The Ostomy Files: A Validated Ostomy Care Algorithm: Applications to Clinical Practice

Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN, CRNP, Professor of Nursing and Director, Wound Ostomy, Continence Nursing Education Program, La Salle University School of Nursing and Health Sciences, Philadelphia, PA; and Nurse Practitioner/Clinical Research Assistant, Our Lady of Lourdes Surgical Associates, Camden, NJ

   An algorithm is a step-by-step procedure designed to solve a specific problem by advancing through a series of pre-determined logical steps. Initially used in computers and digital processing, algorithms now are used for many diagnostic and therapeutic problems in medicine and healthcare.1

When algorithms are designed to promote safe patient care, they must have established validity and reliability. Validity entails two aspects: content and construct. The algorithm must have research evidence demonstrating inclusion of the items or components (content) appropriate to its use (eg, ostomy care) and that it performs in the real world as theoretically purported (construct). The algorithm also must create these outcomes consistently (reliability).2-4 Content and construct validity are particularly critical to patient care scales or algorithms.

   A new ostomy care algorithm recently was developed and assessed for content validity with ostomy experts.5 What strengths does a problem-solving device such as this algorithm potentially offer to practicing clinicians? The most obvious benefit is that the algorithm guides users (both neophytes and experts) to appropriate therapeutic choices more efficiently and effectively and reminds users about critical assessment components. In other words, the algorithm serves to identify patients who stand to benefit (or not benefit)6 from a particular ostomy management strategy or product based on a series of assessments and choices. The ostomy care algorithm may fill a vital need that addresses shortages or inadequate distribution of health specialists — eg, wound, ostomy, continence (WOC) nurses.

   A clinical exemplar best demonstrates the algorithm’s potential clinical power. A patient with recently diagnosed colorectal cancer has a newly constructed left lower quadrant (LLQ) colostomy. His staff nurse, a new clinician, is required to assess the effectiveness of his pouching system and the current status of his fecal diversion. No ostomy specialist is available for assistance or consult.

   Using the ostomy care algorithm, the staff nurse observes and “chooses” several steps to best identify the patient’s product needs while simultaneously noting critical components of stomal and peristomal assessment for documentation. Using the algorithm as a guide, the nurse notes an end colostomy that is draining semi-formed stool through a round stoma with a flush profile. The patient’s abdomen is slightly rounded and the peristomal pouching surface is flat. No bridge devices are in place because it is not a loop stoma and no abnormalities are noted in the stomal or peristomal areas. Using the algorithm, the clinician correctly selects a clear, two-piece, cut-to-fit convex appliance to address both the flush postoperative stomal profile and the patient’s preferences. Subsequently, the patient’s stomal and peristomal areas stay healthy. Although not an expert, the staff nurse has been guided to an appropriate product choice and simultaneously reminded what to assess and document related to stomal and peristomal status. Without the algorithm guidance, the nurse may have overlooked assessing and documenting issues such as stoma color and moisture and observing for peristomal complications such irritant dermatitis, mucocutaneous separation, allergic dermatitis, or peristomal infection. The algorithm directed her about what and how to document stomal and peristomal lesions so healthcare colleagues can appreciate any changes without necessarily removing the pouching system. The assistive instrument supported the clinician’s choice of an appropriate, safe technology and promoted optimal documentation.

   As the forces driving evidence-based practice accelerate and resources shrink, the need for validated algorithms increases. Health technology is increasingly scrutinized. Payors, governmental agencies, and their fiscal partners are asking, Does this algorithmic choice or product work? Approaches and methods with clinically supported data (real world testing with good outcomes for patient safety and satisfaction) are more likely to be reimbursed7 and patients are likely to be more satisfied with their care.