WCET Journal. President s message: Let evidence lead the way. Don't let diabetes mellitus knock you off your feet

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1 WCET Journal Volume 35 Number 3 July/September 2015 Official Journal of The World Council of Enterostomal Therapists CELEBRATING 35 YEARS OF THE JOURNAL In this issue President s message: Let evidence lead way Editorial: To volunteer Care of a case of peristomal allergic contact dermatitis using Ostomy Skin tool Don't let diabetes mellitus knock you off your feet Complex issues: travelling with total parenteral nutrition and an ostomy Critically reading and understanding published research: The use of p-values and confidence intervals Ostomy terms and definitions continued WCET board nominations a world of expert professional nursing care for people with ostomy, wound or continence needs

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3 World Council of Enterostomal Therapists Journal Volume 35 Number 3 July/September 2015 Contents The World Council of Enterostomal Therapists Journal ISSN Published quarterly Copyright 2015 by World Council of Enterostomal Therapists Printed in Australia ANNUAL SUBSCRIPTION RATES Non-members International all regions (airmail) US$60 Institutional subscriber International all regions (airmail) US$120 Single copies and reprints available on request at US$15 each (includes airmail postage) PUBLISHED QUARTERLY BY President s message: Let evidence lead way 4 Susan Stelton Editorial: To volunteer 8 Karen Zulkowski Care of a case of peristomal allergic contact dermatitis 10 using Ostomy Skin tool Deniz Harputlu and Süheyla A Özsoy Don't let diabetes mellitus knock you off your feet 14 Gulnaz Tariq and Salvacion P Cruz a division of Cambridge Media 10 Walters Drive Osborne Park WA 6017 Australia Tel (61) Fax (61) Advertising Sales Simon Henriques simonh@cambridgemedia.com.au Copy Editor Rachel Hoare Graphic Designer Mark Orange NON-EDITORIAL WCET CORRESPONDENCE WCET Central Office 1025 Thomas Jefferson Street, NW Suite 500 East Washington, DC United States of America Tel Fax admin@wcetn.org Connect with us free on Skype search for wcetoffice to connect with us or leave an Instant Message. Remittances and notification of change of address to be directed to WCET Central Office (address above) Complex issues: travelling with total parenteral nutrition 36 and an ostomy Kathleen Capitulo and Linda Shohatee Critically reading and understanding published research: 44 The use of p-values and confidence intervals Thom R Nichols Ostomy terms and definitions continued 48 Karen Zulkowski WCET board nominations 51 The World Council of Enterostomal Therapists Journal is indexed in Cumulative Index to Nursing and Allied Health Literature. WCET: a world of expert professional nursing care for people with ostomy, wound or continence needs. Disclaimer Opinions expressed in WCET Journal are those of authors and not necessarily those of World Council of Enterostomal Therapists, Editor or Editorial Board. Journal Sustaining Partnerships 1

4 World Council of Enterostomal Therapists An Association of Nurses Registered Charity EXECUTIVE OFFICERS President Susan Stelton MSN, RN, ACNS-BC, CWOCN Clinical Nurse Specialist St Joseph Regional Medical Center, 5215 Holy Cross Parkway, Mishawaka, Indiana 46545, USA Vice-President Elizabeth A Ayello PhD, RN, ACNS-BC, CWON, ETN, MAPWCA, FAAN Faculty, Excelsior College School of Nursing Avenue, Hollis Hills New York 11427, USA elizabeth_ayello@yahoo.com Treasurer Alison Crawshaw RGN, BSc, ENB216 Independent Clinical Nurse Specialist, 92 Lasswade Road, Edinburgh EH16 6SU, Scotland Crawshawalison@hotmail.com CHAIRPERSONS OF STANDING COMMITTEES Education Vera Lúcia Conceição de Gouveia Santos PhD, CWOCN (TiSOBEST) Professor, Medical Surgical Nursing Department, Nursing School, University of São Paulo, Member of Scientific Committee, Brazilian Association of Stomal Therapy: ostomy, wound and continence care (SOBEST) Av Dr Eneas de Carvalho Aguiar 419/CEP São Paulo, Brazil veras@usp.br Norma N Gill Foundation Carmen George Mob (61) carmensmith@adam.com.au Publications and Communications Laurent Chabal Centre of Stomarapie, Ensemble hospitalier de la Côte Laurent.chabal@ehc.vd.ch Congress and Meeting Coordinator Dee Waugh RN, RM, ET PO Box 44598, Claremont 7735 South Africa Mobile dwaugh@mweb.co.za Skype dee.waugh1 JOURNAL EXECUTIVE EDITOR Karen Zulkowski DNS, RN College of Nursing, Montana State University Bozeman MSU Billings Campus, Box 574, Billings, MT 59101, USA drkarenz@aol.com JOURNAL EDITORIAL BOARD MEMBERS Elizabeth A Ayello, USA, Executive Editor Emeritus Erica Thibault, USA, Assistant Editor, Wounds Judy Hanley, UK Assistant Editor, Ostomy Sarah Lebovits, USA, Assistant Editor, Ostomy Kevin Woo, Canada, Assistant Editor, Incontinence Jo Sica, Assistant Editor, UK content Carmen Akaoui, Australia Elizabeth Ayello, USA Sharon Baranoski, USA Pat Black, UK Carmel Boylan, Australia Eva Carlsson, Sweden Jill Cox, USA Alison Crawshaw, UK Barbara Delmore, USA Laurie Goodman, Canada Chi Keung Peter Lai, Hong Kong Rona Levin, USA Jill Marshall, UK Daniel K O Neill, USA Sandy Quigley, USA Ravathy Ramamurthy, Malaysia Deborah Rastinehad, USA R. Gary Sibbald, Canada Hiske Smart, South Africa Barbara Suggs, USA Michelle Lee Wai-Kuen, Hong Kong The WCET mission is to lead global advancement of specialised professional nursing care for people with ostomy, wound or continence needs WCET Journal Volume 35 Number 3 July/September

