Patient experience has been enshrined as a vital element of service improvement in England since the High Quality Care for All review in 2008 (Darzi, 2008). In March 2020, with the arrival of the COVID-19 pandemic, outpatient clinics had to adjust and reduce the number of face-to-face appointments.
Cambridge University Hospitals NHS Foundation Trust (CUH) has a number of Trust priorities and a Trust strategy for 2019-2020. In line with this the team endeavours to provide the highest quality of care and patient experiences within available resources, reducing variation and sustaining excellent outcomes. The stoma nurse service needed to adapt during the pandemic, so that patients had timely contact, support and care. One of the Trust strategies is ‘improving patient journeys’. The team felt a patient experience survey would determine whether they were maintaining the current standard of specialist nurse follow-up and identify where improvements could be made to the patient journey, flow and capacity brought about by the need for reduction in face-to-face appointments.
Background
CUH is one of the largest Trusts in the country, with a capacity of over 1000 acute beds across its sites (Addenbrooke's Hospital and The Rosie Hospital). In terms of stoma care, it is a specialist centre for advanced pelvic malignancy, multi visceral transplants and encapsulating peritoneal sclerosis. The Trust is also a regional trauma centre and has an intestinal failure unit. The service cares for neonatal, paediatric and adult patients.
The Trust performs 350 new stoma-forming operations a year as well as ileoanal pouches and antegrade colonic enema procedures (ACE). The stoma care service consists of three band 7 clinical nurse specialists (CNSs) (2.12 whole-time equivalent (WTE)), one band 6 support nurse (1 WTE) and one band 4 assistant practitioner (0.80 WTE). There is no designated administrative support. The CNSs work across campus in Addenbrooke's Hospital and The Rosie Hospital and neighbouring Royal Papworth Hospital NHS Foundation Trust.
Patient pathway
To provide care and support for this large number of new patients in addition to the ongoing care of existing patients, the stoma care service has created an integrated stoma care pathway (Figure 1). The pathway is based on the four phases identified by Davenport (2014): pre-operative, in hospital, returning home and life with a stoma. It provides clear anticipated care in an appropriate time frame and has been agreed by the multidisciplinary teams to ensure optimum and standardised support is given to all patients (Davis, 2005).
Pre-operative
This is an appointment prior to the formation of a stoma, to assess patients and their ability to cope with the stoma, provide them with information about life with a stoma, offer psychological and emotional support and sometimes assess the best site for the stoma to guide the surgeons. This meeting is a crucial part in the pathway because it has proven its contribution to a successful rehabilitation of the patient (Borwell, 2009).
In hospital
This phase consists of multiple meetings, starting on the day of surgery to assess with the patient the best site for the stoma. The stoma site will affect its function and therefore will have a great effect on the physical, psychological and emotional wellbeing of the patient (Cronin, 2014). Care continues postoperatively providing adequate teaching of practical stoma care, enhanced recovery, dietary and lifestyle advice and continued psychological support in preparation for safe discharge.
Returning home (0-3 months)
This period includes follow up phone calls and regular clinic reviews. The purpose of these appointments and early follow-up is to address any issues, problems or concerns the patient might have, which will prevent unnecessary and costly readmission to hospital and referrals to consultants (Carter, 2020).
Life with a stoma (4-12 months)
Patient reviews are held at 6 and 12 months. In addition, patients will have access to a stoma care helpline and can request an urgent appointment. Stoma-related complications can arise at any time following stoma formation, which could be debilitating and life changing, hence the importance of long-term management and follow-up (Association of Stoma Care Nurses UK, 2013; Carter, 2020).
Patients who are unable to attend clinics due to health conditions will be referred to the community stoma nurse. Patients who are out of area and referred for specialised surgery at CUH will be referred back to their local stoma nurses on discharge.
Clinics are run on CUH campus every Tuesday and Thursday morning. The slots are 30 minutes and double booked with two CNSs taking the clinic. Approximately 6-16 patients are booked into each clinic.
