key: cord-0912840-dnqx7w7p
authors: Sims, Terran W.; Wilson, Karie
title: Telehealth Management of Urostomy Postoperative Complications: A Case Study
date: 2020-09-09
journal: J Wound Ostomy Continence Nurs
DOI: 10.1097/won.0000000000000698
sha: bbd0314199f4210bb544495e3657c3a36536c764
doc_id: 912840
cord_uid: dnqx7w7p

Surgical creation of a urostomy with or without radical cystectomy is a common urologic procedure. Despite advances in techniques, ostomy and surgical-related postoperative complications are prevalent and may impair physical recovery and health quality of life. Restrictions in face-to-face clinic visits created by the coronavirus disease-2019 (COVID-19) pandemic have dramatically altered care for patients with a new urostomy. CASE: This case report describes our management approaches using telemedicine and complementary communication strategies during the recent COVID-19 pandemic for a patient with multiple complex chronic conditions and multiple stoma and related postoperative complications. CONCLUSIONS: Despite challenges imposed during the COVID-19 pandemic, we were able to manage multiple surgical- and ostomy-related complications using a combination of telecommunication techniques that mitigated the need for routine and urgent postoperative clinic visits, hospital readmission, or unplanned visits to an emergency department. The new onset use of telemedicine approaches (telephone, televideo, and direct telemedicine) and various Health Insurance and Portability and Accountability Act-secure platforms due to pandemic conditions can improve access to care.

Surgical creation of a urostomy with or without cystectomy is a common urologic procedure. Despite advances in techniques, ostomy and surgical-related postoperative complications can delay recovery and affect health quality of life. 1 Even patients who are farther out from surgery can experience ostomy-related problems that require expert evaluation and recommendations with troubleshooting and treatment planning. 2 Frequent postoperative visits for stoma and pouch/ appliance assessment, discussion of postoperative concerns such as hydration, bowel function, or managing pain, and review of laboratory abnormalities can be beneficial for patients who undergo urostomy surgery. The advent of the pandemic and restricted travel and distancing has led to a variety of new support systems for urostomy patients.

Recent advances in the postoperative hospital care have led to patients being discharged earlier, resulting in limited inpatient ostomy teaching and acquisition of self-care skills. During the pandemic, families and caregivers may not be allowed to visit inpatients and therefore may be of limited assistance to the patient following discharge. Healing of the urostomy surgical site takes time and medical comorbidities can delay healing after discharge. Support systems for patients during a pandemic requiring social and caregiver distancing can challenge the patient's ability to provide self-care. This can increase the need for support mechanisms delivered by the health care team through a variety of communication modalities. Patient access to advanced practice providers (APPs) and those trained in ostomy care (Wound Ostomy Continence certified) is key. CASE N.D. is a 69-year-old woman with medical history significant for chronic urinary incontinence, urinary retention, and hematuria with recurrent urinary tract infections with 2 episodes of urosepsis in 2017 and 2018. She also has a history of cervical cancer in 1971 and underwent pelvic radiation therapy. In 2018, she had a colostomy placement due to perforated diverticulum in the sigmoid colon. In the fall of 2019, she had surgery for placement of a diverting ileal conduit with partial cystectomy and appendectomy by our urology service and simultaneous, had takedown of the end colostomy, component separation to repair ventral hernia, and primary colorectal anastomosis performed by the colorectal service.

Her postoperative course was confounded by a variety of complications including diarrhea, physical deconditioning, laboratory abnormalities, pyelonephritis, worsening of chronic kidney disease (CKD), and formation of a parastomal hernia. She required inpatient rehabilitation due to her prolonged hospital course and deconditioning. The parastomal hernia contributed to challenging urostomy pouching and obstruction Her pouching issue was due to a new parastomal hernia that generated a telehealth phone visit for an ostomy consultation. The APP (WOC certified) was able to assess the hernia and stoma complication and make recommendations for more successful pouching until she could be seen in consultation. The team was able to use telehealth platforms to provide consultation and collaboration for a plan, allowing the patient to avoid face-toface visits in light of the COVID-19 pandemic. A referral to general surgery for parastomal hernia repair was placed. She was seen by the surgical team and surgery was performed urgently due to the symptomatic nature of the hernia. She tolerated the surgery and while an inpatient her left J stent was replaced by the urology team. During this hospitalization she was seen by the urology APP and WOC team for stoma assessment and care. The hernia repair led to improvement in overall health quality of life, which improved dramatically, and she was able to once again be independent in self-care of her urostomy.

