On 8 February 2019, the British Journal of Nursing (BJN) and Medicareplus International held a round-table discussion in Birmingham, UK, on how to prevent, manage and treat peristomal skin complications. The expert panel included clinical nurse specialists in stoma care (four participants); a bladder, bowel and stoma-care clinical nurse specialist; a lead colorectal nurse; a lead stoma care nurse; a consultant nurse in pouch and stoma care; and an expert in gastrointestinal nurse education—all nine of them based in England, UK.
The objectives of this meeting were to:
The meeting also aimed to identify the typical types of peristomal skin complications in clinical practice, particularly in association with moisture; understand what drives decision-making around the products used for peristomal skin complications; and find out if there are any particular features looked for when choosing a skin protectant.
Determining the frequency of skin-related complications in practice
The chair opened the discussion by inviting the panel members to estimate how often they saw peristomal skin-related complications in their daily practice. One delegate mentioned that up to 80% of patients will see skin complications after stoma formation (Colwell et al, 2017). One delegate estimated that, from a cohort of 10 patients, half of them would present with skin damage. Apart from this, none of the attendees had robust data to illustrate the frequency of skin-related complications in practice, but they briefly mentioned the new guidelines (NHS Improvement, 2018) being put in place across NHS England to prevent and manage pressure ulcers, which tissue viability nurses (TVN) in some trusts are already sharing with stoma clinical nurse specialists.
These guidelines highlight the need to count and report incidences of moisture-associated skin damage in addition to pressure ulcers on local monitoring systems, thus acknowledging the importance of the condition and its potential to impact on patients, clinicians and organisations. Subsequently, some clinical nurse specialists in stoma care are being asked to record data on patients who have sore skin around their stoma on datix, an NHS patient-incident reporting system which facilitates risk management in healthcare, a panel member said. Most of the attendees have not started this initiative; however, there was a general consensus that, in future, this would be part of stoma nurses' general role. A participant added it would be a good way to reflect on their practice, as they would have to document and monitor each individual patient. Collating these data would further highlight that there is no standardised skin assessment tool to evaluate patients with damaged skin, a member pointed out.
Another participant mentioned that their trust used the DET score (Coloplast Global Advisory Board, 2010; Martins et al, 2013), which stands for discolouration, erosion and tissue overgrowth. The total score provides information on the severity of the damage, while the sub-scores for the three separate areas enable nurses to define the skin problem. Some of the panel members said they found this scoring system easier than documenting whether the stoma had maceration without being able to adequately express any signs of improvement. With this tool, the clinical nurse specialist and their team could look at the stoma, give it a DET score and identify the improvement of the peristomal skin to calculate a new score.
Not every attendee showed an interest in this scoring system though, as it mainly comes down to perception. Some agreed that the DET score is not sensitive to small changes, so improvements or deterioration are not always easy to identify. One of the participants suggested that having a picture of the patient's peristomal skin to go alongside a score could complement the system and make it visually easier for nurses to determine the improvement or deterioration of peristomal skin. Photographic evidence would facilitate continuity and quality of care between different stoma nurses who care for the same patients, they pointed out.
Another point emphasised by the panel was that most ostomates would generally face some sort of soreness of skin during their life. Therefore, the difference between frequency of in-hospital patients and out-patients is a factor that may explain how often an acute clinical nurse specialist would see damaged skin. It was also noted that there is the enhanced recovery pathway, which reduces surgical stress, lessens complications and shortens patients' stay in hospital (Bryan and Dukes, 2010). Patients on the enhanced recovery pathway, however, may then develop skin complications, whether that is due to stoma shrinking, change in body shape, change of lifestyle or patient technique. All participants agreed it is after they have left the hospital that these complications occur and, if left for too long, the skin damage can become severe. The frequency of these complications can also be affected by a lack of effective communication between different specialist teams, which can delay patients being referred to a stoma clinical nurse specialist.
