RECONSTRUCTIVE Outcomes Article
Reduction of Pulmonary Complications and Hospital Length of Stay with a Clinical Care Pathway after Head and Neck Reconstruction Justin K. Yeung, M.D. Jonathan F. Dautremont, M.D. A. Robertson Harrop, M.D., M.Sc. Tiffany Asante Naushad Hirani, M.D. Steve C. Nakoneshny, B.Sc. Vim de Haas, M.D. David Mckenzie, M.D. T. Wayne Matthews, M.D. Shamir P. Chandarana, M.D., M.Sc. Christiaan Schrag, M.D. Joseph C. Dort, M.D., M.Sc. Calgary, Alberta, Canada
Background: Pulmonary complications are common after major head and neck oncologic surgery with microsurgical reconstruction and are associated with increased mortality and morbidity. Clinical care pathways are evidencebased tools that reduce unnecessary practice variation and ultimately improve patient outcomes. In this study, the authors evaluate the effectiveness of a comprehensive care pathway on reducing postoperative pulmonary complications and hospital length of stay in patients undergoing major head and neck carcinoma resection with free flap reconstruction. Methods: Fifty-five consecutive patients treated according to a prescribed postoperative clinical care pathway were compared to a historical cohort of patients treated before the implementation of the pathway. The incidence of pulmonary complications, hospital length of stay, and free flap survival were compared between the control and intervention groups. Results: Patients on the clinical care pathway had 32.5 percent fewer pulmonary complications (p < 0.0001) and 7.4 days’ shorter hospital length of stay (p = 0.0007) than patients not on the postoperative pathway. There was no significant difference in the rate of flap reoperation. Conclusions: A multidisciplinary, comprehensive, clinical care pathway for patients undergoing major head and neck surgery with microsurgical reconstruction is effective in reducing postoperative pulmonary complica tions and hospital length of stay. The postoperative pathway is safe in this patient population and should be considered for adoption into clinical practice. (Plast. Reconstr. Surg. 133: 1477, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
P
ostoperative pulmonary complications after major resection with microsurgical reconstruction for oral cancer defects are common and include pneumonia, pulmonary emboli, and atelectasis. Respiratory complication rates in head and neck patients have been variously reported at 10 to 47 percent.1–4 These complications lead to longer hospital stays and increased mortality4,5; one recent study reported a 12.8 From the Sections of Plastic and Reconstructive Surgery and Otolaryngology–Head and Neck Surgery, Department of Surgery, Bachelor of Health Sciences Program and the Ohlson Research Initiative, Faculty of Medicine, and the Department of Medicine, University of Calgary. Received for publication October 15, 2013; accepted December 9, 2013. The last two authors should be considered co-senior and co-corresponding authors on this project. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000217
ercent mortality rate in patients with postoperap tive pulmonary complications.4 Many risk factors for pulmonary complications such as age, smoking history, and alcohol consumption in this group of patients are not modifiable.5 Conversely, many aspects of postoperative care of these patients could be considered modifiable risk factors for development of pulmonary complications. As an example, we have previously shown a four-fold increase in pneumonia rate when patients were immobilized during the postoperative period for more than 4 days.6 Surgical teams must develop patient management strategies that optimize surgical outcomes and minimize medical complications. The postoperative course is complex, involving intensive care management and prolonged hospitalization. Disclosure: None of the authors has a financial interest in any of the products or devices mentioned in this article.
www.PRSJournal.com
1477
Plastic and Reconstructive Surgery • June 2014 Surgeons must lead a multidisciplinary care team including surgeons and intensivists, physiotherapists, occupational therapists, nutritionists, speech language pathologists, respiratory therapists, and the nursing team. A clinical pathway is an evidence-based and diagnosis-specific treatment algorithm designed by compiling input from multiple health care disciplines. The pathway defines health care milestones that must be met to provide a targeted patient population with high-quality care. The goal of the pathway is to provide the essential aspects of care by multiple providers in the appropriate sequence to deliver safer and more effective care.7 These clinical pathways also ensure that the necessary steps to achieve these important care milestones are not delayed or forgotten so that adverse events may be avoided. Clinical pathways lead to improved physical functioning and enhanced patient satisfaction.8 A well-designed pathway combines best practices and reduces practice variations. One criticism of clinical care pathways is that they are rarely evidence based.8,9 In contrast, studies of clinical care pathways have demonstrated improvements in length of stay and associated costs; and the resource savings are persistent over time.10 As such, clinical pathways are quickly becoming adopted in many institutions around the world.
