Team Collaboration: Innovative Approaches to Facilitate Wound Healing in the Presence of Enteroatmospheric Fistulas

Clinical Problem:  A 27 year old male was transferred to a large quaternary health sciences centre in February 2015, 29 days following an out of country motor vehicle accident. Injuries at the time were extensive and two abdominal surgeries were performed in a patient with a past medical history of small bowel obstructions that required surgery.  Critical care support was necessary on transfer given the patient’s complex care needs, one of which included the development of two enteroatmospheric fistulas.   Past Management: The enteroatmospheric fistulas resulted in problems with containment of effluent.  Frequent dressing changes were ineffective and moisture associated skin damage occurred.  The Ostomy Advanced Practice Nurse was consulted.  Initial management strategies included troughing, intubating the fistulas with catheters and the use of wound managers.    Clinical Approach: Negative pressure wound therapy was initiated using a “donut-ring” technique over one fistula, the second fistula was managed with a fenestrated catheter connected to low wall suction.  Given this new innovative approach, detailed pictoral guides were developed.  As wound closure occurred and fistula outputs decreased, a combination of ostomy products, accessory items and advanced wound care products were introduced.    Patient outcomes:  Ongoing patient assessments coupled with strong interprofessional collaboration and support ensured changes to the care plan were executed efficiently and effectively. The patient was transitioned to a rehabilitation centre in June 2015.  The abdominal wound had healed and the patient was independent with fistula management.  His quality of life improved and he verbalized gratitude for the care received.  Conclusions:  Understanding best practice management of fistulas, interprofessional collaboration, detailed care plans, continuity and ongoing support of nursing staff and patient engagement is invaluable when managing complex cases.  This approach will be considered for future patients presenting with enteroastmospheric fistulas.