Abstract
Simple SummaryTreatment for head and neck cancer (HNC) often involves complex surgery to remove the tumour followed by a reconstructive procedure to restore function and appearance. Getting out of bed and moving after surgery (early mobilization) is key to a good recovery. Clinical guidelines (called Enhanced Recovery after Surgery or ERAS guidelines) recommend getting out of bed and moving in the first 24 h after HNC surgery. This study looks at compliance to mobilization recommendations in 445 patients within an ERAS care pathway for HNC surgery. Implementing a new mobilization recommendation resulted in a 10% increase in recommendation compliance, despite a more aggressive target for (from 48 to 24 h). Patients who had surgery after the new guideline were more likely to leave the hospital on time (within ten days after surgery). Engaging the healthcare team and changing the care instructions improved mobilization and adherence to guideline-recommended care after HNC surgery with free flap reconstruction.One of the foundational elements of enhanced recovery after surgery (ERAS) guidelines is early postoperative mobilization. For patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction, the ERAS guideline recommends patients be mobilized within 24 h postoperatively. The objective of this study was to evaluate compliance with the ERAS recommendation for early postoperative mobilization in 445 consecutive patients who underwent HNC surgery in the Calgary Head and Neck Enhanced Recovery Program. This retrospective analysis found that recommendation compliance increased by 10% despite a more aggressive target for mobilization (from 48 to 24 h). This resulted in a decrease in postoperative mobilization time and a stark increase in the proportion of patients mobilized within 24 h (from 10% to 64%). There was a significant relationship between compliance with recommended care and time to postoperative mobilization (Spearman’s rho = −0.80; p < 0.001). Hospital length of stay was reduced by a median of 2 days, from 12 (1QR = 9–16) to 10 (1QR = 8–14) days (z = 3.82; p < 0.001) in patients who received guideline-concordant care. Engaging the clinical team and changing the order set to support clinical decision-making resulted in increased adherence to guideline-recommended care for patients undergoing major HNC surgery with free flap reconstruction.
Highlights
Background and RationaleClinical practice guidelines are systematically developed syntheses of the best available evidence that incorporate expert opinion through consensus and help guide clinical care [1]
We found that mobilization delayed beyond 24 h was associated with more complications, providing novel head and neck cancer (HNC)-specific evidence for the enhanced recovery after surgery (ERAS) recommended timeframe [18]
We explored whether recommendation compliance was a significant predictor of major postoperative complications and a prolonged length of stay (LOS) using multivariable models presented in our companion paper
Summary
Clinical practice guidelines are systematically developed syntheses of the best available evidence that incorporate expert opinion through consensus and help guide clinical care [1]. Uptake and incorporating evidence-based practice guideline recommendations in clinical practice can be challenging [4,5]. Implementation science, the application and integration of evidence into practice, has made great advances to understanding why guidelines are not readily adopted into clinical practice [7]. Guidelines that are developed by sources perceived as credible, that are applicable to the target population, aligned with current views of best practice, and are supported by organizational structures are more likely to be adopted into clinical practice [5,8,9]
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