Enhancing Stoma Care Quality: Implementing a PDSA Cycle-Based Program for Colorectal Cancer Patients

doi:10.21203/rs.3.rs-4371901/v1

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Enhancing Stoma Care Quality: Implementing a PDSA Cycle-Based Program for Colorectal Cancer Patients

https://doi.org/10.21203/rs.3.rs-4371901/v1

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Background: Effective quality management is of prime importance in reducing the risk of ostomy’s complications. It is necessary to improve the quality of stoma practice specialist and increase patients' awareness of self-care and the need to temporarily withhold certain medication.

Objectives: A quality stoma practice specific program (QSPSP) was introduced to address these concerns and enhance the care among patients who had received a diagnosis of colorectal cancer (CRC) and underwent surgery with stoma creation at a single medical center. PDSA model was approached for care service improvement in three cycles (the Plan, Do, Study, Act/cycle) to test and generate new ideas relating to patients' needs.

Measurements and Results: The QSPSP was identified through the application of the PDSA model. Viable strategies to address these challenges within the QSPSP program encompass: (1) Recruitment of a certified stoma-specific nurse. (2) Creation of standardized guidelines. (3) Integration of an interdisciplinary team. (4) Enhancement of patient self-care education. (5) Identification of specific goals. (6) Provision of feedback on intervention and evaluation by comparison of QLQ-C30 scores

Conclusion: The quality stoma practice specific program has achieved qualification, and its initiatives have been effectively disseminated to enhance professional awareness of the paramount importance of quality in patient care.

Colorectal cancer

stoma care

PDSA

Quality Stoma Patient Support Program

Colorectal cancer (CRC) has been well known to be a common malignant tumor and generally causes increasing incidence among not only the elderly, but also the middle-age between 40 to 50. Many epidemiological studies showed colorectal cancer is ranking third among gastrointestinal malignancies and all malignant tumors. The optimum management in CRC is systematic in selection which is based on critical assessments of the patient’s general health, disease stage and consequent responses to intervention. Although surgical treatment is recognized as a most possibly curing option for early diagnosed CRC, the patients often experience physical and psychological endurance especially the need of the postoperative care. Accumulative evidence has shown that the clinical significance of surgical resection and anastomosis was achievable for parts of the colon or rectal to be removed and the remaining healthy parts be joined together. One of consequences through an abdominoperneal resection and other surgical procedures for colorectal cancer is the formation of a stoma. Data suggested a 26.5% of patients' colorectal cancer surgery caused this outcome. It is one of significant concerns among immediate postoperative issues, of which related complication accounts 20–60% of impediments. For example, stomas were identified as problematic within three weeks of surgery in British hospitals. In the early post-surgery (0–10 days), three common complaints affect most likely: retraction (the bowel pulling back into the abdomen) and separation (the stoma edging away from the surrounding skin) (1), and skin excoriation including peristomal dermatitis (2). The late complications may be experienced including parastomal hernia, prolapse, bowel obstruction, bleeding, constipation, and diarrhea, etc. In some cases, a parastomal hernia can occur when the abdominal wall weakens, resulting in a bulge near the stoma (3) or may lead to bowel obstruction or incarceration, necessitating surgical intervention (4). The intestine can protrude through the stoma, potentially leading to ischemia or necrosis (2). The constipation and stool impaction are common among patients with colostomies and leads to discomfort and potential blockages (3) and may manual decompaction (5). The observative studies on the ileostomy reported that high-volume output from an ileostomy can lead to fluid and electrolyte imbalances, resulting in dehydration (6). Also, frequent liquid output can irritate the peristomal skin, leading to skin breakdown and excoriation (7).

Stoma Stenosis and ulceration can take place as to the narrowing of the stoma opening, making it challenging to manage waste output (5)(6). Finally, peristomal infections due to bacterial or fungal invasion in the peristomal area, may lead to discomfort and potential complications (2). While the complications mentioned above can vary based on the type of stoma (ileostomy or colostomy) and their specific locations (e.g., transverse colostomy, sigmoid colostomy), early identification and management of these complications are essential for the overall quality of life (QoL) and well-being of patients with colorectal cancer who have undergone stoma surgery. In clinical care practice, the postoperative care of stomas is evolving rapid, with a new pattern pursuing a transformation from being short-term to a generally chronic disease.