Although much of the research on care pathways highlights efficiency, there are to date no studies in head and neck cancer patients demonstrating decreased rates of complications. Our goal in this study was to design and implement a care pathway for patients undergoing major head and neck cancer resection and free flap reconstruction. In particular, this study focused on the impact of a clinical pathway on postoperative pulmonary complications and hospital length of stay. Because poorly designed pathways can be potentially harmful, we were also interested in determining whether the pathway had an impact on the rates of flap reoperation and failure.
PATIENTS AND METHODS Study Population and Data Collection One hundred fifty-six patients with head and neck carcinoma underwent major ablative surgery with free flap reconstruction at our tertiary academic medical center in Calgary, Alberta, Canada, during the study period (Fig. 1). Patients older than 18 years undergoing ablation with tracheotomy and free flap reconstruction were eligible for inclusion. A team of experienced head and neck/reconstructive surgeons operated on all study patients. The surgical team remained similar throughout the entire study period.
Fig. 1. Study Consolidated Standards of Reporting Trials diagram.
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Volume 133, Number 6 • Clinical Care Pathways in Surgery The patient cohort comprised two groups: a historical cohort (nonpathway cohort) of 100 consecutive patients operated on between 2005 and 2009, and a group consisting of 56 consecutive patients (pathway cohort) who were seen and treated between February of 2011 and April of 2012 (Fig. 1). Clinical characteristics were collected retrospectively by reviewing hospital, clinic, and electronic medical records. Patients in the nonpathway cohort were managed according to the usual preferences of the responsible surgeon. Patients in the pathway cohort were managed using a standardized perioperative head and neck care pathway. Safe progression of care was evaluated by the surgical team on a daily basis, and deviations from the pathway were documented. Comorbidities and risk factors (age, prior pulmonary/cardiac disease, diabetes, preoperative albumin, hypertension, and smoking and alcohol history) were documented based on the preoperative medical and anesthesia consultations that took place for all patients. Intraoperative data (e.g., intraoperative complications, operative time) were collected by reviewing the operating room record and the operating room reports. Postoperative data were collected from the intensive care unit database, the hospital electronic medical record, and the hospital charts. Clinical outcome parameters such as intensive care unit length of stay, time on a ventilator, readmission to the intensive care unit, time of mobilization, date of tracheotomy decannulation, and overall length of stay were collected. Pulmonary complications occurring during a 14-day postsurgical window were diagnosed based on a combination of clinical signs and chest radiographs. Pneumonia was defined as either chest radiograph suggestive of pneumonia or positive sputum culture plus two of the following: increased oxygen requirement, fever, and increased white blood cell count.11 Atelectasis was defined as increased oxygen demand and chest radiographic findings. All equivocal results were reviewed on a case-by-case basis with a p ulmonologist (N.H.). Clinical Pathway Development A team of head and neck surgeons, reconstructive surgeons, nurses, and other allied health professionals developed the head and neck clinical pathway. The pathway was developed in an iterative fashion and used a combination of literature review/published evidence, practitioner experience, and consensus to arrive at a consistent approach to patient care. During the development phase, pathway drafts were circulated
among team members and feedback was incorporated into each successive revision. The final draft pathway was then tested in several patients and further refinements were made before the pathway was put into clinical use. These “test patients” were not included in the data analysis. The final pathway is shown in Table 1. Providers (i.e., staff surgeons, surgical residents, nurses, allied health professionals) were all educated on the nature and purpose of the pathway before its implementation, and incoming patients and their families were also informed about the clinical pathway. Hard copies of the pathway were created and posted in the patients’ rooms to facilitate communication between patients, families, and members of the care team. Finally, an electronic version of the pathway was created and incorporated into the hospital computerized order entry system. Statistical Analysis Categorical outcome variables were compared using either a chi-square or Fisher’s exact test as appropriate. Continuous variables were compared using a nonparametric test for independent continuous outcomes (Wilcoxon rank sum test). Statistical analyses were performed using Stata version 11.2 (Stata Corp, College Station, Texas). Clinical data were collected and stored in a head and neck research database (Otobase). This study was reviewed and approved by the Conjoint Health Research Ethics Board of the University of Calgary.