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6 President s message Let evidence lead way Susan Stelton MSN, RN, ACNS-BC, CWOCN Clinical Nurse Specialist St Joseph Regional Medical Center 5215 Holy Cross Parkway, Mishawaka Indiana 46545, USA president@wcetn.org Greetings to all WCET members and friends of WCET. In many countries June is a traditional month for nursing school graduations. In June I celebrated 43rd anniversary of becoming a registered nurse. In addition to making me feel old, this anniversary prompted me to think about nursing practice today compared to practice in Many things have changed: both health care equipment we use in course of care and our care practices. For this discussion, I will focus on nursing practice changes. While in nursing school, I learned many nursing practices that I now know were based in tradition. I heard expression, "Nurses have always done it this way." Over past four decades many of those practices have been challenged, studied and changed, based on evidence. These practice changes have resulted in care that is safer and more effective than in years past. Using evidence to guide practice has been an important evolution that puts nursing as a profession on a level with or disciplines. As members of our organisation, think about how WCET uses evidence. The 2014 WCET International Ostomy Guideline is a document that makes stoma care recommendations based on evidence. The MEDLINE, CINAHL and Cochrane databases were searched for stoma-related research articles. The articles were reviewed and evidence tables were made and strength of evidence was evaluated. From this body of evidence, nine general recommendations for stoma care were given that are universal for care in any country. These nine recommendations cover following topics: 1. The importance of preoperative stoma site marking. 2. Preoperative education of patient and family. 3. Available peristomal skin assessment tools. 4. Importance of individually fitting stoma containment devices. 5. Identification of causes of peristomal skin complications. Three organisation presidents meet at CAET, May 2015 L R: Susan Stelton WCET; Paulo Da Rosa CAET; and Phyllis Kupsick WOCN 6. Prevention and management of peristomal skin complications. 7. The effect of a stoma on quality of life, body image and sexuality. 8. The impact that caring for a person with a stoma has on caregiver. 9. Approach patients' stoma concerns, aware that concerns may vary by country and culture. This message has thus far touched on stoma care practice changes. Obviously, wound and continence care practices have also advanced over years. In wound care, think of all of liquids that were used in past to 'clean' open wounds: hydrogen peroxide, povidone-iodine, sodium hypochlorite (Dakin's Solution) and acetic acid, to name a few. Over time, research has shown that each of se liquids is actually toxic to healing tissue and will do more harm than good when put on an open, healable wound. Newer wound cleansing methods use non-toxic solutions to clean healable, non-infected wounds 1. Also think of various methods that were employed in past to try to treat healable pressure ulcers: massage of red skin over bony prominences, application of heat lamps, putting milk of magnesia, methylate, povidone-iodine or sugar on wound. Over time, evidence has shown that WCET Journal Volume 35 Number 3 July/September

7 all of se methods are ineffective and, in some instances, harmful. Think of debates around "Should it be moist wound healing or dry wound healing?", "Should wounds be covered or 'left open to air'?" Evidence supports keeping a covered moist wound bed for most* healable wounds. (*Exceptions: wounds resulting from arterial insufficiency, non-healable/palliative wounds, maintenance wounds) 1. Nursing practices for continence management have also changed over time. Indwelling urinary caters used to be left in place for long periods of time after abdominal surgeries, for immobile patients, and to manage chronic urinary incontinence. Research has shown that urinary caters cause highest percentage of hospital-acquired infections and, longer cater stays in place, greater chance for an infection. With this information in mind it is now standard practice to remove caters as soon as possible after surgery and to not use caters to manage most types of urinary incontinence. Caters were also routinely irrigated with antiseptic solutions to "prevent urinary tract infections". This practice was discontinued after it was found to have no effect in prevention of urinary tract infections. In this message I have touched on a few of nursing practices that apply to stoma, wound or continence care nurses that have changed over time with evidence. I am sure that each of you can think of many more examples. In your practice as a stoma, wound or continence care nurse, think about how your care is based on evidence. How do you use evidence in teaching staff, patients and families? How do you answer ir questions about care? When anor nurse says, "I think we should do it this way," do you ask, "What does evidence say?" REFERENCE 1. Sibbald G et al. Special considerations in wound bed preparation 2011: an update. Adv Skin Wound Care 2011; 24(9): Norma N Gill Foundation The aim of Norma N Gill Foundation is to facilitate education in enterostomal rapy (ET) nursing worldwide. We would not be able to carry out this task without support of our members and sponsorship from our colleagues in industry. 2014/2015 NNGF Scholarships ETNEP/REP Scholarships 2014 Gita Kilambu Nepal Saraswati Bhandari Nepal 2015 Supun Prageeth Samarakoon Sri Lanka Vincent Kouami Togo Stella Rithara Kenya Grace Wanyoike Kenya Josephine Gachango Kenya Congress Travel Scholarships 2014 Yajuan Weng China Lijuan Chen China Zhang Ling Ling China Qian Chen China Silindile Mavanini South Africa Silvana Prazerez Brazil Udena Kumura Sri Lanka Kokou Kouami Togo Maria Susiati Indonesia Membership Scholarships 2015 Sponsored by Friends of World (FOW) USA and WCET members: Indonesia Sestramita Tuah Turkey Sevil Guler Demir Zehra Göçmen Baykara Sri Lanka Supun Prageeth Samarakoon Nepal Saraswati Bhandari Gita Kilambu Shanti Bajracharya Sarojini Sharma Kenya Stella Rithara Grace Wanyoike Josephine Gachango Jane Wanja Ndungu Grace Waceke Mjoroge Faith Kinaitobe Kobia Joyce Mogaka Lydia Myaboke Omari Selline Atieno Onginjo Patrick Onde Amasinde Edward Avula Kilmonda Mercy Wambui Njau Alice Zachary Imelda Nasambu Makokha Jannette Akinyi Otieno Harriet Kangia Ibaya Nancy Jepkemboi Boinett Lawrence Gichini Beldine Ayoo Carine Watiri Kamwere Christine Mutinda Mutuku Tanzania Geofrey Mtengo Lemali Mbise 5

