In December 2019, a new virus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes a disease called COVID-19 was identified (World Health Organization (WHO), 2021). The SARS-CoV-2 virus affected people from countries across the globe and in March 2020, the WHO declared a pandemic. Symptoms of COVID-19 include pyrexia, a continuous dry cough, shortness of breath, fatigue, loss of appetite and the loss of sense of smell (anosmia) and taste (ageusia) (National Institute of Health and Care Excellence (NICE), 2021). The transmission of the virus occurs when people are in close proximity, typically within 1 metre. An infected person can spread the virus through respiratory droplets and aerosols. Thus, the virus is spread by an infected person when they cough, sneeze, speak and even breath heavily (WHO, 2020). Infection can occur when these aerosols or droplets containing the virus are inhaled or come directly into contact with the eyes, nose, or mouth (WHO, 2020). Additionally, the virus can be spread if an infected person who has droplets on their hands touches a surface such as handrails or door handles and another person touches the same contaminated surfaces and then touches an entry point such as their mouth without first decontaminating their hands by washing them or using alcohol hand disinfectant. There is also evidence that the virus can be present and thus transferred in faecal matter (Marino et al, 2020). Marino et al (2020) describe that this transference risk requires additional precautions, such as the use of negative pressure rooms for certain procedures.
To reduce the risk of transmission, the Government put in place three mandatory rulings; hands–face–space (Department of Health (DH), 2020). The guidance has been subsequently revised to include vaccination, meeting outdoors where possible, opening windows and doors for meetings inside as well as limiting the number of people that meet (NHS, 2021). These precautions have undoubtedly helped reduce the spread of the virus.
The COVID-19 pandemic and its resultant rulings have resulted in changes to healthcare, including how GP services are accessed as well as changes to hospital outpatient appointments.
Effects on healthcare provision
The effect of COVID-19 on healthcare provision has been unprecedented. Elective surgery was cancelled in many hospitals due to lack of staff and beds (Fowler et al, 2020). Earlier this year even colorectal cancer surgery was cancelled due to lack of intensive care beds (The Lancet Oncology, 2021).
It remains uncertain how the backlog of patients with cancelled operations will be addressed post-pandemic (Fowler et al, 2020). When surgery has not been cancelled, the directives have been to minimise the risk of surgical complications.
Pandemic and stoma care
A way to reduce complication rates after colorectal surgery is to limit the number of operations where the bowel is re-joined. This will result in more people having a stoma (Pata et al, 2020). An increase in the percentage of people across the globe receiving an end stoma formation for rectal cancer, including the UK has been noted. The COVIDSurg Collaborative (2020) reported that the percentage of people with a defunctioning (temporary) or an end stoma formation for rectal cancer prior to the pandemic was 35% and 24%, respectively. While the percentage of people having a temporary stoma remained stable at 35%, the number of people receiving an within 31 days of their end stoma increased to 65%.
Earlier this year, many stoma specialist nurses were re-deployed because of other nurses contracting COVID-19, or having underlying medical conditions, resulting in them needing to ‘shield’ at home. Re-deployment of stoma specialist nurses put stress on the depleted stoma team to manage the new and existing patients with a stoma. During the pandemic there have been fewer people treated for colorectal cancer. Morris et al (2021) report that there was a 22% reduction in the number of people treated within 31 days of their colorectal cancer diagnosis when comparing pre-pandemic with data from during the pandemic. Similarly, there has been a reduction in the number of patients referred on the 2-week wait pathway during the same time period. Therefore, it could be surmised that when patients do get treated for colorectal cancer they will be at a more advanced stage and potentially presenting as an emergency rather than for a planned procedure. Adding additional pressures is the likelihood that patients with a temporary stoma will need to wait longer for a stoma reversal (Vailas et al, 2021).
Stoma care nursing
Stoma care has historically been a very practical service. Stoma care nursing includes visual assessments of the stoma and the skin around the stoma (peristomal skin). When caring for people with a newly formed stoma it is important to provide advice, such as how to care for the stoma, how to manage problems with the peristomal skin and ensuring that stoma products are appropriate to the individual and their needs.
Concerns for many patients heightened during the pandemic. These included worries about availability of stoma products, although it was a potential problem, very few patients encountered delays in obtaining products in the UK. However, reassurance for people with a stoma during the pandemic became more important and necessary than before the pandemic.
Innovation in stoma care
Although stoma care practice varied throughout the UK, many ideas were similar. Fulham et al (2020) described how COVID-19 restrictions made face-to-face appointments difficult. Within the author's hospital outpatient clinics have also been cancelled not just for stoma care but other nursing and medical clinics. Thus, to ensure patients are adequately cared for, stoma specialist nurses have needed to be innovative in how they deliver an effective stoma service. These innovations include altered practice in the three areas in which stoma specialist nurses are in contact with patients; hospital, stoma clinics and home visits.