Both CUH sites use an electronic record system called EPIC: this is a Trust-wide notes system, with all the information in one place, and notes (including test results and charts) can be accessed from the office, wards, clinic and home (Stevens, 2017). More specifically for CNSs it allows access to patients' GP records (within Cambridgeshire), including prescriptions authorised for stoma products, allowing the CNS to ensure responsible prescribing and determine whether appropriate stock is being used and therefore ensure cost-effective stoma care. Prescribing and over-ordering of stoma products are frequently identified in primary care as an important cause of wasteful prescribing. Prescribers are also often unfamiliar with the differing needs of stoma patients, the products available and the specific ordering requirements for stoma appliances and accessories. Monitoring and review of prescribing of appliances for stoma patients is also frequently lacking (PrescQIPP, 2015).
The EPIC system also allows the service to have set templates (smartphrases) and direct routing of records following stoma clinic review to GP. This ensures GPs are updated with the clinic outcome, any requests or changes in products are identified and prescriptions altered accordingly and in a timely manner.
Changes in response to COVID-19
In March 2020, when the first wave of the COVID-19 pandemic hit and in line with government guidelines around social distancing and reducing in-person contact to limit transmission of the coronavirus, the stoma service reduced face-to-face clinic appointments, changing these to telephone appointments.
NHS England and NHS Improvement (2020) defines a remote consultation as an appointment that takes place between a patient and a clinician over the telephone or using video, as opposed to face to face. Using remote consultations supports the coronavirus response by:
- Preventing the transmission of the disease by reducing the need for patients to travel to hospital
- Allowing clinicians to speak to patients who are unable to travel to hospital (eg patients in at-risk groups, or who are to self-isolating or have travel difficulties)
- Allowing clinicians to carry out clinical work from home (eg staff in at-risk groups, self-isolating or who have travel difficulties)
- Supporting providers to meet increased demand in a particular locality.
The CNSs sought and obtained access to the NHS England Attend Anywhere call management system. Attend Anywhere is a secure NHS video call service for patients with pre-arranged appointment times. The CNSs liaised with IT team regarding the need to access and use MyChart. MyChart is the electronic patient portal at Addenbrooke's and The Rosie, which allows patients to securely access parts of their health record held within the hospitals' EPIC electronic patient record system. It allows teams to receive direct messages from patients including photographs that can be uploaded; all these are stored within patients' electronic records.
Patients attended clinic only if they were having major stoma issues and were agreeable to coming. New clinic templates and smartphrases were written (Box 1)
Box 1.Updated clinic notes template following changes during pandemicPlease note that, as per our Trust's guideline during the COVID-19 pandemic, this outpatient appointment has been converted into a telephone consultation.Any assessment and clinical decision made is therefore limited by the fact that the patient has not been seen and has not received a physical examination.At the beginning of the consultation, all details have been confirmed and the patient has agreed to proceed with a phone consultationSTOMA CAREReason for appointment: ………………………………………………………………………..Surgery: ………………………………………………………………………………………………Stoma: ……………………………………………………………………………………………….Skin: ………………………………………………………………………………………………….Output: ……………………………………………………………………………………………….Nutrition/diet: ……………………………………………………………………………………..Wound: ……………………………………………………………………………………………….Wellbeing: ……………………………………………………………………………………………Supplies and order code: ………………………………………………………………………..Plan/next review: …………………………………………………………………………………
If patients were having multiple speciality appointments, then the team would try to see them at the same visit. So if, for example, a patient had an oncology appointment, a CNS would go to see them in the oncology department. A small number was referred to the community stoma nurse to assess.
The CNSs were issued secure laptops by the Trust to enable telephone clinic appointments to be conducted from home. Every Tuesday and Thursday one CNS would hold the in-person clinic, if needed, and one CNS would carry out telephone appointments from home.
Aim
The CNSs wished to establish whether the implementation of telephone clinic appointments was effective in meeting patients' needs during the pandemic and to determine whether patients would prefer this method of follow-up to continue once restrictions were lifted.
