barbera, S., Lombraña, M., Izquierdo, L., & Baños, C. (2014). Health-related quality
of life in patients urostomies. Journal of Wound Ostomy Continence Nursing, 41(3), 254256. doi: 10.1097/WON.0000000000000026
Grant, M., McCorkle, R., Wendel, C., & Krouse, R. (2012). Development of a chronic care
ostomy self-management program. Journal of Cancer Education, 28(1), 70-78.
doi:10.1007/s13187-012-0433-1
Hayden, D. M., Pinzon, M. C., Francescatti, A. B., Edquist, S. C., Malczewski, M. R., Jolley, J.
M.,...Saclarides, T. J. (2013). Hospital readmission for fluid and electrolyte abnormalities
following ileostomy construction: Preventable or unpredictable? Journal of
Gastrointestinal Surgery, 17(2), 298-303. doi:10.1007/s11605-012-2073-5
Hu, A., Pan, Y., Zhang, M., Zhang, J., Zheng, M., Huang, M.,...Wu, X. (2014). Factors
influencing adjustment to a colostomy in Chinese patients. Journal of Wound, Ostomy
and Continence Nursing, 41(5), 455-459. doi:10.1097/WON.0000000000000053
Indrebø, K. L., Andersen, J. R., & Natvig, G. K. (2014). The ostomy adjustment scale:
Translation into Norwegian language with validation and reliability testing. Journal of
Wound, Ostomy and Continence Nursing, 41(4), 357-364. doi:
10.1097/WON.0000000000000041
Kement, M., Gezen, C., Aydin, H., Haksal, M., Can, U., Aksakal, N., & Öncel, M. (2014). A
descriptive survey study to evaluate the relationship between socio-demographic factors
and quality of life in patients with permanent colostomy. Ostomy Wound Management,
60(10), 18-23.
Knowles, S. R., Tribbick, D., Connell, W. R., Castle, D., Salzberg, M., & Kamm, M. A. (2017).
Exploration of health status, illness perceptions, coping strategies, psychological
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
28
morbidity, and quality of life in individuals with fecal ostomies. Journal of Wound,
Ostomy and Continence Nursing, 44(1), 69-73.
Knowles, S. R., Wilson, J., Wilkinson, A., Connell, W., Salzberg, M., Castle, D.,...Kamm, M. A.
(2013). Psychological well-being and quality of life in Crohn's disease patients with an
ostomy: a preliminary investigation. Journal of Wound Ostomy Continence Nursing,
40(6), 603-610. doi: 10.1097/WON.0b013e3182a9a75b
Kulaylat, A. N., Dillon, P. W., Hollenbeak, C. S., & Stewart, D. B. (2015). Determinants of 30-d
readmission after colectomy. Journal of Surgical Research, 193(2), 528-535. doi:
10.1016/j.jss.2014.09.029
Lindholm, E., Persson, E., Carlsson, E., Hallén, A. M., Fingren, J., & Berndtsson, I. (2013).
Ostomy-related complications after emergent abdominal surgery: A 2-year follow-up
study. Journal of Wound Ostomy Continence Nursing, 40(6), 603-610. doi:
10.1097.WON.0b013e3182a9a7d9
Nagle, D., Pare, T., Keenan, E., Marcet, K., Tizio, S., & Poylin, V. (2012). Ileostomy pathway
virtually eliminates readmissions for dehydration in new ostomates. Diseases of the
Colon and Rectum, 55(12), 1266-1272. doi:10.1097/DCR.0b013e31827080c1
Neuman, H. B., Park, J., Fuzesi, S., & Temple, L. K. (2012). Rectal cancer patients' quality of
life with a temporary stoma; shifting perspectives. Diseases of the Colon and Rectum,
55(11), 1117-1124. doi:10.1097/DCR.0b013e3182686213
Paquette, I. M., Solan, P., Rafferty, J. F., Ferguson, M. A., & Davis, B. R. (2013). Readmission
for dehydration or renal failure after ileostomy creation. Diseases of the Colon and
Rectum, 56(8), 974-979. doi:10.1097/DCR.0b013e31828d02ba.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
29
Pereira, A. P., Cesarino, C. B., Martins, M. R., Pinto, M. H., & Netinho, J. G. (2012).
