POSTER - #PI1059

The Future of Caring for Free Flaps Free Flap Patients on a Specialty ENT Floor

Nicole Lira, Mary Pfaff, Ann Benson, Erin Shields
UC DAVIS HEALTH -  QUALITY IMPROVEMENT

Background
Historically, Head and Neck cancer-free flap patients spend the first 24 hours post-operatively in an Intensive Care Unit (ICU). Aimed to decrease the length of stay and costs along with increased ICU bed availability, the Ear, Nose and Throat (ENT) team proposed sending appropriate post-surgical free flap patients directly to an acute care ENT floor from the Post Anesthesia Care Unit (PACU). From July 2016 to September 2018, Tower 4 (T4) participated in a randomized control trial
(RCT) which demonstrated that patients designated to T4 had an average length of stay of 8.35 days and hospital charges were $456,000 compared to 8.95 days and $466,000, respectively, in the ICU. Based on these findings, we aimed to establish specialized acute care floor admission from PACU as routine care for free flap patients.

Purpose
The purpose of this project was to implement an effective workflow and update policy for nursing care of post-operative ENT free flap patients admitted directly from the PACU to an acute care ENT unit. While it was identified that it was a cost-effective measure, the aim was to establish workflows to assure that patient safety and quality of care was not compromised in the process.

Design & Methods
The T4 Free Flap committee, consisting of T4 management, bedside nurses, and the ENT nurse practitioner, updated the policy and workflow for this patient population. ENT free flap patients are high acuity patients requiring frequent nursing care and hourly assessments. The policy was updated to include the acute care unit setting. The updated workflow implemented the use of a buddy system to assist with the admitting nurse’s patient load during the first hour of the free flap admission. An online module with updates was developed and assigned to educate all T4 nurses. Additional equipment was purchased to accommodate for the increase in free flap patients. The team sought to identify if any complications occurred and if patients required transfer to ICU.

PICO Question
Will free flap patients who are admitted to T4 from PACU have a decreased cost and length of stay compared to the RCT study?

Performance Data
(See poster)

Implementation Plan
• Formation of Free Flap committee to create nursing workflow and update policy for ENT free flap care.
• Dissemination of workflow and updated learning module about free flap care to nursing staff.
• Implementation of updated policy.

Findings
A retrospective chart review showed that from July to December of 2019 there were 34 free flap patients, 20 of which went to T4 from PACU. One patient required transfer to the ICU. Overall, the average length of stay and hospital costs decreased. In the process, interdisciplinary collaboration, resources and preparation have improved.
Conclusions & Further Study
Standardization of the pilot process has demonstrated that with collaboration, education and resources, acute care nurses are able to efficiently and effectively care for patients who traditionally go to ICU. It was observed that the buddy system did not work out as intended. Limits of generalizability include the lack of comparability between ICU and acute care patient acuity and complications. Overall, this project also suggests there is a need to review and refine current nursing workflows. Additional research may be done to determine if other patient populations that have traditionally been cared for in the ICU may be safely cared for in acute care units.

References
1. UCD Policy 12009
2. Cerenka, B., Olinde, L., Gould, E., Farwell, D., Moore, M., Kaufman, M., Bewley, A. (2019)

"Use of non-ICU specialty ward for immediate post-operative management of head and neck free flaps; a randomized control trial. Elsevier.

T4 UBPC
Carlos Acevedo, Ana Calvo, Iris Catubig, Brenda Cheatum, Peter Lindbeck, Carolyn Mofidi, Fey Saechou, Betty Jo Splendorio, Melody Thai, Jeff Torok, Emily Torres, Denise Yumul