Cara M. Henderson, RN, BSN, CMSRN, is patient service manager, Smilow Cancer Hospital, Yale New Haven Health, New Haven, Connecticut.
Tracy Carafeno, MS, RN, CNML,
is director of nursing, Patient Services, Smilow Cancer Hospital, Yale New Haven Health, New Haven, Connecticut.
At Smilow Cancer Hospital, a National Cancer Institute–designated comprehensive cancer center, patients undergoing free tissue flaps and composite resections for cancers of the head and neck historically had a 24- to 48-hour postoperative stay in the surgical intensive care unit (SICU). After that time, they were transferred to the surgical oncology inpatient unit for the remainder of the postoperative period. Surgical oncology is a 28-bed unit specializing in postoperative care for patients who have undergone oncologic surgery. Although head and neck reconstruction is an extensive surgical procedure, many of the patients require intensive care unit (ICU)-level care solely for frequent monitoring of vital signs and hourly assessment of flap perfusion. Therefore, specialized nursing care on the surgical oncology unit created an opportunity to bypass the SICU and transition patients directly from the post–anesthesia care unit (PACU) to the surgical oncology unit.
The goal of this practice change was to reduce length of stay, postoperative complications, and readmission rates of patients with head and neck cancer undergoing free flap surgery. Bypassing the ICU could potentially decrease the length of stay for these patients by mobilizing them earlier. A review of the literature strongly suggested that early postoperative ambulation improves patient outcomes and reduces length of stay.1
An interdisciplinary team was convened to establish criteria for patient selection. Patients with minimal medical comorbidities undergoing free tissue flap reconstructive surgery and/or composite resection were chosen as candidates to bypass the SICU and receive all postoperative care on the surgical oncology unit. A standard of nursing care was established by creating a pathway for each of the postoperative days, to outline the expected patient milestones. Order sets and electronic health record optimizations were executed prior to implementation in order to standardize care. The reconstructive surgeon educated unit staff on the free tissue flap pathway, including postoperative care. Nurses observed patient care in the SICU prior to caring for their first patient. A standardized handoff from PACU to surgical oncology was created and education provided to the PACU prior to the first patient in May of 2015.
Data collected over a 2-year period included length of stay and postoperative complications, such as return to the ICU, return to the operating room, and rate of readmission. Three time periods—pre-pathway, early pathway (first year after implementation), and the current state—were measured. The length of stay was reduced by 3 hospital days and ICU utilization decreased by 94%. We also experienced tremendous reduction in the rate of readmissions: from 16% to 3%. Reduction in length of stay has a significant impact on direct care costs and ensures appropriate ICU bed utilization for patients who require life-sustaining measures. Shortened length of stay reduces the incidence of hospital-acquired infections and improves patient outcomes. Overall, the change in practice improved the teamwork on the unit as well as interdisciplinary communication. Future development of guidelines for patient selection to bypass the SICU will be based on data review of those patients who required ICU transfer from surgical oncology or returned to the operating room.
We are now standardizing the tracheostomy policy across the system and implementing a process for safe transport of patients with artificial airways throughout the hospital, whether that be from unit to unit or from unit to procedural area. A task force created a travel kit for emergent patient events during travel, and the concept is now being modeled at the institutional level.
This initiative not only demonstrated a reduction in length of stay, ICU utilization, and rate of readmission, but it also improved the interdisciplinary teams’ approach to patient care. Interdisciplinary collaboration improved teamwork on the unit, in particular among physicians and nurses. The physician team reported that it relies heavily on the nurses’ assessment of the patient’s condition and have included them on morning rounds to provide input on a patient’s overall progress. As patient acuity increases and the hospital continues to care for patients’ complex healthcare needs, there are opportunities to model this approach within other patient populations.
- Oliveria RA, Guatura GMGBDS, Peniche ACG, Costa ALS, Poveda VB. An integrative review of postoperative accelerated recovery protocols. AORN J. 2017;106(4):324-330.e5. doi: 10.1016/j.aorn.2017.08.005.