Since patients undergoing colorectal cancer surgery often have concerns regarding their long-term outcomes and quality of life, understanding the postoperative experience is crucial in ensuring comprehensive care and support for these individuals. Indeed, having a stoma led to higher levels of psychologic distress (8) and poorer scores in most aspects of quality of life (9). Studies have shown that QoL can be significantly affected by the presence of a stoma. Research by Huang et al. (2) explored the QoL in patients with permanent stomas after rectal cancer surgery, revealing that stoma creation had a substantial impact on their daily lives and psychosocial well-being. Another study by Danielsen et al. (3) highlighted the psychosocial outcomes and QoL in patients with colostomies, emphasizing the importance of addressing the emotional and social aspects of life with a stoma. The long-term outcomes of patients with stomas after colorectal cancer surgery depend on various factors, including stoma type, perioperative care, and complications. Stoma-related complications can have a significant influence on long-term outcomes. Krouse et al. (6) discussed a framework for preventing and managing stoma complications, emphasizing the need for proactive care. Alves et al. (4) studied postoperative mortality and morbidity in patients undergoing colorectal surgery, providing insights into the broader surgical outcomes.

In summary, long-term outcomes and quality of life in patients with stomas following colorectal cancer surgery are multifaceted. It is essential to consider not only the surgical aspects but also the psychosocial and emotional well-being of these individuals. The cited studies shed light on the various dimensions of this topic, providing valuable insights into the challenges and potential solutions for enhancing the lives of these patients.

Stoma care, following colorectal cancer surgery, extends far beyond the physical aspects of managing the stoma itself. It encompasses the broader well-being, quality of life, and psychological aspects of patients. A multidisciplinary team, consisting of special nurses, personal care aides, oncologists, and psychologists, plays a vital role in delivering comprehensive care.

Personal Care Aide provides invaluable assistance to patients, ensuring that stoma care tasks are performed accurately and hygienically. This support helps in reducing patient anxiety and enhancing their comfort (1). Patient education especially self-care, can benefit them adapt to the changes in their daily routines which is crucial for promoting independence and confidence (10). The special nurse, as expertise in stoma care, possess in-depth knowledge and expertise in stoma management. Ideally, they are well-versed in the technical aspects of stoma care, including appliance changes, skin protection, and complication prevention (2). Medical oncologist can provide a critical medical perspective in stoma care, especially in cases where patients may have other medical conditions e.g., diabetes or require ongoing cancer treatment (4). The role of psychologist in coping with a stoma can offer emotional support in perioperative time (5) and is associated with mental health assessment to assess and address any anxiety, depression, or adjustment issues, improving the patient's overall quality of life (3). Other critical components of the multidisciplinary team include observation and reporting which is often the first to notice changes in stoma health and can promptly report any issues to the healthcare team so as to facilitate an early intervention (6); coordination of care which focuses on the integration of stoma care into the broader cancer treatment plan, thus ensuring that stoma management complements the patient's overall healthcare strategy. Overall, the need of incorporating this multidisciplinary approach ensures that patients receive well-rounded care, addressing not only the physical aspects of stoma management but also their psychological and emotional well-being. By working together, these professionals enhance patient outcomes and contribute to a more positive and holistic stoma care experience. In Australia’s public hospital, a specialist- colorectal cancer liaison nurse visits patients each day and access to other members of the allied health care team as needed including the stomal therapy nurse, dietician, and social worker to establish an adapted diet to the patient with a stoma (11)

The PDSA (Plan-Do-Study-Act) cycle is widely embraced in healthcare due to its straightforwardness and real-world applicability. It has received the endorsement of reputable organizations such as the institute for healthcare improvement. The beauty of the PDSA approach lies in its adaptability, making it a valuable tool for addressing a myriad of quality improvement issues in clinical settings. From streamlining administrative tasks by revamping the accessioning process to patient safety through the implementation of a paperless signout workflow, the PDSA cycle has proven its effectiveness in healthcare quality enhancement (12)(13).

The current study reports the qualitative findings in sing-center hospital institute from a middle size-population study that focused on quality stoma practice specific program (QSPSP) for patients with stoma related to their quality of life. Aim of the study was particularly to explore an initiative QSPSP through introducing ostomy care specialist and perioperative counselling support. Its quality was evaluated by PDSA module. The PDSA multiple cycles started with a small group of patients who believe in the proposed improvement of their stoma care. With more numbers were added into the process, the refined QSPSP quality ideas were implemented for all the possible ways of achieving the improvement with confidence.

