Free flap surgeries are among the most complex for patients with head and neck cancers. In these reconstructive procedures, tissue from one part of the body is transplanted to another site, where the new tissue gets reconnected to the blood supply through intricate microsurgeries. Recovery is difficult for patients.
“Many patients will have a tracheotomy, a feeding tube into the nose, a number of drains and wires,” said Saral Mehra, MD, MBA, FACS, Assistant Professor of Surgery (Otolaryngology), who specializes in free flap reconstructions. “They find it hard to communicate because of the tracheotomy. We’re operating all over their bodies, sometimes their legs, their back, their arms, in addition to the head and neck region, because we’re transferring tissue to reconstruct their jaw or their tongue or part of their throat.”
Until recently, these patients would spend several days in the hospital’s intensive care unit (ICU) before moving to the 15th floor of Smilow Cancer Hospital for further care and rehabilitation. Dr. Mehra and Patient Service Manager, Cara Henderson, RN, BSN, CMSRN, saw an opportunity. “Patients were getting hung up along the post-operative path by going to the ICU,” Dr. Mehra said. “Their heart and lungs are fine, so they don’t need ventilators, complicated medications, and all the things the ICU is great at handling. They just need high-intensity, nursing care.” Dr. Mehra and Ms. Henderson put together a multidisciplinary team of nurses, nurse practitioners, surgeons, coordinators, and administrators to design a new clinical care pathway for patients recovering from free flap surgery. The plan sent them straight from the OR recovery room to the 15th floor of Smilow, where they would be cared for by a dedicated team of nurses. Beginning in May 2015, 40 patients were assigned to the new pathway, and their outcomes were compared with those of 81 patients who took the normal course of care through the ICU.
The results were impressive. Patients on the new pathway left the hospital an average of two days sooner—8.9 days compared to 11.2 days. The 30-day readmission rate dropped from 13.6 percent to zero. Bypassing the ICU didn’t affect other outcomes either, such as surgical complications. The pathway is now standard procedure for free flap patients at Smilow.
Dr. Mehra sees several reasons for its success. Instead of staying bed-bound in the ICU for several days, patients are up and walking almost immediately on the 15th floor. Second, the nurses and care coordinators begin planning for the patient’s discharge on the first day instead of waiting until after the patient arrives from the ICU. “Patients are learning from day one how to manage their wounds and their tracheotomy tubes,” said Dr. Mehra. “A lot of readmissions are from a lack of education.” Aside from the obvious cost savings, cutting two days from a patient’s stay is medically significant. “Spending it ensures consistency of care and clear communication between nurses and physicians. Ms. Henderson also believes that having a dedicated team of nurses gives patients a psychological lift. “These surgeries can be disfiguring,” she said. “That causes a tremendous amount of stress and impairs their self esteem. So making a connection with the same people over and over gives a less time in the hospital reduces a patient’s exposure to hospital-acquired infection,” said Ms. Henderson, who put together the teams of nurses that made the pathway successful. She agrees with Dr. Mehra that early ambulation is key. “Getting patients out of bed, even one day sooner,” she said, “can ensure better outcomes by preventing pneumonia, blood clots, and deep vein thrombosis. All of these early interventions improve outcomes.”
Cutting two days from the stay also has psychological benefits for patients. “They are quite frustrated after surgery,” said Dr. Mehra. “Our patients are often slowly re-learning functions that most of us take for granted, such as speech and swallowing, they have many scars, and they just want to be at home with their families as they continue their recovery.”
Each patient is assigned a dedicated team of nurses, which Dr. Mehra and Ms. Henderson both cite as critical, because it ensures consistency of care and clear communication between nurses and physicians. Ms. Henderson also believes that having a dedicated team of nurses gives patients a psychological lift.
"These surgeries can be disfiguring." she said. "That causes a tremendous amount of stress and impairs their self-esteem. So making a connection with the same people over and over gives a patient a feeling of family and support, as opposed to having to reestablish a connection with someone different.”
To keep this pathway smooth takes a lot of skill, communication, and coordination. Ms. Henderson’s team of 35 nurses and 16 patient care associates received special training to handle the intensive care needed by free flap patients, especially in the first 24 hours when the tissue graft is taking hold and the patient’s head must remain relatively immobile. The patient’s room has to be fully furnished beforehand with all the special equipment necessary to start immediate care. The nurses also monitor the patient’s vital signs every hour rather than the usual four hours.
“It’s more work for the nurses on that floor,” said Dr. Mehra, “so there could be some reticence at doing a program like this. But everybody got together and made it happen, to make patient care better.”