8 Arabic translation لندع الدليل يقودنا إلى مبتغانا سوزان ستيلتون أود أن أعبرعن تحياتي لجميع أعضاء وأصدقاء المجلس العالمي الختصاصيي عالج الفغر المعوي. يعتبر شهر يونيو في العديد من الدول شهر التخرج من كليات التمريض ففي شهر يونيو احتفلت بالذكرى السنوية الثالثة واألربعين لتخرجي كممرضة م سج لة. ورغم أن هذا األمر يجعلني أشعر بتقدمي في العمر فقد دفعتني هذه الذكرى للتفكير حول ممارسة مهنة التمريض في الوقت الراهن مقارنة مع ممارسة هذه المهنة في العام 1972 حيث طرأت العديد من التغييرات من ناحية األجهزة والمعدات المستخدمة في تقديم الرعاية الصحية وممارستنا لهذه الرعاية. سوف أسلط الضوء على التغييرات التي.طرأت على ممارسة مهنة التمريض عندما التحقت بكلية التمريض تعلمت العديد من الممارسات التي أعرف اآلن أنها كانت تعتمد على األمور التقليدية. لقد سمعت عبارة تقول: "الممرضات فعلن ذلك دائما بهذه الطريقة" وخالل العقود األربعة السابقة فقد تم مجابهة ودراسة وتغيير تلك الممارسات بناء على الدليل إذ ساهمت هذه التغييرات في وجود رعاية أكثر أمانا وفعالية عن السنوات السابقة. يعتبر استخدام الدليل لتوجيه الممارسة تطورا هاما يضع التمريض.كمهنة بنفس مستوى التخصصات األخرى وكأعضاء في منشأتنا الصحية تأم ل كيف قام المجلس العالمي الختصاصيي عالج الفغر المعوي باستخدام الدليل حيث يعد الدليل اإلرشادي الدولي للفغر للمجلس العالمي الختصاصيي عالج الفغر المعوي بمثابة وثيقة تجعل توصيات رعاية الفغرتستند على الدليل. تم البحث عن قاعدة بيانات كل من نظام استرجاع المنشورات الطبية والمؤشرالتراكمي للتمريض ومنشورات المهن المساعدة وكوتشراني للحصول على مقاالت بحثية تتعلق بالفغر. تم مراجعة هذه المقاالت وعمل جداول للدليل حيث تم تقييم قوة الدليل وفي ضوء هذا الدليل تم تقديم تسع توصيات عامة حول رعاية الفغر والتي :تمثل الرعاية على المستوى العالمي ألي بلد وتغطي المواضيع التالية.1.أهمية تحديد مكان الفغر قبل إجراء العملية.2.تثقيف المريض وعائلته قبل إجراء العملية.3.توفر أدوات تقييم الجلد المحيط بالفم.4.أهمية أجهزة احتواء الفغر المناسب بشكل فردي.5.تحديد أسباب مضاعفات الجلد المحيط بالفم.6.الوقاية من وعالج مضاعفات الجلد المحيط بالفم.7.أثرعملية الفغر على جودة الحياة وشكل الجسم والقدرة على ممارسة الجنس.8.أثر العناية بالفرد الذي جرى له عملية الفغر على مقدم الرعاية الصحية.9 معالجة مخاوف مرضى عملية الفغر ومعرفة أن هذه المخاوف قد تختلف من بلد.آلخر وثقافة هذا البلد جافا عند الشفاء أو أن يتم العمل على تغطية الجروح أو أن تبقى مفتوحة لكي تتعرض للهواء فالدليل يؤكد على بقاء تغطية قاعدة الجرح رطبا وذلك لمعظم الجروح القابلة للشفاء لكن هناك استثناءات مثل الجروح الناجمة عن النقص في تدفق الدم من خالل الشرايين بسبب تصلب الشرايين والجروح غيرالقابلة للشفاء/الجروح القابلة للتسكين.وصيانة الجروح كما تغيرت ممارسات التمريض حول عالج حصرالبول مع مرور الزمن حيث تم استخدام قسطرات بولية حية تبقى في مكانها لمدة طويلة بعد العمليات الجراحية التي ت جرى للبطن وذلك للمرضى غيرالقادرين على الحركة والتنقل وكذلك عالج سلس البول المزمن. بينت األبحاث أيضا بأن القسطرات البولية ت سبب أعلى نسبة من االلتهابات التي ي صاب بها المرضى خالل وجودهم في المستشفى وطالما بقيت القسطرة في مكانها لفترة طويلة فهناك فرصة كبيرة لحصول االلتهاب. ومن خالل أخذ هذه المعلومات باالعتبار ينبغي نزع هذه القسطرات بالسرعة الممكنة بعد إجراء العملية الجراحية وعدم اللجوء الستخدام القسطرات لعالج معظم أنواع سلس البول. كان يتم تزويد القسطرات بشكل روتيني بمحاليل مائية مطهرة لتجنب حصول التهابات في المسالك البولية ب ي د أنه قد تم التوقف عن هذه الممارسة بعد أن تم اكتشاف عدم فعالية تجنب حصول التهاب في المسالك.البولية كما تطرقت في هذه الرسالة إلى بعض الممارسات التمريضية الستخدامها من قبل طاقم التمريض المعني برعاية عملية الفغر والجروح وحصر البول والتي تغيرت مع مرور الزمن بوجود الدليل على ذلك وأنا متاكدة بأن أي شخص فيكم يستطيع التفكير بالمزيد من األمثلة المتعددة حول هذا األمر. ومن خالل ممارستكم كممرضة ترعى عملية الفغروالجروح وحصرالبول عليكم التفكير حول كيفية أن تكون رعايتكم قائمة على الدليل وكيفية استخدام الدليل لتثقيف الطاقم العامل معكم والمرضى وعائالتهم وكيفية اإلجابة على األسئلة المطروحة حول الرعاية. عندما تقول ممرضة أخرى: "أعتقد أن."علينا فعل ذلك بهذه الطريقة" فبادري بالسؤال: "ماذا يقول الدليل حول ذلك تطرقت في هذه الرسالة للتغييرات التي طرأت على ممارسة رعاية الفغر حيث تقدمت ممارسات العناية بالجروح وحصر البول بشكل واضح مع مرور السنين. بالنسبة للعناية بالجروح بادربالتفكير حول كافة السوائل التي تم استخدامها في السابق لتنظيف الجروح المفتوحة مثل: الماء األكسجيني البوفيدون اليودي تحت كلوريت الصوديوم الم عقم و حمض الخل. ومع مرور الوقت بي نت األبحاث إن هذه السوائل هي في الواقع سام ة.لشفاء النسيج وسيكون ضررها أكثر من نفعها عندما يتم استخدامها تم استخدام طرق تنظيف جديدة للجروح بشكل تام باستخدام محاليل غير سامة وذلك لتنظيف الجروج القابلة للشفاء وغيرالملتهبة. تأمل طرق مختلفة تم استخدامها في السابق لمحاولة عالج التقرحات القابلة للشفاء: تدليل الجلد األحمر فوق البروزات العظمية واستخدام لمبات التسخين ووضع حليب المغنيسيا والكحول الميثيلي والبوفيدون اليودي أو السكر على الجرح. ومع مرور الوقت أظهر الدليل عدم فعالية هذه الطرق وكانت في بعض الحاالت ضارة. كما عليك تأمل المناقشات حول أن يكون الجرح رطبا أو WCET Journal Volume 35 Number 3 July/September

