An interprofessional QI project engages patients and enhances communication.

Deep inferior epigastric perforator (DIEP) flap procedures use a patient’s own blood vessels, skin, and fat from the lower abdomen to reconstruct a breast after mastectomy. In 2018, at an inpatient 514-bed oncology hospital, the volume of patients undergoing a DIEP flap procedure had increased by 30% in 2 years, with an average 3- to 4-day length of stay.

These patients typically went to an inpatient surgical unit with nurses who have specialty training in DIEP flap recovery. Increasing demand and overall hospital census, which resulted in a lack of beds, led to many patients overnighting in the post-anesthesia unit (PACU). To decrease this occurrence, an interprofessional team of plastic surgeons, anesthesiologists, nursing teams (from operating room, PACU, inpatient, and outpatient units), and perioperative support services personnel worked to improve and innovate practice. This rapid-cycle quality improvement (QI) project aimed to develop and implement a surgical pathway across the care continuum to safely reduce patient length of stay to 1 day.

Project focus

Physical recovery and the range of education patients must comprehend and demonstrate before discharge factors into length of stay after DIEP flap surgery. At the end of 2020, the interprofessional team launched its QI project with a focus on improving surgery efficiency, enhancing patient recovery, and creating alignment across the care continuum to decrease length of stay.

When reviewing areas of opportunity for improvement, the team identified two inefficiencies: poor care coordination and lack of pa­tient engagement in their recovery. Although this surgery doesn’t meet criteria for the organization’s enhanced recovery after surgery (ERAS) program, the team wanted to correlate the lessons learned from those programs. According to Nelson and colleagues, the benefits of an ERAS pathway include reduced length of stay, decreased costs, less opioid use, and increased patient satisfaction.

Roadmap to recovery and engagement

Prior to this QI project, the outpatient and inpatient teams performed duplicate work, which overwhelmed patients and resulted in disengagement. Patients shared these concerns with nurses and nursing leadership. The project team saw an opportunity to identify and improve outpatient and inpatient nurse workflows and responsibilities.

Interactive checklists and trackers

The team began by targeting patient education and engagement. Nursing staff recommended a novel approach to enhance patient engagement—transparent plans (roadmaps) visible to patients and caregivers throughout their stay. The nursing teams created separate outpatient and inpatient My Recovery Roadmaps to prepare patients for what to expect before and after surgery.

The roadmaps include interactive checklists that account for preoperative and postoperative days with specific tasks to improve communication. These visual aids collaboratively engage patients with goals and milestones, which they must accomplish for a successful discharge; they also make nurses aware of completed milestones and those they must address with the patient before discharge. The road­maps also include preoperative education; patient surgical restrictions; Jackson-Pratt (JP) drain care; subcutaneous injection to prevent postoperative microvascular clotting; discharge education; and ambulation goals, including physical therapy consults.

Before surgery. At the preoperative visit, nurses review each milestone on the preoperative roadmap, focusing on specific education regarding JP drains and subcutaneous injections in addition to important general surgical preoperative instructions (for example, nothing by mouth, showering before surgery, and medications to avoid). To increase engagement and centralize patient access, nurses use the organization’s online patient portal to upload the roadmaps along with educational documents about the surgery.

In the PACU. The interprofessional team revised the inpatient order sets to support and align with the 2-day length of stay pathway, including changes to urinary catheter removal, flap monitoring cadence, mobility goals, and nursing education. Previously, a patient’s catheter wasn’t discontinued until postoperative Day 1. The new roadmap requires catheter discontinuation before admission to the inpatient unit, a major culture change. According to Banks and colleagues, early catheter removal promotes early ambulation.

The previous flap monitoring cadence prevented many patients from transferring from the PACU to the inpatient unit. According to Shen and colleagues, the cadence (every 15 minutes for 1 hour, every 30 minutes for 2 hours, then every hour until transfer to the in-patient unit) wasn’t evidence-based. The inpatient unit can continue monitoring flaps every hour for an additional 24 hours. This cadence allows nurses to perform close monitoring postoperatively, which ensures better outcomes and prompt detection of vascular compromise. According to the organization’s internal data, early vascular compromise detection allows for successful results in microvascular surgery and flap salvage.

In the inpatient unit. When the patient arrives at the inpatient unit, nurses use large roadmaps hung in each room as an interactive postoperative checklist. The QI team trained the nursing staff to use the roadmap as a focal point for continuous conversation, transparency, and engagement with milestones required before discharge. These milestones include early ambulation, out-of-bed to chair for all meals, oral medications for postoperative pain control, return demonstration for JP drains and subcutaneous injections, and showering.

Nursing documentation

In collaboration with nursing informatics, the QI team created a new inpatient DIEP flap flowsheet for nurses to document milestone completion and challenges per shift. This flowsheet allows nurses to easily identify specific tasks and education that patients must complete before discharge. The accountability and importance of accurate documentation in both outpatient and inpatient settings drive standardized communication techniques, which allow nursing staff to optimize patient interactions.

This collaborative approach has streamlined processes and aided successful recovery. After a patient achieves all milestones, they’re ready for discharge, which comes as no surprise because they’ve remained engaged throughout recovery.

Tracking recovery after discharge

At discharge, patients receive a Recovery Tracker questionnaire through their patient portal. The tracker includes questions about their drains, surgical flap changes, bowel and respiratory function, ambulation, and overall recovery. Patients’ responses go directly to their assigned outpatient nurse, who then contacts the patient directly if their answers warrant follow-up about a possible postoperative complication or issue. The roadmaps and the recovery tracker facilitate the clinician and patient relationship across the care continuum.

