A team at Penn Colon and Rectal Surgery has developed a text-based application to help patients who've had ileostomy surgery avoid dehydration, a leading reason for hospital readmission in this population.
Ileostomy, a surgical conduit between the small bowel and the wall of the abdomen, is a common method to divert fecal waste away from diseased or resected portions of the large and small bowel. Often a life saving measure, ileostomy is not an easy procedure for its recipients to become accustomed to. Ileostomy care is a complex, learned behavior, and one fraught with issues — not the least of which is dehydration.
The small bowel and colon are the body's engine for salt and water absorption. In the absence of the colon or a sufficient portion of small bowel to sustain absorption, fluids that might otherwise be absorbed and expelled in the breath, sweat, urine, and saliva can exit the body via the ileostomy, akin to severe diarrhea. Without careful effort to maintain euhydration (the normal state of the body's fluid levels), dehydration and its corollaries, acute renal failure and severe electrolyte imbalance, can set in. This can happen quickly, cannot be addressed through simple replenishment alone, and accounts for ~30 percent of ileostomy-related hospital readmissions.
Beyond the effect upon a patient's wellbeing and quality of life, readmissions are a target for governmental bodies who can levy fines in the name of improvement in outcomes and cost. Both the Centers for Medicare and Medicaid Studies and the National Surgical Quality Improvement Program have specifically designated colorectal surgery outcomes among the top five areas for improvement, and recommend their use as barometers for quality in individual hospitals.
The challenge for hospitals, however, is that euhydration is challenging in the hospital setting, let alone among individuals in the community. How then, to reach these patients before dehydration and its effects can occur?
Enter the Penn Division of Colon and Rectal Surgery.
There's an App for That: Reducing Readmissions for Ileostomy Patients
A leading resource in the Philadelphia region for ileostomy surgery, Penn Colon and Rectal Surgery is a highly regarded center of clinical research, as well. Among the Division's recent achievements was a Quality Improvement project created by Joshua Bleier, MD, Jenna Moyer, RN, MSN, and colleagues. Dr. Bleier is the Vice-Chair of the Department of Surgery at Pennsylvania Hospital, and the Section Chief of Colon and Rectal Surgery at Pennsylvania Hospital.
The project led to the development of the Remote Ostomy Output Monitoring application, an automated text-based application created through WaytoHealth, a platform from the Center for Healthcare Innovation initiated to quickly develop, test and scale out ideas to improve health care for patients. The application was designed to optimize health outcomes by supporting ostomy patients both before and after ileostomy surgery, and is integrated into the electronic health record for easy enrollment and review of patient output.
"The app is part of a larger ileostomy readmission reduction project called the Ostomy Output Program," says Dr. Bleier. "It absolutely helps with patient outcomes and care planning and has been the key driver in a substantial reduction in ileostomy readmissions here at Penn Medicine."
Using the Ostomy Output application is simple. Pre-operatively, patients receive text reminders about how to prepare for their surgery, including instructions for taking antibiotics, bowel prep, and tips for getting their homes ready for their return. After discharge, patients are prompted to report their stool and urine output via text message. If output falls outside of the predetermined limits, the care team receives an alert and adjusts care as needed.
Proof of Concept
During a yearlong piloting period beginning in August 2020, the Ostomy Output Program reduced the average ileostomy readmission rate from 23 percent to 16 percent, a 31 percent decline. In addition, nearly two-thirds of the patients enrolled were identified as needing an at-home intervention in the form of medication adjustment, provider phone calls, or home IV fluids to decrease the risk of dehydration. As a result, only two readmissions occurred, neither of which was related to hydration status. The number of prevented readmissions resulted in an estimated cost savings of $100,000.
In October 2021, the Ostomy Output Program scaled to several Penn Medicine hospitals, and is now available to ileostomy patients at the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, and Pennsylvania Hospital. Extended to the additional colorectal surgeons at these locations, the program is expected to free up more than 60 patient bed days and save the health system $250,000 annually. Most importantly, it allows surgical teams to continue to support patients through the critical pre-operative and post-discharge periods in ways that were previously unavailable.