9 WCET Celebrates World Ostomy Day 2015 In celebration of World Ostomy Day, WCET will be hosting a webinar on Friday, October 2. Please stay tuned at for more information. How Patients and Nurses Diverse Cultures Affect Nursing Care Given diversity of patients and nurses who provide care, cross-cultural communication and competency are essential. Cultures have diverse focuses which are globally defined as collectivism (group identification) or individualism (selfdetermination of person). In this webinar, Dr. Purnell, author of Purnell Model for Cultural Competency, will explain se cultural perspectives and how y impact nursing and healthcare practices within specialty of stoma, wound, and continence care. Distinguished Faculty Larry Purnell, PhD, RN, FAAN Professor Emeritus, University of Delaware, Newark, DE Adjunct Professor Florida International University, Miami, FL Adjunct Professor, Excelsior College, Albany, NY Moderator Susan Stelton, MSN, RN, ACNS-BC, CWOCN WCET President, Objectives and Topic Outline 1. Explore basic assumptions and complexity of culture a. Diversity among healthcare providers. b. Cultural awareness, sensitivity, and competence; c. Cultural relativism, imposition, and imperialism; d. Ethnocentrism, stereotyping, and generalisation; e. Acculturation, assimilation, and enculturation 2. Distinguish general collectivistic and individualistic cultural attributes and characteristics Moral, political, or social outlook that stresses human interdependence or dependence and impact y have on nurse patient relationships. a. Individualistic cultures: Scandinavian countries, USA, Eastern European, German, Great Britain, and Appalachian; b. Collectivist cultures: Hispanic/Latino and Latino; Asian and Pacific Islanders; Turks; Native Americans; African American and Blacks from Nigeria, Ghana, and many or African countries; Middle Easterners; and traditional tribal societies. 3. Apply collectivistic and individualistic attributes and characteristics to exemplars (European American and Asian) in provision of stoma, wound, and continence care. 7

10 Editorial To volunteer Karen Zulkowski DNS, RN College of Nursing, Montana State University Bozeman MSU Billings Campus, Box 574, Billings, MT 59101, USA I googled word volunteer and it produced 282,000 possible sites. According to Merriam-Webster dictionary, a volunteer is a person who voluntarily undertakes or expresses a willingness to undertake a service". Or definitions I found included unpaid helper or worker. What se definitions don t tell you is number of hours WCET board and committee members give for free to our organisation. These volunteers come from across globe. They may be board members giving many hours each month, committee members asked to do things, international delegates (IDs) getting messages to ir country members or it can be individuals writing for journal, submitting abstracts for our Congress or promoting WCET to ir colleagues. Any of you can become involved as much as you would like. You can be members of education committee or an editorial board member. You can help Norma N Gill Foundation through local fundraising, NNG day activities, or you can sponsor a member from a developing nation or your own country. Sure re are language barriers at times, but with today s technology we always find ways to communicate. This open communication and openness between countries to share time and knowledge is what makes WCET special. Some of us are newer members and don t know history of WCET. Those that have been members longer help us newbies understand great work that has been accomplished in past which, in turn, helps shape our future. Some of our dedicated, long-term members are life members. To be a life member, people must have shown distinction and eminence in his/her contributions to field of enterostomal rapy nursing. Our life members include Patricia Blackley (Australia), Judy Chamberlain (South Africa), Dianne Garde (Canada), Hear Hill (Australia), Karine Jeter (United States), Mary Jo Kroeber (Australia), Marilyn McManus (South Africa), and Prilli Stevens (South Africa). Some of you may have noticed that last Journal (June 2015) listed Elizabeth Ayello as Executive Editor Emeritus. This was approved by WCET board to honour her for her exemplary volunteer service to journal. If you have opportunity to meet se women, please be sure to thank m. The slate of candidates for 2016 board positions is included in this issue. These are people (volunteers) that will represent WCET and that means y represent you. When you come to Congress, look for m and get to know m. Talk to your country s ID about m. Anyone can come to meeting and express opinions, but only your ID can vote for board positions, or or items. One vote per country. This insures countries with fewer members have equal say. Above all, consider how you can volunteer. This strengns our organisation, helps all of us learn from one anor and brings new ideas to WCET. WCET is on Facebook The WCET has joined Facebook and would like you to become a fan! We would like to keep WCET members as well as ostomy, wound and continence community up to date with news and special announcements from our organisation. To follow WCET on Facebook, please log into your account and visit: and 'Like' us! WCET Journal Volume 35 Number 3 July/September

11 Mobile stoma care education for your patients New FREE app NEW The NEW Salts Healthcare mobile app has been specifically designed to help you offer high quality education to your patients. Featuring 3-D photo-realistic animations and innovative advice tools, it covers everything from changing a pouch to lifestyle hints and tips, in an engaging and accessible format. This is most advanced presentation of stoma care education materials of its kind and it s available to download FREE now, courtesy of Salts Healthcare. Tailored for ileostomists, colostomists and urostomists Innovative pre-op training for all new ostomists 3-D photo-realistic anatomical pre-op and post-op videos Lifestyle leaflets FREE to download Comprehensive FAQ section Scan your QR code to download app for FREE today! Salts Healthcare Nurse Academy The new app is just part of a dedicated range of specialist educational resources for healthcare professionals. Visit to access our latest product research studies and a wealth of or useful resources aimed solely at Stoma Care Nurses. For more information, please call FREEPHONE (UK) or (Ireland). Overseas customers can contact our International Customer Services Team: Tel: +44 (0) or international@salts.co.uk Excellence in stoma care

