key: cord-0978786-qyz83xx2 authors: Pata, Francesco; Bondurri, Andrea; Ferrara, Francesco; Parini, Dario; Rizzo, Gianluca title: Enteral stoma care during COVID‐19 pandemic: practical advice date: 2020-07-21 journal: Colorectal Dis DOI: 10.1111/codi.15279 sha: c52611bee7af21f8135526eb59f30f84cdceff1a doc_id: 978786 cord_uid: qyz83xx2 The COVID‐19 pandemic represents an enormous challenge for global health systems. Stoma care represents a potentially neglected component during the outbreak and no specific recommendations on stoma care have been published up till now. In this manuscript, MISSTO (Multidisciplinary Italian Study group for STOmas) provides practical advice on optimal enteral stoma care in adults during the COVID‐19 pandemic. Translations in four other languages (Spanish, Italian, Traditional Chinese, Simplified Chinese) are attached in the appendix to enable dissemination of the document worldwide. in December 2019 1 and declared a pandemic on March 11, 2020 by the World Health Organization (WHO) 2 . The COVID-19 outbreak represents the biggest challenge for the global health system since the Second World War 3 with 6,535,354 confirmed cases and 387,155 deaths as of June 6, 2020 4 . The healthcare, societal and financial burden of COVID-19 on patient management is associated with potentially catastrophic effects for non-COVID-19 patients due to untimely, delayed and suboptimal care during the pandemic 5-7 . Stoma patients may represent a frail and neglected category in this scenario. To face the COVID-19 pandemic, metamorphosis of surgical services is required to prevent in-hospital transmission, optimize allocation of scarce resources, establish new intensive care units (ICUs) and redeploy healthcare workers to emergency departments or COVID-19 dedicated wards [8] [9] [10] . Several recommendations and guidelines on surgery 10-15 and endoscopy [16] [17] [18] [19] have already been published, but none are specifically focused on stoma patients. Furthermore, although many recommendations suggest to consider performing stoma surgery instead of primary anastomosis in high-risk emergency surgery 14,20-23 none of those consider the potential problems related to reduced availability of stoma care services and reduced access in the hospital to caregivers for stoma training which may represent a problem for elderly and frail patients after discharge. The Multidisciplinary Italian Study group for STOmas (MISSTO) is a multidisciplinary group, founded in 2018, aiming at delivering recommendations, guidelines and educational activities for stoma patients 24 . The guidelines for the surgical management of enteral stomas in adults were published in 2019 25 . A rapid expert consensus within the MISSTO group, involving stoma nurses and colorectal surgeons, often working in centers severely affected by the outbreak, was organized to debate the potential issues of stoma care during the pandemic, especially in the most critical phases (III-V) 26 . In light of the authors' personal experience and literature background, mainly based on expert opinion, a consensus was reached when all participants agreed on a topic. This article provides practical advice for the optimal enteral stoma care in adults during the COVID-19 pandemic. A translation in other 3 languages (Chinese, Spanish, Italian) is available to promote global dissemination. The COVID-19 outbreak is severely stressing the healthcare systems worldwide. Reduction of non-essential services, reallocation of resources and staff represent the first response to the overwhelming need for ICU beds and dedicated COVID-19 units 27 . Shortage of healthcare workers, due to sickness or imposed isolation, may further stretch the system. In-hospital and outpatient stoma care must be provided with the aim of minimizing the burden on the overall pandemic response. services and not be redeployed to other roles to avoid service disruption (Tab. 1). Keeping senior stoma nurses is preferable to deliver timely and effective assistance, and to minimize the risk of simultaneous infection. Student This article is protected by copyright. All rights reserved nurses, nurses in training or surgical trainees should not attend the clinic. An exception may be made for low-resource settings, when condensed stoma training provided to other healthcare workers can guarantee service continuity to minimize the impact of infection and quarantine on the personnel available to provide specialist nurse care. A periodic assessment of stoma devices is also recommended, because the lock-down initiatives could affect normal supply. The stoma outpatient clinic should be located in an easily accessible area of the hospital, and, if possible, away from the emergency department, with clear visual signs highlighting the route. in order to reduce local workload and to streamline the local response to the growing number of COVID-19 admissions. In this phase the establishment of a territorial network of ostomy services may be of benefit for patients whose usual referral centers have been temporarily suspended. All recommended actions for the ostomy service environment organization are