Analysis of Nursing Professionals Criteria Regarding the Application of Ostomy Devices at Each Stage of the Care Process

Introduction

Adapting to life after undergoing an ostomy can become a challenge, especially when it comes to digestive elimination ostomies. Therefore, choosing the right device that anatomically adapts, prevents fecal content leaks, and aligns with the ostomy person’s lifestyle, is a key aspect. Addressing this soon in the care of these patients is crucial to promote their recovery and early return to daily life [1].

There are a wide variety of devices or systems for ostomy care, which can be classified according to different criteria. Based on the number of pieces composing the device, they are classified as one or two pieces [2]. Both have distinguishing features that can provide significant benefits to ostomy carriers, providing the possibility of alternating their use according to daily life requirements and situations. Ostomy devices should offer security, protection, comfort, and discretion to avoid disrupting the carrier’s lifestyle [3, 4].

Health education is crucial, and the role of the nurse or stomatherapist facilitates patient training in the care of his or her stoma throughout the entire care process. All biopsychosocial aspects that are altered or at risk of alteration should be comprehensively addressed [5, 6, 7, 8, 9].

There are studies [10, 11] addressing ostomy patient care, quality of life, complications associated with the stoma and skin, economic costs [12, 13, 14], and even considerations regarding the use of the device based on its convexity [15, 16, 17]. However, after conducting a literature review, no research providing evidence regarding the application of one or two-piece devices in ostomy patients and their optimal use was found.

Therefore, the objectives of this study are to analyze the opinions of nursing professionals on the application of ostomy devices at each stage of the care process for ostomy patients, evaluate professional opinions on the use of one- piece devices considering ostomy and patient characteristics, and identify criteria for recommending different types of devices.

Results

A total of 233 surveys that met the inclusion criteria were obtained. Regarding sociodemographic data, the average age of survey participants was 47 years (SD: 9.6). Most respondents were female, accounting for 91.4% (n=213). Concerning their occupational roles, 45.3% (n=106) worked in hospitalization units, and 51.7% (N=121) had less than ten years of professional experience. Only 9.9% (n=23) acknowledged having no specific training in ostomies.

In terms of knowledge about the use of one-piece and two-piece devices, 78.5% (n=183) of respondents in healthcare centers had access to all ostomy devices (open and closed one-piece, open and closed two-piece). When not all device systems were available, 4.3% (n=10) stated that the most common options were two-piece devices with both open and closed bags and an open one-piece.

Following the creation of the stoma, the choice of ostomy devices varied depending on the service area: one- piece devices were most used in the operating room, while in hospitalization and upon patient discharge, two-piece devices were preferred (Graph 1).

Click to enlarge

Graph 1: Devices used according to the surgical stage.

When evaluating patients’ predisposition to changing from a two-piece system to a one-piece system, 44.4% (n=104) respond “yes, reluctantly.” 43.3% (n=101) of the participants occasionally recommend the one-piece device, and the same percentage recommends it frequently.

Out of the total sample, 86.3% (n=201) considers it essential to include different types of ostomy devices in electronic prescriptions based on patient needs, compared to 13.7% (n=32) who doubt their benefits.

Regarding beliefs about ostomy device usage, as shown in Graph 2, when analyzing aspects related to ostomy that should be considered when recommending one-piece devices, it is noteworthy that the majority values the peristomal skin condition, followed by the number of changes per day, and to a lesser extent, the height of the stoma.

Graph 2: Considerations for the use of a one-piece device in relation to Ostomy.

Most professionals believe that when indicating a one- piece device, the patient’s manual and/or visual dexterity and their degree of dependence should be taken into account (Graph 3). When asked about the most appropriate device option for immediate postoperative use, 62.2% (n=145) consider it should be a two-piece, and 37.8% (n=88) prefer a one-piece.

Click to enlarge

Graph 3: Aspects to consider for the use of a one-piece device in relation to the patient.

Only 85 professionals justify their response:

• 76.5% (n= 65) base their choice of a two-piece device on benefits for both the stoma and the professional. 35.4% (n= 23) consider that, in an immature stoma, the use of two-piece devices minimizes the risk of infection, avoids peristomal complications, and reduces pain during device removal. Regarding benefits for the professional, 17% (n= 11) believe that using two- piece devices reduces workload, 18.6% (n= 12) increases safety in handling effluent by facilitating stoma visibility without removing the entire device, and finally, 29.4% (n= 19) find it more comfortable due to the irregularity of effluent consistency during the first days.
• 23.5% (n= 20) justify the use of a one-piece device; 25% (n= 5) of the cases for its ease in emptying effluent, and 75% (n= 15) for the simplicity of the device.

Regarding the professional’s knowledge about the use of one-piece devices, 94% (n= 219) recommend the use of one- piece devices, while 6% (n= 14) claim to have never done so.