12 Care of a case of peristomal allergic contact dermatitis using Ostomy Skin Tool Deniz Harputlu RN, PhD, WOCN İzmir University of Economics, Faculty of Health Sciences, Nursing Department, Sakarya Street, No. 156, Balçova, İzmir, Turkey deniz.harputlu@ieu.edu.tr Tel: (+90) Süheyla A Özsoy Ege University, Faculty of Nursing, Community Health Nursing Department, Bornova, İzmir, Turkey suheyla.ozsoy@ege.edu.tr Tel: ( ) ABSTRACT Background: Peristomal skin disorders are a common problem for ostomy patients. Peristomal allergic contact dermatitis (PACD) is one type of peristomal skin complication. In this case, Ostomy Skin Tool (OST) is used in assessment, intervention, planning and evaluation of PACD. Objective: The aim of this case study is to analyse a PACD case according to OST, which allows standardised and objective assessment at all settings. Methods: In our case, first we evaluated patient in stoma care unit. According to both visual changes on his peristomal skin, and patient statements, we decided that patient had PACD. Then we applied interventions according to OST, that is, patch test, avoidance of allergens, and use of barrier film. Results: In first assessment, patient s DET (discolouration, erosion, tissue overgrowth) score was 6; two months later DET score was 0. We were able to cure his peristomal skin with help of OST. Conclusions: Ostomy care nurses have a crucial role in assessment and management of peristomal skin disorders, and spend a significant proportion of ir time preventing and managing m. In our case, OST provided both objective evaluation criteria and standardised interventions. Keywords: Peristomal allergic contact dermatitis, Ostomy Skin Tool, ostomy and wound care nurse. INTRODUCTION Peristomal skin disorders are a common problem for ostomy patients. In respect of studies related to incidence of peristomal skin complications, 12% to 76% of ostomy patients experience some type of peristomal skin problems 1-7. Peristomal allergic contact dermatitis (PACD) is one type of peristomal skin complication. Allergic contact dermatitis is essentially a T-cell mediated, delayed hypersensitivity reaction. The cause of PACD is sensitivity to a specific product or part of pouching system, which causes an inflammatory response seen in peristomal skin 8,9. Clinical features of PACD include eryma, oedema, and eroded, weepy, sometimes bleeding skin with itching. Persistent eryma usually corresponds to area of skin in contact with specific product. The treatment of PACD is aimed at removing an allergic agent and using a different pouching system. Patch testing alternative products can help identify what patient can tolerate 8,9. Assessment of peristomal skin disorders is an integral part of any diagnostic and rapeutic decision. This process is highly individualised among health care professionals, but standardised assessment schemes may help describe clinical reality and reduce inter-observer variation. Such tools are, refore, useful in routine clinical assessments, research and in communication between health care professionals 10. Therefore, we used Ostomy Skin Tool (OST) in assessment, intervention, planning and evaluation of PACD for our case. The OST was developed by a group of 12 ostomy care nurses from around world in collaboration with an ostomy products manufacturer 10,11. The OST comprises two sections. The first part uses discolouration, erosion and tissue overgrowth (DET) tool. For calculation of DET score, peristomal skin is examined and evaluated based on descriptions in each of three domains (discolouration, erosion and tissue overgrowth). The maximum score for extent of affected area in terms of every domain is 3 and, for severity, maximum score is 2. Firstly, extent of affected area (area is defined as peristomal skin area that is covered by adhesive) is assessed in each of three domains and scored based on key (below). Affected area Score Unaffected 0 <25 % % 2 >50 % 3 WCET Journal Volume 35 Number 3 July/September

13 Severity Score Domain 1: Discolouration Slight redness or or discolouration of peristomal skin 1 Deep red or highly macerated skin potentially causing furr complications 2 Domain 2: Erosion Damage to upper/top level of skin (epidermis) 1 Damage to lower layers (dermis) of skin with complications (moisture, bleeding or ulcer/ulceration) 2 Domain 3: Tissue overgrowth Tissue overgrowth that interferes with application of adhesive 1 Tissue overgrowth that interferes with application of adhesive and causes bleeding and/or pain 2 Table 1: Severity score guide Then, severity in each of three domains is assessed by using definitions and photographs, and scored according to Table 1. The total score is calculated by adding all of subscores from each domain toger 11. The second part of OST is Assessment, Intervention and Monitoring (AIM) guide for peristomal skin care, which allows categorisation of peristomal skin disorder according to its cause, and offers guidance on care. Clinical observations are matched with standard descriptions, which are grouped according to probable cause. For each cause re is a set of questions to be considered. There are three causes, 10 interventions, and one visual changes statements for PACD 12. The aim of this case study was to analyse a PACD case according to OST, which provides standardised and objective assessment at all settings. PATIENT BACKGROUND AND HISTORY Mr ZG is a 67-year-old man who was diagnosed with a perianal abscess three years ago. Mr ZG is retired and lives in Turkey with his wife. He had several surgical interventions, finally undergoing an abdominal perineal resection with colostomy in Recently, Mr ZG experienced a new onset of peristomal eryma and pruritus. Since n, he has visited a hospital-based outpatient stomarapy unit and had follow-up care at home. CLINICAL ASSESSMENT First assessment at stomal rapy unit: At unit, Mr ZG said that he was experiencing itching. There was no leakage. When we removed his ostomy pouch, we realised that re was a red, ring-shaped eryma with erosive sides (Figure 1). According to both visual changes, explanation of OST for PACD, and patient statements, we decided that re was an allergic contact reaction. After that, we calculated DET score as 6 out of a possible 15 (Table 2). Thereafter, cause of PACD was identified, and interventions were applied, according to AIM guide. The first offered intervention was consider patch testing to identify an unknown allergy, so we performed a simple patch test in unit. Firstly, we applied a small amount of pouch and paste to clean area on his abdomen, n we covered se samples with transparent film. Later we noticed that re was no reaction under pouch, but re was a reaction under paste. Therefore, we decided PACD was due to paste. Subsequently, we carried out Domains Area Severity Total Discolouration (D) Erosion (E) Tissue overgrowth (T) Total DET score 6 Table 2: Calculation of DET score at first assessment Figure 1: Mr ZG s peristomal skin at first assessment 11

14 Domains Area Severity Total Discolouration (D) Erosion (E) Tissue overgrowth (T) Total DET Score 3 Table 3: Calculation of DET score at fifth home visit second intervention following advice to avoid using appliances containing allergenic materials 11. Accordingly, his stoma care was performed without paste. At same time, we used barrier film to protect erosive sides from deep erosion, as or intervention suggested in AIM guide. There is no evidence about length of pouch wearing time for patients 9. Therefore, we prefer to change pouch every five days according to our hospital base regulations in Turkey. At same time, we consider individual patient s needs to decide pouch wearing time but generally we change pouch every five days. Consequently, we encouraged him to follow up every five days and closely examine his peristomal area. Mr ZG was living far from hospital and we were performing research relating to effectiveness of home care on peristomal skin complications during his first assessment. As a result, we decided to visit him at home to closely examine his peristomal skin for one month with his acceptance and we did same interventions without patch test during each home visit. PACD in 10 patients. According to ir findings, stoma paste and pouch were causative factors of PACD 17. All researchers in reported research avoided using appliances containing allergic materials in treatment of patients. The causes of PACD and interventions reported in literature to heal peristomal skin in our case report are similar. SUMMARY Ostomy care nurses have a crucial role in assessment and management of peristomal skin disorders, and spend a significant proportion of ir time preventing and managing se disorders. The OST is useful in routine clinical assessments, research and in communication between health care professionals, both in hospital and at home. In our case, OST provided both objective assessment and standard interventions for peristomal skin disorders. CONFLICTS OF INTEREST AND SOURCE OF FUNDING This study is a part of a PhD sis at Ege University. The authors have no source of funding or conflicts of interest to disclose. Twenty-five days after first assessment, in or words during fifth home visit, Mr ZG stated that his itching was reduced, and his DET score fell to 3 (Table 3). We examined his peristomal skin again and ring-shaped eryma was smaller and pink, with no erosive sides (Figure 2). Two months later, Mr ZG was assessed in stomal rapy unit. He stated that he no longer had itching. His DET score was 0 and his peristomal skin was completely healthy (Figure 3; Table 4). Figure 2: Mr ZG s peristomal skin at fifth home visit assessment DISCUSSION There is very limited research in literature about PACD. When we analyse research, three case reports state that cause of PACD was stoma paste 13-15, while anor report states that cause of PACD was adhesive remover 16. Anor study by Landis et al. investigated cause of Domains Area Severity Total Discolouration (D) Erosion (E) Tissue overgrowth (T) Total DET Score 0 Table 4: Calculation of DET score at last assessment Figure 3: Mr ZG s Peristomal Skin at The Last Assessment WCET Journal Volume 35 Number 3 July/September