Associations among socio-demographic and clinical factors and the quality of life of
ostomized patients. Revista Latino-Americana de Enfermagem, 20(1), 93-100.
Person, B., Ifargan, R., Lachter, J., Duek, S. D., Kluger, Y., & Assalia, A. (2012). The impact of
preoperative stoma site marking on the incidence of complications, quality of life, and
patient's independence. Diseases of the Colon and Rectum, 55(7), 783-787.
doi:10.1097/DCR.0b013e31825763f0
Prieto, L., Thorsen, H., & Juul, K. (2005). Development and validation of a quality of life
questionnaire for patients with colostomy or ileostomy. Health and Quality of Life
Outcomes, 3(1), 62. doi:10.1186/1477-7525-3-62
Ratliff, C. R. (2014). Factors related to ostomy leakage in the community setting. Journal of
Wound Ostomy Continence Nursing, 41(3), 249-253.
doi:10.1097/WON.0000000000000017
Tal, R., Cohen, M. M., Yossepowitch, O., Golan, S., Regev, S., Zertzer, S., & Baniel, J. (2012).
An ileal conduit - who takes care of the stoma? Journal of Urology, 187(5), 1707-1712.
doi: 10.1016/j.juro.2011.12.064
Tyler, J. A., Fox, J. P., Dharmarajan, S., Silviera, M. L., Hunt, S. R., Wise, P. E., & Mutch, M.
G. (2014). Acute health care resource utilization for ileostomy patients is higher than
expected. Diseases of the Colon & Rectum, 57(12), 1412-1420.
doi:10.1097/DCR.0000000000000246
Wound Ostomy Continence Nursing Certification Board. (2014). Certification. Retrieved April
2, 2016, from http://www.wocncb.org/
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
30
Yang, X., Li, Q., Zhao, H., Li, J., Duan, J., Wang, D.,...Fu, J. (2014). Quality of life in rectal
cancer patients with permanent colostomy in Xi'an. African Health Sciences, 14(1), 2836. doi:10.4314/ahs.v14i1.6
Zhang, T. L., Hu, A. I., Xu, H. L., Zheng, M. C., & Liang, M. J. (2013). Patients after colostomy:
Relationship between quality of life and acceptance of disability and social support.
Chinese Medical Journal, 126(21), 4124-4131.
Zheng, M. C., Zhang, J. E., Qin, H. Y., Fang, Y. J., & Wu, X. J. (2012). Telephone follow-up for
patients returning home with colostomies: Views and experiences of patients and
enterostomal nurses. European Journal of Oncology Nursing, 17(2), 184-189. doi:
10.1016/j.ejon.2012.05.006
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
31
Appendix A
Title
1
2
3
4
5
6
7
8
9
10
Author
Details
Take Away Points
J Surg Res. 2015
Emergent ileostomy surgery patients have higher rate
Determinants of 30-d readmission after
Kulaylat AN, Dillon PW, Hollenbeak Feb;193(2):528-35. doi: of 30 day readmission. Does not look at QOL or
colectomy.
CS, Stewart DB.
10.1016/j.jss.2014.09.02 stoma management. Emergent surgeries and those
9.
due to ischemia more likely to be readmitted.
Support Care Cancer.
A mixed-method study on the generic and Jansen F, van Uden-Kraan CF,
Compared QOL for cancer vs non-cancer patients;
2015 Jun;23(6):1689-97.
ostomy-specific quality of life of cancer and Braakman JA, van Keizerswaard PM,
cancer patients had more colos; non-cancer more
doi: 10.1007/s00520-014non-cancer ostomy patients.
