Development and implementation of an “Internet+” management plan for cancer patients with wounds/stomas during the coronavirus disease 2019 pandemic

To explore the practical application and effect of the management plan for cancer patients with wounds/stomas based on the “Internet+” model during the coronavirus disease 2019 (COVID‐19) pandemic. Based on the specific situation during the COVID‐19 pandemic, we established the “Internet+” management team for cancer patients with wounds/stomas. After systematical literature search and brainstorming analysis, we developed a management plan for cancer patients with wounds/stomas based on the “Internet+” model. Then, we included cancer patients with wounds/stomas who needed follow‐up visits or consultations at Jiangsu Cancer Hospital from January 25 to April 30, 2020. A total of 304 patients were participated in the study. The effects of the plan were evaluated including patient satisfaction, the proportion of patients who did not need to go to the hospital for treatment, the proportion of patients with improved symptoms and the rate of the patients or nurses contracted COVID‐19. After the implementation of the plan, 56.3% of the patients mastered the relevant self‐care methods under the guidance of specialist nurses and did not need to go to the hospital for treatment. A total of 89.5% of the patients showed improvement in symptoms, and 99.4% of the patients were satisfied with the online treatment. None of the patients or nurses contracted COVID‐19. The “Internet+” management plan for cancer patients with wounds/stomas during the COVID‐19 pandemic had supported epidemic prevention and control in medical institutions and reduced the risk of cross infection. In addition, this type of plan effectively improved disease symptoms in the patients, and their level of satisfaction was high.


| INTRODUCTION
At the end of December 2019, coronavirus disease 2019 (COVID- 19) was first reported in Wuhan, which is the capital of Hubei Province in China. 1 COVID-19 is highly infectious and spreads rapidly; in addition, the entire population is susceptible. 2,3 On January 20, 2020, the National Health Commission of the People's Republic of China included COVID-19 on the list of second-class infectious diseases and mandated that it should be managed in accordance with the prevention and control measures for first-class infectious diseases. 4 On January 30, 2020, the World Health Organization declared that COVID-19 was a public health emergency of international concern (PHEIC) and rated the risk level of the epidemic as "very high," which is the highest possible level. 5 Hospitals are public places with dense populations and high population mobility, 6  Therefore, to provide the medical treatment needed by patients, relieve patient anxiety, and avoid cross-infection, the nursing department of our hospital rapidly developed an "Internet+" management team for cancer patients with wounds/stomas and implemented a series of management strategies. In this retrospective study, we analyzed the outcomes and effects of the "Internet+" management plan for cancer patients with wounds/stomas, hoping to provide a reference for other health care workers during the COVID-19 pandemic.

| Patients
In this retrospective study, we included cancer patients with wounds/stomas who needed follow-up visits or consultations at Jiangsu Cancer Hospital from January 25 to April 30, 2020. The study was conducted in accordance with the principles of the Declaration of Helsinki. The study was approved by the Jiangsu Cancer Hospital ethics committee (reference number: 2019-007). In addition, we have obtained the informed consent from participants in this study.
2.2 | Establishment of the "Internet+" management team for cancer patients with wounds/ stomas during the COVID-19 pandemic An "Internet+" management team for cancer patients with wounds/ stomas was established under the purview of the hospital's nursing department. The team consisted of 10 members, with 3 enterostomal therapists, 2 wound stoma specialist nurses, 2 scientific research nurses and 3 network engineers. The head of the hospital wound, stoma and incontinence nursing group was appointed as the management team leader and was responsible for the overall plan, personnel training process and management supervision. The other nurses were responsible for the retrieval of the relevant literature, management plan formulation and implementation, and coordination with the network engineers. The network engineers were responsible for the design of the "online nursing clinic" application, the design of module on the Internet platform, the management of the information, and the collection of user feedback.

| Development of management plan
The management team first performed a preliminary statistical analysis on patients with wounds or stomas who needed follow-up visits or consultations at Jiangsu Cancer Hospital. Then, we conducted a literature search systematically, including the COVID-19-related diagnosis and treatment plan and prevention and control guidelines issued by the National Health Commission of the People's Republic of China, 11,12 studies on the "Internet+ nursing" service model [13][14][15] and other related studies. After considering the existing "Internet+ nursing" platform and other resources, such as the official accounts of patients with wounds or stomas and WeChat groups in our hospital, the team used brainstorming method to discuss and formulate the "Internet+" management plan for cancer patients with wounds/ stomas during the epidemic. In addition, to adapt to changes in the epidemic, the performance of the plan and feedback, the team implemented timely adjustments and improvements to the plan (Table 1).