Regular audits against departmental benchmarks and standards, together with feedback from those that use the service, are paramount to ensure that the service meets the changing needs of its users (Davenport, 2011). The change in clinic methods imposed by the pandemic presented a great opportunity to re-evaluate the standard pathway used by the service. Patients on different parts of the pathway are able to compare their previous experience of face-to-face clinics with their most recent experience of telephone clinics.
Method
A cross-sectional survey was conducted between April and June 2020 to evaluate the stoma clinic service using patient's feedback.
All patients who had clinic appointments during this period (n=160) were invited to take part. There were no exclusion criteria. Patients who agreed to take part filled in a questionnaire to evaluate their experience.
The questionnaire consisted of 19 closed questions with few opportunities to elaborate on some answers, and a chance at the end for free-text comments.
It was sent by the hospital's patient experience team via mail and a stamped addressed envelope provided for patient to return the completed questionnaire.
The patient experience team ensures that when mailings are sent to patients a robust process is followed and that there is a legitimate reason for the mailing; this process also ensures that any patients known to be deceased are removed from the mailing list and that the most up-to-date demographic is used.
The stoma nurse service ensures that all patients are offered follow-up in line with the Trust pathway, so it was hoped that respondents would feel confident and able to feed back on their experiences in the initial weeks or months following stoma-forming surgery.
In this way the service aims to offer a robust pathway, as advocated by the Stoma Care Nurses High Impact Action Steering Group (2013), which states that CNSs provide information and support for patients prior to surgery, during their hospital stay, and following discharge.
Findings
Out of 160 eligible patients to whom the questionnaire was sent to them, 72 (45%) agreed to take part in the survey. Of these, 34 were colostomists, 31 ileostomists, 1 had multiple stomas and 6 did not specify. Not all the participants answered every question, so the percentages are of those who did reply to each.
Patients were asked when they had had surgery resulting in a stoma in order to determine where they fell on the stoma pathway: 41% were pre-2019, suggestive of annual clinic follow-up or urgent review, while 7% had had their stoma formed during the first lockdown period (April-June 2020). Of note, 62 new stomas were formed in surgeries at the Trust during the period April-June 2020, of which 46% were referred back to local stoma teams and some were long, complicated admissions that had not been discharged during this time.
The questionnaire allowed the CNSs to establish when their last clinic review had been: 7% within 2 weeks of discharge, 55% being the 3-12 week reviews, 21% at 4-12 months, 6% over a year and 10% not sure, 1% had never had an appointment.
Nearly one quarter of respondents (24%) needed to contact the CNS before their scheduled appointment, with 44% stating that after contacting the CNS and discussing their stoma problem they needed to send in photographs. One patient did not consider that he had received appropriate support on how to send in photographs, and commented that, although it was explained to him, he did not have the equipment to carry it out. This respondent was then offered and attended a face-to-face appointment. It can be easily assumed that patients are digitally adept and able to achieve this task.
Respondents should have received an appointment letter before their booked telephone clinic appointment; 77% did receive correspondence, 9% did not and 14% were unsure. At CUH patients have the option of registering with MyChart in which case all hospital appointments are communicated via this app and an appointment letter would not be sent. It could be interpreted that the answer ‘No’ had been from those respondents registered for MyChart. Future surveys could be worded ‘Did you receive an appointment letter or communication via MyChart with your appointment date/time before your telephone clinic appointment?’
All telephone clinic appointments were allocated a 30-minute time slot, 96% strongly agreed/agreed that their appointment started on time, and 97% felt that the allocated 30-minute slot was adequate (Figure 2). This finding indicates good time management of the clinic and a seamless service.
CNSs throughout the country are now spending more time on the telephone with patients as part of their consultation service, and receive many more emails from patients to problem solve (Woodhouse and Yeung, 2020). If a patient had another planned face-to-face hospital appointment the CNS would try to offer a face-to-face review in the stoma department to coincide, reducing the number of visits the patient is making to the hospital and ultimately reducing ‘foot fall’.The NHS vision of ‘putting patients first’ (NHS England, 2013) is always at the forefront of care delivery. By working in collaboration with patients, specialist nurses can strive to meet patient needs.