Associated risk factors for patients developing skin complications
There are several reasons why a patient would develop peristomal skin damage. According to the panel, these include:
The panel agreed that it can sometimes be overwhelming for patients on the enhanced recovery pathway to consolidate what their clinical nurse specialist has taught them in relation to taking care of their stoma, due to the discharge process being sooner than it was historically, while they are still trying to process their diagnosis and recent surgery. Other factors that may lead to patients developing skin complications are underlying skin conditions, such as dermatitis and eczema, and patients undergoing chemotherapy.
Non-patient related factors were also discussed. Changes to prescription that are not always necessary, such as adding new products and removing old products, is more likely to confuse a patient and make them wary of the new product, the panel said. Changes to the amount of product prescribed can also confuse the patient.
There are also delays when the damage is identified. Most patients would wait until the stoma area is sore and they are in pain before coming back to the clinic. Quite often, the panel said, it is not until a patient's stoma appliance starts leaking that they reach a ‘crisis point’ and rush to the clinic. Members deliberated that part of that was patients being taught to self-care and not being encouraged to call a clinical nurse specialist just because of a small change. This can be damaging to some patients, as they may not realise when to stop self-caring and seek medical attention. Other attendees suggested that this depends on the hospital they are discharged from, as some trusts will explain the role of community nurses sufficiently for patients to make use of these services, when available.
The risk factors were far too multifactorial for the panel to agree on one for peristomal skin damage. However, there was a general consensus on non-specialist input, such as ward nurses, as well as lack of knowledge among other teams, such as district nurses, on who to refer patients to when problems occurred.
Type and characterisation of skin damage most frequently seen
The panel was asked to share the words they most commonly used to identify and categorise skin complications. The chair questioned whether the terms ‘medical adhesive-related skin injuries’ (MARSI) or ‘moisture-associated skin damage’ (MASD) were used by the attendees, and although one or two panellists had heard the term MASD, most of the group were not familiar with either term.
The most commonly used words to describe skin damage among the panel were:
Another participant commented that they would usually use simpler words so that the patient, non-specialist colleagues and carers could understand the terms more easily. All members agreed with this and mentioned that common words were wetness, redness, superficial and depth of erosion or ulceration.
Standardised protocols and guidelines
The panel agreed that there were no current standardised protocols that all stoma clinical nurse specialists would follow. They were then asked about whether they had treatment and prevention strategies in place.
1) Treatment strategies
When asked about sore skin or treatment protocols, or standard strategy, the majority of the panel said they did not have one in place. One panellist disagreed and mentioned the Association of Stoma Care Nurses UK (ASCN) guidelines (ASCN, 2016) as a standard point of reference for their team. However, the panel was quick to point out that this was just a guideline and that it was not research based; therefore, there is no national evidence and research-based guideline for managing peristomal skin available for stoma clinical nurse specialists that could lead to an effective treatment algorithm.
Most panel members agreed that there cannot be one standardised approach as one shoe does not fit all, and stomas are just as individual as the patients. They pointed out that most stoma clinical nurse specialists base their choices on experience and what has previously worked for them in similar situations. This is usually alongside collaboration with colleagues to draw on their expertise and experience. Another participant highlighted that it is also down to the patient's ability, as having a standard protocol in place could limit the flexibility for patients who are unable to use certain powders or sprays due to frailty or dexterity issues. The most important aspect, suggested by a panel member, is the simplicity of the process—the less complex, the more likely patients will be on board with their treatment strategy. There was a general consensus by the panellists at the end of this discussion that a standardised approach to stoma care is not viable.
2) Prevention strategies:
The chair asked whether or not there was a prevention strategy in place in regard to preventing skin-related complications for stoma patients. The answer was that stoma care nursing is prevention in itself. One panellist said:
‘It is all about calculating the risk in your head and taking the necessary steps to lower the risk of complications occurring.’