summarized in Table 1 . The general philosophy for any healthcare service during the outbreak is to avoid unnecessary risks to both patients and healthcare workers. Viral RNA has been detected in the faeces of COVID-19 patients 28 and potential transmission during enteral stoma manipulation cannot be excluded. Telemedicine must be encouraged and is effective in most cases. During follow-up, evidence suggests that it can reduce readmission rates and the burden of travel 29 . This also allows healthcare workers to visually analyze clinical signs or lesions and to evaluate their relationship with symptoms. Furthermore, telemedicine allows the stoma therapists to correct any errors in stoma management, such as cleaning, application of powders or ointments, and the correct positioning of stoma devices. Telemedicine may enforce, in this period of social isolation, the relationship between an ostomy patient and his/her caregiver, especially if the caregiver is not a family member. Follow-up care by mobile apps improves the psychosocial adjustment level and the stoma self-efficacy score when compared to routine discharge care, with a reduction in stoma-related complications 30 This article is protected by copyright. All rights reserved In the presence of these criteria, measures should be in place to allow stoma patients to be evaluated directly at a stoma center, and to avoid potentially unsafe exposure to the emergency department. Preliminary phone or telemedicine interviews, the day before whenever possible, is mandatory in triaging symptoms related to COVID-19 and for risk stratification into two categories: • Low-risk: no symptoms (i.e. cough, fever, breathlessness, diarrhea, hypo/anosmia, hypo/ageusia), no contact with SARS-CoV-2 positive persons, non-stay in high-risk area during the previous 14 days. . Patient's body temperature should be checked before entering the stoma center in order to reclassify patients with a temperature above 37.3°C 32 . All patients entering the stoma center should wear a surgical mask 33 and, if classified as high risk to wear gloves as well 16,34 , although there is no universal agreement on this 18, 35 . Unless there is a need for specific assistance and/or translation service, caregivers and relatives should be strictly prohibited from entering. Only one surgeon or one stoma nurse should attend the visit of a stoma patient; residents and students should not be present in the consultation room. All attending personnel should wear adequate personal protective equipment (PPE). No more than one patient simultaneously should attend the clinic. All recommended actions for outpatient management are summarized in Table 2 . Several recommendations advocate that for high-risk operations stoma formation instead of primary anastomosis should be considered to reduce the risk of complications 14,15,20-22 , need of ICU facilities which are already overwhelmed by COVID-19 patients, and hospital stay. An effective inpatient strategy must reduce stoma-related complications, expedite discharge and implement in-hospital stoma education pathways to decrease the need for home nursing care after discharge. First, stoma siting, carried out by a specialist surgeon or a stoma nurse, represents a mandatory and essential procedure even in the COVID-19 era 25, 36 . Second, in-hospital stoma training pathways should be implemented to allow patients to confidently manage their own stomas independently prior to discharge and reduce the need for home nursing care 37 . Several studies have demonstrated the effectiveness of information tools (such as brochures, also multimedia), in learning stoma care practices 25 . Therefore, the educational phase of stoma care should be implemented with multimedia and non-multimedia information tools. The educational phase of stoma care should be the same both in This article is protected by copyright. All rights reserved COVID-19 positive and negative patients, with the only difference relating to the use of PPE and allowing both the caregiver and stoma patient to attend face-to-face teaching sessions together for negative patients. Stoma care for COVID-19 positive patients presents a further problem due to issues arising from advanced age (median age of SARS-CoV-2 patients in Italy: 62 years 38 ). Therefore, the stoma nurse could be faced with elderly patients whose learning and adaptation skills to the newly created stoma may be suboptimal leading to further difficulties. It is important to promptly identify a caregiver, to proceed with his/her education, in geographical locations separately from the patient's room for COVID-19 positive patients, through the usage of brochures and multimedia information tools. In the case of a COVID-19 positive stoma patient, home discharge should be allowed in recovered patients. The identification of a caregiver in elderly and poorly compliant patients is paramount for remote follow-up after the discharge. Moreover, considering the social restrictions during this period, it is preferable that the caregiver is a person who lives or can live in the same home as the stoma patient for the time being. In the absence of any