Witte BI, Verdonck-de Leeuw IM.
ileostomies; lower QOL for cancer
2528-1.
Pt with ileo had higher ED & admission than colo
Dis Colon Rectum. 2014
Tyler JA, Fox JP, Dharmarajan S,
w/in 30 days; colo higher than resection w/ no
Acute health care resource utilization for
Dec;57(12):1412-20. doi:
Silviera ML, Hunt SR, Wise PE, Mutch
ostomy. Supports ileo harder to manage than colo.
ileostomy patients is higher than expected.
10.1097/DCR.00000000
MG.
Most HBAC due to infections and bleeding; not
00000246.
necessarily due to ostomy.
A descriptive survey study to evaluate the
Supports lower QOL for women and those living
relationship between socio-demographic
Kement M, Gezen C, Aydin H, Haksal Ostomy Wound Manage.
alone; limitations: follow up was >15 months after
factors and quality of life in patients with a M, Can U, Aksakal N, Öncel M.
2014 Oct;60(10):18-23.
completing all cancer treatments.
permanent colostomy.
J Wound Ostomy
Continence Nurs. 2014
Factors influencing adjustment to a
Hu A, Pan Y, Zhang M, Zhang J, Zheng Sep-Oct;41(5):455-9.
Better adjustment and self-care ability with increased
colostomy in Chinese patients: a crossM, Huang M, Ye X, Wu X.
doi:
social support
sectional study.
10.1097/WON.0000000
000000053.
J Wound Ostomy
Continence Nurs. 2014
The Ostomy Adjustment Scale: translation
Jul-Aug;41(4):357-64.
into Norwegian language with validation
Indrebø¸ KL, Andersen JR, Natvig GK.
Only looked at translation of tool
doi:
and reliability testing.
10.1097/WON.0000000
000000041.
Patients' quality of life and role of the
Magistri P, Scordamaglia MR, Giulitti
Suggests that temporary ostomy have higher QOL.
Ann Ital Chir. 2014 Marambulatory in after-surgery stoma care. A D, Papaspyropoulos V, Eleuteri E,
Pts more concerned with stoma management than
Apr;85(2):105-8.
single center experience.
Coppola M.
social prejudice.
J Wound Ostomy
Continence Nurs. 2014
Health-related quality of life in patients with Gomez A, Barbera S, Lombraña M,
May-Jun;41(3):254-6.
Had moderate QOL scores with follow up w/
urostomies.
Izquierdo L, Baños C.
doi:
WOCN during 6 months after surgery
10.1097/WON.0000000
000000026.
I didn't feel like I was a person anymore":
Med Anthropol Q. 2014
Ramirez M, Altschuler A, McMullen C,
realigning full adult personhood after
Jun;28(2):242-59. doi:
Not helpful; all about cancer pts; description only
Grant M, Hornbrook M, Krouse R.
ostomy surgery.
10.1111/maq.12095.
Cerruto MA, D'Elia C, Cacciamani G,
Health Qual Life
De Marchi D, Siracusano S, Iafrate M,
Behavioural profile and human adaptation
Outcomes. 2014 Apr
Niero M, Lonardi C, Bassi P, Belgrano
of survivors after radical cystectomy and
7;12:46. doi:
All about urostomy
E, Imbimbo C, Racioppi M, Talamini R,
ileal conduit.
10.1186/1477-7525-12Ciciliato S, Toffoli L, Rizzo M, Visalli F,
46.
Verze P, Artibani W.
Living with the physical and mental
consequences of an ostomy: a study among Mols F, Lemmens V, Bosscha K, van
11
1-10-year rectal cancer survivors from the den Broek W, Thong MS.
population-based PROFILES registry.
12
Quality of life in rectal cancer patients with Yang X, Li Q, Zhao H, Li J, Duan J,
permanent colostomy in Xi'an.
Wang D, Fang N, Zhu P, Fu J.
13
Factors related to ostomy leakage in the
community setting.
Ratliff CR.