Another participant highlighted that correct assessment and anticipating issues are key for prevention:
‘It is not about waiting until sore skin occurs that you decide to change the bag; it is about assessing the risk before that occurs and coming to the conclusion that this patient is at higher risk, so this bag is much more appropriate for them.’
When asked whether it was possible to standardise care, again, the majority of the panel did not believe that it was possible. ‘What works for one patient may not work for the other,’ pointed out an attendee. Another participant stressed that this is why there should only be guidelines instead of protocols and algorithms: ‘There isn't just a standard path to follow, every experience is unique.’
One panellist stressed that, although this is true from the prevention side of stoma care and there is little research on this, when discussing treatment there is an argument for more research to be done:
‘This is for the treatment of problems which already exist, due to the nature of stoma care being predominantly preventative in nature.’
There was no consensus on this point, as most of the panel emphasised there is a lack of controlling research variables.
Management of skin complications
The panel agreed that careful assessment and subsequent management of the stoma appliance/and or accessory can lower the risk of the patient attaining skin damage. However, due to product choice, this can become overwhelming for patients and the non-specialist nurses. One attendee pointed out:
‘The nature of the stoma industry means that it is heavily saturated with commercial influence.’
A nurse argued unless the clinical nurse specialist assessed the patient properly, they could become reliant on one of the many products available without figuring out the cause of the damage. As opposed to understanding the cause, working out how to resolve it and then looking at the product, it is quite common for some healthcare professionals to just turn to a product to treat the patient as quickly as possible. This can also be attributed to the lack of time, knowledge and resources that the NHS is currently dealing with (Newcombe, 2016; Boyles, 2010).
The panel agreed with this statement and reinforced that education is needed right from the beginning, for both clinical nurse specialists and ward nurses. This led back to the discussion of monitoring data for moisture-associated skin damage as outlined in the NHS improvement document referenced above. ‘It could be a wonderful tool if examined correctly and communicated to ward nurses efficiently and effectively,’ highlighted an attendee. However, another group member pointed out that despite educating their ward staff, and as a result of their lack of training, other time commitments result in the ward nurses having little time with each patient for stoma care. For a variety of reasons, the ward nurses do not always follow the stoma clinical nurse specialist's instructions, nor do they always inform the stoma clinical nurse specialist when they see a problem. ‘They want the quickest way to solve it, so they can move on to the next patient,’ they expressed. Most of the panel shared this sentiment.
Choosing the right product
The panel were asked about product selection and the driving factors in that decision. A few of them said they use formularies, which, in some trusts, can be developed with input from the centralised prescribing area, stoma clinical nurse specialists and patients. The list that is put together is primarily price-based, looking at the effectiveness of a product against its cost. Products that are low-priced but have little value are not included in the list, an attendee explained.
There was a general consensus that the panel would use their history and experience to determine what product to use, and some said they generated a ‘tool box’ to refer to in such circumstances. Another participant told the group they would try to give the patient some choice in certain products, for example, if the product was scented:
‘It is key to talk to patients about their choices and find out which one works better for them.’
There was a general consensus on this point.
Another panellist noted that formularies are not a list set in stone, that there is room for movement if products are not working and that a new product outside the formulary could be trialled and tested. Panel members who also had a formulary agreed to this statement.
All delegates disagreed that cost was a determinant before efficacy. The group agreed that the product had to work for the patient, as well as being cost-effective, even if it cost more than another product:
‘The cost is justified by the efficacy of the product.’
One of the participants added that, instead of the term ‘cost-effective’, the concept ‘value for money’ was a better indicator when choosing products to go on a formulary.
Overall, the general consensus was that, despite costs being a driver for choice so was value, and it is important that nurses have autonomy in the decision-making process for product selection.
The group then discussed how industry influenced product choice, as many stoma clinical nurse specialists can be sponsored by companies and some panel members felt that could make them think they had to choose their company products over others. However, most panellists agreed that they could speak to stoma companies about a particular product to change, to highlight certain features that either are not relevant or useful to patients and clinical nurse specialists.