| Organization and implementation
Before the implementation of the management plan, we organized online training for the team members. The training mainly consisted of (1) the outline of the "Internet+" management plan for cancer patients with wounds/stomas and related network operation exercises; (2) COVID-19-related diagnostic programs, prevention and control guidelines, personal protection and other related information; and (3) psychological counseling training. Team members were encouraged to increase their confidence in providing these care services during the epidemic.
In addition, to reduce the movement of personnel and avoid cross-infection, we gave detailed assignments to specific team T A B L E 1 "Internet+" management plan for cancer patients with wounds/stoma during the COVID-19 pandemic

Categories
Main points For patients who need follow-up in our hospital 1. We contact the patients or their family members through official accounts, WeChat groups, the telephone, etc. To avoid cross-infection and reduce the flow of personnel, it is recommended to attempt online medical treatment first. 2. Patients register and log in to the online wound stoma specialist clinic, describe their situation, upload disease-related pictures, and make an appointment for treatment. 3. The specialist nurses then receive the request for consultation. After learning about the patient's existing nursing problems and needs through video calls, texts and pictures, they provide personalized answers, guidance and health education to the patient. 4. Specialist nurses provide appropriate treatment suggestions based on the classification standards for various types of wounds and the classification standards for stoma complications, with consideration given to the patient's comorbidities. Patients with wounds ① When the specialist nurses treat patients with mild symptoms, they teach patients and their families online how to master the relevant nursing methods and arrange follow-up visits with the patients. ② When the specialist nurses treat patients with moderate symptoms who are at moderate risk of complications, they teach patients and their families online about the relevant issues, and advise them to go to the nearest community hospital for treatment in a timely manner. ③ When the specialist nurses treat patients with severe symptoms who are at high risk of complications, they teach patients and their families online about the relevant issues. Nonlocal patients are advised to go to the specialist outpatient clinic of their nearest hospital in a timely manner to receive treatment. When necessary, we discuss the specific nursing plans with specialist nurses in the patient's closest hospital. Local patients are advised to go to the specialist nursing clinic of our hospital for treatment. Patients with stoma ① When the specialist nurses treat patients with mild stoma complications, they teach patients and their families online how to master the relevant nursing methods and arrange follow-up visits with the patients. ② When the specialist nurses treat patients with complicated illnesses and serious complications, they teach the patients and their families online about the relevant issues. Nonlocal patients are advised to go to the specialist outpatient clinic of their nearest hospital in a timely manner to receive treatment. When necessary, we can discuss the specific nursing plans with specialist nurses in the patient's closest hospital. Local patients are advised to go to the specialist nursing clinic of our hospital for treatment. 5. After the online consultation, the patients fill out the satisfaction survey and provide feedback. 6. If the patient needs additional wound-related dressings or ostomy care supplies, the specialist nurse submits the order to the Medical Equipment Department after review. After the patient pays the related fees, the Medical Equipment Department delivers the items via contactless express delivery.
For patients from the medical cooperation unit 1. The medical cooperation unit connects with our hospital through the telemedicine platform, sends the basic information about the patient and related pictures, and makes an appointment. 2. The specialist nurses then receive the request for the consultation. After learning about the patient's existing nursing problems and needs through video calls, texts and pictures, they talk with the patient's medical and nursing team to formulate a treatment plan, which will provide the medical cooperation unit with guidance regarding how to treat the patient's wound or stoma. 3. After the online consultation, the patients fill out the satisfaction survey and provide feedback.
For outpatients 1. Before the patients come to the hospital, online consultation information is added, including the relevant epidemiological history and whether they have fever, cough, expectoration, diarrhea and other symptoms. 2. When the patients come to the hospital, they are screened again for the relevant epidemiological history and symptoms such as fever, cough, expectoration and diarrhea. 3. Stratified management is adopted for patients after screening.
① If the patient's temperature is normal and there is no relevant epidemiological history, we implement first-level protection measures. The specific measures are as follows: Implement adequate standard prevention measures. Specialist nurses are equipped with disposable surgical masks, disposable caps and disposable latex gloves. The masks and caps are replaced every 4 hours and any time they become wet or contaminated. In addition, the consulting room is strictly managed and controlled, and only one patient is received at a time. More than one meter of distance is maintained between waiting patients. ② If the patient has a fever or has relevant epidemiological history, the outpatient screening staff immediately report this to the Preventive Health Care Department, Medical Department, Nursing Department, and Infection Control Department, and place the patient in an independent consulting room. Then, the infectious disease experts in our hospital consult with the patient. After excluding the diagnosis of COVID-19, specialist nurses implement second-level protection measures. The specific measures are as follows: Implement adequate standard prevention measures. Specialist nurses are equipped with isolation gowns, medical goggles, N95 masks, disposable caps, disposable shoe covers and disposable gloves. ③ If the patient is suspected of having or is diagnosed with COVID-19, they are placed in an independent consulting room. The specialist nurses implement third-level protection measures. The specific measures are as follows: Implement adequate standard prevention measures. Specialist nurses are equipped with disposable protective clothing, full-face respiratory system protectors, N95 masks, disposable caps, disposable shoe covers and disposable gloves. The patient is

