The impact of a quality management program for patients undergoing head and neck resection with free-flap reconstruction: longitudinal study examining sustainability

Abstract

Background: Care pathways (CPs) are helpful in reducing unwanted variation in clinical care. Most studies of CPs show they improve clinical outcomes but there is little known about the long-term impact of CPs as part of a sustained quality management program. Head and neck (HN) surgery with free flap reconstruction is complex, time-consuming and expensive. Complications are common and therefore CPs applied to this patient population are the focus of this paper. In this paper we report outcomes from a 9 year experience designing and using CPs in the management of patients undergoing major head and neck resection with free flap reconstruction. Methods: The Calgary quality management program and CP design is described the accompanying article. Data from CP managed patients undergoing major HN surgery were prospectively collected and compared to a baseline cohort of patients managed with standard care. Data were retrospectively analyzed and intergroup comparisons were made. Results: Mobilization, decannulation time and hospital length of stay were significantly improved in pathwaymanaged patients (p = 0.001). Trend analysis showed sustained improvement in key performance indicators including complications. Return to the OR, primarily to assess a compromised flap, is increasing. Conclusions: Care pathways when deployed as part of an ongoing quality management program are associated with improved clinical outcomes in this complex group of patients.

Efficacy of Multimodal Analgesia for Postoperative Pain Management in Head and Neck Cancer Patients

“…Two patient groups were compared. A pre-MMA cohort that included patients who underwent surgery between January 2015–December 2015 and were managed using the Calgary Head and Neck Enhanced Recovery Program (CHERP) protocol [ 4 , 17 , 18 ]. The MMA cohort included all patients who underwent surgery between December 2017–June 2019 and received the CHERP protocol plus additional ERAS elements including treatment with MMA.…”

Wearable activity trackers and mobilization after major head and neck cancer surgery: You can't improve what you don't measure

“…Still, after HNC surgery, it is strongly recommended that patients are mobilized within 24 hours if possible 5 . Established and long-term HNC ERPs have shown consistent reductions in the time to mobilization that occurred alongside a reduction in pulmonary complications and hospital length of stay (LOS) 4,7 . Unfortunately, evidence for an association between improved mobilization and better outcomes is limited because early mobilization is only a single care element within an ERP incorporating many care elements.…”

“…To date, mobilization after major HNC surgery has been reported as the time to mobilization, i.e. the interval between the date of surgery and the date of the initial meaningful mobilization 4,8 . In the Calgary Head and Neck Enhanced Recovery Program, the median time to mobilization has improved to 2 days (interquartile range 1-3 days) 4 .…”

“…the interval between the date of surgery and the date of the initial meaningful mobilization 4,8 . In the Calgary Head and Neck Enhanced Recovery Program, the median time to mobilization has improved to 2 days (interquartile range 1-3 days) 4 . A dedicated research nurse collects mobilization data from the hospital electronic health record, which records when the patient was out of bed/up in chair/ambulatory.…”

“…Two-thirds of patients will have at least one surgical or medical complication, with most occurring on postoperative day (POD) 1-4 2 . To ensure the best possible patient outcomes, evidence-based HNC-specific enhanced recovery pathways (ERPs) that detail perioperative care processes and timelines have been implemented [3][4][5] . The goals of ERPs are to improve the quality of care and fast-track postoperative recovery.…”