Hospital-based stoma care
Prior to the pandemic, when a patient was in hospital following their stoma formation, it was necessary for stoma specialist nurses to ensure that they were independently able to manage the practical care of their stoma prior to discharge home. This involved training the patient and, in some situations, family members or carers in how to care for the stoma. Training for family members in stoma care management had to be revised due to restrictions on visiting in hospitals. Woodhouse and Yeung (2020) describe the use of a training film that they shared with patients and carers, which helped to resolve this issue. Anecdotally, nurses have also used video calling to enable practical management of the stoma to be taught remotely to family members.
Clinic follow-up
The Government produced guidelines for health professionals encouraging remote working and remote consultations to reduce the risks of disease transmission (DH, 2020). Nurses needed to rapidly change their practice, although often in the initial period there was inadequate IT support. One solution was for nurses who are isolating to provide patient support in the form of virtual clinics. It is acknowledged that remote consultations are not suitable for people who require a physical examination or investigations (DH, 2020). However, they are potentially useful for patients with long-term, stable conditions such as a yearly follow-up clinic.
Telemedicine has been discussed in healthcare for some time, but with the pandemic it has become essential to find new and innovative ways in which to contact with patients while keeping risks to a minimum. To make telemedicine work it is essential for both health professionals and patients to have the necessary equipment and skills. People who might not have used online communication software such as Skype, Teams or Zoom prior to the pandemic, might now regularly use it to keep in contact with family and friends. It is likely that some patients may still feel more comfortable and confident to use virtual clinics rather than come to hospital.
D'Antonio et al (2020) describe the use of telemedicine in Italy. Although they do not fully define what form this takes, it is likely that there were visual consultations. D'Antonio and colleagues reported that although telemedicine was not suitable for all patients or all medical scenarios, it can be effective in people who live a distance from the hospital. It does mean that for some issues it is still necessary to have a face-to-face appointment or a hospital admission; for example, if a person with an ileostomy requires treatment for dehydration after discharge home. In the authors workplace there is increasing use of telemedicine in the outpatient setting. However, it was necessary to see some patients following a telephone assessment. Similarly, in Turkey, Vural and Özlü (2020) explained that telemedicine was useful but face-to-face care was still needed.
Home visits
Many people were and still are reluctant to have people enter their home even to provide healthcare due to the risk of virus transmission. For stoma specialist nurses, home visits become more complicated as precautions such as additional PPE need to be used. Therefore, in most situations home visits were stopped for all patient contact at one stage during the pandemic. Now home visits are more carefully considered to ensure that this is the appropriate contact modality for patients.
Telephone and email clinics
Woodhouse and Yeung (2020) described how emails and telephone calls were used to talk to patients when their normal stoma services ceased in the pandemic. In this case, patients could telephone a dedicated number and speak to an administrator who was working remotely from the hospital. The administrator would email the stoma specialist nurses with the patient's query. To assist in addressing issues with stomas and peristomal skin, the patients sent emails including photographs of their stoma for specialist opinion. Fulham et al (2020) also describe the use of emailed photographs, used in conjunction with a structured telephone or video assessment, which has enabled treatment options to be determined. The necessary stoma care products are then posted to people, which only minimally delays the commencement of treatment.
Meetings
Another change that has occurred as a result of the pandemic within the authors Trust and many other healthcare settings is the cancellation of face-to-face meetings of health professionals. The DH (2020) suggested virtual multidisciplinary team meetings. Online multidisciplinary meetings enable health professionals who need to work remotely to join meetings. Although there are some negative aspects of remote meetings, anecdotally, remote meetings can save time and money. Savings can be made when health professionals who work in different geographical locations no longer need to travel to a different location for meetings.
Patient feedback
Although it can be seen that there are some benefits for health professionals to work differently it is also important to ensure that patients feel their needs are being met. Fulham et al (2020) provide positive feedback from a selection of their patients. They found that patients considered virtual clinics to be time efficient; negating the need for travel to the hospital. Some patients also liked the use of email, finding it was beneficial.
Moving forward
Fulham et al (2020) deliberate about what form stoma services should take once the pandemic is resolved; considering that it would be beneficial to keep for the future some of the new ‘normal’ practices. One benefit would be to give patients a greater choice in the way in which care is provided. Incorporating some of the new methods of communication would reduce travel time and costs for patients. Fulham et al (2020) have found that some patients are choosing to have video and telephone contact for future appointment despite face-to-face appointments being available.
Conclusion
It can be seen that the pandemic has changed the way in which healthcare is provided. However, not all changes are negative. The pandemic has resulted in greater use of online communication platforms, which in some situations has led to benefits to patients and health professionals by reducing travel times for example. How stoma services will be conducted in the future is uncertain, but it is likely that patients may benefit from lessons learned during the pandemic.