The role of patients and their caregivers is critical to patient safety and improving health care outcomes. Leading the way to optimize the transition of care and recovery in the home setting, the American College of Surgeons (ACS) was the first organization to use simulation to launch skills-based training programs to educate patients on how to confidently manage their postoperative care.
Patient education and system improvement
For the surgical patient, technological advances in surgery, anesthesia, and nursing have resulted in 70 percent of all operations in the U.S. being conducted in the ambulatory or outpatient setting.1 The shortened hospital stay has resulted in limited opportunities for traditional inpatient education and relegated greater responsibility for postoperative care to the home setting. The quality of discharge teaching (amount of content and skill in delivery) and skills training were the strongest predictors of discharge readiness, and an associated reduction in preventable surgical complications, and fewer readmissions.2,3
More recent reviews from 2000 to 2016 concluded that patient education interventions decrease hospitalization and visits to the emergency department, improve quality of life, and reduce loss of productivity.4 Yet standardized surgical patient skills education is strikingly absent from perioperative programs, with less than 25 percent of surgeons and surgical nurses providing patients with postoperative skills training.5 These data underscore the importance of a program with structured teaching, practice, and verification that surgical professionals can easily provide to ensure the safe transition and recovery post-discharge.
The ACS Ostomy Home Skills Kit: Setting the standards
In 2010, the ACS released the first home skills kit for the patient requiring an ostomy, which included content and training related to colostomy, ileostomy, and urostomy. The ACS Ostomy Home Skills Kit was identified as the prototype of this kind of skills training because of the high incidence of stoma-related postoperative complications. In fact, 25 percent to 71 percent of patients who underwent these procedures experienced postoperative complications. Mounting evidence showed that focused education resulted in significantly improved outcomes, including a positive correlation in quality of life and social functioning.6-9
The kit was developed based on a psychomotor training model using visualization and basic skill development, including step-by-step training and proficiency through repetitive practice.10 A multidisciplinary team representing eight associations, including patient groups, was assembled to develop the first training program (see sidebar). The goals of the group included the following:
- Develop a standardized curriculum and credentialed home ostomy training kit for patients and caregivers to facilitate familiarity with the ostomy appliance (pouch and wafer), emotional preparedness, and psychomotor skills.
- Conduct program and surgical outcomes evaluations by patients, families, and professionals regarding the effectiveness of skills education delivered preoperatively by a virtual coach (and available postoperatively) to support decision-making and skills acquisition.
- Develop a national evaluation tool and database for patients undergoing an ostomy. Participants are encouraged to submit their outcomes data for aggregate evaluation.
Following expert consensus on the curriculum, all scripts and content were written to meet health literacy guidelines. Several computer models for training were considered, and H. Randolph Bailey, MD, FACS, FASCRS, then Co-Chair of the ACS Patient Education Committee and coauthor of this article, and the staff and patients at Houston Methodist Hospital, TX, provided essential feedback on the needs of surgical patients in remote and rural areas. Family isolation and lack of access to high-speed Internet led to the development of a DVD and the self-contained skills kit or “training in a box.”
A layperson trial was completed to assess knowledge and skill demonstration comparing the kit (video, booklet, checklist, and practice equipment) with a group lecture, printed handout, and model demonstrations. Kit use resulted in significantly greater knowledge scores and accurate skills completion (measuring and applying a new pouch) with less help requested.11
FIGURE 1. PATIENTS WHO NEVER OR RARELY HAD PROBLEMS IN FIRST TWO WEEKS
Patient and professional outcomes
In the last 10 years, more than 170,000 kits have been distributed to the surgical community through the ACS and its partner associations. Access to the video, booklet, and educational resources also are available on the websites of the ACS, the collaborating associations, and the National Library of Medicine, with 500,000 combined views in 2020
When the kit was first introduced in 2011, the ACS asked professionals who used the kits to report on their experience. The kit overall was rated as great (4.7 on a five-point scale, with five equating to great). Surgeons (n = 111) also stated the kit users had improved satisfaction and confidence with care than non-kit users. Surgeons reported the kit reduced the time needed for patient education, less skin excoriation, and fewer unplanned visits.
