Improving patient safety in colorectal surgery: The role of the nurse.

Pat Black, St Mark’s Hospital.Consultant Nurse , Coloproctology and Senior Lecturer in GI Nursing.

First, do no harm.

The profession of nursing and medicine are founded on many ethical principles including the concept of non- maleficence derived from the ancient ethical maxim –

primum non nocere – “first, do no harm”.

Patients expect to be safe during care and they principally rely on nurses to protect them from injury and harm or infection.

Skilled, aware and compassionate nurses know how to do this

Patient safety.Patient safety is everyone’s business, regardless of what role you hold in the organisation.

Patient safety must be your first concern.

Patient safety is both a characteristic of a healthcare system and a way of improving the quality of care.

Pre operative care.

The beginning of patient safety in colorectal surgery starts with the Enhanced Recovery After Surgery (ERAS)

Programme and in the pre operative period for the patient.

Enhanced Recovery Programme.ERAS was described by Henrik Kehlet in the 1990s and is widely used in the UK in colorectal surgery.

Kehlet felt that surgical outcomes were not solely related to the expertise of the surgeon and anaesthetist as complications could occur regardless of the level of skill.

Kehelet (1997) questioned if modifications to the body’s pathophysiological response to surgery could be improved which would then improve patient outcomes.

On the basis of Kehlets hypothesis programmes to enhance patient care were developed using terminology such as:

Fast track

Multimodal optimisation

Rapid recovery

ERAS Programme The programme consists of a number of elements:Reduced fastingCarbohydrate loadingAvoidance of mechanical bowel preparationAvoidance of drains, naso-gastric tubesGoal directed intraoperative fluid replacementShorter incisionsPatient information and goal setting

The Nurses role in ERAS The move to ERAS requires a multidisciplinary (MDT)

approach. Mitchell (2011) considered that the role of the ward

nurse should not be driven by medical protocols, but nursing staff should focus on care compatible with the nursing role involving;

A holistic approach Psychosocial care Information giving Discharge planning Management of common complications

ERAS interviewThe nurse checks the patient’s identity and gives the information about the ERAS programme . She then confirms the patient’s level of knowledge by asking him what he understands is going to happen.

The evidence for stoma siting.Baykara et al (2014)

A multicentre retrospective study to evaluate the effect of pre-operative stoma site marking on stomal and peristomal complications.

748 patients were recruited.

Patient data including age, gender, diagnosis, type of surgery, pre op stoma siting, the person who marked the site and post operative complications.

In 287 (38.4%) patients the stoma or wound care nurse or surgeon marked the stoma area pre operatively.

Stomal or peristomal complications developed in 248 (33.2%) patients.Peristomal skin problems – 136(48.7%)Mucocutaneous separation – 52 (18.6%)Retraction – 31 (11.1%)

OutcomeThe rate of complications was higher in the patients who did not have their stoma marked 46% than those who stoma was sited 22.9%.

The results of this study confirm that the stoma area should be marked pre operatively in all planned surgical interventions in order to reduce the risk of post operative complications.

Stoma siting.The position of elective stomas is determined prior to surgery as part of the ERAS programme.

Patients who do not have their stoma sited pre operatively have a higher risk of post operative complications such as;Leakage and odourPoorly fitting appliancesSkin excoriation Psychological sequalaeDifficulty in self care

Bad siting Good siting

The 3 aspects of quality in health care

The use of PREMs Patient Reported Experience Measures

Is seen as one of the three aspects of quality in health care alongside safety and clinical effectiveness.

Patient experience comprises two main aspects – relational and functional.

Relational refers to the interpersonal aspects of care – the ability of doctors and nurses to empathise, respect patients’ preferences and include them in decision making and provide information to enable self care.

Functional refers to aspects that relate to the patient’s basic expectations about how care is delivered such as clean safe environment, timeliness of care and effective communication.

PROMs Patient Reported Outcome Measures

Assessment of quality of care , evaluating outcomes of specific interventions, clinical assessment and decision support.

Both tools can be used for identifying areas for improvement and areas of excellence and for sharing best practice.

Both PREMs and PROMs are pertinent in todays clinical practice and provide rich information to improve care.

WHO Surgical Safety list

Post operative safetyPost operatively there are several areas that the nurse needs to observe to make sure the patient recovers from the operation in a safe environment.The standard observations after surgery.Care of any tubesCare of IVIObservation of the stomaObservation of the output

MDT workingMultidisciplinary team working(MDT) requires interdisciplinary , trans-disciplinary and effective collaborative practice in order to provide high quality and safe patient care.

Hogston and Marjoram (2007) state:

“ MDT working in practice is a collaborative process among groups of individuals with different backgrounds such as nurses, psychologist, doctors, surgeons, radiologist, histologist, colorectal nurse and colorectal co-ordinator, who share common objectives”.

The MDT should strive to work to provide a safe and secure environment in order to achieve high quality care.

Conflict and ineffective ways of team working result in disintegration of patient care.

The 6Cs should form the epicentre of MDT working in order to achieve high standards of quality patient care.

The 6Cs. Care Compassion Competence Communication Courage Commitment

Creating the evidence base.The ability to deliver accurate evidence based information when helping patients to make decisions about their care is fundamental to the role of the Clinical Nurse Specialist (CNS).

The role of the CNS in stoma care involves providing expert advice and clinical care to any patient undergoing stoma formation. This includes the provision of highly specialist emotional, psychological, psychosexual and practical advice.

The role of the CNS demands a thorough understanding of the evidence base on which care is based.

Phenomenological research by nurse researchers utilize the Heideggerian approach when investigating the lived experience of patients.

Providing evidence where non exists is seen as part of the role of the CNS, enhancing the knowledge base and improving patient care and safety.

Evidence Based Literature Review Park et al (1999).Most common early complication:

improper siting. Bass et al (1997). Reduction of complications /

Marked by a stoma care nurse. Milan et al (2009). Significant reduction of

complications /marked by a stoma care nurse. Chaudri et al (2005). Education and siting reduced

stoma related interventions (first 6 weeks).

The ultimate purpose of caring for people with colorectal problems is to facilitate individual, dynamic, empowered patient care journeys to allow optimum quality of life, health or death as appropriate.

Thank you for listening. C m n b n đã l ng ngheả ơ ạ ắ .