A stoma (from the Greek meaning opening or mouth) is a surgical intervention that may be used to manage cancer related to the urinary system, colorectal cancers, ulcerative colitis, Crohn’s disease, diverticular diseases, imperforate anus, traumas, intestinal obstruction, familial polyposis, and congenital abnormalities.1,2 One of the most common stoma types is the intestinal stoma.4 The creation of a stoma for the purpose of evacuation, a fundamental human need, may lead to physiological, social, and psychological problems for the individual. Gas and odor, fecal leakage, skin problems, fatigue, loss of appetite, indigestion, nausea, diarrhea, constipation, and pain are among the physiological problems.3,4 According to a descriptive study by Baykara et al,2 odor and fecal leakage are the most discomforting problems. In a multicenter prospective observational study by Bosio et al,5 surgical technique and experience, procedure type (planned or emergency), patient health problems such as obesity and diabetes, and the ability of the individual to perform self-care have been shown to have an impact on the prevalence of complications.
Stoma complications can develop instantly (ie, within 12 hours of ostomy creation) and include hemorrhage and ischemia.1,6 Early stage complications (those that develop within 1 month of stoma surgery) include hemorrhage, ischemia, excessive output, obstruction, retraction, peristomal skin irritation, peristomal infection/abscess/fistula, acute peristomal herniation, and early postoperative intestinal perforation.6 Later-stage complications can occur months after the operation; these include peristomal skin problems, stenosis, retraction, hernia, prolapse, fistula, perforation, fluid/electrolyte loss, renal calculus, and gallstones.1,7 Peristomal skin problems can occur at any stage of living with a stoma.
Stoma complication prevalence varies in the literature8 from 10% to 70%. In a retrospective extensive study of 20 years of ileostomy and colostomy data by Park et al,9 the most frequently observed early stage complication was peristomal skin irritation (12%). In a retrospective study conducted on 128 individuals regularly observed at a stomatherapy clinic, Karadağ10 found 32.8% experienced stoma complications and the most frequently encountered complication was peristomal skin irritation (17.9%).10 Akçam et al1,11 obtained data from the records of 120 patients with a stoma; 24.1% experienced stoma complications and the most frequent complication was dermatitis (5.8%). Reasons for the discrepancies in data could be inconsistencies in the terminology, as well as the absence of a standard observation (data collection, assessment) instrument.12,13
Even though peristomal skin complications are not life-threatening, they make the placement of the ostomy appliance difficult and may cause leakage, odor, fear of appliance nonadherence, and difficulty choosing clothing, which can lead to social isolation, anxiety, and depression.1,3,5,14,15 Observational prospective, cross-sectional, and quantitative studies have shown peristomal skin complications and the accompanying symptoms also lengthen the course of treatment, increase of the cost of care, and cause loss of labor.14,16,17 All of these outcomes lead to an adverse impact on activities of daily living and reduce individual quality of life. In prospective, observational, and systematic review studies, prevention of peristomal skin complications has been shown to be easier and cheaper than treatment,12,18,19 making assessment of the peristomal area important in diagnosis and treatment decisions.14,17,20 Using a stomal complication assessment instrument with proven validity has been shown in prospective observational and cross-sectional quantitative studies5,16 to help establish the prevalence and incidence of peristomal complications, be a factor in the comfort and life quality of the patient, and decrease care costs and frequency of use of many products.
Ostomy Care and Ostomy Nurses in Turkey
The first stoma care unit was opened in the Turkish capital of Ankara in Gazi University Hospital in 2000; by 2013, there were 22 stoma care units with 376 certified stoma care nurses. Most of these nurses are employed in university and public hospitals and involved in ostomy and wound care. Stoma care nurses in these units provide stoma care and counseling; teach patients, their families, and health care professionals; and conduct research. The stoma care units provide service free of charge based on an appointment system.23 If a decision has been made to create a stoma, the patient will be referred to a stoma care nurse for an appointment at the policlinic for the patient and his/her family. During the appointment, stoma care nurses provide information about the stoma and stoma care, answer questions, and mark the stoma site. After the surgery, stoma nurses visit the patient in the intensive care unit or ward, assess the stoma and peristomal area, change the pouch, and show the patient and his/her relatives how to empty the pouch. Finally, the stoma nurse provides a booklet that includes information about stoma and stoma care to the patient and his/her relatives and makes an appointment to change the pouch with the patient or his/her relative for the purpose of correcting their mistakes. These services are designed to decrease the length of hospitalization; improve quality of life by addressing physiological, psychological, and social problems; and perform scientific studies. The Turkish Wound Ostomy Incontinence Nurses Society (TWOINS) has 136 members; 111 are certified stoma care nurses.22
Peristomal Skin Assessment Instruments
Although the literature discusses instruments utilized in the assessment of peristomal skin lesions,18,24 these instruments have undergone only limited validity-reliability studies. Salvadalena18 conducted a meta-analysis of 21 studies assessing stomal or peristomal complications to determine their incidence. The author concluded differences in study designs, absence of standard definitions, and variation in assessment times thwarted determination of the incidence of stomal or peristomal complications.