Unfortunately, she was readmitted for pain and J stent dislodgement that required a procedure to place a new J stent to the left kidney collection system. Her stoma continued to be easily pouched without difficulty. To date, the patient has recovered from her bouts of diarrhea and after hernia repair, her urostomy remains easily managed for additional improvements in quality of life.

The purpose of this case was to describe our experience using telemedicine and complementary communication strategies during the recent COVID-19 pandemic. The various components of telehealth and patient messaging provide a range of communication modalities to facilitate interdisciplinary care for patients with complex care needs. Multimodal communication strategies including telehealth/telemedicine visits, patient portal messaging, access to outside health database results, and secure text messaging with photograph sharing allow for quality care when patients cannot be seen for in-person visits. For us, these strategies provided the ability to diagnose, evaluate, treat, and manage care by a range of internal and external health care providers for optimal outcomes.

Complex postoperative care in the pandemic era requires innovative strategies and use of multiple modalities for assessing the patient and providing comprehensive care. The combined use of telehealth, telephone, patient portal messaging, secure text messaging with "still" photographs, and shared health data demonstrated success in the management of a complex patient. This case demonstrates the successful management of multiple complex clinical events using a variety of communication strategies. We suggest that multidisciplinary care delivered via the use of telehealth strategies can be provided safely and securely during a pandemic for which clinical care in outpatient and other hospital and/or clinic settings limits direct patient contact. leading to pyelonephritis. She required 3 admissions and 1 additional surgery in the first 5 months after her cystectomy and ileal conduit surgical procedures.

A variety of communication strategies and interventions were used to work with the patient from a distance, both while in the rehabilitation setting and then at home including telephone calls, an embedded secure electronic medical record (EMR) messaging patient portal, and the transmission of "still" photographs of her challenging stoma issues due to uneven contours created by her new parastomal hernia. Her complications managed from the rehabilitation setting included diarrhea and dehydration with concomitant worsening of her CKD. Outside laboratory results were reviewed via a shared electronic database and improved with recommendations for hydration and treatment of diarrhea. N.D. accessed the team through telephone and the EMR patient portal messaging account. She was being treated for both Clostridium difficile--induced diarrhea and a urinary tract infection. The rehabilitation facility sent her for CT scan and additional laboratory assessment which our team could review via the shared/ health information database portal. She recovered, the CKD stabilized, was routinely followed by the colorectal team, and released to the urology service for further urostomy care. Unfortunately she was presumed to be positive again for C. difficile due to recurrence of diarrhea and incontinence-associated dermatitis (IAD). Fortunately the culture was negative and the diarrhea was attributed to postoperative bowel dysfunction. She was managed by her primary care team for the diarrhea and IAD and recovered with eventual discharge home from the rehabilitation setting. At this point she was gaining weight and her functional mobility had returned to presurgical baseline and she became independent in self-care.

Two months later she experienced 2 episodes of acute pyelonephritis requiring hospitalization outside of our team's hospital; there she had cross-sectional imaging that suggested left hydronephrosis. Our team provided consultation by remote review of films as well as telephone consultation and formulated a treatment plan. Further diagnostic testing was performed, which identified a left ureteral stricture and resulted in a left percutaneous nephrostomy placement, which relieved her worsening CKD. She developed a fever that was managed by her primary home primary care team and included antibiotics; unfortunately C. difficile developed again and required treatment and care for the ensuing IAD. Weeks later, the percutaneous nephrostomy was converted to an internal left ureteral stent to provide maximum drainage of the left collecting system to the conduit, relieving the hydronephrosis. Her persistent diarrhea and C. difficile required 2 fecal transplants and close management by the colorectal team. The team believed she did not have sphincter incompetence and continued to assist with management of her bowel dysfunction.

N.D. was admitted via the emergency department after worsening diarrhea and fever. After discharge she again communicated her progress to our team via patient messaging and phone. This timing coincided with the coronavirus disease-2019 (COVID-19) outbreak in our area and patients' desires to avoid ambulatory visits. She continued to be managed through electronic communication and patient messaging via the portal.

A month later she sent a message about a pouching issue she was experiencing and pain around her stoma. She was able to describe her stoma and sent photographs through secured text messaging. These photographs were then uploaded to her EMR.

Stoma complications. Clin Colon Rectal Surg

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