ERAS for Patients with an Ostomy

1. Preoperative care
    1. Patients who may or will have an ostomy constructed during surgery and their families should be referred to an Enterostomal Therapy Nurse (ETN). (Level of Evidence: Low-Moderate). The ETN referral should include:
      1. Stoma Site Marking
        Patients should have the stoma site(s) selected using established principles of stoma site marking. Marking should be performed by an ETN, surgeon or a health care professional who has received training in this procedure. (Level of Evidence: Moderate)
      2. Preoperative Education
        Patients and their families should receive preoperative education either individually or in a group setting. Information should be provided in a variety of modalities including, but not limited to, verbal, written and digital formats. Multi-lingual educational resources should be available for non-English speaking patients and families. (Level of Evidence: Moderate-High). At a minimum the following should be included in the teaching:

        ● Basic anatomy and physiology of the GI/GU tract

        ● The surgical procedure and type of stoma, location and anticipated functional expectations

        ● Psychological preparation and lifestyle adjustment

        ● Introduction to pouching system options

        ● A demonstration on how to empty and change a pouching system. A return demonstration of pouch emptying should be done by the patient or family member. Patients should be encouraged to practice wearing and emptying their pouch and doing a pouch change at home prior to surgery.

        ● Postoperative expectations related to self-management of the ostomy (See recommendation 2.3)

        ● Possible complications related to dehydration, small bowel obstruction, stoma and peristomal skin health, development of parastomal hernia formation and pouching system wear times (See recommendation 3.4)

        ● Offer to pair individuals with a person with an ostomy (“ostomy buddy”)

        ● Information about industry sponsored programs

2. Postoperative Care
    1. Supporting rods are usually unnecessary. If used, timing for removal of the supporting rod should be decided in collaboration with the surgeon. (Level of Evidence: Moderate)
    2. Information provided to patients and their families in the preoperative phase should be reinforced postoperatively. (Level of Evidence: Low)
    3. Patients should be taught a minimum skill set specific to their ostomy needs prior to discharge from hospital:
      1. Patients should be encouraged to look at their ostomy on post-op day (POD) 0. (Level of Evidence: Low)
      2. Patients should be encouraged to participate in emptying their pouch on POD 1 and empty their pouch independently on POD 2. (Level of Evidence: Moderate)
      3. Patients should be encouraged to participate in changing their pouching system on POD 2 and fully participate in changing their pouching system on POD 3 or 4. Patients should have a minimum of 2 pouching system changes by POD 3 or 4. (Level of Evidence: Low)
    4. Families and caregivers should be encouraged to participate in the care and management of the patient’s ostomy. (Level of Evidence: Moderate)
    5. After ostomy surgery, patients should be discharged with community care support, which includes referral to a community ETN. (Level of Evidence: Moderate)
3. Post-discharge care
    1. Patients with an ostomy should have the recommended and required supplies and community care support. This includes follow-up care by an ETN in the acute care setting or in the community. (Level of Evidence: High)
      1. Minimum intervals of 2, 4, 6 weeks visits with an ETN
      2. Minimum of 6 visits by the community nurse
      3. Frequency of visits will be based on patient/family needs
      The patient should receive the following:
      1. Reinforcement of recommended ostomy care education and general support through their local community care team (e.g. CCAC) (Level of Evidence: High)
      2. Regular evaluation of the patient’s stoma and peristomal skin, the ability to achieve a predictable seal, and the ability to maintain peristomal skin health (Level of Evidence: Low-High)
      3. Ongoing information and support to the patient about adaptation to an ostomy (Level of Evidence: Moderate-High)
      4. Follow-up to ensure the patient (or primary care giver) is independent with pouch changes by postoperative week 2 (Level of Evidence: Low-Moderate)
    2. Patients should be provided with information on support services to facilitate their adaptation to a new ostomy including how to access ostomy support groups/resources, and programs sponsored by industry (Level of Evidence: High) 
    3. Patients should receive a follow-up phone call from an ETN within 7-10 days after discharge from the hospital to assess their adaptation to a new ostomy. (Level of Evidence: Low)
    4. Patients must be able to recognize potential complications and know what resources to contact for the following:
      1. Hydration status through monitoring expected volume of ostomy effluent, oral fluid intake and urine volume for 2 weeks post-discharge (Level of Evidence: Moderate)
      2. Signs and symptoms of obstruction which include abdominal pain, cramping, distention, high velocity watery output or no output, and/or vomiting (Level of Evidence: High)
      3. Normal and common abnormal peristomal skin conditions, such as Peristomal Moisture Associated Skin Damage (PMASD) (Level of Evidence: High)
      4. Signs and symptoms of a parastomal hernia include bulging of the abdomen around the stoma, pain and discomfort (Level of Evidence: Low)
      5. Wear-times for their pouching system are less than expected (Level of Evidence: Low)
    5. Families and caregivers should be encouraged to participate in the care and management of the patient’s ostomy. (Level of Evidence: Moderate)
    6. After ostomy surgery, patients should be discharged with community care support, which includes referral to a community ETN. (Level of Evidence: Moderate)
Appendix 1 - Preoperative Education

Preoperative information provided will vary from person to person based on their individualized needs and preferences (Level of Evidence: Low). Teaching may include:

  • Basic anatomy and physiology of the GI/GU tract
  • The surgical procedure and type of stoma including stomal characteristics (location, construction, colour size, protrusion, output/consistency, gas/flatus and odour, temporary vs. permanent)
  • Pouching system options and other possible accessories
  • A demonstration on how to empty and change a pouching system. A return demonstration of pouch emptying should be done by the patient of family member. Patients should be encouraged to practice wearing and emptying their pouch and doing a pouch change at home prior to surgery
  • Post-operative course and goals of care, including the need for active involvement in ostomy care
  • Vendor information
  • Available funding sources (government and supplemental health coverage).
  • Industry sponsored programs
  • Home care support on initial discharge
  • Transition programs  
  • Role of the ETN and other members of the health care team in post-operative teaching
  • Temporary physical restrictions imposed on the patient to prevent incisional complications
  • Dietary modifications when indicated
  • Bathing and showering
  • Intimacy and sexuality
  • Offer to pair individuals a person with an ostomy (“ostomy buddy”) and to enroll in industry sponsored programs (Ostomy Association, CCS)
  • Lifestyle adjustment
  • Psychological preparation
  • Possible complications related to dehydration, small bowel obstruction, stoma and peristomal skin health, development of parastomal hernia formation and pouching wear-times
  • Other topics as guided by patients/family questions/concerns arising during the teaching session

At a minimum the following should be included in the teaching: (Level of Evidence: Low)

  • Basic anatomy and physiology of the GI/GU tract
  • The surgical procedure and type of stoma, location and anticipated functional expectations
  • Psychological preparation and lifestyle adjustment
  • Introduction to pouching system options
  • A demonstration on how to empty and change a pouching system. A return demonstration of pouch emptying should be done by the patient or family member. Patients should be encouraged to practice wearing and emptying their pouch and doing a pouch change at home prior to surgery
  • Postoperative expectations related to self-management of the ostomy (See recommendation 2.3)
  • Possible complications related to dehydration, bowel obstruction, stoma and peristomal skin health, development of parastomal hernia formation and pouching system wear times (See recommendation 3.4)
  • Offer to pair individuals a person with an ostomy (“ostomy buddy”) and information about industry sponsored programs
  • Other topics as guided by the patient’s/family’s questions/concerns arising during the teaching session