RESULTS Fifty-six consecutive patients were enrolled in the pathway; however, one was excluded for failing to meet the inclusion criteria (Fig. 1). Data were collected prospectively. The historical control group included 100 consecutive patients for head and neck cancer resection between January of 2005 and December of 2009. Thirty-nine patients were excluded because of incomplete data or because surgery included nonmicrovascular reconstruction. Charts were reviewed for the remaining 61 patients. Table 2 summarizes the comparison between patients in the pathway group and the nonpathway group. There was no difference in patient age or comorbidities. Free flaps performed in the two cohorts were comparable (Table 3). There were significantly fewer pulmonary complications in the pathway group (30 percent versus 63 percent; p < 0.0001), representing an absolute reduction of 33 percent. Univariate analyses were performed on possible confounders such
1479
Plastic and Reconstructive Surgery • June 2014 Table 1. Head and Neck Construction Clinical Pathway Day of Surgery
POD-1
Trachea
Sterile for 72 hr Cuff deflated by RT upon arrival to unit 30/31
Flap donor
Donor remains dressed for 5 days
Skin graft donor Flap checks
Every hour for 48 hr
Remove outer covering over donor-site dressing →
POD-2
POD-3
POD-4
Routine trachea care protocol
Every 2 hr for 48 hr
→
Every 4 hr for 48 hr
Drains
Laboratory
Vital signs Suture care
Every hour for 48 hr
IV therapy/ antibiotics
Pain management CIWA Activity Nutrition
CBC, lytes, CA, Phos, Mg, Cr, glucose INR (usually completed in ICU prior to transfer) →
CBC, lytes, CA, Phos, Mg, Cr, glucose INR Every 2 hr for 48 hr
→
PCA
IV rate should be adjusted according to tube feed rate to accommodate TFI order PCA
Antibiotics should be discontinued 3 doses postop TFI ordered PCA
PCA
Start if appropriate Bedrest NPO → trickle Feed
Tube feed starts (24 hr)
Elimination Physiotherapy
Chest physiotherapy ordered on all patients
Miscellaneous
PT, dietician, respiratory, social work, transition services consults
CBC, lytes, CA, Phos, Mg, Cr, glucose INR Every 4 hr for 48 hr
Sitting in bed or on Activity as tolerated bedside
Discontinue Foley; simple bowel routine ordered
Cancer center OT consult for splint nurse sees patient on POD 5 - consult regarding followto speech up appointments pathology
ICU, intensive care unit; trach, tracheostomy; POD, postoperative day; CBC, complete blood count; CA, calcium; Phos, phosphate; Cr, creatinine; Mg, magnesium; INR, international normalized ratio; IV, intravenous; TFI, total fluid intake; PCA, patient-controlled analgesia; D/C, discontinue; NG, nasogastric; CIWA, Clinical Institute Withdrawal Assessment; NPO, nothing by mouth; PT, physical therapist; TBCC, Tom Baker Cancer Centre; OT, occupational therapist; H/N, head and neck.