Room for improvement

From 2018 to 2022 the volume of patients receiving DIEP flap reconstruction increased from 130 to 173 per year. After the successfully reduced length of stay to 2 days, the QI team looked for interventions and initiatives to reduce length of stay to 1 day.

Anticoagulation adjustment

The team reviewed the need for daily postoperative subcutaneous injections, which decrease the risk of flap failure. Many patients and caregivers felt overwhelmed by the amount of time spent on education as well as the psychological impact of performing self-injections for 7 to 30 days. The team’s literature review noted research by Kotha and colleagues, which found reduced mortality and bleeding risks using oral factor-Xa anticoagulation compared to other anticoagulation therapies. The transition to oral anticoagulation could help reduce the amount of bedside education.

The team agreed that patients would receive subcutaneous injections throughout their hospital stay to reduce the risk of complications, such as hematomas (which typically occur within 24 hours after surgery), surgical flap failure, or bleeds. They would then transition to oral anticoagulant after discharge.

Physical restriction updates

The project team also reviewed the physical therapist’s workload, which included lengthy bedside assessments, exercise training, and physical restriction review (including arm restrictions). The team found that surgeon preference (not evidence) determined physical restrictions.

Historically, surgical-side arm movement and exercises begin on postoperative Day 5. After reviewing these restrictions with the surgeons and physical therapy, the team agreed to start exercises on postoperative Day 1 to reduce complications caused by immobility and decrease the number of physical therapy consults after the patient’s follow-up appointments. In addition, physical therapy worked to eliminate duplicative education provided during outpatient appointments, instead focusing on return demonstration exercises and early mobility, including stairs.

The QI team updated the outpatient and inpatient roadmaps with the changes. In addition, the team added a QR code to each roadmap for easy access to patient education material and updated milestones.

After reviewing the barriers and achievements of the milestone flowsheet, the team identified postoperative nausea and vomiting (PONV) as a common discharge delay. This correlated with an increase in postoperative anti-emetic administration, which resulted in ambulation delays. The anesthesia and QI teams worked to standardize anti-emetic use before surgery and in the OR to mitigate symptoms and aid overall functional recovery.

Patient satisfaction and results

After the QI team’s initial phase of interventions, they wanted to ensure that patients felt prepared for and comfortable about discharge. The inpatient nursing staff began distributing and collecting anonymous patient satisfaction surveys to analyze intervention impact. When asked if they felt ready to leave the hospital to continue their recovery, 100% agreed. Patients also were asked if the healthcare providers they saw before and after surgery estimated the same length of stay (77% agreed) and if they were satisfied with the care they received before, during, and after surgery (84% agreed).

This valuable feedback helped identify inconsistent communication regarding length of stay. To improve compliance, project leads addressed these inconsistencies during daily survey reviews.

The QI team’s efforts helped to successfully reduce patients’ hospital stay. The average length of stay dropped 28% (from 2.9 days pre-intervention to 2.1 days post-intervention). Successful 2-day discharge increased by 72% (from 13% to 85%). This data, captured from January 4, 2021, to March 21, 2021, included 134 patients with no re-admissions for postoperative complications.

After the oral anticoagulation and physical therapy modifications, the discharge results from September 2022 to September 2023 improved postoperative Day 1 discharge from 5% to 60%. The average length of stay for 104 patients decreased to 1.5 days.

Unified patient journey

This QI project successfully decreased length of stay for patients who received DIEP flap surgery with no postoperative complications. However, the team did experience some challenges. For example, they encountered barriers with regard to timely authorization of oral anticoagulants. As a new practice for discharge, prior authorization from insurance companies slowed the process. To decrease this delay, inpatient pharmacists and advanced practice providers prepared the patient’s discharge medications earlier in their hospital stay.

The interprofessional team’s motivation to continue their success of a 1-day length of stay triggered real-time data review and solution proposals. To ensure sustainability, the organization has updated the standard of care to mirror the project’s interventions for all nurses. Beyond reducing length of stay, coordinating and aligning care across the care continuum serves as the project’s primary success. The interventions unify the patient journey from beginning to end and keep them actively involved in their own care. Communication continues among outpatient and inpatient nursing teams, surgeons, and other stakeholders to identify and resolve any new barriers to sustain a 1-day length of stay.

The authors work at Memorial Sloan Kettering in New York City, New York. Dana Mazzella is clinical nurse IV, and Eleni Kalandranis is a nurse leader.

American Nurse Journal. 2024; 19(12). Doi: 10.51256/ANJ122423

References

Banks KC, Sun A, Le ST, et al. Effect of reduced urinary catheter duration on time to ambulation after vats lobec­tomy. Surg Pract Sci. 2023;12:100150. doi:10.1016/­j.sipas.2022.100150

Kotha VS, Nigam M, Aivaz M, Chao JW, Buescher TM. Less is more: Microvascular thrombophylaxis with factor-Xa inhibitor monotherapy. Plast Reconstr Surg Glob Open. 2019;7(8 Suppl ):141-1. doi:10.1097/01.GOX.0000585044.61158.e7

Memorial Sloan Kettering Cancer Center (MSKCC). DIEP flap (belly) surgery. mskcc.org/cancer-conditions/breast-cancer/breast-reconstruction-surgery-after-mastectomy#autologous-tissue-reconstruction

Nelson G, Bakkum-Gamez J, Kalogera E, et al. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update. Int J Gynecol Cancer. 2019;29:651-68. doi:10.1136/ijgc-2019-000356

Shen AY, Lonie S, Lim K, et al. Free flap monitoring, salvage, and failure timing: A systematic review. J Reconstr Microsurg. 2021;37(3): 300-8. doi:10.1055/s-0040-1722182

Key words: deep inferior epigastric perforator, DIEP, length of stay, patient engagement