Wong SK, Young PY, Widder S,
A descriptive survey study on the effect of
Khadaroo RG; Acute Care and
14 age on quality of life following stoma
Emergency Surgery (ACES) Group of
surgery.
the University of Alberta, Canada.
Compared 10year QOL and health care resource
Psychooncology. 2014
utilization btwn rectal CA pts w/ and w/out ostomy.
Sep;23(9):998-1004. doi:
Ostomy pt have lower QOL and higher use of
10.1002/pon.3517.
resources.
Afr Health Sci. 2014
Mar;14(1):28-36. doi:
10.4314/ahs.v14i1.6.
J Wound Ostomy
Continence Nurs. 2014
May-Jun;41(3):249-53.
doi:
10.1097/WON.0000000
000000017.
Problems with QOL were highest in first month after
surgery
Women were more likely to have leakage than men;
2 piece had less leakage
Great article: looked retrospectively at ostomy
Ostomy Wound Manage. patients. Found that >65 were less likely to be self2013 Dec;59(12):16-23. efficient in ostomy care but scored higher on QOL.
Results not statistically significant.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
Title
Patients after colostomy: relationship
15 between quality of life and acceptance of
disability and social support.
16
17
18
19
20
21
22
Take Away Points
Patient population limited to those who had post d/c
Zhang TL, Hu AL, Xu HL, Zheng MC, Chin Med J (Engl). 2013
follow in ostomy clinic; emphasized increased family
Liang MJ.
Nov;126(21):4124-31.
bonds and social support
J Wound Ostomy
Continence Nurs. 2013
Psychological well-being and quality of life Knowles SR, Wilson J, Wilkinson A,
All about Crohns. Emergent ostomy had higher
Nov-Dec;40(6):623-9.
in Crohn's disease patients with an ostomy: Connell W, Salzberg M, Castle D,
adverse events which were believed to decreased
doi:
a preliminary investigation.
Desmond P, Kamm MA.
QOL
10.1097/WON.0b013e3
182a9a75b.
J Wound Ostomy
Continence Nurs. 2013
Ostomy-related complications after
Loop ileostomy had most complications 2 weeks
Lindholm E, Persson E, Carlsson E,
Nov-Dec;40(6):603-10.
emergent abdominal surgery: a 2-year
after d/c; recommends early and ongoing follow up
Hallén AM, Fingren J, Berndtsson I.
doi:
follow-up study.
with WOCN
10.1097/WON.0b013e3
182a9a7d9.
The correlation between ostomy
knowledge and self-care ability with
Higher knowledge of stoma care and ability to
Cheng F, Meng AF, Yang LF, Zhang Ostomy Wound Manage.
psychosocial adjustment in Chinese patients
perform stoma care alone were more psychologically
YN.
2013 Jul;59(7):35-8.
with a permanent colostomy: a descriptive
adjusted
study .
Dis Colon Rectum. 2013
Readmission for dehydration or renal failure Paquette IM, Solan P, Rafferty JF,
Aug;56(8):974-9. doi:
Found 17% in 30 day readmission secondary to
after ileostomy creation.
Ferguson MA, Davis BR.
10.1097/DCR.0b013e31 dehydration in ileostomy patients
828d02ba.
J Wound Ostomy
Continence Nurs. 2013
Learning to live with a permanent intestinal
Danielsen AK, Soerensen EE,
Jul-Aug;40(4):407-12.
Suggests aiming teaching at situations that patient will
ostomy: impact on everyday life and
Burcharth K, Rosenberg J.
doi:
encounter after d/c
educational needs.
10.1097/WON.0b013e3
182987e0e.
Validation of a stoma-specific quality of life
Colorectal Dis. 2013
Canova C, Giorato E, Roveron G,
Validated Stoma QOL survey and stated that # of
questionnaire in a sample of patients with
Nov;15(11):e692-8. doi:
Turrini P, Zanotti R.
questions could be decreased
colostomy or ileostomy.