In according to Chinese expert consensus (version 2022) on protective stoma for colorectal cancer debriefed by Stoma/Ostomy Professional Committee, Colorectal Tumor Professional Committee elected by Chinese Society of Colorectal Surgery, Chinese Society of Surgery, and Chinese Medical Doctor Association, the rate of sphincter ⁃ preserving surgery for colorectal cancer is increasing, but anastomotic leakage remains to be one of the common serious complications after operation. How to reduce the morbidity and mortality of anastomotic leakage is always a hot and difficult point in colorectal surgery. Protective stoma is a common method to deal with the above problems in clinical practice. However, some problems such as inappropriate stoma and stoma ⁃ related complications etc. become the current clinical challenges. The purpose of the consensus was to emphasize indication of stoma, prevention of stoma complications, reversion of stoma and stoma nursing. One of advice in the consensus was to provide guidance for the quality improvement of stoma care in clinical practice in China. We believe it is a necessary approach to create a comprehensive stoma care specialist program to assess surgery nurses through surveys and provide customized care training. Accordingly, the current study focused a step-by-step organization of the program to improve stoma healing and reduce complications.

Our oncology center is one of the main Fujian Province medical centers, which offers internal and surgical services particularly comprehensive care to patients from all over the province. Between December 2017 and October 2022, 106 patients with stoma were recruited to participate in the trial. We executived the test our intervention and assessed the quality improvement of the QSPSP though rapid change cycles of PDSA.

Step 1

To collect references for the program included stoma care guidelines, nursing education literature and research articles in stoma care.

To support the role of stoma care specialists: the specialists played a crucial role in the success of the program, offering valuable expertise and continuity of care. Their contributions encompassed their extensive knowledge of stoma, colorectal cancer, a comprehensive understanding of the disease, its treatments, side effects, and broader psychological and social implications. This support was instrumental in ensuring high-quality patient care.

To ensure continuity of care: To maintain the presence of stoma care specialists throughout the patient journey, from the initial diagnosis to follow-up clinics and telephone//WeChat contact, a strong focus on continuity of care was established. This approach ensured that patients received consistent and comprehensive support. In particular, the nursing staff facilitated access to the oncologist and oncology surgeon's expertise by addressing questions and conveying the guidance to the participants. Moreover, it was anticipated during their care to alleviate patient uncertainties, treatment plans were explained, along with clear explanations of what patients.

Step 2 To expose the underlying problems/weaknesses of stoma care by root cause analysis in our center. We aimed to minimize problem and develop improvement ideas. The central emphasis of the ideas was to preserve homeostasis under stoma care and reintroduce oral fluids and nutrition at the earliest feasible moment as well as reduce the infection. The purpose of the development will reduce complications and length of stay in colorectal resections and be proven to be valuable in large-size stoma management.

Step 3 To establish documentation of QSPSP guide:

I. Program Goals and Objectives

Goal: Defined the goal “what are we trying to accomplish in the program?” – within one month, we plan to enhance stoma care quality and reduce complications among patients with colorectal cancer.

Objectives: Define our measurements to demonstrate that we have achieved our goal; Assess the knowledge and practices of surgery nurses in stoma care; Provide targeted training to address identified gaps; Improve patient outcomes and satisfaction in stoma care; Promote evidence-based best practices in stoma care.

Program Components

A. Assessment of surgery nurses

Pre-program survey: Conduct a baseline survey to assess the current knowledge and practices of surgery nurses regarding stoma care. The survey should include questions related to stoma types, complications, and patient education.

Knowledge and skills assessment: Evaluate the surgery nurses' stoma care knowledge and skills through written tests and practical assessments.

B. Customized care training

Identification of gaps: Analyze the survey and assessment results to identify specific knowledge and practice gaps among surgery nurses.

Design customized training: Develop a tailored training curriculum to address the identified gaps. Training may cover areas such as stoma types and location, peristomal skin care, complication prevention and management.

Patient education and psychosocial support.

C. Training delivery:

Conduct workshops, seminars, and hands-on training sessions.

Provide educational resources, such as manuals and online modules.

Encourage peer learning and mentorship among surgery nurses.

III. Evaluation and Monitoring

Post-training assessment: Administer post-training assessments to measure the effectiveness of the program in improving surgery nurses' stoma care knowledge and skills.

Ongoing evaluation: Continuously monitor and evaluate the impact of the program on patient outcomes, including stoma healing and complication rates.