15 REFERENCES 1. Cottam J, Richards K, Hasted A & Blackman A. Results of a nationwide prospective audit of stoma complications within 3 weeks of surgery. Colorectal Dis 2007; 9: Sung YH, Kwon I, Jo S & Park S. Factors affecting ostomy-related complications in Korea. J Wound Ostomy Continence Nurs 2010; 37(2): English E & Claessens I. How peristomal skin disorders impact on ostomy care. WCET J 2008; 28(2, Supp): Richbourg L, Thorpe JM, Rapp CG & Hocevar BJ. Difficulties experienced by ostomate after hospital discharge. J Wound Ostomy Continence Nurs 2007; 34(1): Ratliff CR. Early peristomal skin complications reported by WOC Nurses. J Wound Ostomy Continence Nurs 2010; 37(5): Ratliff CR, Scarano KA, Donovan AM & Colwell JC. Descriptive study of peristomal complications. J Wound Ostomy Continence Nurs 2005; 32(1): Salvadelena G. Incidence of complication of stoma and peristomal skin among individuals with colostomy, ileostomy and urostomy. J Wound Ostomy Continence Nurs 2008; 35(6): Erwin-Toth P, Stricker LJ & Rijswijk L. Wound wise: peristomal skin complications. Am J Nurs 2010; 110(2): Colwell JC. Stomal and peristomal complications. In: Colwell JC, Goldberg MT, Carmel JE (Eds). Fecal and Urinary Diversions Management Principles, Mosby, 2004, pp Jemec GB, Martins L, Claessens I, Ayello EA, Hansen AS, Poulsen LH & Sibbald RG. Assessing peristomal skin changes in ostomy patients: validation of Ostomy Skin Tool. Br J Dermatol 2011; 164(2): Coloplast Ostomy product. The Ostomy Skin Tool. Retrieved 30 September 2010 from: topics/educationtools/ostomyskintool/ 12. Martins L, Tavernelli K & Serrano JLC. Introducing a peristomal skin assessment tool: The Ostomy Skin Tool. WCET J 2008; 28(2,Supp): Scalf LA & Fowler JF. Peristomal allergic contact dermatitis due to gantrez in stomahesive paste. J Am Acad Dermatol 2000; 42: Gallo R, Ciambellotti A, Cozanni E & Parodi A. Peristomal allergic contact dermatitis caused by stomahesive paste: an additional case. J Am Acad Dermatol 2002; 45(4): Martin JA, Hughes TM & Stone NM. Peristomal allergic contact dermatitis-case report and review of literature. Contact Dermatitis 2005; 52: Lazarov A & Trattner A. Short communication, allergic contact dermatitis from adhesive remover wipe of stoma bags. Contact Dermatitis 1998; 39: Landis MN, Keeling JH, Yiannias JA, Richardson DM, Linehan DLN & Davis MDP. Results of patch testing in 10 patients with peristomal dermatitis. J Am Acad Dermatol 2012; 67:3. Norma N Gill Foundation Roll of Honour Members 2015 The following persons have given financial support to help promote stomal rapy throughout world. This will enable realisation of Norma s vision. The Committee would like to acknowledge ir sincere appreciation. Sponsored a member: Fiona Bolton Australia Maria Caliri Brazil Paul Rademaker Australia Ann Williams USA Dorathy Benz USA Helen Richards Australia Leslee Carle Australia Molly Holt USA Vashti Livingston USA Patricia Sinasac Australia Jacqueline Geddis Canada Judy Wells Australia Qin Zhou China Or member donations: Jennifer Bank Wendy Rae Helen Arguthanathan Li Lei Yemen Du Qing Wang Hua Elizabeth Clarke Sharon Gibbons Lidia Krijit Soraia Rizzo Joanna Lo Ahmad Wibisono Lois Maunder Ani Maryani Eleanore Howard Carol Katte Jacqueline Clemit Toni Johnson Jane Fellows Ann Payne Marie Grimes Lisa Wilson Wajan Udjianti Erica Taylor Remedios Wilson Jenny O'Donnell Denise Hibbert Susanne Mckay Molly Holt Vashti Livingston Patricia Sinasac Susan Stelton Susan Grace Dunne Hong Yang Hu Helen Richards Jennifer Sekatawa R. Gary Sibbald Beatrice R. Razor Maria Culleton Theresa Luebcke Qin Zhou Leslee Carle Frances Geschimsky Kathryn Froiland Sharon Baranoski Linda Coulter Christine Vurlod Vigdis Hannestad Nobuko Murphy Yan Li Song Linda Readding Ahmad Wibisono Lois Maunder Ani Maryani Eleanore Howard Carol Katte Toni Johnson Jane Fellows Ann Payne Kelley Dunk 13

16 Don t let diabetes mellitus knock you off your feet Gulnaz Tariq RN, PG Dip (Pak), IIWCC Iran, MSc Dermatology/Skin Integrity UK Wound Care Manager Sheikh Khalifa Medical City, Abu Dhabi IIWCC Course Coordinator Abu Dhabi, United Arab Emirates Co-Director IIWCC (Middle East) President IIWCG Gulnaz.t5@gmail.com Salvacion P Cruz BSN, RN, IIWCC-KSA Wound Care Nurse Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates salvepcruz@gmail.com Keywords: Diabetes mellitus, diabetes mellitus foot ulcer, highrisk diabetic foot, diabetes education, 60-second screening, diabetic foot ulcer prevention. INTRODUCTION AND BACKGROUND The United Arab Emirates (UAE) is among top 20 countries with highest prevalence of diabetes, and among top five countries in Arab region. The population of people with diabetes has continued to increase dramatically for past three decades. Several research studies predict that in 2020, about one-third of UAE residents will be diabetic. The constant growth of diabetes tremendously affects health of each individual, resulting in furr complications. This wide array of diabetes complications led to establishment of this foot initiative. Sheikh Khalifa Medical City (SKMC) is a premier health care provider in region and created a program that will help people of UAE ABSTRACT be aware of and be part of complex management of Introduction and and background We United describe United Arab our project Arab Emirates Emirates to implement (UAE) (UAE) is among is 60-second among top screening diabetes and its complications. The 60-second foot exam tool, 20 top countries 20 countries with with highest highest prevalence prevalence of diabetes, of diabetes, and and tool for high-risk diabetic foot in our hospital in UAE. By adapted and modified by hospital, is a cost-effective, among among top 5 top countries 5 countries in in Arab Arab region. region. The The population population of of people people with with diabetes diabetes has continued has continued to to educating our frontline staff and including routine assessment of valid tool that can be used in any health care setting. A good increase increase dramatically for for past past 3 decades. 3 decades. Several Several research research studies studies predict predict that that in 2020, in 2020, about about 1/3 of 1/3 of persons with diabetes, along with proper footwear, amputation example of a facility that also adapted tool is Georgetown UAE rate in UAE residents our residents hospital will has will been be diabetic. reduced. diabetic. The The constant constant growth growth of diabetes Public of diabetes Hospital tremendously Corporation affects in affects George Town, health health Guyana of each of each 1. individual individual resulting resulting furr in furr complications. This This wide wide array array of diabetes of diabetes complications led to led to establishment of this of this foot foot initiative. initiative. Sheikh Sheikh Khalifa Khalifa WCET Journal Volume 35 Number 3 July/September 2015 Medical 14 Medical City City (SKMC) (SKMC) is a premier is a premier health health care care provider provider in in region region and and created created a program a program that that will help will help people people of UAE of UAE be aware be aware of and of and be part be part of of complex complex management of diabetes of diabetes and and its complications. its The The

