Head and neck cancer readmission reduction(HANCARRE)project:Reducing 30-day readmissions

Objective:Unplanned 30-day readmissions result in increased costs and decreased patient satisfaction.The objective of this study was to compare readmission rates before and after a multidisciplinary quality improvement initiative that focused on patient and staff education,use of targeted skilled nursing facilities,and appropriate use of patient observation status.Methods:This was a quality improvement study of all unplanned admissions to the Head and Neck Oncology service at a tertiary care facility during a 3-year period between October 2015 and September 2018.In October 2016,the Head and Neck Oncology service revised its discharge practices for patients undergoing extirpative and/or reconstructive surgery.These changes included enhancing patient education,increasing the use of a skilled nursing facility with directed staff education and patient handoffs by advanced practice nurses,and appropriate utilization of 23-h observation status for returning patients.The readmission rate from the pre-intervention era(October 2015 through September 2016)was compared to the readmission rate from the post-intervention era(October 2016 through September 2018).Secondary outcomes were the rates of 23-h observation within 30 days of the discharge as well as emergency room visits within 30 days of discharge.Results:In this sample of 449 patients,161(35.9%)were observed before the change-in-practice(before October 2016),and 288(64.1%)were observed following the change-in-practice(after September 2016).On univariable analysis,the risk of readmission declined by approximately 41.4%from the pre-intervention era,though this conclusion was not statistically significant(P=0.06).On multivariable analysis,patients at moderate or high risk of death were 2.31 times more likely than those at minor risk of death to readmit within 30 days(P=0.03).Similarly,those with recurrent or persistent cancer were 3.33 times more likely than those undergoing initial curative surgical management of cancer to readmit within 30 days(P=0.001).No patient characteristics were associated with a 23-h observation following discharge(allP>0.05).Conclusions were similar for emergency room visits following discharge.Conclusions:A three-part quality improvement strategy resulted in a clinically important decrease in 30-day readmissions,though the decline was not statistically significant.There were no significant changes in 23-h observation within 30 days of discharge or emergency room visits within 30 days of discharge.

Designing an evidence-based free-flap pathway in head and neck reconstruction

Background:The use of autologous free-tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer.This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center's approach to standardized free-flap care.Data Sources:This article examines English literature from PubMed and offers expert opinion on perioperative free-flap care for head and neck oncology.Conclusion:Free-flap reconstruction for head and neck cancer is a process that,while individualized for each patient,is best supported by a comprehensive and standardized care pathway.Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence-based practice is rewarded with improved outcomes.