10.1111/codi.12324.
Hospital readmission for fluid and
J Gastrointest Surg. 2013
Hayden DM, Pinzon MC, Francescatti
electrolyte abnormalities following
Feb;17(2):298-303. doi:
AB, Edquist SC, Malczewski MR,
Higher readmission with high output ileostomy
ileostomy construction: preventable or
10.1007/s11605-012Jolley JM, Brand MI, Saclarides TJ.
unpredictable?
2073-5.
Ileostomy pathway virtually eliminates
23 readmissions for dehydration in new
ostomates.
Author
32
Details
Dis Colon Rectum. 2012
Nagle D, Pare T, Keenan E, Marcet K, Dec;55(12):1266-72. doi: Recognized higher HBAC after d/c for ileostomy
Tizio S, Poylin V.
10.1097/DCR.0b013e31 secondary to dehydration
827080c1.
Dis Colon Rectum. 2012
Nov;55(11):1117-24.
Rectal cancer patients' quality of life with a Neuman HB, Park J, Fuzesi S, Temple
24
doi:
Ileostomy in rectal cancer; overall QOL not affected
temporary stoma: shifting perspectives.
LK.
10.1097/DCR.0b013e31
82686213.
Very small (#11). Found that pts valued phone call
after d/c; helped with feelings of assurance, timely
Telephone follow-up for patients returning
Eur J Oncol Nurs. 2013
stoma problem solving, psychological support and
home with colostomies: views and
Zheng MC, Zhang JE, Qin HY, Fang Apr;17(2):184-9. doi:
25
resuming normal life. Nurses felt helped them
experiences of patients and enterostomal YJ, Wu XJ.
10.1016/j.ejon.2012.05.0
understand pt practical problems and complicated
nurses.
06.
feelings. Supports that pts are hesitant to call after d/c
even though they have contact information.
Dis Colon Rectum. 2012
The impact of preoperative stoma site
Person B, Ifargan R, Lachter J, Duek Jul;55(7):783-7. doi:
Pre-op marking in elective stoma surgery had higher
26 marking on the incidence of complications,
SD, Kluger Y, Assalia A.
10.1097/DCR.0b013e31 QOL regardless of stoma site on abdomen
quality of life, and patient's independence.
825763f0.
Cancer Nurs. 2013 JanA Chinese version of the City of Hope
Gao W, Yuan C, Wang J, Du J, Wu H, Feb;36(1):41-51. doi:
27 Quality of Life-Ostomy Questionnaire:
Chinese City of Hope (not stoma QOL)
Qian X, Hinds PS.
10.1097/NCC.0b013e31
validity and reliability assessment.
82479c59.
Rev Lat Am Enfermagem.
Associations among socio-demographic
Pre-op teaching has positive influence on QOL;
Pereira AP, Cesarino CB, Martins MR, 2012 Jan-Feb;20(1):9328 and clinical factors and the quality of life of
found no associations between age, marital status or
Pinto MH, Netinho JG.
100. English, Portuguese,
ostomized patients.
gender and QOL
Spanish.
29
An ileal conduit--who takes care of the
stoma?
Tal R, Cohen MM, Yossepowitch O,
Golan S, Regev S, Zertzer S, Baniel J.
J Urol. 2012
May;187(5):1707-12.
Pre-op teaching improves QOL for urostomy
doi:
patients
10.1016/j.juro.2011.12.0
64.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
33
Appendix B
Interventional Phone Call Script
My name is Debra Orr. I’m one of the wound ostomy nurses from the hospital where you
had your surgery. I wanted to touch base with you about how you are doing after your ostomy
surgery. Is that okay with you?
1. Many people have trouble with their fatigue and sleeping when they go home
after surgery. Make sure that you are eating a balanced diet with plenty of protein
and water and increasing your physical activity gradually. Walking a little bit
more each day is a good way to improve your strength and energy. If you are
having trouble sleeping at night, it might help to avoid caffeine after lunch and cut
back on any daytime napping.
