Impact of COVID-19 on stoma care: the experience of one team in Oxford

COVID-19 has caused significant disruption to the delivery of patient care across the globe (Ren et al, 2020; Sud et al, 2020; Wexner et al, 2020). To the authors' knowledge, the impact of COVID-19 on the management of patients with stomas during the pandemic and in the recovery phase has not been described in detail before in the literature. In this article, we discuss our experiences at Oxford University Hospitals NHS Foundation Trust.

Before the COVID-19 pandemic, our stoma nursing team covered daily clinics at the John Radcliffe Hospital (for emergency surgical patients) and the Churchill Hospital (for elective patients). The team also covered the Horton Hospital (a district general hospital with no acute surgical admissions) twice weekly, and a clinic each month in the neighbouring towns of Abingdon and Witney.

In February 2020, there were 82 face-to-face clinic appointments and 31 home visits performed. There were also six telemedicine appointments for stoma patients, and 10 telemedicine appointments for ileoanal pouch patients. Table 1 summarises the number of patients who have had face-to-face specific stoma/pouch clinic appointments or telemedicine appointments between February and July 2020.

On 16 March 2020, there was an abrupt end to normal practice and all face-to-face clinics and home visits were suspended with immediate effect in line with the UK Government's recommendation. Anticipating a huge influx of patients needing beds and the uncertainty of COVID-19, some stoma specialist nurses in our team undertook additional basic training to allow them to become ward nurses should the need arise. Some of our colleagues have been specialist nurses for more than 20 years, so the prospect of working ward shifts in the surgical emergency unit, and the upper gastrointestinal and lower gastrointestinal/breast wards was a new challenge. This ward working affected the stoma team mostly at the John Radcliffe, who had to work long shifts on the surgical emergency unit to support the ward teams. The answerphone service based at the John Radcliffe was transferred to the colorectal nursing administrator, who covers the colorectal cancer nursing team and stoma team, and who has worked remotely from home since March. She forwards all the call details by email for the Churchill or John Radcliffe stoma teams to answer.

We have had to write standard operating procedures and risk assessments to enable a clinic service and home visits to be resumed in the near future.

As lockdown eased in July we reopened one Horton clinic, but run a reduced service, with half the patient numbers, as the risk assessment dictates that we need to leave 30 minutes for a thorough room clean in between patients. Previously we ran this clinic twice a week, but it now runs once a week as we are unable to access a clinic room for the second clinic due to the increasing pressures on space, as other services require rooms.

We have embraced the use of digital photography, and patients are happy to email their stoma photos through for an opinion. We have made training films that we share with patients and carers using a secured link in Google Drive, and each time we have sought specific consent for publication with our Trust.

We are using Microsoft Teams extensively with colleagues. In particular, multidisciplinary meetings that were difficult to attend in person pre-COVID have now been easier to access and we have found them very valuable. Our virtual meetings have facilitated team-based discussions and staff appraisals, which is crucial as we are spread over several sites. This has also reduced feelings of isolation for colleagues who have been working from home. We are also planning to use Attend Anywhere, a secure video call service, for video conference calls with patients (Greenhalgh et al, 2020).

Overall, we are now spending much more time on the telephone with patients as part of our consultation service, and we receive many more emails from patients to problem solve. Some patients need a face-to-face clinic appointment or home visit. We are very strict on the criteria and we try to combine these with any other appointments that the patient may have in the hospital, to reduce the number of visits they have to make. This has worked well and we have held mini-clinics in the radiology department, day-case units and haematology outpatients, where it is possible to book a room and socially distance from other patients and colleagues.

We have collaborated with the infection control specialist nursing team to risk assess safe practice for when our face-to-face clinics reopen fully and are awaiting Trust guidance on when this can recommence. We have built up an extensive list of patients who are keen to have a face-to-face appointment when this happens.

At the Trust, a swabbing service for elective patients was established at the beginning of the pandemic and has been pivotal to ensuring that elective surgery has continued and that the Churchill remains a ‘clean’ site. More specialties are now accessing this service and the colorectal nurses were asked to run and support this service.

Colorectal cancer operations have continued at the Churchill site, which has resulted in a steady stream of patients having stoma formation. Recent surgical guidelines issued by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) have in some cases resulted in more patients having stomas who may not have done before the pandemic (ACPGBI, 2020). This is because if they experienced an anastamotic leak, they would most likely have required an intensive care bed and, if they had subsequently contracted COVID-19, it could have been catastrophic for them. There have also been tertiary referrals from localities that have had to reduce their bowel cancer operations.

Overall, COVID-19 has had a significant impact on how the stoma nursing team delivers care, with a move towards more telephone, email and video consultation. It is important to remain flexible and creative during the pandemic, especially as services are starting to reopen in the recovery phase.