Keywords
free flap - monitoring - flap salvage - ICU nurse
For patients with complex defects in the head and neck resulting from malignancy,
or extirpation of it, free tissue transfer is often the reconstructive method of choice.
Success rates for free tissue transfer are routinely cited to be at or above 90 to
95%.[1] The high rate of success is the result of a gradual increase in the cumulative experience
of microsurgeons, improved instrumentation and advancing technology in microscopes,
and intensive early monitoring of free flap viability. In recent years, the performance
of free tissue reconstruction in otolaryngology departments has gradually increased
such that there are 1.6 microsurgeons per department and free tissue surgeons make
up an average of 12% of the departmental faculty.[2] As a result, free tissue reconstruction experience for otolaryngology trainees has
gone from unusual to very common over a 15- to 20-year period.
While techniques and protocols for flap monitoring vary widely, data suggest that
early periodic examinations of free tissue transfers allow for developing problems
to be identified early enough such that flap salvage is possible.[3] Given the fact that vascular insufficiency can develop quite suddenly in the early
postoperative period, flap examinations should occur frequently in the early postoperative
period, to offer the best possible chance for flap salvage in the event of a microvascular
obstruction.
At teaching institutions, the burden of free tissue monitoring is most commonly borne
by the house staff. With the advent of duty hour restrictions for trainees, the need
for multiple flap examinations overnight can make compliance difficult. We sought
to identify an alternate means of providing excellent postoperative observation of
flap health, while minimizing resident burden. Many centers have developed a “step-down
unit” for flap monitoring, but for a variety of reasons, this was not possible at
the University of Minnesota Medical Center. Because patients receiving free flaps
require intensive monitoring, our protocol is to keep these patients in the intensive
care unit (ICU) for the first 48 hours after surgery, with the nurse-to-patient ratio
of 1:2.[4] We sought to develop a physician-led curriculum to train a core team of ICU nurses
to perform these duties. This article describes the material and strategies utilized
to implement the new approach as well as initial experience following implementation.
Methods
Training of nurses consisted of three steps. First, we identified a core group of
high-quality, accountable nurses with low turnover. At our institution, the charge
nurses in the ICU represented a suitable group that met our criteria. We then worked
with the hospital administration and nursing leadership to gain approval for our initiative.
Once approved, we instituted the nursing training program.
The initial step in training was a didactic session consisting of a PowerPoint presentation
by a faculty microsurgeon (S. S. K.) to this group of ICU charge nurses. The presentation
covered basic topics relating to microvascular free tissue transfer, including basic
flap physiology, the nature microvascular anastomoses, common donor sites, and common
indications for transfer. We also briefly discussed postoperative monitoring as well
as normal and abnormal postoperative bedside examination findings. Lastly, we showed
a short video of a “flap check” being performed by one of the faculty members.
The second step in the training regimen was the development of a “reference manual,”
which was uploaded to a web site accessible to all nurses. The manual is a seven-page
document that included background information on free flaps, monitoring protocols
and day-by-day descriptions of normal appearance, signs of concern, and a summary
checklist for each flap check (see Supplementary Table 1 available in the online version of the article; [Fig. 1]). The day-by-day description was intended to bring attention to some finer points
in free flap physiology during the early postoperative period. For example, nurses
were taught to understand that a flap that appeared somewhat pale the first 24 hours
was usually normal and that flaps would often slowly become pinker over the coming
days as the microvasculature dilated. Importantly, we sought to teach the nurses that
examination of a flap is a skill that requires consideration of multiple data points
which include color, arterial/venous Doppler, turgor, warmth, needle poke, etc., to
determine an accurate overall picture. They were also taught that, in general, a single
data point (i.e., arterial Doppler) was rarely sufficient to determine the true status
of the flap.
Fig. 1 Summary checklist for free flap examinations.