2. Some people with ostomies have problems with irritation of the skin around their
stoma, leakage around their pouch, and management of gas and odor. Emptying
the pouch when it is only 1/3 full helps prevent the pouch from loosening.
3. Frequently people with new ostomies have trouble adjusting to life with an
ostomy including feeling embarrassed, anxious, depressed, or out of control. Any
of those feelings are normal and I would be happy to listen if you would like to
talk about how you are feeling.
4. Having a new ostomy can be challenging at first. Trouble taking care of your
ostomy, getting out of the house, and interacting with your friends can be difficult
at first but it will improve over time. It’s okay to ask for help from your friends
and family.
5. Some people are concerned about odor and noise from their pouch. Remember
that an intact pouch is odor proof. You can use lubricating deodorant to help with
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
34
odor or many patients report that putting 2 white Tic Tacs or Altoids in the pouch
help control odor. If you feel that you are about to pass gas into your pouch, you
can fold your arms over your stomach to muffle any noise.
Thank you for taking time to talk with me today. I will plan on calling you again in two
weeks to see how you are doing and complete a survey with you. Is that okay with you?
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
35
Appendix C
Stoma QOL Questionnaire and Script
My name is Debra Orr. I’m one of the ostomy nurses from the hospital where you had
your surgery. We are conducting a quality improvement project I would like to ask you some
questions about how you are doing after your ostomy surgery. Today, our phone call will take
less than 10 minutes. Any information you give me will be kept totally private and participation
in this phone call is voluntary. Do I have your permission to continue?
I am interested in knowing how the experience of having an ostomy affects your quality
of life. Please answer all the following questions based on your life at this time with either
always, sometimes, rarely, or not at all. Do you have any questions? Again, your answer choices
are always, sometimes, rarely, and not at all.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
36
Appendix D
1. I become anxious when the pouch is full.
2. I worry that the pouch will loosen.
3. I feel the need to know where the closest toilet is.
4. I worry that the pouch will smell.
5. I worry about noises from the stoma.
6. I need to rest during the day.
7. My stoma pouch limits the choice of clothes that I can wear.
8. I feel tired during the day.
9. My stoma makes me feel sexually unattractive.
10. I sleep badly during the night.
11. I worry that the pouch rustles.
12. I feel embarrassed about my body because of my stoma.
13. It would be difficult for me to stay away from home overnight.
14. It is difficult to hide the fact that I wear a pouch.
15. I worry that my condition is a burden to the people close to me.
16. I avoid close physical contact with my friends.
17. My stoma makes it difficult for me to be with other people.
18. I am afraid of meeting new people.
19. I feel lonely even when I am with other people.
20. I worry that my family feels awkward around me.
Total Score:
Not at all
Rarely
Survey Number
Sometimes
Pre Post
Always
Stoma QOL Survey
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
37
Appendix E
Pre-Practice Change QOL Scores Collection Form
Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Patient
Name/Phone Number
Ostomy
Type
Date
Surgery
Discharge
Date
Attempt 1
Date QOL
Attempt 2
Attempt 3
QOL Score
Note: This form will be used for gathering information. It will be kept in a locked cabinet and be accessible only to the DNP student.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
Pre-Practice Change QOL Scores Report Form
Patient Number
QOL Score
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Note: This is the form that will have the information which will be
presented in the project paper.
38
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
39
Practice Change QOL Scores Collection Form
Patient
Date Support Call
Date QOL
Ostomy Date Discharge
Number Name/Phone Number Type Surgery
Date
Attempt 1 Attempt 2 Attempt 3 Attempt 1 Attempt 2 Attempt 3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Note: This form will be used for gathering information. It will be kept in a locked cabinet and be accessible only to the DNP student.
QOL
Score
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
Practice Change QOL Scores Report Form
Patient Number
QOL Score
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Note: This is the form that will have the information which will be
presented in the project paper.
