The Journal of Stomal Therapy Australia - Australian Association of ...

poor construction of the stoma patients were unable to remain
independent with their stoma care, discharge was delayed
and costs increased in outlay for additional ostomy products.
Importantly, ostomates who were sited pre-operatively had no
problems with their stoma site.
On completion of the third audit the results of the study were
summarised and presented to the RHH Division of Surgery
medical staff. Mr Oakley commented on the surgical problems
that he recognised and gave advice.
Mr Oakley also advised consultant surgeons and surgical registrars
that all patients admitted for emergency bowel surgery should be
sited for possible stoma formation. The siting should be done in
preference by an STN or, in the absence of an STN, an otherwise
experienced nurse; surgeons should site their own patients preanaesthetic
and, if necessary, on the operating table 14 .
The audit process demonstrated what was acceptable in terms
of patient outcomes and unacceptable major risks of poorly
sited or constructed stomas with consequential adverse effects
on patient rehabilitation.
Treat Risks
At the time of the stoma audit, stoma construction did improve
and siting was remembered. However, in the absence of ongoing
attention to the problem, standards relapsed and the likelihood
of an unsited, poorly constructed stoma again became an issue.
In fully adopting the clinical risk management process STNs
need to develop and implement specific, cost-effective strategies
and action plans for increasing potential benefits and reducing
potential costs 15 .
Like any nurse, STNs are familiar with the nursing process, using
assessment, planning, implementation and evaluation to organise
patient care. The same process works well to treat risks, along with
analysis and evaluation to identify and treat residual risk 1 . A good
example of evaluation and identification of residual risk is the
Audit Nursing Risk Assessment Tool developed by the Pressure
Ulcer Prevention Project Officer at the Austin Hospital, Victoria.
The aim of this audit was to review the usage of the Austin
Health nursing risk assessment tool, a form used on each ward
to evaluate pressure ulcer prevention. The information collected
was used to assist in evaluating the effectiveness, utilisation and
clinical appropriateness of the form 16 .
Simply using the post-operative stoma photography audit with
peer review has insufficiently addressed the risk that patients
will progress to theatre without siting. Controlling risk is better
addressed by developing and implementing policies, standards,
procedures and making physical changes. If STNs do not have
the organisational authority or power to bring about change
from within their practice, it is recommended that there is a
shift of responsibility to another party or higher authority 1 ,
using the chain of command to bring about warranted and
effective change. Listing suggested changes to ensure the siting
procedure was performed would include:
• A stomal therapy orientation package given to all new staff
joining the general surgical team – doctors, nurses, allied
healthcare professionals.
• All medical staff participating in basic surgical training
– registrars, residents, interns attend a mandatory lecture on
the necessity of siting. This practice to be sanctioned by the
Medical Director – Division of Surgery.
• STN education program be advocated at every possible
opportunity to ensure the availability of suitably qualified
staff to provide a service after hours and at weekends, and
that their availability be widely advertised amongst nursing
and medical staff.
• That pre-operative siting be added to the operating theatre
checklist and an audit conducted on compliance with the
checklist.
• Risk management policy and procedure document be written
for the AASTN Education and Professional Sub-committee
to approve and post on the AASTN website.
Once further controls have been instigated the pictorial audit
can be repeated to re-evaluate risk stabilisation.
CONCLUSION
The intention of this paper is to promote risk management
as a meaningful adjunct to quality improvement and realise
positive outcomes for patients following ostomy surgery. Using
the example of pre-operative siting demonstrates the need to
constantly evaluate and re-evaluate procedures, and to measure
and justify the effectiveness of our stomal therapy practice.
REFERENCES
1. Risk Management Guidelines – Companion to AS/NZS 4360:2004
(Handbook). Standards Australia/Standards New Zealand.
Wellington New Zealand. 2004:17.
2. ibid, Risk Management Guidelines:VII.
3. Desk Top Guide to Clinical Risk Management – Toolkit for Managing
Risk in Health Care. Dept of Health Western Australia. 2005:3.
4. Australian Nursing Federation (ANF). Revised Competency
Standards for the Advanced Registered Nurse. Draft, undated:1.
5. Australian Association of Stomal Therapy Nurses Inc (AASTN).
Standards of Stomal Therapy Practice. Draft, 2005:3.
6. ibid, AASTN:7.
7. op cit, Risk Management Guidelines:13.
8. Blackley P. Practical Stoma Wound and Continence Management.
Victoria:Research Publications Pty Ltd. 1998:1.
9. Health Risk Management – Policy and Framework. Western Australia
Public Health System. Feb 2005:3
10. op cit, Desk Top Guide:8.
11. op cit, Blackley:108.
12. op cit, Blackley:112.
13. op cit, Desk Top Guide:11.
14. Hicks S. A Site to be Seen – Striving for Excellence. The Journal of
Stomal Therapy Australia, Sept 2002; 22(3):18.
15. op cit, Desk Top Guide:17.
16. Allen A. Audit Nursing Risk Assessment Tool, M15.21. Austin
Health , Victoria. September 2005.
20 JOURNAL OF STOMAL THERAPY AUSTRALIA 2007 27(3)