caregiver, the homecare outreach service should be designed in a way to guarantee proper follow-up of such patients at home if virtual assistance not feasible or practical. All recommended actions for inpatient management are summarized in Table 3 . Since the potential risk of faecal transmission of SARS-CoV-2 cannot be excluded 28, [39] [40] [41] [42] [43] , in the consultation room disposable items and accessories must be disposed into specific infectious waste containers, according to national and local guidelines. The Center for Disease Control and Prevention (CDC) established that medical waste generated during the treatment of COVID-19 patients, or persons under investigation (PUI), must be managed in accordance with standard protocols. There are no additional packaging or transportation requirements for regulated medical waste or sharps. Coronaviruses are susceptible to the same disinfection procedures in community and healthcare settings as other viruses, so current disinfection methods and wastewater treatment are expected to be sufficient 44 . • Guarantee a good standard for indoor air quality in the outpatient clinic. In addition to standard precautions for infection prevention and control (i.e. correct use of PPE, keeping appropriate interpersonal distance, proper hand washing) indoor air quality should be preserved to limit the SARS-CoV-2 spread, and to protect patients and healthcare workers. This can be obtained by: : 1) Ensuring good air ventilation in all stoma clinic environments by more frequent opening of windows and balconies, especially in buildings without specific ventilation systems . 2) Ventilation systems should be active to ensure airflow, in buildings equipped with specific engines and fans. In this emergency period to increase the level of protection, the air recirculation function must be eliminated to avoid the possible transport of pathogens. In the case of windowless This article is protected by copyright. All rights reserved rooms that are fitted with fans/extractors these must be kept in activity for the entirety of stay to reduce pathogen concentrations in the air. Cleaning must cover the surfaces most frequently touched (i.e. doors, handles, windows, glass, tables, light switches, toilets, taps, sinks, desks, chairs, keys, keyboards, remote controls, printers). Extensive environmental contamination Table 4 . Personal protective equipment (PPE), although being the most visible initiative to control infection, should be thought of as only one part of an overall prevention strategy. In the absence of effective administrative and engineering controls, PPE alone has limited benefit 48 . Surgeons or ostomy nurses in contact with a suspected or confirmed COVID-19 case should wear a surgical mask 33 or, if available a FFP2 respirator tested for fitting, eye protection (i.e. visor or goggles), a long-sleeved gown or apron, and gloves (Table 5) . Putting on (donning) and safely removing (doffing) PPE procedures must be strictly followed in the correct sequence 49 . Active assistance during donning and doffing will help to minimize the risk of accidental contamination. Hands should be washed immediately after the removal of PPE. It is essential to ensure that all staff assigned to treat COVID-19 patients are trained in the proper use of PPE. However, due to the rapidly evolving scenario and different availability of PPE across countries, local guidelines and international updated recommendations, such as those released by WHO 50 , must be consulted periodically by stoma care providers. This article is protected by copyright. All rights reserved The COVID-19 outbreak represents a great challenge to the global healthcare system. We are nowhere near the end of this crisis and the situation on the ground requires periodic evaluation to avoid service disruption that may cause harm to patients. Stoma patients represent an at risk and frail population, both due to their underlying comorbidities for (such as cancer and inflammatory bowel disease patients) and for logistic reasons. Pragmatic and clear plans for COVID-19 patients need to be established locally and on a national level, without compromising care of patients suffering from other diseases. Telemedicine and home care visits must be encouraged wherever possible, but an effective and easily accessible stoma care service is still necessary to provide timely care for highly selected cases. Even in this difficult period, healthcare organizations should guarantee the provision of an efficient stoma service for optimal patient care and caregiver education. In the near future, measures implemented during this pandemic may potentially lead to an overhaul of existing stoma services and fundamentally change the relationship between patients, caregivers and healthcare staff. • Hospital discharge for COVID-19 recovered patients • Preferential selection of main caregiver who is living or can live with the patient during the pandemic with social restriction measures in force Recomendaciones de actuación patología colorrectalde la AECP ante COVID-19 Laparoscopy at all costs? 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