1. Improving patient safety in colorectal surgery: The role of
the nurse.

2. Pat Black, St Mark’s Hospital.
Consultant Nurse , Coloproctology and Senior
Lecturer in GI Nursing.

3. First, do no harm.
The profession of nursing and medicine are founded on
many ethical principles including the concept of non-maleficence
derived from the ancient ethical maxim –
primum non nocere – “first, do no harm”.

4. Patients expect to be safe during care and they
principally rely on nurses to protect them from injury
and harm or infection.
Skilled, aware and compassionate nurses know how to
do this

5. Patient safety.
Patient safety is
everyone’s business,
regardless of what role
you hold in the
organisation.
Patient safety must be
your first concern.

6. Patient safety is both a characteristic of a healthcare
system and a way of improving the quality of care.

7. Pre operative care.
The beginning of patient safety in colorectal surgery
starts with the Enhanced Recovery After Surgery (ERAS)
Programme and in the pre operative period for the
patient.

8. Enhanced Recovery Programme.
ERAS was described by Henrik Kehlet in the 1990s and
is widely used in the UK in colorectal surgery.
Kehlet felt that surgical outcomes were not solely
related to the expertise of the surgeon and
anaesthetist as complications could occur regardless of
the level of skill.

9. Kehelet (1997) questioned if modifications to the
body’s pathophysiological response to surgery could be
improved which would then improve patient
outcomes.
On the basis of Kehlets hypothesis programmes to
enhance patient care were developed using
terminology such as:
Fast track
Multimodal optimisation
Rapid recovery

11. ERAS Programme
The programme consists of a number of elements:
Reduced fasting
Carbohydrate loading
Avoidance of mechanical bowel preparation
Avoidance of drains, naso-gastric tubes
Goal directed intraoperative fluid replacement
Shorter incisions
Patient information and goal setting

13. The Nurses role in ERAS
 The move to ERAS requires a multidisciplinary (MDT)
approach.
 Mitchell (2011) considered that the role of the ward
nurse should not be driven by medical protocols, but
nursing staff should focus on care compatible with
the nursing role involving;
 A holistic approach
 Psychosocial care
 Information giving
 Discharge planning
 Management of common complications

14. ERAS interview
The nurse checks the
patient’s identity and
gives the information
about the ERAS
programme . She then
confirms the patient’s
level of knowledge by
asking him what he
understands is going to
happen.

16. The evidence for stoma siting.
Baykara et al (2014)
A multicentre retrospective study to evaluate the
effect of pre-operative stoma site marking on stomal
and peristomal complications.
748 patients were recruited.
Patient data including age, gender, diagnosis, type of
surgery, pre op stoma siting, the person who marked
the site and post operative complications.

17. In 287 (38.4%) patients the stoma or wound care nurse
or surgeon marked the stoma area pre operatively.
Stomal or peristomal complications developed in 248
(33.2%) patients.
Peristomal skin problems – 136(48.7%)
Mucocutaneous separation – 52 (18.6%)
Retraction – 31 (11.1%)

18. Outcome
The rate of complications was higher in the patients
who did not have their stoma marked 46% than those
who stoma was sited 22.9%.
The results of this study confirm that the stoma area
should be marked pre operatively in all planned
surgical interventions in order to reduce the risk of
post operative complications.

19. Stoma siting.
The position of elective stomas is determined prior to
surgery as part of the ERAS programme.
Patients who do not have their stoma sited pre
operatively have a higher risk of post operative
complications such as;
Leakage and odour
Poorly fitting appliances
Skin excoriation
Psychological sequalae
Difficulty in self care

21. Bad siting Good siting

22. The 3 aspects of quality in health care

23. The use of PREMs
 Patient
 Reported
 Experience
 Measures
Is seen as one of the three aspects of quality in health
care alongside safety and clinical effectiveness.
Patient experience comprises two main aspects –
relational and functional.

24.  Relational refers to the interpersonal aspects of care
– the ability of doctors and nurses to empathise,
respect patients’ preferences and include them in
decision making and provide information to enable
self care.
 Functional refers to aspects that relate to the
patient’s basic expectations about how care is
delivered such as clean safe environment, timeliness
of care and effective communication.

25. PROMs
 Patient
 Reported
 Outcome
 Measures
Assessment of quality of care , evaluating outcomes of
specific interventions, clinical assessment and
decision support.

26. Both tools can be used for identifying areas for
improvement and areas of excellence and for sharing
best practice.
Both PREMs and PROMs are pertinent in todays clinical
practice and provide rich information to improve care.

27. WHO Surgical Safety list

28. Post operative safety
Post operatively there are several areas that the nurse
needs to observe to make sure the patient recovers
from the operation in a safe environment.
The standard observations after surgery.
Care of any tubes
Care of IVI
Observation of the stoma
Observation of the output

29. MDT working
Multidisciplinary team working(MDT) requires
interdisciplinary , trans-disciplinary and effective
collaborative practice in order to provide high quality
and safe patient care.

30. Hogston and Marjoram (2007) state:
“ MDT working in practice is a collaborative process
among groups of individuals with different
backgrounds such as nurses, psychologist, doctors,
surgeons, radiologist, histologist, colorectal nurse and
colorectal co-ordinator, who share common
objectives”.

31.  The MDT should strive to work to provide a safe and
secure environment in order to achieve high quality
care.
 Conflict and ineffective ways of team working result
in disintegration of patient care.
 The 6Cs should form the epicentre of MDT working
in order to achieve high standards of quality patient
care.

32. The 6Cs.
 Care
 Compassion
 Competence
 Communication
 Courage
 Commitment

33. Creating the evidence base.
The ability to deliver accurate evidence based
information when helping patients to make decisions
about their care is fundamental to the role of the
Clinical Nurse Specialist (CNS).
The role of the CNS in stoma care involves providing
expert advice and clinical care to any patient
undergoing stoma formation. This includes the
provision of highly specialist emotional, psychological,
psychosexual and practical advice.

34. The role of the CNS demands a thorough
understanding of the evidence base on which care is
based.
Phenomenological research by nurse researchers
utilize the Heideggerian approach when investigating
the lived experience of patients.
Providing evidence where non exists is seen as part of
the role of the CNS, enhancing the knowledge base and
improving patient care and safety.

35. Evidence Based Literature Review
 Park et al (1999).Most common early complication:
improper siting.
 Bass et al (1997). Reduction of complications /
Marked by a stoma care nurse.
 Milan et al (2009). Significant reduction of
complications /marked by a stoma care nurse.
 Chaudri et al (2005). Education and siting reduced
stoma related interventions (first 6 weeks).

36. The ultimate purpose of caring for people with
colorectal problems is to facilitate individual, dynamic,
empowered patient care journeys to allow optimum
quality of life, health or death as appropriate.

37. Thank you for listening.
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