40
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
41
Appendix F
Letter of Organizational Support
WakeMed
3000 New Bern Avenue
Post Office Box 14465
Raleigh, North Carolina 27620-4465
919-350-8000
April 21, 2016
To Whom It May Concern:
I have reviewed Debra S. Orr's DNP Scholarly Project, "Impact of Post-Discharge
Telephone Calls by WOC Nurse on Quality of Life for Adult Patients with New Ostomies". This
letter is to confirm that Ms. Orr has organizational support and approval to conduct her project
within our institutions. We understand that for Ms. Orr to achieve completion of the DNP
program, a public presentation and manuscript submission related to the scholarly project will be
required by the University.
Our organization has deemed this project as a quality improvement initiative, but we will still
request our IRB to review. Please do not hesitate to contact me should you have questions about
this endorsement.
Sincerely,
Elizabeth K. Woodard, PhD, RN
Director, Nursing Research & BP
(919) 350-1 700 x 10124
[email protected]
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
42
Appendix G
Institutional Review Board
3000 New Bern Avenue
Raleigh, NC 27610
[email protected]
Tel: 919-350-8795
Fax: 919-350-1743
Date: June 22, 2016
To: Debra Orr, BSN
Re: Expedited Initial Approval Letter [IRBNet# 917837-1]
Study Title: Post-Discharge Phone Call and Quality of Life for New Ostomy Patients
After review of the following documents:
• IRB Application
• Patient Information Sheet
• QOL Survey Data Sheets
• Interventional Phone Call Script
• Stoma QOL Questionnaire and Script
• IRB Project Plan
• Study Methodology
the New Project materials for the above-referenced study were approved by expedited review by
the WakeMed Institutional Review Board on June 21, 2016 for one year with an expiration date
of June 20, 2017.
The purpose of this minimal risk study is to determine if the Quality of Life (OQL) for patients
with newly created ostomies is improved when receiving a scripted supportive phone call by the
wound ostomy continence (WOC) nurse after discharge from WakeMed. This project will
involve calling patients and providing a supportive, scripted phone call one week after hospital
discharge with the stoma QOL survey. This information will be reported to the WakeMed
Institutional Review Board at its next regularly convened meeting.
Any proposed changes to this study must be immediately submitted to the IRB for review and
approval prior to implementation unless such a change is necessary to avoid immediate harm to
the participants.
Please promptly provide updates of events related to this study to the IRB and if you have any
questions, don't hesitate to give me a call through the IRB office at (919) 350-8795.
NOTE:
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
1.
2.
3.
4.
5.
6.
7.
43
Review Type: Expedited Review
Category: [5 & 7]
Total number of participants/charts/specimens approved for this study: 50
This IRB complies with the requirements found in 45 CFR 46 (Common Rule), 45 CFR
164 (HIPAA), and 21 CFR 50 & 56 (FDA), where applicable. The assurance of
compliance with HHS regulations, FWA0000213, is available on the HHS website.
Re-review of this research is necessary if:
(a) Any significant alterations or additions to the study are to be
made.
(b) You wish to continue the study beyond.
A completed continuing review form must be submitted to the WakeMed IRB
approximately30 days before the IRB termination date or upon completion of the study
(whichever comes first). The IRB will send a study renewal notice approximately 60 days
prior to the termination date.
It is required that all consent forms become a permanent part of the medical record.
TheWakeMed IRB stamped consent form is the approved consent form.