The last component of the nurse training was performed with the assistance of the
house staff and consisted of “on-the-job” training. To accomplish this, the house
staff called the charge nurse on duty to the bedside at the time of each flap check
during the day or night (to increase the chances for all charge nurses to gain experience)
so that the check could be performed in the presence of the nurse. The resident discussed
all the pertinent findings with the charge nurse and helped them to develop an overall
picture of the flap status (see Supplementary Table 2 available in the online version of the article). Each charge nurse was required to
document 10 instances of flap checks performed with residents. Each nurse had a checklist
that documented the time and date of each check. After completion of the 10th supervised
check, the ICU nurses were considered “certified.”
After such time that all ICU charge nurses had completed their training with house
staff and were deemed “certified,” the transition to nurse-led flap checks was initiated,
starting on postoperative day (POD) 1. Because the checks are so critical on the first
evening, we continued resident-only checks on the first night following surgery (POD
0). However, starting on PODs 1 to 4, flap checks between 10 pm and 6 am were performed by the ICU charge nurse using a “virtual flap check.” The virtual
flap check consisted of the ICU nurse performing the examination while on the telephone
with the resident on-call so that the findings could be discussed in real time. If
both the nurse and the on-call resident felt comfortable with the findings as reported
by the nurse, no further action was required. If, on the other hand, the ICU nurse
expressed concern or was unsure of the appearance of the free flap, the resident was
called to the bedside for an in-person examination. Although a description of the
educational framework used is the primary focus of this effort, we collected data
on the first 50 free tissue transfers monitored on the new protocol. Therefore, there
were no specific enrollment criteria for this secondary study aim. The study was approved
by the University of Minnesota Institutional Review Board (study # 1403M49022). We
documented missed findings by the nurse, flap returns to the operating room, flap
loss, neck hematoma, events requiring house staff flap examination after nurse exam,
and number of resident flap exams replaced by “virtual flap checks” performed by ICU
nurses.
Results
A group of 24 ICU nurses was enrolled in the planned training curriculum. All 24 nurses
completed this successfully including the 10 checks performed in conjunction with
house staff. In our first 50 cases of ICU nurse–assisted flap checks, there were no
missed findings of flap compromise. There was only one instance in which the nurse
was uncomfortable with the appearance of the flap, and the resident on-call was summoned
to the bedside. Subsequent examination performed by the resident revealed that the
flap was healthy.
More importantly, no flap losses were experienced during this period. One patient
was taken back to the operating room due to loss of the implantable Doppler signal
and poor blood return on needle poke. Exploration revealed that the implantable Doppler
had become dislodged but the anastomoses were patent and the flap healed without issues.
We estimated the time saved for the on-call house staff as a result of the new flap
monitoring protocol. Since the residents performed the free flap checks on the evening
of surgery, this program had no impact on the first night (POD 0). Our program requires
two checks on POD 1 (10 pm, 2 am) and then one check on POD 2 and POD 3 (midnight), so the ICU nurse–assisted flap
checks saved the residents four trips to the hospital per patient. Our residents live
at variable distances from the hospital and sometimes come in from other hospitals,
so it was not possible to compile the data with exact time figures. However, each
flap examination was conservatively estimated to require 45 minutes for the resident
to drive to the hospital, park, walk to the bedside, perform the examination, document
the examination, walk back to the parking area, and drive home. At 45 minutes per
examination, 180 (4 × 45) minutes, or 3 hours, were saved per patient. Over the course
of the 50 patients studied here, this amounts to 150 hours of time saved.
Discussion
Our study demonstrates that a curriculum and training program designed to train ICU
nurses in free tissue monitoring can be successfully developed and implemented. Once
successfully implemented, the use of ICU nurse–led free tissue monitoring has the
potential to assist in adherence to house staff duty hour restrictions. ICU nurse–assisted
flap checks are feasible and, in our initial experience, did not result in adverse
outcomes. We anticipate that this trend will continue as the nurses become more experienced
and comfortable with free flap monitoring.