Collect feedback from both surgery nurses and patients to make program improvements.

IV. Resources and Support

Expert guidance: Collaborate with experienced stoma care specialists and educators to develop and deliver training content.

Educational materials: Provide surgery nurses with access to up-to-date resources, research papers, and guidelines on stoma care.

V. Integration and Collaboration

Multidisciplinary approach: Encourage collaboration with other healthcare professionals, including personal care aides, oncologists, and psychologists, to ensure comprehensive patient care.

Peer Support and networking: Facilitate networking opportunities for surgery nurses to exchange experiences and share best practices.

VI. Program Impact and Continuous Improvement

Data Analysis: Analyze patient outcomes and complication rates to measure the program's impact.

Feedback mechanism: Establish a feedback loop to gather suggestions and concerns from surgery nurses and patients for program improvement.

Periodic updates: Regularly update the training curriculum and resources to align with the latest advancements in stoma care.

VII. Program Promotion and Awareness

Communication: Promote the program within the healthcare facility through newsletters, meetings, and presentations.

Patient education: Educate patients about the program's benefits to encourage them to participate.

VIII. Program Sustainability

Integration into hospital protocols: Integrate the stoma care specialist Program into the hospital's standard operating procedures for stoma care.

Continual learning: Encourage surgery nurses to engage in ongoing professional development in stoma care.

Overall, by disseminating the idea about stoma care specialist program with these components, we can effectively assess surgery nurses, provide customized care training, and continuously improve stoma care practices, leading to better outcomes and patient satisfaction.

Step 4 QLQ-C30 assessment

The European Organization for Research and Treatment (EORTC) quality of life questionnaires (QLQ-C30) were chosen as a widely accepted assessment tool for colorectal-related cancer. This selection was based on the recognition that its functional subscales demonstrate a higher level of responsiveness in evaluating the quality of life among patients undergoing chemotherapy or other intervention. The items are scored from 0 to 20 in which a meaningful change score falls within the range of approximately 5 to 10 for those who reported a 'slight' change, around 10 to 20 for those who reported a 'moderate' change and exceeds 20 for individuals who reported a 'significant' change. The simplified Chinese version of QLQ-C30 was reported a good validity, reliability (the Cronbach's α coefficients of all domains > 0.7), and responsiveness in QOL measurement of Chinese cancer patients (14) (15). In clinical settings, measurements typically exhibit both internal and external responsiveness. Internal responsiveness pertains to a measurement's ability to detect changes in response to an effective intervention. A commonly used approach for assessing internal responsiveness involves analyzing how the measurement changes within the context of a randomized clinical trial that utilizes a treatment with a proven track record of efficacy. External responsiveness indicates the extent to which changes in a measurement over a specified time align with concurrent changes in a reference measure of health status. In the present study, the QLQ-C30 questionnaire offered insights into internal responsiveness, highlighting which groups of respondents experienced changes in health status, particularly when receiving care from a certified professional nurse with specialized training in quality stoma practices during perioperative treatment courses. The patient's self-assessment of their overall change in health served as the primary criterion for assessing the responsiveness of the questionnaires." The question was phrased as follows: "When compared to your health condition before receiving stoma care education and nursing care, how would you assess your current state of health?" The responses were categorized into seven levels: the initial three responses (much worse, moderately worse, and slightly worse) were deemed indicative of a clinically significant decline in health. The fourth response (no change) signified stability, while the final three responses (slightly better, moderately better, and much better) indicated a clinically significant improvement in overall health. Thirty-items/15- domains contain functioning, symptoms (inching, bleeding, fatigue, pain and nausea/vomiting), and distresses (low appetite, insomnia, diarrhea, constipation, breathing difficulty and financial difficulty). The questionnaire was scored following the directions given by the developers of the original scale.

Quality of Life (QOL) assessments were carried out through direct interviews, ensuring a uniform language and approach were maintained when interacting with the patients. The questionnaires underwent thorough review, and any elements that might be confusing were clarified for the participants. To assess the consistency and stability of the QOL assessments, we conducted test-retest reliability evaluations with a five-day interval involving twenty-four subjects. The internal consistency scores ranged from 0.65 to 0.78, indicating that the assessments were reliable and acceptable in this study. Both the subscales and total scales exhibited stability between the two data collections, with stability coefficients averaging r = 0.77. In our investigation, the QLQ-C30 scale demonstrated high reliability and validity, with an overall Cronbach's α coefficient of 0.782, affirming its suitability for assessing the quality of life in this context.