| Data collection
After each online consultation, we collected data on patient satisfac- For patients in our hospital 1. The nurse in the ward applies to the contingency management team for an intra-hospital consultation.
2. Specialist nurses inquire about the basic condition of the patient and take appropriate protective measures. If the patient's temperature is normal and there is no relevant epidemiological history, we implement first-level protection measures. Specialist nurses are equipped with disposable surgical masks, disposable caps and disposable latex gloves. If the patient has a fever or relevant epidemiological history but does not have COVID-19, we implement second-level protection measures. Specialist nurses are equipped with isolation gowns, medical goggles, N95 masks, disposable caps, disposable shoe covers and disposable gloves. If the patient is suspected of having or diagnosed with COVID-19, we implement thirdlevel protection measures. Specialist nurses are equipped with disposable protective clothing, full-face respiratory system protectors, N95 masks, disposable caps, disposable shoe covers and disposable gloves. 3. After the first in-person consultation, specialist nurses enroll the patient in the online management system. 4. During hospitalization, if the patients experience any discomfort in the wound or stoma, they can first receive care through the online wound and stoma specialist clinic. If the problem cannot be solved online, the specialist nurse will go to the ward to administer treatment, and the corresponding protective measures will be the same as those for the first visit. 5. For those who are not cured by the time they are discharged, we will guide them to continue treatment according to the protocol for patients who need follow-up in our hospital.     infected. 26 These finding suggest that we should implement response measures as soon as possible to minimize the damage caused by public health emergencies.

| "Internet+" management plan alleviates symptoms and led to high levels of patient satisfaction
In our study, after the implementation of the "Internet+" management plan, 89.5% of patients showed improvements in symptoms, indicating that the management plan effectively alleviated the symptoms of cancer patients with wounds/stomas during the epidemic.
This may be related to the timely initiation of the management plan.
After the implementations of the program, the patients were no longer required to visit the hospital in person during the pandemic. They were able to obtain professional guidance and advice from specialist nurses in a timely manner, which helped them avoid delays in treatment to the greatest extent and prevention complication with the early detection and treatment of problems. 27 In addition, our study also showed a high level of patient satisfaction with the online treatment, with 99.4% of the patients indicating that they were satisfied.
This indicates that the management plan was generally accepted by patients. Due to the epidemic, the government has recommended limiting the movement of people. This is inconvenient for cancer patients with wounds/stomas who urgently need follow-up visits and consultations. After the implementation of the plan, the specialist nurses were able to provide the patients with one-on-one online guidance and health education and to answer any questions the patients had regarding their condition, which alleviated the patients' anxiety regarding seeking medical treatment during the COVID-19 pandemic.

| Limitations
There are some problems regarding the collection of fees for medical services that will need to be addressed in the future. During the pandemic, all online diagnosis and treatment services have been provided free of charge, and only delivery services cost a fee.
Therefore, it is necessary to further refine and improve the management plan in the future, which will reduce the pressure on hospital visits by triaging patients and provide a convenient alternative to in-person visits for patients.

| CONCLUSIONS
In summary, the "Internet+" management plan for cancer patients with wounds/stomas during the COVID-19 pandemic has been shown to be effective; it has helped alleviate the burden imposed on medical institutions by the epidemic prevention and control measures and reduced the risk of cross-infection. In addition, it effectively improved patient symptoms, and the level of patient satisfaction was high. Furthermore, this plan provides a foundation for further discussions on "Internet+" online nursing service standards for cancer patients with wounds/stomas and the expansion of nursing service models.

CONFLICTS OF INTEREST
The authors declare that they have no conflicts of interest.

AUTHOR CONTRIBUTIONS
All authors had access to the data. Niu N., Meng A.F., Zhi X.X., Zhang

ETHICS STATEMENT
The study was conducted in accordance with the principles of the Declaration of Helsinki. The study was approved by the Jiangsu Cancer Hospital ethics committee (reference number: 2019-007). In addition, we have obtained the informed consent from participants in this study.