Regarding the appropriate care moment for the placement of a one-piece device, 25.3% (n= 59) believe it should be after stoma creation in the operating room, 24% (n= 56) during outpatient follow-up when intestinal transit is regularized, and the skin is intact, and 6.4% (n= 15) when the suture is removed (Table 1).

In Table 2, responses are listed based on the advantages, disadvantages, and contraindications that professionals have considered for the use of one-piece devices, highlighting flexibility as an advantage, which provides greater freedom of movement. Regarding disadvantages, the majority emphasize the difficulty of placement when the bag is opaque and the belief that it offers less protection to peristomal skin. They believe that the use of this device is contraindicated in cases of sunk/invaginated stomas, peristomal injuries, mucosal necrosis, and/or dehiscence.

Regarding the appropriateness of using a one-piece device while peristomal sutures are in place, 42.9% (n= 100) believe there is no contraindication. 43.5% (n= 44) state that they do not use one-piece devices with peristomal sutures due to the risk of dehiscence.

The frequency of changing one-piece devices is, for 32.7% (n= 76) of respondents, one bag per day; for 23.6% (n= 55), two changes per day; and for 6.4% (n=15), a maximum of three changes per day. In contrast, 31.3% (n= 73) of professionals consider the use of a one-piece device independent of the number of changes per day if the skin is intact.

Discussion and Conclusion

In the absence of evidence on the topic of “the use of one or two-piece devices in ostomy patients,” this study aimed to review the types of devices most commonly used in clinical practice for the daily care of ostomy patients. Exposures of clinical cases or industry-sponsored research were found where the use of the devices employed was not justified, but rather the characteristics of the devices were emphasized [17, 18, 19]. Among them, Welser, et al. [20] compared two-piece devices, and Voergaard, et al. [21] conducted a comparative study of a single piece closed bag compared to the old reference for this bag. In both cases, devices of the same brand were compared without analyzing the better use between one or two pieces.

On the other hand, Salvadalena, et al. [22] refer to the treatment and recommendations applied to peristomal complications, indicating the use of flat to convex plates or the frequency of device changes without specifying the use of one or two-piece devices.

This study raises the question of what aspects should be prioritized for the use of one device or another, highlighting skin peristomal condition as the top consideration at 34.3%, and secondly, at 23.6%, the frequency of device changes. These data align with the annotations in clinical guidelines for ostomy patients [23, 24], recommending device use based on the number of bag changes, peristomal skin condition, and stoma characteristics, without specific details.

Ratliff [25] describes that patients who use two-piece systems had a 78% lower chance of experiencing leaks. This study agrees in that only a minority states that the one-piece device offers security (1.7%) or skin protection (0.9%); the majority define the advantage as being more flexible, easy to place, and discreet.

The use of devices varies by country. In the United Kingdom, one-piece devices are commonly used [26], while in the rest of Europe and the United States, two-piece devices are more commonly used as they are considered more cost- effective, with longer device usage time (in the United States, a minimum of three days is recommended) [27].

The indication or use of ostomy devices may be related to their funding or not, depending on the country, different types of distributors, nursing prescription or not, and the economic cost for the patient. Some countries, such as Belgium [28], analyzed deficiencies in the regulatory framework that set prices, reimbursement, distribution, and prescription of ostomy devices, recommending an evaluation of the role of nurses in ostomy care, introducing a competitive bidding process, and providing a fixed grant to patients for device purchase. This regulation would contribute to promoting competition among manufacturers and reducing device costs.

Regarding the manufacturing costs of ostomy devices, no studies providing updated evidence were found; however, the articles already found reflected the price difference between the two devices, with the one-piece device being of lower economic cost.

In Spain, ostomy devices are funded by Social Security (National Health System), resulting in minimal costs for patients. This fact may have influenced the results presented in this article, being a non- relevant factor in the decision of using one or two-piece devices.

Conducting a nationwide survey provides a comprehensive view of the criteria followed by nursing professionals in the care and management of ostomy patients and in the selection and/or change of ostomy devices.

The results confirm that, despite the availability of all types of devices in most centers, patients are typically instructed in the use of two-piece devices upon admission to the hospital, which would explain their higher frequency of use. There is doubt about whether patients are given the option to try different available devices, and although actual data on the percentage of their usage in Spain (at each health care level) is not available, the study results confirm the inclination of nursing professionals towards the use of two-piece devices compared to one-piece devices, regardless of considering the peristomal skin condition and even the patient’s stoma management.

With all the analyzed data, there are discrepancies among respondents in certain aspects such as professional criteria, evaluation of peristomal skin and injury risk, presence of sutures, frequency of device changes, and lack of knowledge about the use of one-piece devices.

Considering all the points mentioned above, and while recommendations regarding the use of ostomy accessories are useful, it would be crucial to conduct scientific studies and establish consensus related to the use of one or two- piece ostomy devices based on stoma characteristics, patient preferences, and not solely on professional preferences.