Colon and rectal surgeons conducted further external evaluation in 2012, when the video received the American Society of Colon and Rectal Surgeons’ National Media Award. Dr. Bailey accepted the award on the program’s behalf.
Patients (n = 1,100) rated the ostomy skills kit higher than any other resource (surgeon, ostomy nurse, floor nurse, ostomy support group member, and commercial products) in terms of preparing them for in-home self-care. Preoperative ostomy home skills kit use resulted in significantly higher patient and caregiver confidence scores in providing pouch care, such as emptying a pouch and measuring and applying a new pouch. Kit users also had fewer problems and greater satisfaction with overall care (see Figure 1 and Figure 2). Patients who did not use the kit were more than twice as likely to visit the emergency room at least once in the two weeks after an operation and used twice as many services while at home. Services were grouped to include home care visits, phone calls, or additional visits to a nurse or surgeon.
FIGURE 2. PATIENTS CONFIDENT OR VERY CONFIDENT PROVIDING CARE AT DISCHARGE
Ongoing quality improvement
Every two years, the home skills kit is updated based on the workgroup’s recommendations following review of the evaluation data.
In 2012, the box size was reduced to optimize hospital storage space and the Spanish-language kit was released, based on trials and feedback from ACS Governors in Latin America.
In 2014, the Pediatric Colostomy and Urostomy Homes Skills Kits were released with guidance from Marietta Reynolds, MD, FACS, representing the American Pediatric Surgical Association and Teri Coha, RN, WOCN-C, APN-C, representing the American Pediatric Surgical Nurses Association. The adult-focused video was updated with a young adult replacing the senior citizen conducting the welcoming sequence. A three-minute section on coping also was added, which shows ostomates swimming, running, doing construction, and discussing intimacy, and it shows children engaged in robust play.
In 2016, both the adult colostomy and urostomy books were updated. Under the direction of Michael McGee, MD, FACS, a colorectal surgeon, and Jan Colwell, RN, MS, CWOCN, FAAN, representing the Wound, Ostomy, and Continence Nurses Society, new images and guidance on oral replacement fluids and dehydration management for ileostomy were added. The urostomy content, first developed under the guidance of Jack McAninch, MD, FACS, FRCS(Hon), a urological surgeon and recipient of the ACS Distinguished Service Award, was updated with other urinary diversion options. Content on long-term follow-up for the urostomy patient was conducted with guidance from two other urologists, Alexander Kutikov, MD, FACS, and Jay Raman, MD, FACS.
In 2018, all of the skills programs were integrated into the ACS Learning Management System to offer online training. Adult colostomy, adult urostomy (Spanish and English), and pediatric colostomy and pediatric urostomy are available via the ACS Ostomy Home Skills Program page.
The research portal for local studies also is completed, and sites can participate in quality improvement projects using the evaluation tools located in the ACS REDcap data collection platform.
An important feature of the skills training program is the collaboration between participating associations and the ACS Foundation. All the skills programs are partially supported by educational grants, with the Ostomy Kit funded by Coloplast since the kit’s inception. All ACS patient education skills kits follow the same Accreditation Council for Continuing Medical Education standards, including images of all common products, and are compliant with the U.S. Food and Drug Administration’s requirement that any product that is placed on the body include the manufacturer information.
Opportunities to participate in training programs
Ajit K. Sachdeva, MD, FACS, FRSCSC, FSACME, MAMSE, Director, ACS Division of Education, continues to emphasize the need to support the entire surgical community, including patients and caregivers, with the skills and education needed for the safe transition to home care. A standardized ostomy home skills kit that includes practice equipment, instruction delivered by a virtual coach, and checklists is an effective tool to support safe self-care postoperatively. The evidence-based program supports all members of the surgical team with an on-demand quality improvement application that increases confidence and satisfaction while reducing complications and expenditures.