Other key factors in selecting products were:
Not all panel members agreed on whether they would choose a product based on research evidence. Although some believed that it was hard to trust ‘good quality’ research ‘because companies were paying for the marketing and advertisement for their product’, one panel member thought that research evidence should be a contributing factor.
There was further discussion on accessory products and when the stoma clinical nurse specialist would use them when treating a patient. Most panel members said they only used accessories when needed, and that they would prefer using the correct appliance, rather than add an accessory such as barrier films. A few members of the group said they used barrier creams for the soothing effect if a patient had contact dermatitis, rather than as the first line of treatment.
When barrier products were used, the film format, as opposed to creams, was preferred by a few of the panel members. The reason for this was that films provide a silicone barrier around the stoma. Very rarely, when the skin is too sore to touch, a few participants said they would use a barrier film spray; this would not add to the pain levels, as there would be no need to touch the skin during application, which there would be if a barrier wipe or foam applicator was used. Generally, barrier wipes were the format of choice. Some panel members used medical adhesive removers too, to help stoma appliance removal be an easier and painless process.
Attendees also highlighted that not all products are beneficial and that some companies would advertise products, such as manuka honey and lavender, as therapeutic. Most of the panel agreed that they would challenge company representatives to show evidence on, for example, the amount of honey/lavender needed in a product for it to be considered therapeutic. There was a general agreement that more research is needed in this area.
Some delegates disagreed on when to use certain products and said they would only use a powder if the stoma was wet, to dry out the area. There was no general consensus on which was the most popular product within the group, but it was agreed that each stoma clinical nurse specialist and each patient would have an array of different methods.
All panellists said they were willing to try new company products, as they felt they had a duty of care to their patients to find the best available product for them. For this to happen, companies must provide evidence that the product works, explain how it differs from others in the market and bring samples so that the stoma clinical nurse specialists are able to fully understand the product before asking any patients if they are willing to trial it, the panel highlighted.
Industry and education
Most of the participants agreed that education is vital to ensure that clinical nurse specialists are kept up to date with the latest research and insights in the stoma field. However, some panellists were reluctant to go to industry-led education events due to the marketing aspect that remains a constant throughout the day. There was a general consensus that these days would be more beneficial if this aspect was removed.
Conclusion
Overall, the panel agreed that there is a high frequency of stoma patients who present with peristomal skin-related complications in both the acute and community settings. A couple of them referred to existing literature (Cowell et al, 2017), which shows that up to 80% of patients will see peristomal skin complications. However, most of the panel members could not provide an exact number or percentage to illustrate this reality due to lack of data. In future, they said, this will probably change as more clinical nurse specialists are being asked to monitor and record patients with sore skin as a result of moisture damage (NHS Improvement, 2018).
The panel agreed that prevention is key to avoid peristomal complications, and patients' different needs and abilities will determine which prevention techniques to use.
Clear communication with community nurses is vital, and a communication breakdown between clinical nurse specialists and non-specialist colleagues can be harmful for patients, who often present with skin complications during out of hours. Further education and training should be provided to ensure this gap of knowledge is bridged.
Although the group agreed that some of the key drivers in product selection are cost, efficacy and simplicity, they did not reach a consensus on which products are superior than others in terms of quality, or which products should be used as first-line treatment. They did mention that their product selection is largely influenced by past experience.
The panel reached a consensus in regard to how they would like companies to contribute to the management of peristomal skin complications: provide education days for nurses; design products with both patients and nurses; and guarantee accessibility and ease-of-use of such products.
The gap in communication, the different levels of expertise and training, and the variation of practice across the field indicate that there is a need for national guidelines to provide ward nurses, acute nurses, district nurses and healthcare assistants a point of reference when preventing, managing and treating peristomal skin complications.