INTRODUCTION
The care and management of the patient with an enterocutaneous fistula (ECF) or enteroatmospheric fistula (EAF) are complex and challenging for both patient and healthcare provider.1,2 An ECF or EAF is an abnormal connection between the gastrointestinal system and the skin that may occur either spontaneously or related to surgery and is commonly associated with malnutrition and postsurgical sepsis.3 These fistulae require complex care for prolonged periods of time and pose significant quality-of-life concerns for patients. Management challenges include high-volume output from the fistula, causing fluid/electrolyte imbalances, severe moisture-associated skin damage from exposure to effluent, and a variety of physiological and psychological issues. An understanding of the principles of wound care and the various techniques and materials that are available is essential for comfort and fistula healing.3 In addition, an interdisciplinary team approach for the assessment and management of the patient's psychological/psychosocial concerns is essential1,4-6 and care delivery must include emotional and psychological support.1
In 2009, the Canadian Association for Enterostomal Therapy (CAET) developed best practice recommendations as a resource for nurses managing patients with an ECF.7 As evidence evolves, so must practice. Therefore, Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC) (formerly CAET) identified the need to revise the current recommendations. A voluntary network of NSWOCs from across Canada formed a development panel to perform a comprehensive review of current literature and revise the recommendations. The goal of the NSWOC development panel was to provide recommendations for adults with ECF/EAF, regardless of care setting, that (1) reflect current best evidence; (2) clarify prioritization of the original recommendations; (3) create algorithms, resources, and other tools; and (4) create a user-friendly electronic format to optimize access.
RECOMMENDATION DEVELOPMENT
The development panel comprised NSWOCs from multiple care settings, including hospital and community. A comprehensive literature search was performed using the following electronic databases: CINAHL, MEDLINE, PubMed, and Google Scholar. Key terms used included "enterocutaneous fistula," "enteroatmospheric fistula," "nutrition and ECF," "general surgery wound complications," and "nursing management of intestinal fistula." Results were limited by publication type and date. Levels of evidence defined by the Registered Nurses' Association of Ontario (RNAO) were used to appraise the quality of the evidence.8 Results of this literature search informed the new and revised recommendations.
Canadian and international stakeholders representing relevant healthcare professions reviewed the recommendations. The development panel reviewed the feedback and revised the relevant recommendations once panel consensus was reached.
Review of the literature revealed several important concepts related to the management of the patient with an ECF or EAF. These key concepts aligned with those identified by the CAET in 2009; therefore, the panel were able to review and further develop the existing recommendations based on current research and evidence. Additional recommendations were developed based on the key concepts identified in the literature. The 8 principal recommendations address aspects of clinical practice, patient- and family-centered care, education, and policy development (Table). Each recommendation is explored in detail and summarized in an executive summary in this issue of the Journal of Wound, Ostomy and Continence Nursing.
The NSWOCC Nursing Best Practice Recommendations for Enterocutaneous Fistula and Enteroatmospheric Fistula provide evidence-based recommendations for the management of ECF/EAF. Although this document may be beneficial as a resource for various team members, it is specifically intended for use by nurses managing patients with an ECF or EAF. The goal of the NSWOC development panel was to ensure recommendations were up-to-date and reflected current evidence so that they could be used to inform the care of this patient population. The document is available in an electronic format, is interactive, and easily accessible.
SUMMARY
This updated document will facilitate management of the patient with an ECF or EAF. In addition, the panel identified resource gaps, such as the absence of a standardized assessment form. Part of the development work included creation of such tools to address these gaps. Resources and practice supports are available for nurses in the final document. The full document9 is available on the NSWOCC Web site at http://nswoc.ca/ecf-best-practices.
REFERENCES