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Volume 133, Number 6 • Clinical Care Pathways in Surgery
POD-5 Change trachea tube or specific documentation noted by MD regarding plan for trachea Dressing down daily dressings started; OT to splint Staples removed → Discontinue drains (if output appropriate 25 cc or less in 24 hr) CBC, lytes, CA, Phos →
IV saline locked
POD-6 Start corking trial
POD-7
POD-8
Day of Discharge POD - 10
Assess readiness for decannulation
Discharge Goals Trachea out or respiratory checklist completed and at-home trachea teaching completed
Dressings changed to Glaxal if healed
Daily dressing change – Glaxal base or home care orders for daily dressing changes Site care education
Discontinue flap checks (remove blue suture)
CBC, lytes, CA, Phos, Mg, Cr, glucose, INR Every 8 hr Facial sutures to be removed (lip and chin)
Neck sutures to be removed
D/C PCA - meds given via nasogastric
Oral/NG pain medications Independently mobile or at baseline
Patient should be ambulating Start bolus feeds
Early G-tube or discharge teaching for home feeds
Physiotherapy to start full ROM
Fees booked Tolerating at least a full (for 10-14 days fluids diet; if going postop) home with tube feed home enteral teaching completed
Head and neck physiotherapy prescription to be ordered in preparation for discharge and diagrams provided
1481
Plastic and Reconstructive Surgery • June 2014 Table 2. Descriptive Analysis of Patient and Perioperative Variables and Pathway Characteristic No. of patients Age, yr Sex M F ASA class 1 2 3 4 No ASA class recorded Alcohol history Smokers Albumin, g/liter COPD Diabetes mellitus Operative time, hr ICU Time on ventilator, hr Length of ICU stay, hr Ward Mobilization, days Tracheostomy decannulation, postoperative day Hospital length of stay, days Complications Pulmonary complications Flap reoperation* Flap failure
Control
Pathway
61 62.6 ± 13.4
55 62.5 ± 12.1
28 23
37 18
4 24 30 2 1 37 36 22.4 ± 4.0 13 3 13.2 ± 0.2
3 24 24 0 4 41 35 24.3 ± 4.3 13 5 11.6 ± 0.2
NS NS NS NS NS NS
Reduction of Pulmonary Complications and Hospital Length of Stay with a Clinical Care Pathway after Head and Neck Reconstruction Justin K. Yeung, M.D. Jonathan F. Dautremont, M.D. A. Robertson Harrop, M.D., M.Sc. Tiffany Asante Naushad Hirani, M.D. Steve C. Nakoneshny, B.Sc. Vim de Haas, M.D. David Mckenzie, M.D. T. Wayne Matthews, M.D. Shamir P. Chandarana, M.D., M.Sc. Christiaan Schrag, M.D. Joseph C. Dort, M.D., M.Sc. Calgary, Alberta, Canada
Background: Pulmonary complications are common after major head and neck oncologic surgery with microsurgical reconstruction and are associated with increased mortality and morbidity. Clinical care pathways are evidencebased tools that reduce unnecessary practice variation and ultimately improve patient outcomes. In this study, the authors evaluate the effectiveness of a comprehensive care pathway on reducing postoperative pulmonary complications and hospital length of stay in patients undergoing major head and neck carcinoma resection with free flap reconstruction. Methods: Fifty-five consecutive patients treated according to a prescribed postoperative clinical care pathway were compared to a historical cohort of patients treated before the implementation of the pathway. The incidence of pulmonary complications, hospital length of stay, and free flap survival were compared between the control and intervention groups. Results: Patients on the clinical care pathway had 32.5 percent fewer pulmonary complications (p < 0.0001) and 7.4 days’ shorter hospital length of stay (p = 0.0007) than patients not on the postoperative pathway. There was no significant difference in the rate of flap reoperation. Conclusions: A multidisciplinary, comprehensive, clinical care pathway for patients undergoing major head and neck surgery with microsurgical reconstruction is effective in reducing postoperative pulmonary complica tions and hospital length of stay. The postoperative pathway is safe in this patient population and should be considered for adoption into clinical practice. (Plast. Reconstr. Surg. 133: 1477, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
P