Significant progress has been made with the introduction and validation of the patient and caregiver kit. Nonetheless, much more can be done to improve the quality of life for ostomy patients, in particular during the first 30 days after an operation, as they tend to the care of their new ostomy.
All patients have the opportunity to use the ostomy training program and can view the materials on the ACS website or sign up for the course in the ACS Learning Management System. Kathleen Heneghan, Assistant Director for Patient Education, ACS Division of Education, and coauthor of this article, said the most recent patient data indicate that patients who use the kit and practice with the pouches and ostomy simulator have the greatest confidence for self-care at discharge and have the highest degree of satisfaction.
The most recent patient data indicate that patients who use the kit and practice with the pouches and ostomy simulator have the greatest confidence for self-care at discharge and have the highest degree of satisfaction.
The timing of the training also makes a difference. Patients who reported using the kit before surgery and then after discharge had better outcomes than patients first introduced to the training while in the hospital after surgery. These trends were seen for colostomy, ileostomy, and urostomy patients. A takeaway for all surgeons is to have the ostomy home skills kit available during the preoperative visit and instruct the patient and their caregivers to review the materials and practice. The instruction can then be reinforced in the hospital and at discharge using the skills kit checklist.
Education and training aimed at professionals and opportunities for sites to participate in controlled trials need to be completed to further improve how to best prepare a patient needing an ostomy. Does the skills validation or visits with a support group make a difference? Or are there other variables—such as body shape and contour, the way the pouch is applied in the operating room, and skin irritation at discharge from the health care facility—that affect the degree of complications?
Hospital and clinical sites also can participate in the registry-based ostomy education trial using the electronic evaluation tools. Participation in the trial will help determine the education methods that optimize outcomes for the ostomate. For access to the series of home skills programs and the ostomy program, visit www.facs.org/ostomy. For questions regarding the trial, contact Kheneghan@facs.org.
- Agency for Health Care Research and Quality. July 2020. Surgeries in hospital-based ambulatory surgery and hospital inpatient settings, 2014. Available at: www.hcup-us.ahrq.gov/reports/statbriefs/sb223-Ambulatory-Inpatient-Surgeries-2014.jsp. Accessed January 26, 2021.
- Weiss ME, Piacentine LB, Lokken L, et al. Perceived readiness for hospital discharge in adult medical-surgical patients. Clin Nurse Spec. 2007;21(1):31-42.
- Devine E, Cook T. Clinical and cost-saving effects of psychoeducational interventions with surgical patient: A meta-analysis. Res Nurs Health. 1986;9(2):89-105.
- Stenberg U, Vågan A, Flink M, et al. Health economic evaluations of patient education interventions: A scoping review of the literature. Patient Educ Couns. 2018;101(6):1006-1035.
- Heneghan K, Sachdeva AK, McAninch JW. Surgical patient education: Transformation to a system that supports full patient participation. Bull Am Coll Surg. 2006;91(6):11-19.
- Butler D. Early postoperative complications following ostomy surgery: A review. J Wound Ostomy Continence Nurs. 2009;36(5):513-519.
- Krouse R, Grant M, Ferrell B, Dean G, Nelson R, Chu D. Quality of life outcomes in 599 cancer and non-cancer patients with colostomies. J Surg Res. 2007;138(1):79-87.
- Salvadalena G. Incidence of complications of the stoma and peristomal skin among individuals with colostomy, ileostomy, and urostomy: A systematic review. J Wound Ostomy Continence Nurs. 2008;35(6):596-607.
- Colwell JC, Gray M. Does preoperative teaching and stoma site marking affect surgical outcomes in patients undergoing ostomy surgery? J Wound Ostomy Continence Nurs. 2007;34(5):492-496.
- Anderson L, Krathwohl D, Airasian P, et al. A Taxonomy for Learning, Teaching, and Assessing: A Revision of Bloom’s Taxonomy of Educational Objectives. Pearson. New York City; 2000.
- Heneghan KC, Sachdeva AK, Davis E, Bailey HR. Surgical skills patient education program. J Cancer Educ. 2009;24(S1):72.