Ostomy Skin Tool (OST). The validity and reliability of 3 instruments/scales that assess stomal and peristomal skin complications have been tested, including the OST,14,16,24 the Ostomy Algorithm,14,16 and the Studio Alterazioni Cutanee Stomali (SACS Instrument).5,24 The OST is a standardized assessment tool developed by a team of 12 ostomy nurses for assessing peristomal skin. The OST consists of standardized descriptions of the abnormal peristomal skin: discoloration (D), erosion (E) and tissue overgrowth (T). Each domain facilitates assessment of the affected area (scored between 0 and 3) and the severity of the problem (scored between 0 and 2); therefore, for each domain the score is between 0 and 5, and the resultant total DET value is between 0 and 15.24,31 Jemec et al’s14 OST validation study in Denmark and Spain among 20 ostomy nurses demonstrated a high inter-nurse assessment agreement of this scale according to Kappa analysis (K = 0.84).
Ostomy Algorithm. The Ostomy Algorithm is comprised of 11 assessments: type of ostomy, type and volume of output, stoma type, stoma profile, stoma shape, abdominal contour, level pouching surface, presence/absence of devices, presence/absence of stoma complications, SACS score, and presence/absence of peristomal skin complications. Preliminary face validity of the Ostomy Algorithm was established by 9 wound ostomy continence (WOC) nurses in the United States with extensive ostomy experience (7 WOC nursing consultants and 2 WOC nurse employees of ConvaTec [Skillman, NJ], the company that supported development of the algorithm). When used properly, it allows for the selection of a suitable pouching system, maintenance of intact peristomal skin, and effective prevention, identification, and management of commonly identified stomal and peristomal complications. The section that includes the SACS instrument allows clinicians to assess and classify peristomal skin lesions.16
Beitz et al16 conducted a content validation of the Ostomy Algorithm in which validity-reliability studies were performed on real patients. As part of this study, the SACS instrument’s content validity index (CVI) was determined to be 0.94. Based on the content validation assessment results (the overall content validity score was 0.95), the Ostomy Algorithm was well received by expert WOC nurses, and the number of persons willing to participate in the survey (n = 166) suggests a clear need for this instrument.16
SACS instrument. The SACS instrument was developed in Italy between 2003 and 2006 and a validity study was performed. The instrument consists of 3 main parts: assessment of lesion types (5 options with definitions and photographs), assessment of lesion areas (5 options using a clockwise orientation), and documentation examples. Lesion types include hyperemic (L1: peristomal redness with intact skin), erosive (L2: open lesion not extending into subcutaneous tissue; partial-thickness skin loss), ulcerative (L3: open lesion extending into subcutaneous tissue and below; full-thickness skin loss), ulcerative (L4: full-thickness skin loss with nonviable, dead tissue), and proliferative (L5: abnormal growths present; ie, hyperplasia, granulomas, neoplasms). The peristomal lesion areas are determined according to a topographic (T) location scale: TI: left upper peristomal quadrant, 12–3 o’clock; TII: left lower peristomal quadrant, 3–6 o’clock; TIII: right lower peristomal quadrant, 6–9 o’clock; TIV: right upper peristomal quadrant, 9–12 o’clock; and TV: all peristomal quadrants.
The first reliability study of the SACS instrument was performed by Bosio et al5 in 2007. Researchers sent 20 lesion photographs to clinicians who assessed them using the SACS instrument. Inter-observer agreement percentage according to kappa analysis was K = 0.91. A reliability study of the SACS instrument was performed through independent inter-observer agreement and also analyzed using the Kappa statistic. Inter-observer agreement percentage was determined to be very good (K = 0.90). The confidence interval (CI) of the instrument was determined to be between 0.80 and 0.99.
Validated in Italy and the United States, the SACS instrument is currently the only content-validated peristomal skin assessment and classification instrument. As previously noted, the SACS instrument was assessed as part of the Ostomy Algorithm, with a content validity index of 0.94 out of 1.0 (N = 166).16,25
The current descriptive study was conducted for the purpose of assessing the validity, usability, and reliability of the SACS instrument adapted for Turkish patients.