The COVID-19 pandemic has put a strain on patients, their families, and health care providers. The rapid spread of COVID-19 has created unprecedented challenges for medical and surgical health care systems.10 Hospitals not only have to care for patients with COVID-19, but also must guarantee optimal continuity of care.
Di Saverio et al11 stated that according to a nationwide analysis from China, 18 (1%) of 1590 patients with COVID-19 had a history of cancer; among these, 3 (16.7%) had a history of colorectal cancer. Patients with COVID-19 and previous or active cancers seemed to have more serious adverse events.11 According to data from the Italian National Institute of Health (Istituto Superiore di Sanità, ISS), out of a total of 2003 COVID-19–related deaths that occurred in Italy from March 10 to May 18, 2020, 72 patients (20.3%) had a history of active cancer in the past 5 years.10
The current study sought to explore changes that the COVID-19 pandemic has caused in a stoma care center in Italy. In our department, as well as in all Italian hospitals, surgical activity has been limited to emergency and oncological cases since March 11. From January to April 2020, the department performed 40 colorectal surgical procedures: 20 for colorectal (4 rectal cancer, 5 right colon, 7 left colon, 1 splenic flexure, 1 explorative laparoscopy for intestinal occlusion, and 2 synchronous colorectal cancers and subsequently cecostomy) and 20 for IBD (8 for ileocolic Crohn disease, 5 for perianal fistulizing Crohn disease, and 7 for ulcerative colitis). From these procedures, 18 new ostomies were created (8 for colorectal cancer and 10 for IBDs). The department continued to treat new patients: 20 patients from our department as well as patients from other departments (12 patients [7 from gynecology, 3 from oncology, and 2 from clinical medicine]) and other hospitals (8 patients). During this period, the stoma care center performed 280 consultations for 164 patients. There was a reduction of 32.6% of the total in-person visits when compared with the past 3 months, and 99 telemedicine consultations were performed.
During the COVID-19 pandemic, telemedicine represented 35.3% of the consultations with 36.6% of patients. These were preventive in an attempt to reduce nonurgent endoscopic procedures and mechanical bowel preparations. In addition, many patients preferred to adopt telemedicine to avoid leaving the house during the pandemic.
Because of the fragility of patients with an ostomy, the stoma care center remained functional by adopting safety protocols for both patients and hospital staff and offering telemedicine. Since 2006, the center has provided stomal rehabilitation, including mechanical bowel preparation, management and consultations for stomal rehabilitation, and transanal irrigation system training for people with bowel dysfunction.12 The team consists of 2 stoma therapist nurses and 3 surgeons. There is a dedicated outpatient clinic and services are provided in the hospital wards, rehabilitation outpatient clinic, and patients’ homes. Care encompasses preoperative, intraoperative, and early and late postoperative periods and continues until discharge. Fourteen (14) years ago, the center started with only 31 patients. The center has now seen 1454 patients in the past 2 years who mainly come from the health districts of the Campania region (96.6%), while 3.4% come from other regions.
Since the beginning of the lockdown in Italy, the measures adopted for limiting medical visits consisted of telephone triage, limited hours, and limited numbers of patients as well as identifying suitable routes in the building for in-person patient visits that reduce the amount of physical contact; these factors all increased the use of telemedicine services.8 Because stoma management should be considered a high-risk procedure in terms of infective transmission,12 telemedicine should be encouraged. In addition, there is evidence relating to patients with ostomy that telemedicine provides consistent benefits, such as a decrease in readmission rates and mobility-related costs as well as empowerment of the relationship between patients and health care professionals.13–16 Telemedicine often uses resources that are free and accessible to most patients of any age and level of education (eg, WhatsApp and Skype).
In the authors’ center, the stoma therapist nurse calls the patient the day before each visit to perform telephone triage.9 The questions asked concern respiratory symptoms (cough, fever, dyspnea), gastrointestinal symptoms, dysgeusia and anosmia, recent contacts with patients who tested positive for COVID-19, and any trips made to areas initially considered “red areas.” On the day of the visit triage is repeated, and body temperature is measured. While in the hospital building, patients must wear a face mask without exhalation valve and gloves. The patient passes through an independent entrance to reach the stoma therapy clinic. This route was created to help patients avoid contact with other patients because patients with a stoma often have several comorbidities. No relatives are permitted to accompany the patient. The stoma therapist nurse and the surgeons use different personal protective equipment for each patient. Appointment times are scheduled so that patients do not have to stop in the waiting room. Rooms are sanitized between all patients.9
Telemedicine services can be used in almost any medical specialty, but they are best suited for those with a consultation that requires a high visual component.12 Telemedicine has created an opportunity to offer patients such comprehensive and multidisciplinary care.17 There have been considerable advances in the implementation of telemedicine and the development of technology. Telemedicine applications have been applied in new areas, such as surgical telemonitoring, emergency medicine collaboration, education of medical personnel, multidisciplinary team meetings, and postoperative follow-up.17 Postoperative follow-up by telemedicine has the potential to improve care, and the technology has become user-friendly.12 showed that the use of telemedicine increases patient satisfaction and decreases the need for laboratory tests.18 Also in a randomized trial, Sun et al19 showed that a telehealth approach has a positive impact on the unique physical, psychological, social, and spiritual needs of cancer survivors living with a permanent ostomy.19 In a recent randomized clinical trial on telemedicine in postoperative follow-up of STOMa PAtients (the STOMPA trial), the authors showed that telemedicine did not affect quality of life but did reduce the readmission rate and burden of travel.16 Nevertheless, it has to be recognized that telemedicine has some limitations, including the absence of physical interactions or the presence of internet connection problems; however, in a time of crisis, these factors can be overcome.20
In the current study, telemedicine was offered to all patients with a stoma starting in March 2020. Not only did telemedicine reduce the flow of patients to the department, but it also provided an important service. Stoma care consultations increased in this period. Moreover, 83.2% of patients treated with telemedicine were extremely satisfied and 92% would use it in future.
The present study describes management approaches using telemedicine during the COVID-19 pandemic. To the best of the authors’ knowledge, there is only 1 case study in the literature about telemedicine management of postoperative complications in urostomy during the COVID-19 pandemic.21 Therefore, the current work could be the first retrospective study on the use of telemedicine in patients with an ostomy during the pandemic.