ostoperative pulmonary complications after major resection with microsurgical reconstruction for oral cancer defects are common and include pneumonia, pulmonary emboli, and atelectasis. Respiratory complication rates in head and neck patients have been variously reported at 10 to 47 percent.1–4 These complications lead to longer hospital stays and increased mortality4,5; one recent study reported a 12.8 From the Sections of Plastic and Reconstructive Surgery and Otolaryngology–Head and Neck Surgery, Department of Surgery, Bachelor of Health Sciences Program and the Ohlson Research Initiative, Faculty of Medicine, and the Department of Medicine, University of Calgary. Received for publication October 15, 2013; accepted December 9, 2013. The last two authors should be considered co-senior and co-corresponding authors on this project. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000217
ercent mortality rate in patients with postoperap tive pulmonary complications.4 Many risk factors for pulmonary complications such as age, smoking history, and alcohol consumption in this group of patients are not modifiable.5 Conversely, many aspects of postoperative care of these patients could be considered modifiable risk factors for development of pulmonary complications. As an example, we have previously shown a four-fold increase in pneumonia rate when patients were immobilized during the postoperative period for more than 4 days.6 Surgical teams must develop patient management strategies that optimize surgical outcomes and minimize medical complications. The postoperative course is complex, involving intensive care management and prolonged hospitalization. Disclosure: None of the authors has a financial interest in any of the products or devices mentioned in this article.
www.PRSJournal.com
1477
Plastic and Reconstructive Surgery • June 2014 Surgeons must lead a multidisciplinary care team including surgeons and intensivists, physiotherapists, occupational therapists, nutritionists, speech language pathologists, respiratory therapists, and the nursing team. A clinical pathway is an evidence-based and diagnosis-specific treatment algorithm designed by compiling input from multiple health care disciplines. The pathway defines health care milestones that must be met to provide a targeted patient population with high-quality care. The goal of the pathway is to provide the essential aspects of care by multiple providers in the appropriate sequence to deliver safer and more effective care.7 These clinical pathways also ensure that the necessary steps to achieve these important care milestones are not delayed or forgotten so that adverse events may be avoided. Clinical pathways lead to improved physical functioning and enhanced patient satisfaction.8 A well-designed pathway combines best practices and reduces practice variations. One criticism of clinical care pathways is that they are rarely evidence based.8,9 In contrast, studies of clinical care pathways have demonstrated improvements in length of stay and associated costs; and the resource savings are persistent over time.10 As such, clinical pathways are quickly becoming adopted in many institutions around the world.
Although much of the research on care pathways highlights efficiency, there are to date no studies in head and neck cancer patients demonstrating decreased rates of complications. Our goal in this study was to design and implement a care pathway for patients undergoing major head and neck cancer resection and free flap reconstruction. In particular, this study focused on the impact of a clinical pathway on postoperative pulmonary complications and hospital length of stay. Because poorly designed pathways can be potentially harmful, we were also interested in determining whether the pathway had an impact on the rates of flap reoperation and failure.
PATIENTS AND METHODS Study Population and Data Collection One hundred fifty-six patients with head and neck carcinoma underwent major ablative surgery with free flap reconstruction at our tertiary academic medical center in Calgary, Alberta, Canada, during the study period (Fig. 1). Patients older than 18 years undergoing ablation with tracheotomy and free flap reconstruction were eligible for inclusion. A team of experienced head and neck/reconstructive surgeons operated on all study patients. The surgical team remained similar throughout the entire study period.
Fig. 1. Study Consolidated Standards of Reporting Trials diagram.