Establishing whether patients felt that they received and understood information given to them in their telephone clinic appointment was part of the questionnaire. There are barriers to communication with the use of telephone appointments. Non-verbal cues cannot be picked up on, for example, body language or facial expression. It can be difficult to establish if a person has understood the information that has been discussed and it takes a skilled CNS to ascertain this. However, a remarkably high percentage of patients (94%) strongly agreed/agreed that they had understood all the information given. This result was possibly helped by the use of speakerphone. The speakerphone gave the opportunity for carers to be involved and it allowed for information reinforcement and the ability to ask questions and obtain feedback. ‘We must be mindful that patients may not want to involve their family with regards to stoma care’(Walker et al, 2018), but the importance of giving all stoma patients the opportunity to involve their partners or family even when patients are independent with care must not be overlooked.
All patients reported that they were given the opportunity to ask questions and felt comfortable doing so, despite the appointment not being a face-to-face consultation. The time slots for the virtual clinic appointments were kept to 30 minutes, the same as the face-to-face clinic, to allow for patients to express all their stoma-related concerns and issues. It could be questioned whether there was a need to allocate the same time to a telephone clinic appointment, since the CNSs were not visually assessing peristomal skin and stoma in a clinic situation. The survey results confirm that the allocated time was appropriate.
Patients were asked if the telephone clinic appointment had addressed all their stoma care needs at the time. Three patients (4%) disagreed with this. CNSs documented in the clinic notes when they felt the phone call had not been successful and that the patient might benefit from a face-to-face appointment in the future. Overall, 81% of patients rated their most recent stoma care telephone clinic appointment as either excellent or very good (Figure 3).
The majority of patients were clear as to the next plans after their telephone clinic appointment: this was determined according to the CUH pathway and their clinical need. However, 9/51 patients did not feel that the CNS had resolved their stoma problems over the phone, with comments including:
‘I could not explain my problem without him seeing it.’
‘Would have liked my stoma to be seen, it was difficult to describe verbally.’
There were two comments that related to patients wanting to know when their stomas would be reversed, but during the COVID-19 lockdown the surgeons were not undertaking stoma reversal.
Patients were given the opportunity to feed back to the service their preferences for future follow-up. The options were:
- Face to face (Addenbrooke's or outlying hospital in Ely)
- Telephone clinic appointments
- Video clinic appointments.
When asked to indicate their preferred consultation methods (patients were allowed to choose more than one), face to face received 50 votes, telephone 32 votes and video clinic 5 votes.
Respondents were also able to provide general qualitative feedback regarding their telephone appointments as part of the survey design. Comments included:
‘During COVID-19 it has been useful to have telephone appointments. It would only be preferable to have face-to-face appointments when reviewing stoma problems, although in those circumstances sending photographs was adequate.’
‘While COVID-19 is still ongoing I would rather not have an appointment at the hospital. Telephone clinic appointments are fine at the moment but would like an appointment at hospital when all is clear just to see if things are okay.’
‘I think a mix of face to face and telephone appointments would work well. I do not like the idea of video appointments.’
‘The telephone appointment was good albeit that the stoma nurse couldn't view the stoma.’
‘I do not like telephone appointments. I like face to face.’
‘I am sure the younger generation like telephone appointments, with the older generation wanting face to face.’
‘Telephone follow-up is fine unless there are physical problems when a face-to-face appointment or examination is much more preferable.’
‘Telephone appointment is convenient. If I have a problem, I know that I can phone clinic for advice.’
‘Face to face if only considered essential.’
Discussion and next steps
The stoma service found some operational benefits from running predominantly telephone clinics. These included allowing the allocated CNS to work from home, freeing up office space and ensuring a COVID-secure environment, with extended hours to carry out telephone clinics and no interruptions.
Negative aspects were lack of face-to-face contact and assessment of psychological issues and exploring how a patient might be feeling, missing non-verbal cues. Pre-operative consultations were felt to be difficult for the team, but patients were provided with an information pack. This included basic information, a team photo and an introductory leaflet with contact details. This was sent following the phone consultation. Reviewing physical issues such as postoperative complications, sore skin and hernias was challenging, however the ability for patients to send pictures via email or MyChart was very beneficial. Interpersonal contact is an important element of a high-quality service that brings an overwhelming benefit (Bowles, 2012).
