A Clinical Care Pathway to Reduce ICU Usage in Head and Neck Microvascular Reconstruction

Abstract

Objective To design and implement a postoperative clinical care pathway designed to reduce intensive care usage on length of stay, readmission rates, and surgical complications in head and neck free flap patients. Methods A postoperative clinical care pathway detailing timelines for patient care was developed by a multispecialty team. In total, 108 matched patients receiving free tissue transfer for reconstruction of head and neck defects in the year before (prepathway), year after (early pathway), and second year after (late pathway) pathway implementation were compared based on postoperative length of stay, 30-day readmission rate, intensive care unit (ICU) admission, and rates of medical/surgical complications. Results Median length of stay decreased from 10 to 7.5 and 7 days in the pre-, early, and late-pathway groups, respectively ( P = .012). Readmission rate decreased from 16% in the prepathway group to 0% and 3% in the early and late-pathway groups. The number of patients admitted to the ICU postoperatively decreased from 100% to 36% and 6% in the pre-, early, and late-pathway groups, respectively ( P = .025). The rates of surgical and medical complications were equivalent. Discussion This pathway effectively reduced ICU admission, length of stay, and readmission rates, without increasing postoperative complications. These outcomes were sustainable over 2 years. Implications for Practice Free flap patients may not require routine ICU admission and may be taken off ventilatory support in the operating room. This effectively reduces costly resource use in this patient population. Similar pathways could be introduced at other institutions.

The Early Effects of Coronavirus Disease-2019 on Head and Neck Oncology and Microvascular Reconstruction Practice: A National Survey of Oral and Maxillofacial Surgeons Enrolled in the Head and Neck Special Interest Group

“…Among free flap surgeons, 88.9% of surgeons admit patients with head and neck oncology with FMTT to the ICU for an average of 2.4 to 3 days, 29 , 30 slightly less than that of our survey (90%) Figure 3 . An ICU stay is proposed to provide many advantages, high nurse: patient ratios ranging from 1:1 to 1:2/per patient, constant flap monitoring of flap color, trigger, pinprick, and doppler assessment to detect early signs of vascular compromise something that occurs between 5 and 10%.…”

“… 33 These findings support other retrospective studies that compared ICU postoperative stay with the step-down unit and were integrated into many clinical care pathways but frequently demonstrate similar or better endpoints in the step-down unit group. 29 , 34

Figure 3 Postoperative ICU admission of free microvascular tissue transfer patients.

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Immediate postoperative care on high dependency unit or ward following microvascular free tissue transfer: lessons learnt from a change in practice imposed during the COVID-19 pandemic

“…Although the literature suggests an average length of stay on HDU of 2-3 days [7] , [8] , our patients typically stay just one night post-operatively. Most patients developing post-operative medical complications do so several days later and it would be reasonable to postulate that staying less than 24 hours in HDU should not impact on this.…”

The Impact of Enhanced Recovery Pathways in Head and Neck Surgery: A Systematic Review

“…Across these five studies there was an average reduction of LOS in ITU of 3.4 days for those on ERAS pathways. Jandali, et al [11] observed no difference in ITU LOS between the ERAS and control cohorts and Kiong, et al [12] and Morse, et al [13] did not report on ITU LOS; however, the authors did record fewer routine post-op admissions to ITU for those on ERAS pathways.…”

“…pneumonia, delirium, wound infections and flap complications, including flap complications requiring return to theatre) in comparison to patients on 'traditional' or historic pathways. Bertelson, et al [6] recorded 30-day readmission to hospital rates of 6.4% ERAS vs. 13.1% (p = 0.828) of the control cohort, Morse, et al [13], Bater, et al [15], and Dautremont, et al [17] also reported no difference in complication rates, and their findings were not statistically significant. Comparatively, Dort, et al [18] demonstrated a statistically significant reduction in post-operative pneumonia and delirium and Yeung, et al [19] identified a significant reduction in pulmonary complications (30% in ERAS cohort vs. 63% in the control (p = 0.0001)) which were attributed to early extubation and avoidance of prolonged mechanical ventilation.…”