Evidence suggests that trainees in Otolaryngology-Head and Neck Surgery are commonly
exposed to free tissue reconstruction in training programs[2] and that rates of flap loss are exceedingly low in experienced centers. A postoperative
flap monitoring is an important factor in the high rate of success. This has led to
an increase in free flap volumes and the requisite postoperative monitoring. With
the advent of duty hour limitations for house staff, the workload associated with
postoperative free flap monitoring has become difficult to manage in some training
programs. This is especially true for programs in which residents take overnight call
from home and must travel to the hospital for each bedside flap examination.
At our institution, overnight free flap examinations required the residents to make
single or multiple trips into the hospital for free flap examination only. This required
evening/night trips to the hospital specifically for bedside free flap examinations
such that compliance with duty hour restrictions became a challenge. As such, we identified
a need to limit the burden placed on house staff relating to free tissue monitoring.
Many institutions have utilized “step-down” units which usually function as semiclosed
units where nurses working there become very familiar with head and neck patients
having undergone specific procedures. In the case of free tissue transfer, the nurses
can become very familiar with free tissue and, over time, their experience reaches
a point where they can successfully monitor a free flap without direct surveillance.
While Khan et al[5] described the use of a cartoon and teaching sessions to familiarize nurses with
free flaps, our study is the first of its kind to define a structured program that
successfully trains general ICU nurses to monitor flaps without physicians in the
room.
Jackson et al studied two groups of patients receiving free flaps, one monitored primarily
by nurses and one monitored primarily by physicians.[6] In each group, complications, length of stay, reoperations, and flap viability were
studied. All of these variables were similar in both groups, so the authors suggested
that there were no negative effects in having free flaps monitored by nursing. Given
that the use of ICUs is common in the postoperative management of patients receiving
free flaps,[7] we feel that the training protocols presented in this study are easily translatable
to many institutions where these types of procedures are performed. In many cases,
either a step-down unit or ICU would be suitable for this type of free flap monitoring
protocol.
It should be noted that advancements in technology have enabled physicians to become
more comfortable with the possibility of nonphysicians monitoring free tissue transfers.
Indeed, there are now multiple tools available for free flap monitoring that are used
to varying degrees on an institution-to-institution basis. Some of the techniques
currently used include: implantable Doppler, microendoscopy, externalization of a
flap segment, laser Doppler flow meter, tissue oxygenation wonders, and surface temperature
monitors, in addition to many others.[8]
[9] In our institution, we currently use an implantable Doppler as an adjunctive tool.
While we counsel the house staff and nurses that the presence or absence of implantable
Doppler signal is not, in and of itself, a definitive determinant of flaps status,
it does act as another piece of objective data which can be used by nurses and physicians
when determining the overall status of the free flap. In the future, technology including
tissue oximetry sensors may act as an adjunct or even replacement for current protocols
for clinical examination.[10] Tissue oximetry in particular has been studied in non–head and neck reconstruction
but only to a lesser degree in head and neck cases.[11] Thus, additional data are needed to support widespread implementation of this technology
in head and neck reconstruction.
One potential weakness of this study is that, although we did not identify any negative
outcomes after we transitioned to flap checks performed by the ICU nurses, our numbers
are relatively small given the low rate of flap complications. We acknowledge that
the study of complications in free tissue transfer is inherently difficult because
rates of complications are quite low, and therefore it is possible that reporting
of additional cases may at some point identify a missed finding by a nurse. However,
we believe that this possibility could also occur with resident-only examinations.
In summary, we have developed a successful strategy and protocol for training ICU
nurses to perform free flap monitoring in the early postoperative period. Our protocol
utilizes a clear stepwise approach with significant physician involvement to ensure
that nurses reach a high level of comfort and expertise prior to performing examinations
on their own. In addition, we have instituted the use of the “virtual flap check”
which keeps the house staff involved and available for immediate assistance when necessary.
Moving forward, we hope to begin adding the POD 0 examinations to the current schedule
of ICU nurse–led free flap monitoring in the near future. We feel that this approach
is safe and ensures positive patient outcomes while allowing training programs to
more easily adhere to house staff duty hour restrictions and improve resident satisfaction.