17 At SKMC, we found that by using 60-second foot exam, patients with diabetes, who are at high risk of developing foot ulcers, can have problems detected in an earlier stage before y lead to furr complications and possibly amputations. Prevention is definitely a lot better than cure, and this has been proven time and time again by different studies. After assessment of patient with hospital s 60-second foot exam tool, we are giving foot care education and, if needed, we involve multidisciplinary wound care team. Now we are standardising this tool for all facilities of SKMC. The foot is an important part of body for each individual and diabetes is one of main concerns in UAE; refore, we need to seriously battle complications of diabetes. We will describe our project using a quality improvement model. 1 PROJECT SELECTION AND PURPOSE 1Aa Describe types of data and quality tools used to select project, and why y were used. An overview of ini]al situa]on presented to SKMC BASELINE DATA Draw comparisons of data obtained locally to those within region and globally GLOBAL & REGIONAL DATA Present hard facts with reports presented and gared locally STATISTICAL REPORTS & GRAPHS Search for best prac]ces and updated guidelines for efficient and effec]ve disease management EVIDENCE- BASED GUIDELINES & PATHWAYS Consulta]on with interna]onal experts on adop]ng similar prac]ces and customizing m to suit local needs INTERNATIONAL CONSENSUS Idea garing technique and agree on decisions regarding project selec]on BRAINSTORMING & MULTI- VOTING Filter and combine all suggested ideas and come up with projects which will be considered for discussion using rest of tools men]oned IDEA FILTRATION Select projects based on two criteria its importance or impact and how feasible it is go ahead with project Shows a high level view of en]re process which makes process easier to understand and visualize PROJECT COMPLEXITY - VIABILITY MATRIX SIPOC DIAGRAM 3 Clinical Transformational Event

18 1Ab Explain reasons why project was selected. 1Ab 1Ab Explain Explain reasons reasons why why project project was was selected. selected. There are several reasons why SKMC chose this project including; There are several reasons why SKMC chose this project, including: Strong alignment with hospital and governance s (SEHA Abu Dhabi Healthcare Services There There are are several several reasons reasons why why SKMC SKMC chose chose this this project project including; including; Strong Strong Strong Company) alignment alignment priorities with with with hospital and hospital hospital strategy and governances and and as governance s shown governance s in (SEHA section (SEHA (SEHA Abu 1Ba Abu Abu Dhabi to 1Bc Dhabi Dhabi Healthcare Healthcare Healthcare Services Services Services Company) priorities and strategy Company) Company) Encourage as shown priorities priorities in awareness section and and strategy strategy 1Ba to about 1Bc. as as shown shown proper in in section section foot 1Ba 1Ba care to to 1Bc 1Bc and greater patient participation in ir disease To encourage Encourage Encourage management awareness awareness awareness about about about proper proper proper foot foot foot care care care and greater and and greater greater patient patient patient participation participation participation in ir in in disease ir ir management. disease disease management management Promote patient family education which will also help in diabetic disease management To promote Promote Promote Using patient patient opportunity family family education education to which which improve will will also also patient help help in in in diabetic diabetic safety disease disease and effective management management. communication throughout Using Using opportunity opportunity to to improve improve patient patient safety safety and and effective effective communication communication throughout throughout Using opportunity to improve patient safety and effective communication throughout organisation. organization organization Earlier which may result in saving patients limbs from amputations Earlier Earlier Earlier intervention intervention intervention may which which result may may in saving result result in in patients saving saving patients patients limbs from limbs limbs amputations. from from amputations amputations Improve Improve quality quality quality of of life life of of life diabetic diabetic of diabetic patients patients patients To improve Reducing Reducing quality costs costs costs of of of life treatment treatment of diabetic treatment and and patients. hospitalization hospitalization and hospitalization stay stay which which stay means means which that that resources means resources that are are used used resources are used appropriately appropriately Reducing costs of treatment and hospitalisation stay, which means that resources are used appropriately. 1Ac 1Ac 1Ac Describe Describe involvement involvement of of potential potential stakeholders stakeholders in in project project selection. selection. Describe involvement of potential stakeholders in project selection A mul]disciplinary mul]disciplinary mee]ng mee]ng was was called called for for different different poten]al poten]al internal internal stakeholders stakeholders A mul]disciplinary mee]ng was called for different poten]al internal stakeholders Various Various sugges]ons sugges]ons came came out, out, ideas ideas were were n n combined, combined, filtered filtered and and agreed agreed upon upon by by different different stakeholders stakeholders Various sugges]ons came out, ideas were n combined, filtered and agreed upon by The The different different groups groups stakeholders were were n n assigned assigned to to create create SIPOC SIPOC diagrams diagrams of of suggested suggested poten]al poten]al projects projects to to have have a general general overview overview of of different different components components of of each each The different groups were n assigned to create SIPOC diagrams of suggested poten]al Anor Anor projects mee]ng mee]ng to have was was held held a general with with overview different different poten]al poten]al of different stakeholders stakeholders components to to finally finally decide decide of each which which project project will will be be submifed submifed as as this this year's year's clinical clinical transforma]onal transforma]onal event event The The team team Anor used used mee]ng Project Project was Complexity Complexity held with Viability Viability different Decision Decision poten]al Matrix Matrix in in order order stakeholders to to select select to finally best best decide which project project project which which will will be have have submifed a high high impact impact as this but but can can year's be be managed managed clinical transforma]onal with with less less difficulty difficulty event The The diabe]c diabe]c The team foot foot used screening screening Project project project yielded yielded Complexity highest highest Viability score score in in Decision decision decision Matrix matrix matrix in as as order it it is is very very to select best simple simple yet yet almost almost wouldn t wouldn t add add burden burden to to SKMC s SKMC s limited limited resources. resources. project which will have a high impact but can be managed with less difficulty 6 The diabe]c foot screening project yielded highest score in decision matrix as it is very simple yet almost wouldn t add burden to SKMC s limited resources. 1Ba 1Bb 1Bc Identify affected organizational goals, performance measures, and/or strategies. Identify types of impact on each goal, performance measure, and/or strategy. Identify degree of impact on each goal, performance measure, and/or strategy, and how this was determined. 4 Clinical Transformational Event 2014 Clinical Transformational is to Event 2014 The project s main goal is to prevent diabetic patients from from developing foot foot ulcers. ulcers. In relation In relation to this, to this, following figure summarises figure below summarizes organisation goals organization of SKMC, goals how of SKMC, project how directly project or indirectly or affects indirectly m, affects and m, degree of impact of project and in degree each organisational of impact of goal: project in each organizational goal: WCET Journal Volume 35 Number 3 July/September 2015 OrganizaGon Goal: OrganizaGon Goal: OrganizaGon Goal: 4 Clinical Transformational Event 2014 ELEVATE PATIENT PATIENT CARE SERVICES QUALITY 16 OrganizaGon Goal: STEWARDSHIP