1478
Volume 133, Number 6 • Clinical Care Pathways in Surgery The patient cohort comprised two groups: a historical cohort (nonpathway cohort) of 100 consecutive patients operated on between 2005 and 2009, and a group consisting of 56 consecutive patients (pathway cohort) who were seen and treated between February of 2011 and April of 2012 (Fig. 1). Clinical characteristics were collected retrospectively by reviewing hospital, clinic, and electronic medical records. Patients in the nonpathway cohort were managed according to the usual preferences of the responsible surgeon. Patients in the pathway cohort were managed using a standardized perioperative head and neck care pathway. Safe progression of care was evaluated by the surgical team on a daily basis, and deviations from the pathway were documented. Comorbidities and risk factors (age, prior pulmonary/cardiac disease, diabetes, preoperative albumin, hypertension, and smoking and alcohol history) were documented based on the preoperative medical and anesthesia consultations that took place for all patients. Intraoperative data (e.g., intraoperative complications, operative time) were collected by reviewing the operating room record and the operating room reports. Postoperative data were collected from the intensive care unit database, the hospital electronic medical record, and the hospital charts. Clinical outcome parameters such as intensive care unit length of stay, time on a ventilator, readmission to the intensive care unit, time of mobilization, date of tracheotomy decannulation, and overall length of stay were collected. Pulmonary complications occurring during a 14-day postsurgical window were diagnosed based on a combination of clinical signs and chest radiographs. Pneumonia was defined as either chest radiograph suggestive of pneumonia or positive sputum culture plus two of the following: increased oxygen requirement, fever, and increased white blood cell count.11 Atelectasis was defined as increased oxygen demand and chest radiographic findings. All equivocal results were reviewed on a case-by-case basis with a p ulmonologist (N.H.). Clinical Pathway Development A team of head and neck surgeons, reconstructive surgeons, nurses, and other allied health professionals developed the head and neck clinical pathway. The pathway was developed in an iterative fashion and used a combination of literature review/published evidence, practitioner experience, and consensus to arrive at a consistent approach to patient care. During the development phase, pathway drafts were circulated
among team members and feedback was incorporated into each successive revision. The final draft pathway was then tested in several patients and further refinements were made before the pathway was put into clinical use. These “test patients” were not included in the data analysis. The final pathway is shown in Table 1. Providers (i.e., staff surgeons, surgical residents, nurses, allied health professionals) were all educated on the nature and purpose of the pathway before its implementation, and incoming patients and their families were also informed about the clinical pathway. Hard copies of the pathway were created and posted in the patients’ rooms to facilitate communication between patients, families, and members of the care team. Finally, an electronic version of the pathway was created and incorporated into the hospital computerized order entry system. Statistical Analysis Categorical outcome variables were compared using either a chi-square or Fisher’s exact test as appropriate. Continuous variables were compared using a nonparametric test for independent continuous outcomes (Wilcoxon rank sum test). Statistical analyses were performed using Stata version 11.2 (Stata Corp, College Station, Texas). Clinical data were collected and stored in a head and neck research database (Otobase). This study was reviewed and approved by the Conjoint Health Research Ethics Board of the University of Calgary.
