Patient and Provider Outcomes Before and After Enhanced Recovery After Surgery (ERAS) Implementation for Head and Neck Free Flap Surgery

Presentation: A015
Topic: Education / Care Delivery
Type: Poster
Authors: Jake J Lee, MD, MSCI; Ethan J Craig, MD, MPH; Jose P Zevallos, MD, MPH; Randal C Paniello, MD, PhD; Patrik Pipkorn, MD, MSCI; Ryan S Jackson, MD; Sidharth V Puram, MD, PhD; Jason T Rich, MD
Institution(s): Washington University School of Medicine in St. Louis


: Enhanced Recovery After Surgery (ERAS) protocols have improved patient outcomes after complex surgeries within multiple specialties. Recent literature on head and neck ERAS protocols, while sparse, demonstrated an association with improved pain, shorter length of stay, and fewer complications. However, prior published head and neck ERAS pathways lack day-to-day specific guidelines, which is especially crucial in the multidisciplinary care of free flap patients. In addition to detailed patient outcomes, there are no head and neck surgery studies to date that assessed provider perspectives before and after ERAS implementation

Objectives: To comprehensively evaluate patient postoperative outcomes and provider perspectives on the safety, stress, and predictability of head and neck free flap care.

Design, Setting, Participants: A single-center retrospective cohort study of consecutive patients who underwent head and neck free flap reconstructive surgery between July 1, 2018 and December 31, 2018 before ERAS implementation and between July 1, 2019 and December 31, 2019 after ERAS implementation was conducted. Providers, including attendings, residents, midlevel providers, and nurses, were separately queried about their opinions regarding free flap patient care via survey before and after implementation. The protocol addresses postoperative analgesia, tube feeding, flap checks, wound care, tracheostomy care, antibiosis, aspirin, in-hospital transfers, and speech-language pathology involvement stratified by postoperative day.

Main Outcomes and Measures: The primary outcomes were morphine milligram equivalents (MME), length of stay, and provider survey scores. Secondary outcomes were complications, intensive care unit (ICU) admission, progressive care unit (PCU) length of stay, antibiotic duration, and 30-day readmission.

Results: In total, 175 patients (mean age 63.0 [12.4] years, 57 females [33%]) were included, of whom 77 (44%) had surgery before ERAS and 98 (56%) had surgery after ERAS. There were no significant differences in baseline characteristics between the two cohorts. Median MME was much higher in the pre-ERAS cohort (difference 80.5 [95% CI 17.5-157.5]). There was no difference in total length of stay (median difference 0.0 [95% CI -1.0 to 1.0] days). There were also no differences in rates of flap failure, surgical site infection, fistula, hematoma, unplanned operative intervention, ICU admission, and 30-day readmission between the two cohorts. Antibiotic duration was much lower in the ERAS cohort (median difference 3.4 [95% CI 2.0-3.9] days).

Of 106 survey responses, 45 providers (42%) completed the survey before ERAS, and 61 providers (58%) completed it after ERAS implementation. Providers reported a significant increase in ability to anticipate pain management and overall management of free flap patients (difference 21.8% [95% CI 7.8%-35.8%]). Compared to pre-ERAS implementation, 33/40 (73%) reported their ability to anticipate the step-by-step management to be better, and 20/40 (50%) and 30/40 (75%) reported free flap care to be less stressful and safer, respectively.

Conclusions and Relevance: Instituting a head and neck free flap surgery ERAS protocol is associated with decreased narcotic use, antibiotic use, and lengthy PCU stay. It is also associated with decreased provider stress, increased impression of patient safety, and improved ability to anticipate step-by-step management of these patients.