Statistical analyses

The patient data was summarized using percentage for categorical variables and mean with standard deviation (mean ± SD) for continuous variables. To assess differences among continuous variables, independent-samples Student's t-tests were employed. The qualitative results, particularly for the QOL-C30, were presented with 95% confidence intervals. Bivariate analyses were applied to determine whether a statistical relationship exists between the values of rank reference and one of participants in the study. All statistical analyses were conducted using SPSS (Version 6.0), with a significance level set at P < 0.05 for determining statistical significance.

Study population characteristics

The sociodemographic characteristics and the current clinical situation of the study patients are presented in Table 1 and Table 2. The majority of the patients identified as Han ethnicity (90.6%). Among these patients, 23 (22.0%) resided in rural counties, 18 (17.0%) in township areas, and 65 (61.0%) in urban cities. A significant portion, 75 (70.89%), were married and lived with their spouses. Nearly all patients, 100 (94.3%), did not live alone. A considerable proportion, 68 (64.2%), had attained at least a primary school education level, and 82 (77.4%) were employed.

Evaluate the results- Comparison of QLQ-C30 scores with reference values recommended by EORTC

The comparison analysis, conducted using the Wilcoxon test, is presented in Table 4. The results revealed that scores for physical, role, emotional, and cognitive functions were significantly lower than the reference values. However, the score for social function closely matched the reference value. Additionally, symptom scores were higher for diarrhea, appetite loss, constipation, and insomnia, though not for nausea/vomiting and financial difficulties when compared to the reference scores. The global health status score also fell below the reference value.

Summary of all PDSA cycle

Table 3 shows all PDSA cycles’ phases, key points, and corresponding performance details from the QSPSP program is shown in Table 1. This three-cycle PDSA model provides a structured approach to implementing and measuring the impact of your stoma care intervention among patients with colorectal cancer. It allows for iterative improvements and adaptations based on real-world data and feedback from both healthcare professionals and patients.

An idea of a quality stoma practice specific program (QSPSP) at a single medical center was introduced to address stoma care nursing among patients who had received a diagnosis of colorectal cancer (CRC) and underwent surgery with stoma creation. Consistent with some previously indicated (16–20), these patients often required comprehensive support and assistance to manage their stoma and associated conditions, which presented several challenges and difficulties for healthcare professionals. Some of the key challenges in stoma care nursing were concerned: (1) Complex care needs. Stoma care nurses must possess specialized knowledge and skills to provide appropriate care, including managing complications such as peristomal skin issues, leakage, and prolapse. (2) Emotional and psychological support. Adjusting to life with a stoma can be emotionally challenging for patients. Stoma care nurses play a vital role in providing emotional support, counseling, and education to help patients cope with the physical and psychological impact of their condition. This aspect of care requires empathy, communication skills, and sensitivity to individual patient needs. (3) Education and training. Stoma care nursing requires continuous education and training to stay updated on the latest techniques, products, and evidence-based practices in stoma management. Keeping abreast of advancements in surgical techniques, ostomy appliances, and wound care is essential for delivering high-quality care to patients. (4) Managing complications. Patients with stomas are at risk of developing various complications, such as infections, stoma retraction, herniation, and stenosis. Stoma care nurses must be adept at identifying and managing these complications promptly to prevent further health problems and improve patient outcomes. (5) Supporting lifestyle adjustments. Living with a stoma often necessitates significant lifestyle adjustments for patients, including changes in diet, hygiene routines, and physical activity. Stoma care nurses play a crucial role in educating patients about these adjustments and supporting them in adapting to their new way of life. (6) Coordination of care. Stoma care is multidisciplinary, involving collaboration with surgeons, gastroenterologists, wound care specialists, dietitians, and other healthcare professionals. Coordinating care among different specialties and ensuring continuity of care is essential for optimizing patient outcomes and preventing complications. (7) Accessibility and equity. Access to stoma care services may be limited in certain geographical areas or healthcare settings, leading to disparities in care. Stoma care nurses may face challenges in providing equitable access to care for all patients, particularly those from marginalized or underserved communities. And (8) Resource constraints. Healthcare facilities may face resource constraints, including limited availability of specialized stoma care products, equipment, and staffing. Stoma care nurses may need to navigate these constraints while striving to deliver high-quality care within budgetary limitations.