RESULTS Fifty-six consecutive patients were enrolled in the pathway; however, one was excluded for failing to meet the inclusion criteria (Fig. 1). Data were collected prospectively. The historical control group included 100 consecutive patients for head and neck cancer resection between January of 2005 and December of 2009. Thirty-nine patients were excluded because of incomplete data or because surgery included nonmicrovascular reconstruction. Charts were reviewed for the remaining 61 patients. Table 2 summarizes the comparison between patients in the pathway group and the nonpathway group. There was no difference in patient age or comorbidities. Free flaps performed in the two cohorts were comparable (Table 3). There were significantly fewer pulmonary complications in the pathway group (30 percent versus 63 percent; p < 0.0001), representing an absolute reduction of 33 percent. Univariate analyses were performed on possible confounders such
1479
Plastic and Reconstructive Surgery • June 2014 Table 1. Head and Neck Construction Clinical Pathway Day of Surgery
POD-1
Trachea
Sterile for 72 hr Cuff deflated by RT upon arrival to unit 30/31
Flap donor
Donor remains dressed for 5 days
Skin graft donor Flap checks
Every hour for 48 hr
Remove outer covering over donor-site dressing →
POD-2
POD-3
POD-4
Routine trachea care protocol
Every 2 hr for 48 hr
→
Every 4 hr for 48 hr
Drains
Laboratory
Vital signs Suture care
Every hour for 48 hr
IV therapy/ antibiotics
Pain management CIWA Activity Nutrition
CBC, lytes, CA, Phos, Mg, Cr, glucose INR (usually completed in ICU prior to transfer) →
CBC, lytes, CA, Phos, Mg, Cr, glucose INR Every 2 hr for 48 hr
→
PCA
IV rate should be adjusted according to tube feed rate to accommodate TFI order PCA
Antibiotics should be discontinued 3 doses postop TFI ordered PCA
PCA
Start if appropriate Bedrest NPO → trickle Feed
Tube feed starts (24 hr)
Elimination Physiotherapy
Chest physiotherapy ordered on all patients
Miscellaneous
PT, dietician, respiratory, social work, transition services consults
CBC, lytes, CA, Phos, Mg, Cr, glucose INR Every 4 hr for 48 hr
Sitting in bed or on Activity as tolerated bedside
Discontinue Foley; simple bowel routine ordered
Cancer center OT consult for splint nurse sees patient on POD 5 - consult regarding followto speech up appointments pathology
ICU, intensive care unit; trach, tracheostomy; POD, postoperative day; CBC, complete blood count; CA, calcium; Phos, phosphate; Cr, creatinine; Mg, magnesium; INR, international normalized ratio; IV, intravenous; TFI, total fluid intake; PCA, patient-controlled analgesia; D/C, discontinue; NG, nasogastric; CIWA, Clinical Institute Withdrawal Assessment; NPO, nothing by mouth; PT, physical therapist; TBCC, Tom Baker Cancer Centre; OT, occupational therapist; H/N, head and neck.
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Volume 133, Number 6 • Clinical Care Pathways in Surgery
POD-5 Change trachea tube or specific documentation noted by MD regarding plan for trachea Dressing down daily dressings started; OT to splint Staples removed → Discontinue drains (if output appropriate 25 cc or less in 24 hr) CBC, lytes, CA, Phos →
IV saline locked
POD-6 Start corking trial
POD-7
POD-8
Day of Discharge POD - 10
Assess readiness for decannulation
Discharge Goals Trachea out or respiratory checklist completed and at-home trachea teaching completed
Dressings changed to Glaxal if healed
Daily dressing change – Glaxal base or home care orders for daily dressing changes Site care education
Discontinue flap checks (remove blue suture)
CBC, lytes, CA, Phos, Mg, Cr, glucose, INR Every 8 hr Facial sutures to be removed (lip and chin)
Neck sutures to be removed
D/C PCA - meds given via nasogastric
Oral/NG pain medications Independently mobile or at baseline
Patient should be ambulating Start bolus feeds
Early G-tube or discharge teaching for home feeds
Physiotherapy to start full ROM
Fees booked Tolerating at least a full (for 10-14 days fluids diet; if going postop) home with tube feed home enteral teaching completed
Head and neck physiotherapy prescription to be ordered in preparation for discharge and diagrams provided
1481
Plastic and Reconstructive Surgery • June 2014 Table 2. Descriptive Analysis of Patient and Perioperative Variables and Pathway Characteristic No. of patients Age, yr Sex M F ASA class 1 2 3 4 No ASA class recorded Alcohol history Smokers Albumin, g/liter COPD Diabetes mellitus Operative time, hr ICU Time on ventilator, hr Length of ICU stay, hr Ward Mobilization, days Tracheostomy decannulation, postoperative day Hospital length of stay, days Complications Pulmonary complications Flap reoperation* Flap failure
Control
Pathway
61 62.6 ± 13.4
55 62.5 ± 12.1
28 23
37 18
4 24 30 2 1 37 36 22.4 ± 4.0 13 3 13.2 ± 0.2
3 24 24 0 4 41 35 24.3 ± 4.3 13 5 11.6 ± 0.2
NS NS NS NS NS NS