It is recognised that the experiences of non-respondents to the survey may differ from those who responded. The department plans to run the survey again in early 2022, and in the repeat survey the aim will be to capture information that may mean the pathway is adjusted. For example, no patient demographic information was obtained in the first survey, leaving some questions for future research: does preferred type of follow-up vary with age or gender? Is there a pattern at different stages of the pathway as to what type of follow-up patients prefer?
The service plans to develop an online resource for pre-operative patients regarding surgery, hospital stay and expectations and stoma care.
Appropriate clinic space also needs to be identified in order that more video appointments can be offered to patients. At present telephone clinics remain predominantly in place, but a face-to-face appointment is offered for any complications, such as sore skin, leaking appliances and pre-operative consultations if it is the patient's preference. Patients will continue to be triaged by telephone to determine how safe it is for them to attend clinic, based on their stratification criteria and vulnerability score (Table 1).
Table 1. Priority stratification for outpatient activity
| Priority (button) | Definition (guidance) | Time frames New referral booking (may vary per specialty) | Time frames Follow-up booking (may vary per specialty) | Reported as overdue outpatient appointment at |
|---|---|---|---|---|
| P1a – Immediate | Immediate action is required to prevent death, loss of organ function/limb or eye sight | Advice to attend the emergency department or ambulatory care unit within 24 hours | n/a | n/a |
| P1b – Acute | Urgent action is required – to prevent serious clinical harm or permanent injury | Emergency/ambulatory outpatient appointment within 72 hours | n/a | n/a |
| P2 – HIgh | Likelihood of sustained severe harm/pain/psychological injury/effect on functional ability/quality of life (QoL) may occur as result of this condition | Very short time frame (eg 2–6 weeks) | Appointment must be booked within the stated interval for which it was ordered (no delay possible) | Stated intervalFailsafe: Stated date |
| P3 – Moderate | Likelihood of reversible moderate harm/pain/psychological injury/effect on functional ability/QoL may occur as result of this condition | Short/intermediate time frame (eg 6–12 weeks) | Appointment to be booked to stated interval + no more than 50% | Stated interval + 25%Failsafe: Stated date +25% |
| P4 – Low | Likelihood of no or mild symptoms or mild reversible reduced function/harm may occur as result of this condition | In turn | Appointment to be booked to stated interval + 25% | Stated interval + 25%Failsafe: Stated date +25% |
Expert specialist stoma care support is required not just in the acute postoperative period but also in the long term to enable full rehabilitation and independence to an optimal level for the individual. Consequently, a long-term integrated pathway is required. This should be bespoke depending on the needs of the patient, community and trust (Virgin-Ellison, 2019).
The time is ripe to innovate, audit and evaluate these new and different ways of evaluating our services (Fulham et al, 2020).
Conclusion
During the COVID-19 pandemic the stoma service adjusted and found some benefits from running predominantly telephone clinics. However, there were negative aspects to the change, both practical hurdles in terms of visually assessing stoma complications and also the impact of reduced interpersonal contact on non-verbal communication and the nurse–patient relationship.
There is evidence that a pathway for stoma care is invaluable, not only in providing a framework for excellent nursing care but also in relation to cost savings by reducing hospital readmissions and reviewing stoma products. The pathway needs to be flexible, particularly in such unprecedented times.
KEY POINTS
- Understanding the patient experience is essential for service improvement
- Adaptation of service provision is essential in unprecedented times
- A robust pathway has been proved to promote excellence within stoma care provision
- Service provision must be evaluated in order to plan and improve patient care in the future
CPD reflective questions
- What are the benefits of an ongoing pathway of stoma care nursing provision?
- Can CNSs fully assess patients' physical and psychological needs via a telephone consultation?
- How can CNSs further adapt and improve telephone or virtual consultations?
- What do you think are the considerations, challenges and benefits of telephone consultations?