To our knowledge, it was the first time that the Plan, Do, Study, Act (PDSA) cycle as a quality improvement framework was used to implement and evaluate quality stoma practice specific program at the single medical center. It offered several advantages in the context of stoma care nursing. (1) Structured and systematic approaches: The PDSA cycle provides a structured framework for specialized healthcare professionals to plan and evaluate educational programs and training interventions aimed at improving emotional and psychological support, and ensuring that educational initiatives are well-planned and implemented in a coordinated manner, as well as refining changes in care coordination processes in a step-by-step manner for patients with stoma. (2) Flexibility: The PDSA cycle allows for flexibility in testing tailored interventions and strategies for allowing educators and trainers to test different teaching strategies, instructional methods, and training techniques to determine what works best for their learners, and providing emotional and psychological support. By collecting data and feedback at each stage of the cycle, educators can tailor their interventions to the specific needs and preferences of their audience, leading to more effective learning outcomes. (3) Continuous Improvement: The PDSA cycle promotes a culture of continuous improvement by encouraging educators and trainers to regularly assess the effectiveness of care coordination strategies identify areas for improvement, and make iterative changes based on feedback and data. (4) Evidence-Based Practice: Each phase of the PDSA cycle involves gathering data and evaluating outcomes to inform decision-making. This emphasis on data-driven decision-making promotes the use of evidence-based practices in education and training, and emotional and psychological support, ensuring that instructional methods and training interventions are grounded in research and best practices. (5) Rapid Testing and Implementation: The PDSA cycle allows for rapid testing and implementation of changes in practice. Healthcare teams can quickly pilot new interventions on a small scale, assess their impact, and make adjustments as needed before scaling up to larger implementation. (6) Risk Reduction: By testing interventions on a small scale before full implementation, the PDSA cycle helps to mitigate risks and minimize potential negative consequences. This approach allows educators to identify and address potential challenges or barriers early in the process, reducing the likelihood of failure or unintended consequences. (7) Sustainability: The PDSA cycle promotes the sustainability of improvements in emotional and psychological support by embedding a culture of continuous learning and adaptation within healthcare team.

Overall, the PDSA cycle in our single medical center offers a systematic and iterative approach to improving education and training initiatives, emotional and psychological support, and the coordination of care in healthcare settings, enabling educators and trainers to deliver high-quality care that meets the needs of patients effectively (21–26)

Some lessons obtained from this investigation should be applied in our future application of QSPSP program to better the achievement (Table 5). The investigation enabled the care team of stoma, the patients as well as the patient’s family to were involved into multidisciplinary approach to improve performance. Our study was an effective program suable for identifying areas that should be applied in stoma assessment, management, and emotional support. Our study highlights a better-quality care in the patient with stoma should be delivered by appropriate corrective action in multidisciplinary congruence, and dissemination of communication.

Funding Statement：

This work was supported by the fifth batch of Hospital Key Discipline Construction Funds - Medical oncology (2022YYZDXK05)

Ethical Statement：

Ethical approval was obtained from the board -the Research Ethics Committee of Fujian Medical University with the title of Enhancing Stoma Care Quality: Implementing a PDSA Cycle-Based Program for Colorectal Cancer Patients. The approval number is 12942022. The protocol, informed consent document and questionnaire for participants were reviewed and approved. Written consents were obtained from the participants, and all of them were interviewed in person by investigators, and items and response choices were read and explained if necessary.

Conflict of Interest Statement:

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgement:

We are thankful to all patients for their unreserved efforts and willingness to take part in this study. We thank Dr. Hongbo Yang and Mrs. Jianli Wang for giving us the advice in the study.

Author Contribution Statements:

YJ Zhu and Xiaoyan Lin contributed to the conception and design of the study. CBX Yang organized the database and the statistical analysis. N Yao and Xingyu Lin performed the questionnaire. YJ Zhu, LJ Tang and Xiaoyan Lin wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.

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Tables 1-5 is available in the Supplementary Files section.

No competing interests reported.

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Enhancing Stoma Care Quality: Implementing a PDSA Cycle-Based Program for Colorectal Cancer Patients

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Abstract

Introduction

Materials and Methods

Step 4 QLQ-C30 assessment

Statistical analyses

Results

Study population characteristics

Evaluate the results- Comparison of QLQ-C30 scores with reference values recommended by EORTC

Summary of all PDSA cycle

Discussion

Lessons and conclusions

Declarations

References

Tables

Additional Declarations

Supplementary Files

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