19 The project s main goal is to prevent diabetic patients from developing foot ulcers. In relation to this, figure below summarizes organization goals of SKMC, how project directly or indirectly affects m, and degree of impact of project in each organizational goal: OrganizaGon Goal: PATIENT CARE OrganizaGon Goal: SERVICES QUALITY OrganizaGon Goal: ELEVATE PATIENT EXPERIENCE OrganizaGon Goal: STEWARDSHIP Assures pa]ent care is maintained at current levels with selec]ve enhancements Improves quality of service delivered Improve pa]ent experience promote "Pa]ents First" Improve efficient use of resources Project Goal: Pa]ent educa]on on top of care Project Goal: Improve pa]ent assessment Project Goal: Pa]ent par]cipa]on in ir care Project Goal: Proper alloca]on of limited resource Type & Degree of Impact: Direct and High Type & Degree of Impact: Direct and High Type & Degree of Impact: Direct and High Type & Degree of Impact: Indirect and High OrganizaGon Goal: CAREGIVER ENGAGEMENT OrganizaGon Goal: COMMUNICATION OrganizaGon Goal: ACCESS OrganizaGon Goal: SKMC IMAGE Support advancement of physician and staff engagement Improve internal communica]on among caregivers Improve access for inpa]ent and outpa]ent services Promote SKMC image as a Center of Excellence Project Goal: Caregiver training and empowerment Project Goal: Proper pa]ent referral among available services Project Goal: Decrease hospitaliza]on stay Project Goal: Promote diabe]c foot management at SKMC Type & Degree of Impact: Direct and High Type & Degree of Impact: Direct and High Type & Degree of Impact: Indirect and Medium Type & Degree of Impact: Indirect and Medium Identify Identify potential potential internal internal and external and external stakeholders stakeholders and explain and how explain y how y 1Ca 1Ca were identified. were identified. 5 Clinical Transformational Event 2014 Potential Potential stakeholders were identified through team s brainstorming sessions and included in SIPOC diagram Potential stakeholders stakeholders were identified were identified through through team s brainstorming team s brainstorming sessions and sessions included and in included SIPOC in SIPOC mentioned diagram mentioned in section in 1Ac. section The 1Ac. list The of potential list of potential stakeholders stakeholders is in is in tables tables found found in sections on sections 1Cb and 1Cb 1Cc. The organisation diagram mentioned in section 1Ac. The list of potential stakeholders is in tables found on sections 1Cb employed and 1Cc. The three organization levels of stakeholder employed three identification levels of stakeholder process shown identification below: and 1Cc. The organization employed three levels of stakeholder identification process shown process below: shown below: THE VERTICAL THE VERTICAL SCAN SCAN Iden]fied Iden]fied key players key at each players level at of each level hospital of - from hospital organiza]on's - from organiza]on's senior leadership senior leadership ranks to ranks frontline to staff frontline directly staff impacted directly by impacted project. by project. THE HORIZONTAL THE HORIZONTAL SCAN SCAN Classified Classified func]onal func]onal stakeholders stakeholders related to related project to according project to according ir to ir perspec]ve perspec]ve and exper]se and exper]se THE EXTERNAL SCAN THE EXTERNAL SCAN Recognized all external special interest groups and regulatory bodies who Recognized all external special interest groups and regulatory bodies who may be directly or indirectly affec]ng project may be directly or indirectly affec]ng project 1Cb Identify types of potential impact on stakeholders and explain how Identify types of potential impact on stakeholders and explain how 1Cb se were determined. se were determined. 17

20 Recognized all external special interest groups and regulatory bodies who Recognized all may external be directly special or interest indirectly groups affec]ng and regulatory project bodies who may be directly or indirectly affec]ng project 1Cb 1Cc Identify types of potential impact on stakeholders and explain how Identify 1Cb types of potential impact on stakeholders and explain how se were determined. se were determined. Identify degree of potential impact on stakeholders and explain how Identify 1Cc degree of potential impact on stakeholders and explain how this was determined. this was determined. The table below The table summarizes summarises below summarizes potential impact potential identified impact by by identified team during by ir team ir brainstorming during ir brainstorming sessions. The sessions. degree of potential The degree impact The of degree on potential stakeholders of impact potential on was impact identified stakeholders on using stakeholders was two identified criteria: was using identified importance two criteria: using of two importance stakeholder criteria: of to importance project, of and how stakeholder influences stakeholder to project, to process. and project, how The and stakeholder how matrix influences stakeholder below was influences used process. as a The guide: stakeholder process. The matrix stakeholder matrix below was used below as was a guide: used as a guide: HIGH/MEDIUM HIGH/MEDIUM IMPORTANCE IMPORTANCE LOW INFLUENCE LOW INFLUENCE HIGH/MEDIUM HIGH/MEDIUM INFLUENCE INFLUENCE LOW IMPORTANCE LOW IMPORTANCE 6 Clinical Transformational Event Clinical Transformational Event 2014 Below are tables of Below all are potential tables of all stakeholders potential stakeholders of project of and project ir and corresponding ir corresponding degree degree of impact: of impact: WCET Journal Volume 35 Number 3 July/September