Quality Improvement: Preventing Readmission After Ileostomy Formation


Patient population

Intervention

Comparator

Outcomes studied

Patients undergoing ileostomy

Patient education; stoma teaching

Traditional management

Readmission





Results


Only three articles were identified that specifically discussed stoma-related interventions and readmission (Table 44.1) [911]. The quality of evidence of these studies is rated as low.


Table 44.1
Studies of Ileostomies and Readmission Rates












































Study

Study design

Patients

Outcome of interest

Traditional management

Enhanced education

Quality of evidence

Nagle [9] (2012)

Uncontrolled before and after

203

Loop or end ileostomy

Readmission rates

35.4 %

21.4 %

Low

Younis [10] (2012)

Uncontrolled before and after

240

Loop or end ileostomy

Readmission rates

2.5 %

0 %

Low

Phatak [11] (2014)

Systematic Review

NA

Readmission rates

NA

NA

Low

In 2012, Nagel et al. published the results of a non-randomized before-and-after trial examining the impact of a well-defined ileostomy pathway on readmission following formation of a new ileostomy [9]. Their pathway included preoperative education, standardized ileostomy teaching materials, in-hospital teaching including direct patient engagement with their ileostomy, and strict post-discharge tracking of fluid input and output.. The authors compared readmission rate for new ileostomy patients over the 7 months after implementation of the pathway (n = 42) to the rate for new ileostomy patients for the 4 years prior (n = 161). The overall readmission rate dropped from 35.4 to 21.4 % after the pathway was initiated, but this was not statistically significant (p = 0.28). The readmission rate for dehydration, however, dropped from 15.5 to 0.0 % with adoption of the ileostomy pathway (p = 0.02). These authors conclude that their overall decrease in readmissions was almost exclusively “due to preemptive management of potential diarrhea and dehydration by patient’s self-management of their input and output.”

In 2012, Younis et al. published the results of a non-randomized trial evaluating the impact of focused preoperative patient stoma education on post-ileostomy outcomes [10]. In this study, the stoma intervention was included as part of a larger enhanced recovery program (ERP) being evaluated. Patients in their ERP received a stoma instructional DVD and a “practice pack” to allow them to practice ileostomy care preoperatively. Prior to ERP, the patients at their institution had only received routine information and counselling at their surgical preoperative visit. The authors compared 120 patients who underwent ileostomy after institution of the ERP to 120 patients who underwent ileostomy in the 2 years prior to ERP. They found that delay in hospital discharge caused by delay in independent stoma management was reduced from 17.5 % in the pre-ERP group to 0.8 % in the ERP group (p < 0.001). Their readmission rate was very low compared to almost all other published studies. Only 2.5 % of the pre-ERP patients were readmitted, compared to 0 % of the ERP group, although this was not a statistically significant difference (p = 0.001)

Finally, in 2014, Phatak et al. published a systematic review of educational interventions for ostomates [11].This group only identified 3 articles, two of which are discussed above, that reported rates of readmission following new ostomy from a total of 7 articles that evaluated any stoma education intervention. They conclude that the quality of evidence regarding educational interventions and readmission following ostomy surgery is low. Of note, the third article identified in this review was a randomized-trial published by Delaney et al. in 2003 evaluating the impact of a postoperative care pathway using controlled rehabilitation with early ambulation and diet (CREAD) on outcome after intestinal resection. Upon review of this article, there is no clear description of specific stoma-related interventions. The authors do mention that CREAD patients received “supporting written information documenting the expected post-operative milestones.” As such, it is hard to draw any conclusions related to stoma-specific interventions and readmission from this trial, which is why it is not included in our review.

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Jul 13, 2018 | Posted by in ABDOMINAL MEDICINE | Comments Off on Quality Improvement: Preventing Readmission After Ileostomy Formation
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