Sincerely,
Stephen D. Kicklighter, MD
Chair - WakeMed Institutional Review Board
SK/vb
Please note: IRB Approval does not imply operational permission from individual departments (e.g., Nursing units, Pathology, Cath. Lab,
Emergency Room, Medical Records, Radiology etc.) to start the study. It is the Principal Investigator's responsibility to contact each Department
Manager affected by the study and obtain his/her permission to implement the study within their respective departments.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
Appendix H
44
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
45
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
46
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
47
Appendix I
WakeMed IRB
Study # 917837-1
Approval date: 06/21/2016 Init. SK/vb
Study Title: Post-Discharge Phone Call and Quality of Life for New Ostomy Patients
Investigator: Debra S. Orr
Study Information Sheet
DESCRIPTION: You are invited to participate in a research study on quality of life for new ostomy
patients. This will involve a phone call to complete a quality of life survey. Some participants will also
receive a supportive phone call in addition to completing the quality of life survey. The quality of life
survey consists of 20 multiple choice questions related to your experience as a new ostomy patient. No
personal information will be recorded; only your quality of life survey score will be recorded.
TIME INVOLVEMENT: Your participation will take approximately 10 minutes.
RISKS AND BENEFITS: The risks associated with this study are none. The benefits which may
reasonably be expected to result from this study are increased knowledge about ostomy care. We cannot
and do not guarantee or promise that you will receive any benefits from this study. Your decision whether
or not to participate in this study will not affect your medical care.
PAYMENTS: You will receive no payment or compensation of any kind for your participation.
SUBJECT'S RIGHTS: If you have read this form and have decided to participate in this project, please
understand your participation is voluntary and you have the right to withdraw your consent or discontinue
participation at any time without penalty or loss of benefits to which you are otherwise entitled. The
alternative is not to participate. You have the right to refuse to answer particular questions. Your
individual privacy will be maintained in all published and written data resulting from the study.
CONTACT INFORMATION:
If you have any questions, concerns or complaints about this research, its procedures, risks and benefits,
contact the Research Investigator Debra S. Orr at 919-350-7668.
Independent Contact: If you are not satisfied with how this study is being conducted, or if you have any
concerns, complaints, or general questions about the research or your rights as a participant, please
contact the WakeMed Institutional Review Board (IRB) and request to speak to someone independent of
the research Stephen Kicklighter, MD, Board Chair, at (919)-350-8795. You can also write to the
WakeMed IRB, 3000 New Bern Avenue, Raleigh, NC 27610.
The extra copy of this consent form is for you to keep.
If you agree to participate in this research, please indicate this to the researcher.
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
Appendix J
Preintervention Data
Identifier
QOL Score
1
61
2
62
3
75
4
72
5
51
6
71
7
48
8
62
9
55
Average Score
61.89
48
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
Appendix K
Postintervention Data
Identifier
QOL Score
20P
54
21P
47
22P
60
Average Score
53.67
49
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
Appendix L
Figure 1. Relationship between Surgery/Survey Interval in Days and QOL Score
Days and Score
80
70
QOL Score
60
50
40
30
20
10
0
24
29
47
48 64 67 85 105 107 128 134 144
Days Between Surgery and Survey
50
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
51
Appendix M
Figure 2. Correlation between Age and QOL Score
Correlation between Age and QOL Score
80
70
QOL Score
60
50
40
30
20
10
0
24
33
34
45
58
60 63 63
Age in Years
69
86
86
89
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
52
Appendix N
Figure 3. Inclusion/Exclusion Data
Inclusion & Exclusion
Total of 44
Completed, 12
Not reached , 9
Refused, 3
Excluded, 20
0
5
10
Excluded
Refused
15
Not reached
20
Completed
25
POST-DISCHARGE PHONE CALL AND OSTOMY PATIENT QOL
Appendix O
QOL RISK ASSESSMENT TOOL
Points
Surgery
Emergent
2
Scheduled
1
Urostomy
2
Colostomy
1
Ileostomy
3
High-output
4
Ostomy
Relationship Status
In a relationship
1
Single
2
Poor
3
Average
2
Excellent
1
Social Support
Stoma Characteristics
Budded
1
Flush
2
Retracted
3
Peristomal Area
Flat
1
Small fold
2
Large crease
3
0-20
8
21-30
7
31-40
6
41-50
5
51-60
4
61-70
3
71-80
2
>81
1
Age
Total Score
Patient Score
53